Transcript
Transcript: GC Data Conference 2024: Why Government Is Failing in the Digital Age and How We Can Do Better, with Jennifer Pahlka
[00:00:01 The CSPS logo appears onscreen.]
[00:00:04 The title "GC Data Conference 2024, Why government is failing in the digital age and how we can do better" appears on screen with the conference graphics.]
[00:00:12 The screen fades to Erika-Kirsten Easton and Phil Gratton.]
Erika-Kirsten Easton: It is with great pleasure that I welcome our keynote speaker for this closing plenary, Jennifer Pahlka, who is the former U.S. Deputy Chief Technology Officer and Founder of Code for America, alongside Taki Sarantakis, President of the Canada School of Public Service, for their fireside chat.
[00:00:33 Taki Sarantakis appears in a video chat panel.]
So, as you've heard, Jennifer is the former U.S. Deputy Chief Technology Officer for the United States of America and she is also the founder of Code for America. But quite honestly, that is not why she is here today. She is here today because of this.
[00:00:51 Taki Sarantakis holds up a book titled 'Recoding America: Why Government is Failing in the Digital Age and How We Can Do Better'.]
To me, this is the book on government and the digital age so far. And yesterday, we had Shoshana Zuboff, who, for me, again, has written the book kind of explaining the digital age. This is the digital age as it pertains to government. And so far, the digital age as it pertains to governments has not gone so great. So, we're going to talk with Jennifer about that over the next hour.
Jennifer, before we do, I want to kind of tell everybody, and most especially you, my experience with your book. So, I read your book on Kindle, and there's like a highlight feature on Kindle, and I was highlighting and highlighting and highlighting and highlighting. And after like the second chapter, I just kind of stopped highlighting because I was like highlighting the whole book, and the reason I was highlighting the whole book was, in the back of my head, I was thinking, wow, this person gets it, they get government, they get the problems. And then, the second thing I kept thinking was, wow, this person has lived it. You can feel kind of the pain coming out of the author. You can feel the exasperation but you can also kind of feel some hope too. You can also kind of feel like it doesn't have to be like this. So, is that kind of a typical reaction to your book?
[00:02:37 Jennifer Pahlka appears in a separate video chat panel.]
Jennifer Pahlka: Well, Taki, it's a delight to be here, and thank you for your kind words. Your reaction is maybe a little bit more extreme (laughs), but I have had a lot of folks… I think first thing I have heard most is I feel seen, and that makes me so happy because I think public servants have the hardest job in the world and they need to feel seen, and anything that I can do that helps them stay motivated in their job is just… that's what I love to do. So, I will say, someone else from the U.K. said the other day that it was a combination of the empathy and what he called 'cold fury', which I thought was a lovely term, and I think that part of what I was trying to do is speak to public servants and say, you're not alone in this, but also say, look, we need people who are not public servants to actually understand that this is a real thing. It is hard, and they need to be part of solving these problems. Like, we cannot solve them on our own. So, I hope it also speaks to folks who haven't lived it, but they get a little taste of it and then feel more bought in on being part of the solution.
Taki Sarantakis: I love that phrase, and with your permission, I'm going to steal it, 'cold fury', because the fury part we all kind of get, because it is very frustrating to work with antiquated tools and maybe, in some respects, with antiquated mindsets on some of the most important issues in today's society, but I like the 'cold' part because the 'cold' part implies some logic. It implies a little bit of distance. It implies that something good can happen out of that.
So, as I read your book, kind of the one message, if there was an overall arching theme or something that we can go back to over and over and over again, was kind of the relationship between policy and implementation, and I wonder if I could ask you the question in kind of two parts. The first part is kind of, what did you experience in your time in the U.S. government as the relationship between policy and implementation? And then, maybe kind of a part two, what should the relationship be, in your mind, between policy and implementation?
Jennifer Pahlka: Yeah, I'm glad that you read that in the book. I mean, I think a lot of people look at the cover, it's got a QR code and a flag, and they go, it's about government technology, and I do think it's fundamentally about what happens when we have a structure in which policy sits over here and implementation sits over here, and there's really enormous distance and sort of croft between the two, and since you were talking about sort of what the book made you feel and not just think, that was also my experience, is that when I was in government, I felt that but I didn't have the language for it. I had a particular experience when I was working in the White House, trying to set up the United States Digital Service, and I was sort of getting nowhere. I thought that everybody had agreed this was a good idea, but it was taking a very long time. And then, healthcare.gov, which is sort of our famous disaster, launched and had such a rocky start. We like to remind, it did work in the end but had such a rocky start.
