"Six million" is the new "zero" and they knew it would be this way, four years ago.

<<<  Can you believe this?  Just 7 days ago,  the number was "5 million."  One million "sign-ups" in record setting time.  Does anyone in this Administration know that "we" are wise to their word games??  

In a video at the Washington Examiner, here, (sorry but I could not capture the video link)  where the AP reviews the issue of enrollment,  for a fast food worker,  and came up with this surprising fact:  Allen Backer,  a fast food employee,  makes TOO LITTLE to qualify for subsidies and, thus,  cannot afford the premiums quoted to him online with the Federal Exchange.  He could have qualified for Medicaid,  hardly a quality substitute for real insurance (but it IS coverage), but Georgia did not participate in the Federal Exchange and did not expand its Medicaid rolls.  It “did not” because the state does not trust the Feds for reimbursements,  and cannot bear the cost of a blotted Medicaid program.  

What does not get mentioned, in all this,  is the fact that the Feds should have seen this problem coming and posited solutions for the folks like the Backers within the text of the ObamaCare bill,  proper.   Instead,  their  "solution"  was this:  “If folks cannot afford our affordable insurance solutions under ObamaCare,  we will pawn them off onto the various states.”  That was their solution  -  to let someone else worry about it  . . . . . . . kind of the same solution used in Obama’s foreign policy program,  his jobs creation program,  his alternative energy program and on and on. 

Before you start blaming the states for the problems the Backers are having,  understand that public opinion opposed this insurance reform,  from the beginning.  This has been, solely, a Democrat debacle from the start,  and no amount of criticism against the “uncooperative states” will change that fact. 

We, as the American people,  have run out of trust and that is proving to be a huge problem.  Understand that Obama did not create this trust deficit,  but he certainly has magnified its importance – and we all know how well he handles issues of “deficits.” 

In the most recent AP/GfK poll,  covered on this blog,  support for ObamaCare has fallen to a new low of 26%.  While the Obama Spin Machine is busy lying its way to a 6 million-plus-enrollment-number for program sign-ups,  the fact of the matter is this:  it is common knowledge that six million folks lost their existing policies, months ago.  A six million enrollment number simply gets us back to zero. 

Four years ago,  the Administration was talking about the “30 million uninsured.”  Somewhere along the line,  that number was raised to 45 million,  so that the Administration could tout its version of “success,”  arguing that,  while ObamaCare is not “universal,”  as promised,  the uninsured rate has come down from 45 mill to 30 mill.  

Really?  “Masterdebating” is all this amounts to.   It is interesting to me,  however,  that “they” saw this problem (poor sing-up numbers) coming,  years ago,  thus, the change from “30 million” to “40 million.”  Another very subtle piece of evidence telling us that they knew,  all along,  that this program was going to be highly problematic.    

News Flash: During the summer, before the 2014 mid-terms, premiums will double in some regions, taxes will be raised to cover increasing subsidies (used to give the allusion that healthcare is, now, cheaper) and insurance companies will be bailed out.

The Hill admits to what many citizen journalists such as I have been forecasting for two months,  now.  Because of the low enrollment  numbers,  especially as to the enlistment of the young and healthy adult population,  three  things must happen,  this year,  before the mid-terms:  One,  insurance companies will be forced to raise their rates to help cover expenses,  and, two,  bail-out money,  already cooked into the law (“they” knew this was going to be financial debacle years ago,  when they were writing the law), will be doubled and given to participating insurance companies, and,  three, Obama will raise subsidies and associated taxes, as well.  Democrats drafted the Medicare law in the mid 1960’s.  That law now owes itself 42 trillion dollars in,  what is called, “unfunded liabilities.”  That’s a debt to year ratio of 10 trillion dollars.  ObamaCare will be as bad or worse.  Certainly,  its beginnings is far worse than was the start of Medicare.     

Clearly,  New Age, Progressive/Marxist/ Democrats  should never be allowed to write financial  law or command an army. 

The Hill:

Health industry officials say ObamaCare-related premiums will double in some parts of the country, countering claims recently made by the administration.

The expected rate hikes will be announced in the coming months amid an intense election year, when control of the Senate is up for grabs. The sticker shock would likely bolster the GOP’s prospects in November and hamper ObamaCare insurance enrollment efforts in 2015.

