I spoke with a lobbyist yesterday about some new regulations established under health reform. Despite high-level political gridlock, the Centers for Medicare and Medicaid Services is issuing critical rules and regulations required under the Affordable Care Act. Lobbyists are thus descending.

I should talk with them more often. Not surprisingly, lobbyists and their clients have grappled with much of the fine print in those hundreds of pages of forbidding pdf files that emerge from various agencies, advisory groups, and the like.

Lobbyists also bring an unsentimental, tactile sense of organizational realities one wouldn’t otherwise consider. One example among several: the friction between the new CMS innovations center and the traditional Medicare bureaucracy. As this lobbyist tells the story, much of the CMS bureaucracy views itself through the lens of traditional FFS payment, and seems temperamentally resistant to components of health reform. And yeah, you’ve stopped reading if you’re not deeply into health reform.

In part, such organizational resistance reflects well-founded concerns from seasoned professionals regarding particular provisions in a massive new law. In part, such resistance reflects the natural inertia of a hidebound bureaucracy that should be overcome. The CMS bureaucracy has also run demonstration projects for decades, which creates obvious potential conflicts with the new center.

The conversation was doubly chastening. It showed with some granularity an inside game the typical health policy wonk might not otherwise know even exists. It also suggested even greater implementation challenge of health reform. Don Berwick is having a hard time managing these conflicts. Congress cut him off at the knees by making him a lame duck. His bureaucratic adversaries and nominal underlings can wait him out, since he’ll presumably be leaving at the end of this year.

I’m not convinced that Berwick is right in every particular. It’s clear, though, that his recess appointment damaged his ability to implement difficult reforms. Among other consequences, weakening him randomly empowered portions of the CMS bureaucracy in ways that don’t match any obvious partisan divide. This makes government less transparent, more resistant to administrative control. The same problems empower people such as this lobbyist, who have more tools to slow things down and to run out the clock on important matters.

[Cross-posted at The Reality-Based Community]

Harold Pollack

Harold Pollack is the Helen Ross Professor at the School of Social Service Administration at the University of Chicago.