And suddenly, I felt there would be all this political will to bring in digital talent into the White House. And yet, I still felt enormous resistance and I couldn't figure out why. And later, when I was researching the book, I read about a time in 1993, I believe, when two members of Congress had passed something or they were debating this, what became the Clinger Cohen Act. They were seeing, back then, that technology and digital was going to be a really, really big, important part of government, and they wanted the White House, the Office of Management and Budget in the White House, the single most powerful part of the executive branch of the government, to take on the strategy for digital, and this was one of the provisions in the bill that the OMB did not want. They said, no, thank you. And in fact, the words that the deputy used at the time were, this is operational in nature and inconsistent with the policy role of this institution. And when I read those words, I had my highlighter too. I said, that's it. That's what I was feeling.
That's why they didn't want this, or there was such resistance to it, is that it's operational, and policy is where the big brains are, and then details of implementation, someone else will take care of. We don't need to know about those. But when we don't know about those, we don't have a closed loop. We're never really understanding what parts of our policies are working and what they're not. And so, ultimately, yeah, I think simply, I'm saying, we need to not think of these as separate. They need to be in a cycle together, and I see that starting to be practiced. There was a paper that was released, I think, yesterday by Public Digital and Nesta in the U.K., the title of which is The Radical How. And by the way, the first time I heard about it was at the FWD50 conference in Ottawa, and they're really talking about teams practicing policymaking and delivery in the same breaths, and in a way that's just so different from anything I see in the U.S., but I feel like we can now drive towards that and hopefully start to share, with the people who need to sign off on these new ways of working, why this is so valuable and, of course, so needed.
Taki Sarantakis: Absolutely, and it seems to be a very… I'll call it a very public sector idea, this kind of separation between policy and operations. Like, I just can't imagine Jeff Bezos saying in 1996 or 1997, I have this great idea, let's sell books on the internet, how are we going to get the books to people's houses, that's operations, like I've had the big idea, I'm the big brain, I'm going to walk away. And similarly, I can't imagine Bill Gates going, let's write this software system, and it's like, okay, how are we going to get this on computers, that's for the little people. It's a very governmental thing that we kind of think the idea in and of itself, or sometimes even the press release in and of itself, makes it thus. Now, you talked a little bit about healthcare.gov. I didn't want to go there, but you did.
Jennifer Pahlka: (laughs) My bad.
Taki Sarantakis: Yeah, exactly. So, that was kind of the… I don't want to call it the a-ha moment, but that was like the "Houston, we have a problem" moment for the U.S. vis-a-vis digital, and maybe even more than digital, vis-a-vis kind of serving citizens. Now, there was a rumor that either nobody managed to use government.com that day, or six people managed to register out of the entire population of the United States of America. Do you know which one it was?
Jennifer Pahlka: My number that I always knew was eight, but I don't remember now why I knew that, but my boss, I think, was there the first day, but most of the folks that I knew who worked on it sort of were brought in on day two and three. But yeah, I think the official number is eight. Not a big difference.
Taki Sarantakis: Yeah, exactly. So, here we are, United States of America, most technological society on earth, maybe the most technological… well, no, the most technological society in the history of kind of humanity and civilization, very powerful government, a President that was elected in big part on this issue. And then, the President's big idea was turned over to the public service. And as you noted, maybe eight people logged on that day. What did that do to kind of like the American psyche within the public service or to the American psyche within Congress or the White House?
Jennifer Pahlka: I think that it spurred a recognition amongst some people. Like, I would say, having been there at the time, I could see the people who were learning what I considered to be the right lessons, and those who were taking totally different lessons from it. But somebody like Cecilia Muñoz, who was the head of the Domestic Policy Council in the White House at the time, she got the exact right lesson from it. So, her job is policy, and she immediately nailed it. She was like, there is no point in us working for years and years on the policy and the politics of something like health care if we're not going to pay equal attention to the implementation, and she further very instinctively got that it's not a linear process that ends with these guys, the implementation folks at the bottom, but that the policy people needed to be listening to implementers all the way along, that again, it's sort of a build, measure, learn cycle with your policy and implementers together, and she's part of the reason I think that USDS did get to exist, is because we had champions like her who were in that more established part of government, right? You listened to the Domestic Policy Advisor, and she said that was important.
But there were a lot of others who took the lesson of… I remember one woman telling me, no, they just didn't spend their money fast enough. And I said to her, it may be that they spent their money too fast, and she went, oh yeah. Like, just sometimes, we all needed like a little bit of reframing for folks to start seeing that something… the way that we've been talking about building technology and government is fundamentally flawed, but there's such a conventional wisdom, or I found there to be such a conventional wisdom, in Washington, D.C. generally, about what makes technology good or bad, and often just a sense that technology is just often going to be bad and that's not something… like, that's just something we should accept, and particularly, this belief that because government will never be good at this, the only thing we can do is rely more and more on our contractors. Now, I believe very much in contractors and we do have to work well with our contractors, but abdicating responsibility to our contractors seemed to me very much the wrong lessons to have learned, and I was saddened that some just felt like it was a contracting problem. It was more than that.
