I have an hour-plus drive each way to the office and I find that podcasts are both a great way to pass the time while educating and/or entertaining myself along the way. There’s not much rhyme or reason to what I listen to, topic-wise. It may be history or popular culture or true crime – or current events. One that I listened to recently caught my attention because it touched on things that Debbie and I have been talking about and working on for a number of years now and framed them in a slightly different way for me.
The subject of the podcast was the role of “administrative burden” in policy making and policy outcomes. The premise was that policymakers make decisions about desired outcomes and shape administrative requirements to drive those outcomes. They provided Social Security as an example of how government eased administrative burdens because they wanted people to access and use the benefits; examples of how governments create administrative burdens as a deterrence to accessing or using benefits were Medicaid and SNAP benefits, and requirements around voting.
We have also seen and been frustrated by processes that are unnecessarily complicated, that don’t take advantage of available technology, or that completely shift the burden to individuals who just have to keep trying until they get it right. This is particularly troublesome when you are talking about a frail older person who needs supports to stay at home and avoid going to a nursing facility. These are highly unlikely to be fraudulent applications. The cost of those delays is the increased likelihood of nursing facility placement and the administrative costs with processing an application three times for an individual who has been eligible all along but couldn’t get the paperwork right. That’s not efficient or humane.
As the podcast went on, I began to consider that it might not be quite so black and white. Some of these administrative burdens may be seen as defensible. The risk of fraud is one of the reasons cited for the heavy administrative burdens associated with Medicaid that falls squarely on the applicant. However, there is little discussion about how expensive these administrative systems are to maintain and whether that expense is justified by the extent of risk that a non-eligible person may receive benefits, particularly in this day and age, where a lot of this information is already available in an automated format.
While I have no doubt that there is some political context around some of these decisions, some of these practices are just rooted in the culture of government at all levels to minimize risk and ensure compliance. They tend to be self-sustaining once in place. Debbie and I can both think of multiple examples of individual employees who created administrative burden because they were concerned about the possibility of one bad actor slipping through the cracks, despite the fact that such instances are rare and the costs associated with the increased workload far exceeded the risk of the bad actor slipping through.
I have every confidence that most people who administer programs targeted toward persons who are elderly and/or who have disabilities actually want people to access and use those benefits. Institutional placement is far more costly in most cases and quality of life may be superior when people can remain in their homes and communities. But bureaucrats are frequently products of the environments they grow up in and don’t always recognize that systems and processes are burdensome
It’s true what they say: the first step to fixing a problem is recognizing that you have one. If people who are in the systems don’t understand the upstream and downstream impacts of what they are doing and the full measure of risks and costs, then they likely don’t recognize that there is a problem in need of fixing. They may even see adverse program outcomes and not recognize that they are contributing to that. For example – people going into nursing facilities because HCBS can’t be started quickly due to assorted administrative requirements. It’s always easy to blame the OTHER requirements.
We were both fast food managers once upon a time and understanding the customer experience was of paramount importance so we may have some heightened sensitivity. This was an area of focus for us while we were working in Indiana’s Division of Aging and they are continuing to work on related issues so we are hopeful that Indiana will work to streamline and simplify access to LTSS. Streamlining access to LTSS is one of the tenets of No Wrong Door systems so other states have been working on it as well.
Fresh eyes are one of the best ways to spot these kinds of issues. People who haven’t been around the system for a long time are among the quickest to see things. Soliciting input from those fresh eyes can open your eyes to how your systems are experienced by users, both providers and consumers. That input may come from new hires, consumer advocates, or consultants – including the squirrelly ones!
Administrative burdens aren’t limited to state and federal programs. Any organization can create administrative barriers or obstacles that impact people that work there or people that they serve. There are some ways that you can learn about those issues and address them. Invite those fresh eyes, be open to feedback from people who bring you concerns about complicated procedures and don’t let your processes get stale. Sometimes “we’ve always done it this way” is why things get more complicated than they need to be. Institute ongoing review and validation to ensure that your procedures are always accurate, consistent and efficient.
