Advocates of United States President Barack Obama's healthcare programme have been quietly pushing the idea of a chief executive who would set marketplace rules, coordinate with insurers and state regulators on the health plans offered for sale, supervise enrolment campaigns and oversee technology, according to several sources familiar with discussions between advocates and the Obama administration.
Supporters of the idea say it could help regain the trust of insurers and others whose confidence in the healthcare overhaul was shaken by the technological woes that crippled the federal website and the flurry of sometimes confusing administration rule changes that followed.
The advocates include former White House adviser Ezekiel Emanuel, the brother of Obama's former chief of staff Rahm Emanuel, and the Center for American Progress, the Washington think-tank founded by the president's newly appointed senior counsellor John Podesta.
But the White House is not embracing the idea of creating a chief executive, administration officials said.
"This isn't happening. It's not being considered," said a senior administration official.
Some healthcare reform allies say the complexity of the federal marketplace requires a chief executive-type figure with clear authority and knowledge of how insurance markets work.
Obama's healthcare overhaul aims to provide health coverage to millions of uninsured or underinsured Americans by offering private insurance at federally subsidised rates through new online health insurance marketplaces in all 50 states and in Washington, DC.
Only 14 states opted to create and operate their own exchanges, leaving the Obama administration to operate a federal marketplace for the remaining 36 states that can be accessed through HealthCare.gov.
The marketplace is now officially the responsibility of the US Centers for Medicare and Medicaid Services (CMS) and its administrator, Marilyn Tavenner. Healthcare experts say there is no specific official dedicated to running the operation.
A CMS spokesman said exchange functions overlap across different groups within the agency's Center for Consumer Information and Insurance Oversight.
The lack of a clear decision-making hierarchy was identified as a liability months before consulting firm McKinsey & Co's disastrous October 1 launch of the website.
Obama adviser Jeffrey Zients, who rescued the website from crippling technical glitches last month, identified the lack of effective management as a problem.
Former Microsoft executive Kurt DelBene has replaced Zients as website manager, at least for the first half of 2014.
"We're fortunate that Kurt DelBene is now part of the administration – there's no one better able to help us keep moving forward to make affordable, quality health insurance available to as many Americans as possible," said Obama healthcare adviser Phil Schiliro.
The White House appears, for now, to be concentrating on ironing out the remaining glitches in HealthCare.gov to ensure millions more people are able to sign up for coverage in 2014. Good enrolment numbers are seen by critics and supporters of Obamacare as a key measure of the programme's success.
"So my sense is that they're not thinking about appointing a CEO in the short term," said Topher Spiro, a healthcare analyst with the Center for American Progress.
The chief executive proposal calls for removing day-to-day control of the marketplace from the CMS bureaucracy and placing it under a leadership structure like those used in some of the more successful state-run marketplaces, including California.
The new team would be managed by a chief executive, or an executive director, who would run the marketplace like a business and answer directly to the White House, sources familiar with the discussions say.
They point to insurance industry and healthcare veterans as potential candidates, including former Aetna chief executive officer Ronald Williams, former Kaiser Permanente chief executive officer George Halvorson and Jon Kingsdale, who ran the Massachusetts health exchange established under former Governor Mitt Romney's 2006 healthcare reforms. None were available for comment.
Healthcare experts say the idea should have been taken up by the administration years ago.
"It's the right thing to do. It's just two years late," said Republican Mike Leavitt, the former Utah governor who oversaw the roll-out of the prescription drug programme known as Medicare Part D as US health and human services secretary under then president George W Bush.
"The administration is confronted by a series of problems they cannot solve on their own. They do not possess internally the competencies or the exposure or the information," he said.
Emanuel, one of the administration's longest-standing allies on healthcare reform, recommended a marketplace chief executive in an October 22 op-ed article in the New York Times, calling it one of five things the White House could do to fix Obamacare.
"The candidate should have management experience, knowledge of how both the government and health insurance industry work, and at least some familiarity with IT [information technology] systems. Obviously this is a tall order, but there are such people. And the administration needs to hire one immediately," he wrote.
The administration has adopted Emanuel's four other recommendations: better window-shopping features for HealthCare.gov; a concerted effort to win back public trust; a focus on the customer shopping experience; and a public outreach campaign to engage young adults. – Reuters