President Obama’s re-election clarifies the future of health IT, the Affordable Care Act and other key initiatives.
You didn’t build that. Forty-seven percent. Binders full of women. Clint Eastwood yelling at an empty chair. Soon all these memes from the 2012 election will fade from memory, but as the saying goes, elections have consequences.
One of the consequences of President Barack Obama’s re-election is greater clarity about the future of several technology initiatives launched during his first term. In efforts ranging from open government to “cloud first” to cybersecurity to health-care technology infrastructure, a Mitt Romney victory may not have led to drastic change. But at the least there would have been a hiatus as new agency officials evaluated programs in place. No doubt some would have been de-emphasized or jettisoned. The campaigns did not provide many specifics about technology programs, but their general philosophies gave some hints.
The Obama administration has proved itself willing to expand the activities of federal agencies in support of innovation and to create new organizational structures if necessary, said Daniel Castro, senior analyst with t
Photo: States face new pressure to build infrastructure for health benefit exchanges. Photo courtesy of Flickr/Ladawna Howard.
In health IT, for instance, if you don’t see a role for the federal government, that changes how ecosystems develop, Castro said. Even the active approach of the Obama administration on interconnected health records has been decentralized to some degree. It worked on creating regional health networks and building from there up, he said. The administration could have taken a more proactive, top-down approach.
In the weeks following the election, Government Technology asked Castro and several other analysts to speculate about its impact in four key areas.
The day after the election, Farzad Mostashari, the national health IT coordinator, addressed a meeting of the Health IT Policy Committee, a federal advisory group. He said the president’s re-election “gives us the chance to continue to make strides, continue the essential thrust of the policies and the approaches. But it also affirms our responsibility to do the peoples’ work, to come together — Republicans and Democrats — to do the peoples’ work.”
The analysts we spoke with were unanimous in stating that the clearest outcome of the election will be additional momentum for the government’s programs in support of the “meaningful use” of electronic health record (EHR) adoption and state-based health information exchange, as well as the health benefit exchange infrastructure to support the Affordable Care Act (ACA). “If there had been a change in administration, there would have been some kind of pause, especially with ACA-related items,” said Tom Leary, senior director of federal affairs for the Health Information and Management Systems Society. “But I think now there is consensus that the nation needs to keep moving forward on health IT. This means that the meaningful use program can continue to move forward.”
According to the federal government, meaningful use is the set of standards defined by the Centers for Medicare and Medicaid Services that govern the use of electronic health records and allows eligible providers to earn incentive payments by meeting specific criteria.
Photo: Obama's re-election "gives us a chance to continue making strides," says Farzad Mostashari, national health IT coordinator. Photo courtesy of Paul Morse.
Jonah Frohlich, managing director of consulting firm Manatt Health Solutions, believes the re-election means two things for the Office of the National Coordinator for Health IT. First, the office has more time to work on meaningful use incentives; second, it may consider waivers to extend the state health information exchange program to give states more time to implement it, he said.
“I think they also need to consider how to better align infrastructure for the health reform programs. They are done in piecemeal fashion now,” said Frohlich, who previously served as deputy secretary of health IT at the California Health and Human Services Agency. For instance, a demonstration project in 12 states is examining how best to treat patients eligible for both Medicaid and Medicare. “They need to think how those should be supported from a technology standpoint, including EHRs, telehealth and remote monitoring,” Frohlich said. “They should look at which policy levers they need to pull to make those coordinate better.”
Frohlich also expects a stronger federal focus on identity management in 2013. “You have to have hand-offs between local, state and federal agencies and private insurers, where appropriate. That requires identity management so people don’t fall through the cracks,” he said.
With it clear that the ACA is not going to be repealed, states will continue their work on eligibility portals not just for health insurance exchanges, but also tying them to other programs people might be eligible for — including the Supplemental Nutrition Assistance Program and Temporary Assistance for Needy Families — so that when people come to the portal, they are steered to programs they’re eligible for.
“Some states such as Mississippi already have something like this in place and are now updating it to make it compliant with ACA,” said Andrea Danes, director of health care and human services for CSG Government Solutions. For other states, this is more difficult because they are tying in legacy systems and trying to interface with federal systems on tax information and citizenship. Plus, as all the states try to build these systems in parallel, there are only so many vendors with expertise in this area and they are all swamped, she pointed out. Of course, some Republican governors are choosing not to create their own exchanges, but instead opting to let the federal government run one for them. Approximately 18 states will run their own, a dozen or so are seeking partnerships with the federal government and another 18 to 20 would have federal exchanges, according to a New York Times report in November.
With a Medicaid expansion part of the ACA, states are also moving ahead rapidly on the Medicaid Information Technology Architecture (MITA) 3.0 framework, with 90 percent funding from the federal government. (The Romney campaign had talked about sending Medicaid dollars back to the states in block grants. It’s unclear what would have happened with the MITA framework in that scenario.)
In the first Obama administration, there were major initiatives around data center consolidation and getting agencies to use cloud services where they make sense. Those initiatives and others launched to modernize federal IT project management should only gain momentum during Obama’s second term, said Bill Corrington, principal with consulting firm Stony Point Enterprises and former CTO for the U.S. Department of the Interior.
Those efforts all reflect a modern approach to delivering IT services, he added, “but one of the challenges in getting to solid implementation is that they have to be well coupled.”
