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Organizational Challenges & Management Alternatives

How Public Administrators Are Implementing the ACA

By Cheryl and Ferd Mitchell

Implementation of the Affordable Care Act (ACA) has raised numerous challenges for administrators and managers. Insight into these challenges may be obtained by looking at two of the different management techniques that may be applied to problem solving.

The first approach consists of top-down directives with sufficient control and authority to produce the desired results, coupled with behavior modification to link desired actions with a variety of rewards.

A second approach is to consider self-fulfillment and self-actualization as motivating influences to achieve the desired outcomes. Federal and state agencies have typically sought to implement ACA changes through top-down directives expressed through
regulations and “guidance”. Control and authority have often been able to produce conformance by all organizations and managers.

In 2012, as ACA implementation was getting under way, the Office of Inspector General (OIG) of the Department of Health and Human Services (HHS) identified implementation of the ACA as “Management Issue 1”. The stated objective was to ensure “efficient and effective implementation of the ACA”. The emphasis was to be placed on “effective front-end program gate-keeping, sound payment design, the promotion of provider compliance, (and) vigilant monitoring of program operations and outcomes….”

As we approach the end of Fiscal Year 2013 (on September 30, 2013), it is clear that HHS management strategies have largely conformed to this emphasis. In fact, Congress seems to criticize any variation by HHS from these principles. However, some HHS political appeals associated with the ACA have encouraged participation as the “right thing to do.”

In dealing with the public, HHS has turned to a combination of behavior modification (obtain a subsidy and achieve protection) and self-actualization (do the right thing for self and family, and then “feel good about the results.”

The new Health Exchanges have largely chosen to remain “opaque” to the outside world. Managers have been concerned with internal tasks and the performance of designated operations, and with responding as directed by HHS.

Insurance company managers have typically turned to directives to handle risks; behavior modification to encourage providers to agree to participate in new networks (emphasizing the potential rewards of more patients); and both behavior modification and self-actualization to sell health insurance to the public (combining the rewards to be gained with the opportunity to “feel good” with insurance that is being offered.

Managers in organized delivery systems, hospitals and large group practices have often turned to behavior modification to obtain internal cooperation (more income, better working conditions) and to self-fulfillment in building public image and attracting patients (“you will feel better about your care with us”).

Looking back, it is clear that the choice of management strategies has depended on the setting and the nature of the outcome desired. The most effective management results have often been obtained when the two approaches have been used together, with skill, to match tasks and individuals.


This is part of the “The Affordable Care Act and Public Administration Series” that is running on the ASPA blog.

Initial installments of this series have addressed the shift to action for implementation of the ACA (#1) with related struggles by federal agencies (#2), and the emergence of the ACA into public view (#3) leading to new issues (#4).

More background on these subjects is provided in other recent postings by the authors, and in a recent book by the authors on implementation of the ACA.

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