The industry complaints come less than a week after Health and Human Services (HHS) Secretary Kathleen Sebelius sought to downplay concerns about rising premiums in the healthcare sector. She told lawmakers rates would increase in 2015 but grow more slowly than in the past.

“The increases are far less significant than what they were prior to the Affordable Care Act,” the secretary said in testimony before the House Ways and Means Committee.

Her comment baffled insurance officials, who said it runs counter to the industry’s consensus about next year.

“It’s pretty shortsighted because I think everybody knows that the way the exchange has rolled out … is going to lead to higher costs,” said one senior insurance executive who requested anonymity.

No jobs, no wealth redistribution. No redistribution, no Utopia. No Utopia, no more Democrat/Socialist party.

<<<<< whether voluntary or not,  the labor force will continue to register RECORD lows for as far as we can see.  Under Bush,  66% of available labor was working.  Today,  that is down more than 10 million to 63.5% with no end to this downward spiral.  Socialists need a labor force to make their Utopian schemes work - or there can be no wealth redistribution.  (This chart is found on page one of the current CBO report.) 

Its not that ObamaCare will cause job loss (it will do that, of course), but,  for the sake of the current report,  here is the problem:  ObamaCare subsidies is an incentive for people to quit their jobs.   

A day or so of careful reading and cogitation by the media has begun to turn the tide on what had  been the Congressional Budget Office's most widely misunderstood finding about the Affordable Care Act.

It is now recognized that, no, the CBO didn't say that Obamacare would lead to job losses, but instead that it would allow many workers to voluntarily leave their jobs or retire without giving up health coverage.

Even House Budget Committee Chairman Paul Ryan (R-Wis.) felt the need to get things straight at his hearing Wednesday on the CBO report. "Just to understand," he queried CBO Director Doug Elmendorf, "it's not that employers are laying people off?"

"That's right," Elmendorf replied.

But it's now becoming plain that the CBO finding creates a problem for Republican critics of the healthcare law. That's because relieving millions of Americans of "job-lock," which is what the CBO is talking about, is something the GOP has favored for years. In fact, it was a selling point of healthcare proposals they put on the table prior to 2010, when they decided to abandon the field of healthcare reform  . . .  from the LA Times.
______________________________________________________________________________

<<<<< whether voluntary or not,  the labor force will continue to register RECORD lows for as far as we can see.  Under Bush,  66% of available labor was working.  Today,  that is down more than 10 million to 63.5% with no end to this downward spiral.  Socialists need a labor force to make their Utopian schemes work - or there can be no wealth redistribution.  
______________________
Editor's notes:  Of course,  the CBO never refers to "job lock," nor does this report view the stated job loss as a positive event.  In fact,  it is a troublesome negative that will reduce tax collections and increase dependency on the Federal Government.  Again,  the CBO Director has made the point that subsidies create a disincentive to work.  

(CNSNews.com) - The subsidies that help low-income people buy expensive health insurance are a 'disincentive for people to work," Douglas Elmendorf, director of the Congressional Budget Office, told Congress on Wednesday.

"What the Affordable Care Act does, is to provide subsidies focused on lower- and lower-middle-income people to buy health insurance. And in order to encourage a sufficient number of people to buy an expensive product like health  insurance, the subsidies are fairly large in dollar terms. Those subsidies are then withdrawn over time -- withdrawn from people as their income rises. . . .   from found at CNS News.  

The recent CBO report makes it clear that the nation's Progressives have given up on "job creation" and these clowns think this is a good thing.

10 Trillion will be added to the national debt over the course of the next ten years.  Obama's lie had ObamaCare adding more than 150 billion dollars per year,  to the nation's economy.  Instead,  this "10 trillion" number is 1 trillion per year,  more than 10 times the estimated cost  . . . . . estimated by the liars within this Administration.  I do not like the sound of "liar" but there is simply no way to frame this eventuality.  NOTHING about ObamaCare has been proven to be true.  It increases the costs for all you have to actually pay for their coverage,  and those increases are dramatic.  We were promised just the opposite.  We were promised we could keep our current policies and doctors and hospitals  -  outrageous lies told by people who knew these were lies at the time they were spoken.  "Universal?"  Just as many folks will be uninsured by the time "sign-ups" are over,  than before,  and,  the authors of this idiot's bill knew this to be true at the time of the false projections.  Abortions will be funded despite promises arrogantly made,  otherwise.  

