(originally written for The Huffington Post)
We can find out which medical treatments work best with “clinical effectiveness research” (CER). Newt and Hillary both love it – but some people are against it just because the President supports it. They say these measurements would be too “arbitrary.” Well, speaking of arbitrary measurements …
It’s Day 100. That’s early to draw any conclusions, but people will anyway (bringing to mind Henny Youngman’s opening line, delivered as he walked out on stage: “How do you like me so far?”) A fairer measurement might be: How have these 100 days measured up against expectations? Giving a single grade would be too arbitrary, so we’ll give several instead, like doctors do when they check your vital signs:
Building Public Support
So, has the President been effective at articulating the need for health care reform? Has he been building a broad base of support for the idea that we need to change the system? What, are you kidding? This is Obama we’re talking about. When we talk about communications we’re in his house – and it shows in the polling numbers.
You’d think that the economic crisis might lead people to conclude “we can’t afford health reform right now.” While that’s a familiar refrain in Congress, the public’s singing another tune. An April poll by the Kaiser Foundation shows that “59% of U.S. residents believe health care reform is now more important than ever,” while only 37% say that “reform would be too costly to attempt during the current economic climate.”
That’s a home run for the President.
How did he achieve these numbers? First, by adopting a position forcefully supported by Peter Orszag (according to Ryan Lizza’s New Yorker profile): that health reform, if done correctly, is deficit reduction. The New Yorker piece describes Orszag’s “obsession” with “the findings of a research team at Dartmouth showing that some regions of the country spend far more money on health care than others but that patients in those high-spending areas don’t have better outcomes than those in regions that spend less money.” That would be the Dartmouth Atlas of Health Care, designed by Dr. John Wennberg. It’s a critical tool for understanding how healthcare works in this country.
Orszag’s fascination with this kind of research has pushed ideas like CER and results-based doctor reimbursement to the forefront, and Obama’s been able to communicate the notion that reform can be cost-effective, despite scare-mongering on the topic from his opponents. That’s a big win.
It wasn’t supposed to be this way. By now Health Czar Tom Daschle was supposed to have used his DC experience, his insight into the healthcare system, and the power vested in him by the President to launch health reform in a broad and dramatic way. But the Daschle nomination was derailed and the HHS spot stayed open. Things should start to pick up with today’s news that Kathleen Sebelius’ nomination is moving forward.
Progress in filling top health positions has been slow, as the Washington Post points out. This was inevitable, given the delay in filling the top slot, and it should change now. And while there was some grumbling in the press about empty seats during a potential epidemic, there’s nothing to suggest that the interim players haven’t been covering things just fine.
Power is always decentralized in Washington, and even more so when the President is a consensus-builder by nature and by choice. In the absence of a ‘czar,’ influence has coalesced around players like Peter Orszag and Sen. Max Baucus. Orszag has been exploring some of the more interesting corners of health policy research, while Baucus has defined core principles for the Democratic leadership.
Then there’s Ezekiel Emanuel, the physician who’s also a martial arts black belt (thus capable of controlling both supply and demand for his services). Dr. Emanuel (yes, he’s Rahm’s brother) is on Orzsag’s staff. He’s a contrarian and innovator by nature. He’ll probably serve as an idea generator and internal gadfly.
The President also appointed David Blumenthal, M.D., as his Health IT Coordinator. Dr. Blumenthal’s a health policy expert, not a techie, so he’ll probably focus on building an information base for policy objectives. With them all, Obama seems to be building a healthcare team that’s strong on imagination and execution.
Grade: B (but expected to rise soon).
We’re not much closer to a health policy blueprint than we were on Inauguration Day. Is that a flaw? Not necessarily. Health analysts used to speak of the three qualities of medical care delivery as structure, process, and outcome. Most people focus on structure and outcome, but the President is very much a “process” leader.
We’re still in the “process” stage. It began when the President indicated that he’d like to have a consensus bill that includes significant Republican support. While he hasn’t withdrawn that statement, he has indicated that he’s willing to pass a health bill through the reconciliation process if necessary. That suggests he has basic policy goals he won’t compromise, and that he’ll override the GOP if necessary to enact them.
What are they? He’s not giving specifics yet. He’s sketched out broad objectives – rewarding cost-effective medicine, health IT, universal access, and choice – but that’s about it. He stood apart from candidates Clinton and Edwards last year in his opposition to health mandates, saying they hadn’t been proven necessary to achieve universal coverage. He’s not saying that now, and he may have signalled a walk back from that position when he indicated that key reform provisions will be designed in Congress. (Max Baucus supports mandates.)
He’s also staying flexible on the “public plan option,” which would allow people to buy into a Medicare-like program that would compete with private insurers. As we discussed earlier (in The Sentinel Effect and a radio interview with Bill Scher), these two issues are the defining areas in the struggle to define health reform – both practically and politically. A plan that requires people to buy coverage, but only from private insurers, would be a difficult sell.
Is he behind schedule on defining his health policy? That’s the wrong question. He’s on a different schedule, one that favors process over policy. He’s using the first half of 2009 (or so) to build consensus. If that means leaving critical questions unanswered for now, he’s prepared to do that.
Grade: If you want to grade him on outcome already, you don’t understand the President.
So where does this leave us? President Obama has not backed down from his commitment to health reform. That means something will be proposed this year, and something will be enacted into law. “Don’t talk too soon,” said Bob Dylan, “the wheel’s still in spin.” Turning this process into a meaningful outcome will probably be even harder than the President and his team expect. But it’s not impossible – and, as we keep getting reminded, it’s needed even more when times are hard.