Taki Sarantakis: Yeah, and I'll come back to kind of the… I'm glad you raised vendors and contracting and I'll come back to that in a second. I want to talk a little bit before we move on though, kind of, because it seems to me that healthcare.gov was one moment. It seems to me that the second moment, and it was very prevalent in your book, was COVID, and it was kind of, depending on your perspective, whether it was 9/11 or COVID, these were… one of these two is like the emergency of our lifetime, the public sector emergency, and one of the things the political masters in your system and in my system wanted to do during COVID was they wanted to get money out the door quickly to people who were losing their jobs, as society was freezing up, as the economy was freezing up. It was really, really important to be able to do income replacement programs or unemployment insurance programs, and you have a history there that you told through the book. So, I wondered if you can share a little bit of that with our audience because it wasn't kind of a lack of good will that didn't get us there. It wasn't through a lack of really, really hard work. It wasn't kind of lazy officials or dumb officials. It seemed to be another constellation of things. Maybe talk to us a little bit about that.
Jennifer Pahlka: Yeah, well, first of all, just to tie back to your previous question, I think COVID was a moment for a lot of Americans to realize that if we can't deliver on our policies, really, what's the point? And I think it's created, actually, a fair bit of anxiety in folks, that things are as fragile as they seem, and that sense, like wait, this can't be how this works, is something that I did see. Like, I very much saw it on the healthcare.gov team. The folks that came in to help kind of kept looking around going, wait, this can't be how this works, like who's in charge? And that realization is sometimes a little unsettling, and I think that that is the thing that we need to do for citizens, as government, is make them feel like if we say we're going to give you money, we're going to give you money. It's like a basic trust issue.
Taki Sarantakis: I want to reinforce that in a different way. When democratically elected people tell their population that something legal is going to happen for them, and they turn to their officials, their administrators, and say, deliver this legal thing that I have told the population is coming, if the system, quote-unquote, can't do that, we're in a lot of trouble, whether you're the United States of America or Canada or Europe. That's a very, very big deal if our politicians, in good will, are saying, the state is going to do A, B, and C, and the administrative apparatus of the state says, we can't do it.
Jennifer Pahlka: There's another aspect to this. I know we'll get to sort of the meat of your question, but with healthcare.gov, I think everybody thought, it's tech, right? We just don't know how to build tech.
Hopefully, this is not as much of an issue in Canada as it is in the United States, and this, it's a very specific thing, which is health data is reported by local public health officials that exist primarily at the county level. I think there's something like 25,000 counties in the United States. Not states, counties, right? And they do not have a standard way of reporting things like, say, COVID cases. And so, there's this really incredible story of a group called COVID Tracking Project, that when the pandemic hit, there's these volunteers who decided that since there was no data coming out of the government about the spread of COVID, they would go source it, and they had like armies (inaudible) calling up local health officials and getting their data and assembling it, and I remember very clearly when Alexis Madrigal, who was one of the leaders of that, realized the first time that the Trump White House did actually report numbers, they simply reported COVID Tracking Project's numbers. And their whole thing was, we're doing this for a volunteer until the government takes over, because clearly, they had some apparatus for reporting this data.
Taki Sarantakis: Kind of the Wiki numbers became the official numbers.
Jennifer Pahlka: Basically, what they realized is that the federal government didn't have numbers. They were not calling all the local public health officials. And so, they finally decided to announce numbers after they realized, well, we can just say what this group of volunteers has sourced. And again, that's the, this can't be how this works, moment. But I think for the public, it was the first time they realized it's not just technology, it's governance, like it's governance structures. We don't even… I mean, even today, if we had another pandemic tomorrow, we have not solved the problem, which is more of a legal and jurisdictional problem, that we cannot tell our counties to report in a certain format. We cannot tell them to buy systems that integrate at the state level, and then at the state level, integrate at the federal level. They have the authority to make all of their own purchasing decisions, all of their own data strategy and data structure decisions, and these are the kinds of things that that make people… I think after the experience of healthcare.gov, I think a lot of citizens thought, we're just bad at tech. And then, they see COVID and they go, there must be bad tech systems. Sure, there are bad tech systems but that's not the problem. The problem is there's actually no infrastructure and no governance that supports national reporting of something like COVID data, and I do think people needed to understand that what looks like a tech problem, it often goes far, far deeper.