The following is page 14 of this 176 page report.  I think it is as important a single page within this summary by the Congressional Budget Office (CBO), as any.  Editor notes not a part of the CBO text are noted in obvious terms.

  

(Page) 14 

THE BUDGET AND ECONOMIC OUTLOOK: 2014 TO 2024 FEBRUARY 2014

Click on "CBO" for the full and official report. 

CBO’s Baseline Budget Projections for  2015 to 2024

CBO constructs its baseline in accordance with provisions

set forth in the Balanced Budget and Emergency

Deficit Control Act of 1985 (P.L. 99-177) and the

Congressional Budget and Impoundment Control Act of

1974 (P.L. 93-344). For the most part, those laws require

that the baseline projections incorporate the assumption

that current laws governing taxes and spending remain in

place in future years. 

(Note: Baseline budgeting begins with current spending levels as the "baseline" for establishing future funding requirements and assumes future budgets will equal the current budget multiplied by the inflation rate times the population growth rate.  It assumes systemic increases in spending with no end in sight. When discussing a particular budget based on baseline projections,  the particular year used in setting the baseline becomes critical and this changes changes with the passing of each and every fiscal year - blog editor)

Under that assumption, CBO projects that the budget

deficit will continue shrinking in 2015—to $478 billion,

or 2.6 percent of GDP. But beginning in 2016, the deficit

is projected to increase again both in dollar terms and as a

share of the economy, totaling 4.2 percent of GDP by

2022 before dipping back down to 4.0 percent in 2024.

That decline in the deficit is the result of shifts in the timing

of certain payments; without those shifts, the deficit

would increase from 3.9 percent of GDP in 2022 to

4.2 percent in 2024.8

Most of the projected decline in the deficit next year

under CBO’s baseline [using the 2012 or is                                                                     it the 2013 budgetary numbers ??]                                                                                  is the result of a significant rise in

projected revenues. In total, revenues are estimated to

increase by 9 percent in 2015—in part because of the

recent expiration of various tax provisions—reaching

18.2 percent of GDP. They are projected to remain fairly

stable as a share of GDP through 2024.

Outlays in CBO’s baseline grow to about 21 percent of

GDP in 2015 and then generally follow an upward trend,

reaching 22.4 percent of GDP by 2024.9 Because of the

aging of the population, rising health care costs, and a

significant expansion in eligibility for federal subsidies for

health insurance, outlays for Social Security and the

federal government’s major health care programs are

projected to rise substantially relative to the size of the

economy over the next 10 years. In addition, growing

debt and rising interest rates will boost net interest payments.

Total spending on all other programs is projected

to decline relative to GDP between 2015 and 2024,

primarily because of improving economic conditions and

the spending limits in current law.

Revenues

If current laws remained unchanged, revenues would

increase as a share of GDP by 0.7 percentage points from

2014 to 2015, by CBO’s estimates. Slightly more than

half of that increase would result from changes in tax

provisions, including the recent expiration of various provisions

affecting corporate and individual income taxes

and the implementation of fees and fines established by

the Affordable Care Act (see Chapter 4 for more details

on those changes).

From 2016 through 2024, revenues in CBO’s baseline

remain between 18.0 percent and 18.4 percent of GDP,

largely reflecting offsetting movements in receipts from

individual and corporate income taxes and remittances

from the Federal Reserve. Individual income taxes are

projected to generate increasing revenues relative to the

size of economy, growing from 8.5 percent of GDP in

2015 to 9.4 percent in 2024. The increase stems largely

from real bracket creep (a phenomenon in which growth

in real, or inflation-adjusted, income of individuals

pushes more income into higher tax brackets) and from

increases in withdrawals from tax-deferred retirement

accounts as baby boomers retire.

In contrast, after the first few years of the projection

period, corporate income tax receipts and remittances

from the Federal Reserve decline relative to the size of the

economy in CBO’s baseline. Corporate income tax

receipts are projected to decrease relative to GDP after

2016 because of an anticipated drop in domestic economic

profits relative to GDP, the result of rising interest

payments on businesses’ debt, growing labor costs, and

increasing deductions for depreciation on the larger stock

of business capital. Remittances from the Federal Reserve,

which have been very high by historical standards in the

past four years because of changes in the size and composition

of the central bank’s portfolio of securities, decline

in CBO’s projections to more typical levels.

Obama has spent 1 billion dollars on his website and will need another billion to complete the site's remaining 40% (plus "fixes") . . . . and their lies go on and on.