For instance, data center consolidation and cloud strategy really are two parts of the same thing, yet the federal initiatives weren’t coupled well, he believes. The connection wasn’t made explicit enough, he said, adding that agencies sometimes have trouble keeping up with the changing landscape. “Just as they started to make momentum with the cloud, then a ‘mobile first’ initiative came down the pike,” Corrington said. “People in CIOs’ offices tend to focus on the latest memo, and if there are too many, it is difficult to follow through. So they need a little more of connecting the dots between the various initiatives.”
But Corrington added that the continuity in leadership created by Obama’s re-election gives federal IT leaders the opportunity to focus harder on implementing the strategies announced and begun in the first term. “There are certain folks in middle to senior IT management who were playing wait and see on things like the cloud. Now they will move ahead.”
Photo: Daniel Castro, senior analyst with the Information Technology and Innovation Foundation: State/federal open data partnerships could grow.
ITIF’s Castro gives the administration credit for trying to be more experimental in encouraging new approaches to projects to see what works. As an example, he cited the newly launched Presidential Innovation Fellows program, which pairs innovators from academia, industry and nonprofits with government representatives to collaborate on projects that aim to make a difference for Americans. One area that needs improvement in this realm, he said, is procurement regulations, which can put a straitjacket on agency CIOs.
Cybersecurity was a main focus of the first Obama administration, yet there will be some key issues going into 2013, said J.R. Reagan, a principal with Deloitte & Touche. “There will definitely be a renewed focus on cybersecurity in the second Obama administration,” he said, “and the question is how they go about it.”
Among the accomplishments of the first term, he said, were creating the U.S. Cyber Command and adding a U.S. cybersecurity coordinator position in the White House. He added that administration work that began on a National Strategy for Trusted Identities in Cyberspace could prove to be very useful.
But cybersecurity legislation stalled in the last session of Congress. “There is some desire to pick that legislation up again, but not until it has about a 50/50 chance to pass,” Reagan predicted. The private sector has very different ideas about whether the federal government should have the authority to tell them how to go about this. “On the other side, people argue we could have a cyber-Pearl Harbor scenario, and the government has a responsibility to put its resources into making sure that doesn’t happen.”
ITIF’s Castro noted that some of the resistance last session was because some Republicans didn’t want to give the president a win in an election year. “That factor is gone now,” he said. And a presidential executive order is a possibility if the legislation stalls again.
In the second term, the Obama administration also could lend a hand to state technology leaders on cybersecurity, said Srini Subramanian, a director in Deloitte & Touche’s security and privacy services practice. The states are struggling in part because they don’t currently have to comply with regulations, while the federal agencies have to comply with Federal Information Security Management Act (FISMA) rules, which offer a single measure of performance on cybersecurity. “Whether through legislation or an executive order, there may be ways states can be helped in the process with some kind of framework similar to FISMA,” he said. The states need funding help, too, and the U.S. Department of Homeland Security could be a conduit for that.
“My wish is that any legislation or executive order would include state governments in the mix,” Subramanian said.
When he was a senator, Obama helped pass transparency legislation; he talked about open government in his first campaign; and his Open Government Directive has made this a high-profile conversation topic in federal agencies in his first term, according to Amy Bennett, assistant director of OpenTheGovernment.org. “They have momentum, and we would like to see the president recommit to making open data initiatives and transparency a priority,” she said.
She gave the administration high marks for implementing the first open government national action plan in Obama’s first term. “A lot of the things in the first national action plan were the easiest things to do, the low-hanging fruit,” Bennett said, “but to their credit, they went beyond the basics in some areas.”
In terms of Freedom of Information Act (FOIA) reform, the U.S. Environmental Protection Agency recently created a Web service called FOIAonline, a tool to manage agency workflow. The goal is to create a shared cost model so that other agencies could use it. Bennett said the FOIA management systems that agencies use now are costly, run by outside contractors and don’t talk to one another, so this is a real potential area of improvement.
Bennett also applauds the move to reform federal records management in the first term. “We are pleased with the substance of that,” she said. “Our only concern is that the time frame is quite long, but agencies do need time to work these things into their budgets.”
Bennett and other analysts noted that data sharing and open government initiatives could help state CIOs as well. Federal CTO Todd Park gets credit for work on open data when he was at the U.S. Department of Health and Human Services and is now spreading that across the federal space, said ITIF’s Castro. In the second term, the administration could make a more coordinated effort to get state and local governments to open up health data, GIS, business information, and environmental and energy data. “Real cohesive leadership on this could be very helpful,” Castro said. “A lot of open data initiatives involve creating platforms. But once the platform is created, it can be reused in other environments at much lower costs than in the former e-gov 1.0 model, when each government entity was figuring these things out for itself.”
Beyond the specifics of individual programs, Gartner Vice President of Government Research Rishi Sood thinks the continued leadership of Park and federal CIO Steven VanRoekel are important. “The continuity is the major factor coming out of the election,” he said. “The administration will expand on the early stage development of IT initiatives on several fronts. Data center consolidation and cloud efforts will keep their momentum.”
IDC Government Insights Research Director Shawn McCarthy agreed, noting that efforts involving enterprise architecture alignment and making sure the government is more nimble and spending less on IT do rely on strong IT leadership in these federal CTO and CIO positions. Yet some of the change processes won’t be completed in the near term and span several administrations. “Many of these efforts are long term and probably wouldn’t have changed under a Romney administration,” McCarthy said. “The enterprise architecture work began in the Clinton administration. Nobody was going to come in and make wholesale changes to those efforts.”