Taki Sarantakis: And that speaks perfectly to kind of the subtitle of your book, which is Why Government is Failing in the Digital Age, or part of the subtitle, because I want to kind of come to the last part of your subtitle at the end, but Why Government is Failing in the Digital Age. Well, the example that you cite is kind of perfectly normal in the sense of, when government was local, (inaudible), like our ancestors. Peter Diamandis from the Singularity Institute, he likes to say often, and I like to quote him often, that for our ancestors, life was local and linear, but life isn't like that anymore for us. Our life is not local, it's kind of global, and it's not linear, it's not one step at a time, it's (inaudible), it's exponential. It grows really, really quickly. A lot of people have kind of made that shift. A lot of institutions have made that shift, like the tech giants, we all know them, the Facebooks, the Amazons, the Googles. They've not only managed to realize that and do that, which is like life is no longer linear, but they've even done something more that governments haven't done, it seems to me, is that those entities have kind of done personalization at scale. When you log on to Amazon and I log on to Amazon, or The New York Times, we get different websites, like they're for us. They are. Even medicine now is kind of personalized at scale. Like, in the old days when you had cancer, your doctor would treat you as a demographic. Like, a man in his fifties with this kind of cancer will get this kind of treatment, but they don't do that anymore. They're like you, Bob Smith, your genome says you react well to this, you don't react well to that, I'm going to treat you in a highly personalized way. Government doesn't do that.
Jennifer Pahlka: Government has trouble doing that, absolutely. I think it gets back to what you were talking about earlier. You're naming a bunch of companies that were born in an era where we were already sort of passed the idea of a complicated society and into a complex society.
Taki Sarantakis: What's the difference?
Jennifer Pahlka: I think, essentially, somebody will have a better definition, and I think there's technically one, but when something is complex, it's no longer mechanistic. You can't say, because of X, then we will get Y. And if you think about it, that's a big problem because like all of legislation is built that way, right? There's a policy intervention. We do X, we think we're going to get Y because we think there's this sort of clear lever in the middle, but what we're not accounting for is that in the middle is a complex and adaptive ecosystem. And to sort of pull on your metaphor, it's more like a body that has its own sense of regulation, and every single one is different and the environment is going to react with it, than it is a machine that you put a lever and then something will come out the other end, and we're trying to get to a place where government understands and acts as if the systems that we're trying to influence and the systems that inside government themselves are inherently complex, and those companies didn't sit down and write a strategy and then execute on that strategy for ten years. I mean, I'm not a huge fan of Facebook but let's talk about Facebook for a second. It's just this guy tinkering and he didn't go… he evolved Facebook as a tool or a platform for people to use based on what he saw worked.
Taki Sarantakis: So, wait a second. He didn't write a 150-page strategic plan, in 2000, it'll look like this, 2004, then I'm going to do… he didn't do any of that, right?
Jennifer Pahlka: No, he didn't do any of that, and it's not that strategic plans can't be helpful, but a strategic plan that assumes that things will stay the same, that we know that Y will happen when we do X, are fundamentally flawed, but those companies, and again, I don't mean to lionize them, but they have in their DNA, we know what works because it worked, right?
Taki Sarantakis: Right.
Jennifer Pahlka: And I think that's part of the sense that in a complex society, you actually have to try things and observe what happens, and that's what you follow, which is why…
Taki Sarantakis: You follow the feedback loops.
Jennifer Pahlka: You have to follow the feedback instead of saying, we know this will happen, wait, that didn't happen, now we have to go write a whole other strategic plan. Your strategic plan should be, we follow what we see is actually working, and that's why you see the addition of, say, user researchers to teams, to see how people are actually, in the real world, interacting with government programs and interfaces to those programs, starts to put you in that territory where you're like, I get that the policy says X because we assumed this, but in reality, this is what happens when you're, say, two people on this benefit and one of them has this condition. Suddenly, all of that falls apart and we're not supporting this person in a way that the policy intended. We need to revise, we need to revise, and it's the constant revision and adaptation and personalization that is where we need to be, and it does not come from a mechanistic way of thinking.
Taki Sarantakis: Yeah, and to prove to you that we follow America constantly, I'm going to quote Dwight Eisenhower to you, but I'm not sure if I'm quoting President Eisenhower or General Eisenhower, but he said plans are useless, he said, but planning is extraordinarily useful. You can't do enough planning, but you can write all the plans you want, they're worthless. So, I think that really gets to your point.
Now, I want to come back. We talked a little bit about vendors. We talked a little bit about doing stuff in-house. I want to throw a word out to you which is, again, very heavy in your book, and I want you to tell me what it means to vendors, what it means to politicians, and what it means to administrators. That word is 'requirements'. Tell us about the word 'requirements'.
Jennifer Pahlka: I think requirements are sort of a religion.
Taki Sarantakis: (laughs) For who?
Jennifer Pahlka: Yeah, that's a good question. I think that there is a fundamental belief, that is not supported by evidence, that requirements are the thing that make a tech project or any kind of delivery project succeed or fail. And much like I said, I think some people watching healthcare.gov learned the right lessons and others learned the wrong lessons. You see that all over the place, that when, say, a big system development goes sideways, instead of saying, hey, maybe… and so did the last one and so did the last one, instead of saying, hey, maybe there's something wrong with the way they're doing this, the conclusion is, we weren't specific enough about the requirements. We had 1,000 requirements, let's do it again but this time have 6,000 requirements.