The Blaze:

The to-date cost of the glitchy Obamacare website has topped $1 billion, easily surpassing the $394 million originally estimated by the Government Accountability Office, according to a Bloomberg Government analysis.

It’s important to note that the Bloomberg analysis runs through Sept. 30, just before the 16-day partial government shutdown. So the final cost may be more than $1 billion.

Editor's notes:  It is one huge lie after another,  with this bunch of Marxist Misfits  (Progressive theory does have its roots in communism and the thinking of Karl Marx).  The latest is the realization that the Fed's first announced estimate of $160 million,  followed by admissions of more than $400 million (told to us for the past two months) was never close to being true.  Rather,  the truth is more than $1 billion dollars,  with $3.5 million of that total being spent during the six months just before the October roll-out date. 

Understand that that the Democrats had played up the 16 day partial shutdown,  as something that cost the American taxpayer $24 billion dollars,  a "catastrophic"  total that would spell "d.e.f.e.a.t" for the GOP in 2014.   Remember?  Of course not,  because that "24 billion" total was a figure pulled out of Obama's backside.  Turns out,  the "shutdown" only effected 8% of the population,  and almost all of that effect was temporary,  involving government wages that were paid immediately following Sept 30 and the end of the so-called "shutdown."   

Know this:  ObamaCare is a rotting  albatross tied around the Democrats' political necks, and will remain an elective crisis through 2014 and into the 2016 election cycle beginning in late 2015.  There is no getting around this fact - ObamaCare is "all on" the Progressive Democrats with not a single Republican voting for this abortive legislation,  conservative or liberal.  "They" wanted it that way,  somehow believing that their healthcare "reform" would be their ticket to "permanent rule" as the only party of choice for an appreciative voting public.  Turns out that only 30% of the indigent poor are "flocking" to ObamaCare,  none with any serious money,  all of them being placed into the money pit known as "Medicaid," and less than 20% of healthy America joining the cause.  Approximately 200,000 have "signed up" for coverage during the first two months,  when the Administration needed 2.2 million signees to meat their expectations.  "Colossal"  does not begin to capture the extent of failure relating to this program and its "roll-out."   

It is obvious,  now,  that none of the ObamaCare website was completed by October 1,  none of it.  In the six months before the October deadline,  Administration gave up on the "back functions" and directed all its attention the front end of this site,  that part the American people would see first.  The back end of this website,  the part that collates and forwards all applicant information to the various insurance companies, simply does not exist.   The Obama Administration has spent more than 1 billion dollars on 60% of its website,  with millions more needed to complete that "60%,"  not to mention the writing, testing and security of the remaining and unwritten 40%.  Can anyone say "Two billion?"  

I have never thought the current Administration was qualified, professionally,  for the leadership of this once great nation.    Now that we are facing the reality of ObamaCare,  their wonderful words and Utopian theory have gone the way of the wind.  And their problems do not end with website issues.  We now know that the supposed "savings to the economy" promised by Obama/Pelosi/Ried,  has evaporated into a 3 trillion dollar deficit  . . . . .   and counting.  Social Security owes itself 17 trillion dollars;  Medicare is 42 trillion in debt and ObamaCare,  the 800 pound gorilla by comparison, is on track to dwarf either our two largest socialist programs  . . . .  and the beat goes on.  

Obama governs as if he were six years old . . . demanding what he wants with no regard for the complexities of his demands; THAT is what is wrong with ObamaCare.

Updated for minor grammatical changes.

This post is actually an update to an early morning post (Sunday morning ) in  Midknight Review found here.  It confirms the criticisms of David Cutler, a friend of the Administration.  Obama believes he can command something into existence.  As an example,  his Cairo speech (2009) was to be the turning point in US/Muslim relations simply because of Obama's self serving opinion of his own "well received greatness."  There was no follow-up in the months and years after  the speech . . . . .  just the speech followed by  the man's next childish project in the continuing recreation of  his new toy,  namely the United States of America.   Turns out,  after five years,  he is more unpopular in the Muslim world than George Bush 43 was during any time in his tenure as president;  the point being that Obama believes he can speak a reality into existence and move on  . . . .  his Cairo speech and the unread ObamaCare legislation being two examples.  And in the case of each,  his immaturity as a leader (bordering on retardation) has caused great harm to both the world's economy and our own nation's domestic well-being.  His failures are existential in nature and scope and,  sadly,  he is not finished.

