Kent Bottles: How Hard Is It to Get Health Care Reform Passed in Congress

November 16, 2009 at 11:14 am 1 comment

My twitter buddy and former summer ICSI intern @agrey (Ashley Grey) invited me to be on a panel for an open forum titled “Health Care Reform 101.” The target audience for the event that was held in the Mayo Auditorium at the University of Minnesota was undergraduate and graduate students.  Ashley introduced the topic by stating that only one in four young people between the ages of 18 and 24 are engaged in this timely topic for all Americans.

The three speakers gave an informative overview of the issues, but I was more interested in the questions the students asked after the formal presentations.  One asked why the panel had largely ignored the single payer solution, and I don’t think he was satisfied with the answer that at this point in time a single payer bill could not get out of committee, let alone be passed by either the House or the Senate.

I was reminded of the Rahm Emmanuel quote I had seen last week in the papers:

“Let’s be honest,” Emanuel said in an interview with the New York Times on health care reform costs, “the goal isn’t to see whether I can pass this through the executive board of the Brookings Institution. I’m passing it through the United States Congress with people who represent constituents.”

William Galston, the institution’s senior fellow, sent a pretty harsh response: “It may surprise you to learn that many of us here at Brookings like politics as much as you do, and some of us even know something about it. But we don’t understand it exactly the way you do. Yes, politics is the art of the possible. But leadership is the art of expanding the possible. Leadership without politics is futile. But politics without leadership is blind.”

I wonder if the student in the auditorium would side with Emanuel or Galston if he read those two quotes.

Another student wondered why we could not just adjust the calculation of the RVU (relative value units) that currently favor specialists to instead reward primary care physicians.  I wonder what she thought of my answer that specialists who would lose in that scenario would certainly lobby against such a change and that maybe the solution was to deliver more primary care through nurse practitioners and physician assistants utilizing evidence-based medicine protocols. She did not look too satisfied with this response.

A female student challenged my citing of examples of physician overuse of tests and therapies in the Atul Gawande article in the June 1, 2009 New Yorker by asking about medical malpractice and the need to practice defensive medicine.  I tried to explain that studies of the effect of medical malpractice estimate at the upper limits that defensive medicine only accounts for about 3% of overall health care spending ($60 billion).  So, if the medical malpractice problem went away tomorrow, there would still be a health care cost problem to address. I did mention that psychologically medical malpractice is a huge issue for practicing physicians and that in parts of the country malpractice insurance rates were very high for neurosurgeons and obstetricians.  I don’t think she bought my answers.

I enjoyed the entire evening, but I believe there was a gap between the idealistic members of the audience who could not understand why we don’t just fix the health care mess and the panelists who tried to explain how hard and complicated the task is.

I did mention David Blumenthal and James A. Morone’s book The Heart of Power:  Health and Politics in the Oval Office, Berkeley: The University of California Press, 2009.  I wish I could have handed out Xeroxes of the Eight Rules for the Heart of Power:

1) Passion:  George H. W. Bush was not interested in health care or any domestic problems so not much progress was made on health care reform.  Presidents Nixon, Bush senior, Johnson, Clinton, and Truman all had personal reasons to passionately want to reform health care.

2) Speed:  Lee Hamilton, a congressional veteran, said, “Health care is so difficult because Congress is an incremental body and health care is a non-incremental issue.”  And even more famously, President Johnson kept saying, “Every day while I’m in office, I’m gonna lose votes. We gotta get this legislation fast.”

3) Bring a plan with you:  Because every president loses power every day he is in office, one must get a plan together during the transition before taking office.

4) Hush the economists:  Expanding health coverage requires presidents to overrule their economic advisors who always think that health care reform will cost too much. “Those fools had to go to projecting Medicare costs down the road five or six years,” growled President Johnson, who knew full well that accurate cost estimates…”might have sunk the entire reform.”

5) Go public:  Only presidents can rally the public to support health care reform, and if they refuse to do it like they did for PresidentTruman health care reform will fail.

6) Manage Congress: The authors write the “American political system is famous for its sheer, infernal complexity – it is quite possibly the world’s most unwieldy democratic apparatus.”

7) Forget the PSROs:  Presidents must manage the process of health care reform, but they have to leave the technical details to others.  President Carter worried about how to make PSROs work and got too deep into the weeds to be effective.

8) Learn how to lose:  The authors write that Presidents Truman and Clinton both lost on health care reform, but that Truman lost in a way that defined the terms of the debate for years to come.  Clinton, on the other hand, walked away from the wreckage arguing about tactics and not the big picture.

It was interesting and informative to interact with a group of people that I rarely get to talk to.  I worry that I mistakenly think that they are too naïve and impractical, and that they mistakenly think the expert panel was too arrogant and cynical.






Entry filed under: Health Care Redesign, Legislation. Tags: .

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1 Comment

  • 1. Gregg Masters  |  November 16, 2009 at 12:54 pm

    Wow, PSROs! Now there’s an acronym that hasn’t been in mainstream circulation for some time.

    For those of us who suffer from chronic battle fatigue syndrome (CBFS), it’s hard not to look at those who haven’t endured such a fate, as having a real world grasp on the nature of the conundrum and the forces which oppose its taming.

    Thanks for the event and fast forward context; I fear the admonition ‘learn to lose’, absent the historical take aways, is most likely in our future, again!

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