Taki Sarantakis: Not only the wrong lesson but, what one of my professors used to call, the exact wrong lesson. So, requirements for us are… us meaning officials, administrators, we want to specify, we want to write things down, we want to ruthlessly eliminate all volition, we want to ruthlessly eliminate all ambiguity.
Jennifer Pahlka: Judgement, right? We don't really want people exercising judgment in this because their judgment may be wrong. So, let's make sure all they have to do is exactly what the plan says, all you have to do is fulfill all these requirements.
Taki Sarantakis: Yeah, it's kind of analogous to, if you're going to go from the Canadian Embassy in Washington to the White House… and they're on the same street, I don't know if you know that. By the way, we're the only embassy on Pennsylvania Avenue.
Jennifer Pahlka: I did not know that.
Taki Sarantakis: It used to be a Ford dealership, but the United States (inaudible) and we built our embassy there, but it's kind of analogous to saying, the White House is at 1600 Pennsylvania Avenue, use a car, make it a hybrid car, get there, be there before four, and that's kind of what a normal human being would do. But in government, we kind of say, okay, turn left at the stop sign, do not go more than six kilometres or, sorry, six miles an hour for the first hundred feet, and then go 82 miles an hour for the rest, and you're like, but there's people in front of me, it's like, doesn't matter, the requirements say you're in miles 7 to 14, you're supposed to be going 120 miles an hour at this point, and it's a very strange thing. So, that's from our perspective. What are requirements from the perspective of, say, and I can't speak this because I'm not a politician, I work for politicians, but what do requirements mean from the perspective of… let's try and keep my job. What do requirements mean from the perspective of U.S. politicians, not Canadian politicians?
Jennifer Pahlka: I think that requirements are air cover for people, essentially.
Taki Sarantakis: I like that.
Jennifer Pahlka: I think they get used as… it really depends, right? Because I think you've got folks now who are saying there's got to be a different way. If all of these projects that have so many requirements are struggling, let's be open to some different ways of approaching the problem. And when I say air cover, I don't mean it's that the politicians are giving the air cover. What I mean is that if you're in charge of a project like that, you get to say, as you often do, but we met the requirements, and so I cannot be to blame for the fact that it doesn't work, right? There's a great book coming out that, Taki, you will love, which is called… and it's not coming out until April, called The Unaccountability Machine, and it's not sort of an outrage book about, society is unaccountable. It's a thoughtful book about how we create systems in which nobody is actually accountable for the bad outcome, and it gets deep into capitalism and all sorts of other topics, but I think every public servant will read it with a lot of sort of head nodding and maybe a little head shaking, but requirements are a big part of a way in which we can do all the work and all be sort of blameless, I think, in a sense, and yet not serve the public.
Taki Sarantakis: And I'll think back to requirements in a second, but another book that you recommended, I think it was on Twitter or LinkedIn or something, that I really, really enjoyed and I should plug here too, related, Hack Your Bureaucracy.
Jennifer Pahlka: Yes.
Taki Sarantakis: Just a wonderful, wonderful book for our viewers who are interested in these things.
Jennifer Pahlka: I should note that one of the authors of that book is also the key character in the first three chapters. So, the author of Hack Your Bureaucracy, Marina Nitze is the same Marina Nitze in the first three chapters that are set in the unemployment insurance crisis during the pandemic.
Taki Sarantakis: One last thing and then I'm going to get to the unemployment insurance and the pandemic. Requirements, what do requirements mean for vendors?
Jennifer Pahlka: I think it's the same thing. I think requirements are comfortable. They're a way that you know you're going to get paid (laughs), and I frankly think that a lot of vendors are…
Taki Sarantakis: Before that, they're the way you're going to get the contract.
Jennifer Pahlka: Yes.
Taki Sarantakis: Sorry, keep going. They're the way you're going to get paid.
Jennifer Pahlka: I think that there are a lot of vendors… so, when I'm out in the world with people who are sort of not in the government space, they want to prove to me that they know a little bit about my world, and they're like, yeah, those terrible vendors. They're starting to be this really negative public, and it's in the press all the time.
Taki Sarantakis: Not in Canada.
Jennifer Pahlka: (inaudible) government so much and they didn't deliver, it's the fault of the vendors, and my take is like, sure, but they're playing the game that we wrote, right? Like, we made the board game, they're moving their things along, and I'm not sure they're really to blame, and I think that, actually, there are a lot of vendors who now are frustrated with… obviously, when I say requirements, I mean an all-requirements approach, right? Requirements are the thing that we deliver on, we don't actually make an attempt to understand user needs, deliver on user needs, work with our intended users all along the way. It's a little bit of a stand-in for everything, but I think that there are a ton of vendors who are really frustrated with that, and I have to tell people, who just think that the vendors are 100% fighting any changes, that that's not always true.