WaPo:  

In May 2010, two months after the Affordable Care Act squeaked through Congress, President Obama’s top economic aides were getting worried. Larry Summers, director of the White House’s National Economic Council, and Peter Orzag, head of the Office of Management and Budget, had just received a pointed four-page memo from a trusted outside health adviser. It warned that no one in the administration was “up to the task” of overseeing the construction of an insurance exchange and other intricacies of translating the 2,000-page statute into reality.

Summers, Orzag and their staffs agreed. For weeks that spring, a tug of war played out inside the White House, according to five people familiar with the episode. On one side, members of the economic team and Obama health-care adviser Zeke Emanuel lobbied for the president to appoint an outside health reform “czar” with expertise in business, insurance and technology. On the other, the president’s top health aides — who had shepherded the legislation through its tortuous path on Capitol Hill and knew its every detail — argued that they could handle the job. . . . . . . . . . .   read the full article at the WaPo

An ObamaCare supporter and adviser to the president, outlines his deep concerns for the implementation of the ACA fully three years before the fact. And, we are watching his fears come true.

David Matthew Cutler is the Otto Eckstein Professor of Applied Economics at Harvard University. He holds a joint appointment in the economics department and in Harvard's Kennedy School of Government and the Harvard School of Public Health. He graduated from Harvard College, summa cum laude, with a degree in Economics, and then joined the Harvard faculty after receiving his Ph.D. in Economics from the Massachusetts Institute of Technology in 1991.[1] He served in the administration of Bill Clinton and was the senior health care advisor to Barack Obama.[2] From 2003-2008 Cutler was Dean of the Faculty of Arts and Sciences for Social Sciences.

Notes:  The following letter details the problematic issues facing ObamaCare,  and why this program is going to be an absolute mess for 10 to 12 years into the future  . . . . .  an analysis designed to be helpful,  written by a friend of the Administration,  a summary written just six weeks after the signing of this bill.   This advise was almost completely ignored by an Administration that believes it can simply "declare" something to be effective and serviceable  ~ blog editor.   

May 11, 2010 

To: Larry Summers

From: David Cutler

Subject: Urgent Need for Changes in Health Reform Implementation

I am writing to relay my concern about the way the Administration is implementing the new health reform legislation. I am concerned that the personnel and processes you have in place are not up to the task, and that health reform will be unsuccessful as a result.

Let me start by reminding you that I have been a very active supporter of reform.  In addition to being the senior health care advisor to the President’s campaign,  I worked closely with the Administration,  helped Congress draft the legislation, met with countless Members of Congress and interest groups to explain the reform effort, conducted numerous radio and television interviews, walked hundreds of reporters through health care, and wrote a number of op-eds and issue briefs supporting reform. I am told that the President and senior members of the Administration valued my input, though I was never offered a position in the Administration.I say this to illustrate that I have thought about the issues a good deal and have discussed them with many people.

You should also note that while this memo is my own, the views are widely shared,including by many members of your administration (whose names I will omit but who are sufficiently nervous to urge me to write), as well as by knowledgeable outsiders such as Mark McClellan (former CMS administrator) and Henry Aaron (Brookings). Indeed, I have been at a conference on health reform the past two days, and have found not a single person who disagrees with the urgent need for action.

My general view is that the early implementation efforts are far short of what it will take to implement reform successfully. For health reform to be successful, the relevant people need a vision about health system transformation and the managerial ability to carry out that vision.The President has sketched out such a vision. However,  I do not believe the relevant members of the Administration understand the President’s vision or have the capability to carry it out.

Let me illustrate the problem you face and offer some solutions.

Problem Areas

A central concern is the Department of Health and Human Services, the main implementation agency for reform. The Department is making a good start on the immediate deliverables of reform: high risk pools and coverage for young adults. But it is far behind the curve on the key long-term reform efforts, most notably reforming the delivery system to support higher quality, lower cost care. Let me give you a few examples.

1. A good deal of reform implementation needs to occur at the Centers for Medicare and Medicaid Services (CMS). You were dealt a bad hand here. The agency is demoralized, the best people have left, IT services are antiquated, and there are fewer employees than in 1981,despite a much larger burden. Nevertheless, you have not improved the situation. The nominee to head that agency, Don Berwick has never run a provider organization or insurance company,or dealt with Medicare or Medicaid reimbursement. On basic issues such as the transition from fee-for-service payment to value-based payment, Don knows relatively little. Further, he has been ordered not to be involved in anything at the agency until he is confirmed, which will likely be in the fall. Don has a wonderful vision, but there is no way he can carry it out in any reasonable time without substantial help.