Taki Sarantakis: Yeah, I think good vendors actually want to show what they can do and therefore kind of want less requirements. I think kind of paperwork vendors, they're the ones that want requirements lorded it on and on, and I think they want them for two reasons. I think, number one, it kind of eliminates some of the competition for the contracts, because people will go, I can't deliver an ounce of gold for $35, that's just not possible, number one. And then number two, another funny thing that happens with overstated or over-articulated requirements is, it's like, well, that's not what you contracted for, if you want to change, it's now going to cost you 22% more, 50% more, 100% more, 1,000% more. So, we kind of handcuff ourselves through requirements. Sometimes the public sector, we think we're being very, very clever, but I think we're actually being probably too clever (inaudible).
Now, I want to come to you. A lot of your book is about anecdotes. So, I want you to kind of pick one of the anecdotes you want. It could be the unemployment insurance anecdote, it could be any number of other anecdotes, but just kind of tell us one of your anecdotes, because I think a lot of people love learning through anecdotes.
Jennifer Pahlka: Let me pick the one that's close to the end of the book, and my book has been described as pretty dark in the beginning and hopeful at the end, and this is part of that hopeful arc and it ties to healthcare.gov which, as you said, I mentioned. So, now, it's part of this. So, after healthcare.gov, the agency that had delivered that particular implementation got given another law to implement. It was called the Medicare Access and CHIP Reauthorization Act, and we don't need to go into everything it did but Medicare is our program, our health care program, for the elderly and for the disabled. And so, this program was designed to pay doctors better for better quality care. But essentially, doctors were so frustrated with their interactions with Medicare already, and with the Centers for Medicare and Medicaid Services, CMS, that their attitude was, you've been driving us crazy, we're fed up to here, we have very low trust, the way you've asked us to submit our quality data is like throwing things into a black hole, I have no idea if I've done it right, I don't find out until a year later if I got it wrong, and my compensation depends on it, and now, you're telling me you're going to give us a new way that we have to submit this data based on these new program rules, you're going to make a new website, we're going to have to retrain our staff, we're going to have to invest in new electronic health care record software. And so, you had an enormous number of particularly like mom-and-pop doctors, small medical practices who couldn't afford to do any of that, saying, what I'm going to have to do is stop taking Medicare patients.
And especially in rural areas where they are the providers, you had a law that was designed to improve the quality of care that looked like what it was going to do was significantly degrade the quality of care in vast portions of our country, because there was going to be a mass exodus from the program. They're not required to take them. And so, you have a woman named Yadira Sánchez, who was part of the healthcare.gov rescue. She'd been at CMS for quite a while when healthcare.gov had its problems, and she was a key leader in the agency that got it up and running again. And during that time on healthcare.gov, she learned terms like agile development and DevOps and user-centered design. I would argue she'd already been doing them instinctively. She was just an incredible public servant, but she told me she'd never heard the word 'agile' until others came in from outside the agency to help on healthcare.gov. And when she learned that this is an actual framework that you can actually do, it wasn't just like her cheating, she adopted it and really wanted to show that this time, with the new law, CMS could get this right, and she leads a team through the implementation of MACRA and she's learned really all the right lessons, but they're not necessarily the same problem. Like, healthcare.gov, the problem was like the site needed to be up, the site was down. The problem here was it can't frustrate its users the way… it just has to be more usable. So, the first thing that that team has to do is just put up a basic thing explaining what the new roles are going to be. The first question you're supposed to ask doctors as they're enrolling in this new program is, are you a group or are you in private practice, essentially a sole practitioner?
And it turns out that there are nine different legal definitions of a medical group. So, from square one, they're going to have to essentially torture doctors who are already saying, I've had enough of this legalese, with pages and pages of obscure technical terms before they can even get to the second question. And I think, prior to this, she would have not been quite as bold in saying to the policy team, we cannot do this, this is going to make the program fail. And of course, you had the policy team saying, we have to, it's the law, if you read the law, these are all these different… and she kept saying, there's a lot in common in these definitions, you're talking about really tiny differences, let's make one definition of a group. Now, back and forth, back and forth, this is not a simple conversation, but ultimately, they fight this fight and they get to two definitions, not one, but two is a lot better and it just means that the first thing that doctors have to do isn't totally going to drive them crazy, and they continue to sort of fight on those fronts, and one of the other fights that Yadira champions is that doctors who take very few of Medicare patients are exempt by law. So, Congress, in its wisdom, realized that this would be a high burden for someone who only has a handful of Medicare patients, but the way the agency was interpreting this provision of the law was that they would make everybody go through the program the first year and then determine those who were under the threshold and then exempt them, which meant that a lot of sole practitioners with only a few patients were, of course, going to drop out of the program unnecessarily, and she fought to excuse doctors from the program based on the prior year data.
Yes, that is technically a little less accurate in the same way that it's technically a little less accurate to have two definitions of a group instead of nine, but what she's doing is weighing the costs and benefits. And when she wins on that front, those are the choices that she makes to make this program work, and there are 17 others, three or four of which I talk about in the book, but many, many more, but the end of the story is that when they launch this program, the operations team at CMS is sort of braced for the kind of slew of complaints, essentially, that they always get when they launch a new program. And instead, they are flooded with calls from doctors saying, I must be on the wrong website, this is too easy, and all of the analysts who had predicted a mass exodus from Medicare, looked back and said, actually, doctors didn't leave the program, they stayed with the program and they said things like, you're headed in the right direction, you are building trust with us, we're going to keep going with you, but it wasn't because she used DevOps to make sure the website was up. It's that she fought in every case to make it make sense to a person, and that became sort of a mantra for me. It's got to make sense to a person. We have to tame that instinct to be very, very specific and technical, not just on our requirements but in the policy and the legal discussions that we have, and say, I get that it's complicated, all government is complicated, but it has to make sense to a person. And when we do that, it works.
Taki Sarantakis: Absolutely, and it's a very portable and transferrable lesson because essentially, all it means is be empathetic to your user. Understand what your user is going through. In this case, users were medical practitioners, but government does nothing but help or interface with users, whether they're patients, whether they're people getting a passport, whether they're people getting a driver's license. We exist for users, so to speak, and we call them citizens but they're users of a service at a moment in time, and that that user ethos, if we can just get into that mindset, and it's not a technology, like you say, it's a mindset. How can we get into the user ethos?
Now, before you became rich and famous, I'm not sure if you're rich but you are famous, but before you became at least famous, we were introduced by somebody that we use at the Canada School of Law, Gary Bolles, and he asked me… when he found out that we were talking today, he asked me to ask you a question. So, I'm going to ask a question from Gary, and Gary's question to you…
Jennifer Pahlka: Hi Gary.
Taki Sarantakis: I'm not sure if he's watching, but maybe he will now. I'll send it to him after, but Gary's question to you was, talk to us a little bit about the code for America SWAT teams. Have they had an impact? Have you seen positive changes resulting from them?
Jennifer Pahlka: I'm not sure I know what he means by the SWAT teams, and I should caveat my answer with the fact that I have not been with Code for America for over three years now. So, I really can only speak to what I saw there. We did… our original model was that we would place three fellows, sometimes it was more, sometimes less, with usually a city government, but we ended up doing states and counties as well.
Taki Sarantakis: That's what he was talking about.
(Inaudible crosstalk)
Jennifer Pahlka: I mean, I think… with all respect and love for Gary, I think it's a bad term because it really sort of suggests violence and orders, whereas we'd spend a month with these fellows before we sent them off into the cities, and what we tried to teach them there fundamentally was change management, but really respect. Like, you're not going to succeed by going in and telling folks in government, you're just doing it all wrong. You're going to have to really understand why they do it that way, earn their trust, do things for them that might not seem reasonable for you, but if you can help them, they're going to… like, show that you care, and we'd spend a month with them on this training before we sent them off. So, they were kind of the opposite of SWAT teams in a certain sense. But to whether they were successful or not, I think the short answer, which I could dive into a little bit is, yes, and not necessarily in the ways that we thought. So, we did not have the most articulate, strategic plan either, but like when we sold it to funders and sold the whole program to cities, the idea was they're going to go in and they're going to write an app for you, and the app will solve a problem for you. And yes, they sort of did that, and some of the apps had been very successful. But really, what they did was help the public servants that they were partnered with see things in a different way. And often, the app worked and everything, and that was fine, but the value of the program was what those public servants did after, when they said, I don't need a four-year procurement plan to build this thing, I can do this a different way, I don't need to start with requirements, in some cases, I can approach public input in a different way, and I think that was most valuable.