Unfortunately, the senior staff at CMS, which has been appointed, is not up to the task. For example, I recently met with the senior CMS staff about how all the new demonstration and pilot programs envisioned in the legislation might work. This is a crucial issue because the  current demonstration process takes about 7 to 10 years, and thus following this path would lead to no serious cost containment for the next decade. When engaged about the speed of reform,the staff expressed the view that: 

(a) their fear was going too fast instead of going too slow; 

(b) we ought to add a layer of university review to the existing process, to be sure we are doing the right thing; and 

(c) the natural place to start demonstrations is in end-of-life care (Death Panels notwithstanding).

As a result, you have an agency where the philosophy of health system reform is not widely shared, where there is no experience running a health care organization, and where the desire to move rapidly is lacking. The result is that I have very little confidence that the Administration will make the right decisions about the direction and pace of delivery system reform.

2. The second major task of reform is to set up and run insurance exchanges. I amnot encouraged by what is occurring there either. Running exchanges is a collaborative process.  As just one example, the person who ran the Commonwealth Connector in Massachusetts estimates that he had 500 town meetings to discuss reform, the equivalent of 17,000 meetings nationally – and this was in a state where two-thirds of people, along with insurance companies, supported reform. The person newly appointed to head the insurance oversight office has a reputation as an insurance bulldog,  not a skilled facilitator. Remember that most people will get their information about reform from their doctor and their insurance agent.  If you cannot find away to work with hesitant states and insurers, reform will blow up. I have seen no indication that HHS even realizes this, let alone is acting on it.

3. A fundamental issue in making reform work is explaining reform to providers andshowing them how to respond to it. The Department has done nothing along these lines. Most providers know very little about reform, and they are universally surprised to hear a positive philosophy about how they can benefit from health system transformation. Their most common comment is ‘why hasn’t anyone explained this to us?’ As Atul Gawande’s famous  New Yorker  article put it, you need the equivalent of an agricultural extension worker in every community to make reform work. This does not appear to be on HHS’s radar screen, however.

4. Above the operational level, the process is also broken. The overall head of implementation inside HHS, Jeanne Lambrew, is known for her knowledge of Congress, her commitment to the poor, and her mistrust of insurance companies. She is not known for operational ability, knowledge of delivery systems, or facilitating widespread change. Thus, it is not surprising that delivery system reform, provider outreach, and exchange administration are receiving little attention. Further, the fact that Jeanne and people like her cannot get along with other people in the Administration means that the opportunities for collaborative engagement are limited, areas of great importance are not addressed, and valuable problem solving time is wasted on internal fights.  All in all, the administration has immense decisions to make about transforming healthcare delivery and coverage. But no one I interact with has confidence that your current personnel and configuration is up to the task. 

Some Ideas

When a corporation needs to move in a new direction, it sets up a new structure to focus on where it needs to go. You can’t change the culture by piling new responsibilities onto a broken system. I believe you need to follow this model. You need to bring in people who share the President’s vision and who know how to manage health care or other complex operations. These people then need to interact with existing agency personnel to make reform happen.

You need to start with a strong team at the White House. That team needs to lay out the milestone goals for the next 5 to 10 years, coordinate across various agencies, and communicate with the public. 

To avoid the perception of secrecy,  I would recommend an outside Board of Overseers that would monitor progress and report regularly on whether health reform is meeting its goals.

You also need a major change at HHS, which I envision as a revamped and enhanced implementation group. That group needs to share the President’s vision and have expertise in several areas:

1.   Managing large and complex enterprises 
2.  Payment reform, including people who can work with existing employees todesign and implement the necessary programs; 
3. Information technology systems, including how to update the IT structure in CMS and link that to the effort to computerize medical records;
4. Outreach, including people who can lead an education campaign for medical care providers, insurers, and insurance brokers; and  
5.  State coordinators, who can empower and work with state-specific groups to setup and manage insurance exchanges. In each of these areas, you need to take advantage of external experts as well as people inside the Administration.

Editor’s note:  It does not appear that Obama implemented any of the five suggestions listed immediately above.