If you think about the one app that we did that really has lasted far beyond the impact we thought it would have, it's something called GetCalFresh, which began as a new way to apply for California. It's called GetCalFresh. Nationally, it's SNAP, but it's the Supplemental Nutrition Assistance Program, and the funny thing is that didn't start through one of our initial fellowship teams. It was three fellows who had worked with the city and county of San Francisco. Well, one of them had worked with San Francisco, two others had been in that same year, assigned to other cities. When our fellowship program ended, these three men decided that they could not leave, that they had to keep going because there were so many… they'd seen so many issues in San Francisco. And without getting paid, because I was off in D.C., they tried, I think, 15 or 17 different prototypes on their own of projects that could help with the Supplemental Nutrition Assistance Program problems, and ended up creating something that, fast forward quite a ways, the entire state of California essentially adopted as the way people had to apply for SNAP because it just worked better. It came out of the environment that we created for creating solutions, and I think one of the things I am proudest of is when I came back from D.C. to Code for America and saw that this team was working, and said, okay, that's not what we're funded to do but that's what we must do, we must support these folks. I mean, all credit to them that they figured out that this was the thing, and built the relationships and built the initial prototype, but we pivoted because we could see that that was going to have impact, and we turned that into what Code for America became, which was less about one-year engagements and more about working across different jurisdictions on similar problems.
Taki Sarantakis: Now, I have a whole bunch of questions from the audience and they're all kind of variations of kind of what I wanted ask you anyways, which is, the subtitle, the last part of the subtitle of your book. So, let's just go there. How can we do better?
Jennifer Pahlka: I mean, I think that one thing we need to do is focus on our Yadiras. So, Yadira was the person I mentioned.
Taki Sarantakis: Sorry, yeah.
Jennifer Pahlka: She's the person I mentioned at Centers for Medicare and Medicaid Services. There's been a big focus and I think that I am most quite a bit to blame, quite a bit of focus on bringing people in from the outside. In fact, I think it's our public servants like Yadira, who've been in an agency for ten years, who are our secret power, and they just need to be unlocked. So, I think that's a key way that we do better, is that we really support and value our public servants. The metaphor that I've been using to folks, and this is just sort of a shift in thinking that has to happen in a lot of different places, is that the public thinks that the job of our elected leaders, maybe particularly in the legislature, is to plant seeds. They work on a bill. If it passes, then the seed gets planted in the ground, and they expect then that whatever grows from that seed will provide fruit or shade or flowers for the public, and they've done their job. But first of all, we've got to recognize that those seeds are not growing, and then we have to say, why not? And it's because the metaphor of a gardener is incomplete if you only talk about the seed planning. I used to garden a lot in California. Seed planting is like 1% of the jobs. The job is actually tending the soil. It's weeding, taking out what came before, and we didn't end up talking about the unemployment insurance example, but that was a great example of a program that hasn't been weeded. It started in 1935 with our Social Security Act.
We have only ever added mandates, constraints, rules, and policies. We've never subtracted, and that is the work that needs to be done. So, you need to weed. You need to make sure the soil has its sun and water. We're not doing that, and the way I think people should think about it is the seeds aren't growing because the soil is depleted, and I know this is a slightly unpalatable metaphor, but the soil is our civil servants. We are just asking more and more and more of them every day while also constraining them more and more. I'm speaking from a U.S. context, but they have more compliance, more risk aversion, working in a more risk averse environment, more to do, and we don't have enough of them. And so, I don't see why the work is figuring out which seed to put in the ground. I think the work is figuring out how to refresh and revive and take care of the civil service so that whatever policy you care about, we can actually implement, and I think just generally shifting thinking to that is how we're going to do better, and I think it's actually going to start with the public, and I mean the public as all of us. Like, we happen to be public servants, (inaudible), but we also are citizens. We're also members of our community who, when asked a campaign contribution or a vote by an elected leader, can say in whatever words make sense to you, I like hearing about your legislative agenda but I would really like to hear how you're tending the soil. Like, they'll start to be responsive to that as their job if they start hearing it from the communities they rely on to get elected.
Taki Sarantakis: I love that analogy because it's essentially the life of a public servant in the sense that there is a requirement, which was done in good faith and makes a lot of sense, and then seven years later, another requirement, done in good faith, makes a lot of sense, and then four more two years later, and each and every one of them in isolation makes a lot of sense. They're done with good will and you can't criticize it at all. In fact, you applaud it. But when you take them as an aggregate, when they're all just additions, they don't often work that well together, and in fact, sometimes they even contradict each other. And so, that's kind of what happens. I think, to go back to your metaphor and to use your metaphor, that's the weaving, that we don't kind of tend the gardening as well as we should.
Jennifer Pahlka, thank you so, so very much for writing this book. I think every public servant should read this book, quite honestly, because as I said at the beginning, it's one of the few books that I think really gets what it means to be in government. I could feel the empathy and the sympathy and the frustration as I was reading the book, and that's quite a feat because a lot of people have tried it. You're the first one that I know of that has kind of made it work. So, thank you for writing this book, and in the context of today, thank you so, so very much for spending the last hour with us.
Jennifer Pahlka: Thank you so much, Taki, and I will call out one other thing about the book, which is the dedication, and it comes very much from the heart. It's to public servants everywhere. Don't give up.
Taki Sarantakis: Thank you, a wonderful way to close. Thank you, Jennifer.
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