Commentary from Dave Durenberger

NIHP.ORG LINKS UP WITH THE COMMENTARY
I hope you missed my Commentary the last few weeks; the election campaign got to me. The election results didn’t help much.  Like, “gone is the middle from American policy-making;” and “Obamacare is one of the worst pieces of legislation.”  But we were busy converting the website for the National Institute of Health Policy into a timelier and more user-friendly site.

I intend to post daily/weekly comments on current events as the spirit and events move me at www.nihp.org. Every couple of weeks you will receive a commentary with headline links to our web. My hope is to make this commentary more readable and the topics you care about more accessible.

In addition, I intend to post daily/weekly, as the spirit and events move me, comments on current events while they happen. I hope you enjoy this new format and take the time to join me, as the spirit moves you, in the work of defining a public policy and a policy-making process that is worthy of a great nation “conceived in liberty, and dedicated to the proposition that all people are created equal.”

VETERANS DAY
When war, as I knew it growing up, was an episodic event with a beginning and an end, there were good guys and bad guys and winners and losers. There was also an “all in” spirit driven by the draft or “selective service.” Wars occurred every other generation so we needed one day out of 365 days to celebrate ”veterans day” and to remind us of our mutual sacrifices, the values that drove them, and the need to re-commit to those values.

Today wars are 365 day a year with no end in sight events. They are defined by politicians, designed by the military-industrial complex, and fought by professional warriors – half government employees and half private contractors. But they are financed by American taxpayers whose annual financial contributions exceed the total contributions of the 95% of all other citizens of a world we are told we must make safe for our democracy.

That is a mystery still. And President Obama hasn’t made it any easier by his lukewarm commitment to our presence in Afghanistan and withdrawal deadlines. When he announces a deadline change from 2011 to 2014, he loses all credibility that he is invested in defining “winning.”  He now seems more eager than ever to be replaced in the commander-in-chief role.

ACCOUNTABLE HEALTH POLICY
I spent 24 hours in Washington D.C. starting the morning after the election. I visited health policy journalists, lobbyists, officials at HHS and the White House. Several things became very clear to me. (1)  Never has so much talent, substantive not political, been devoted to implementing new health policy legislation. Much more than the Republican MMA 2003 under Tommy Thompson and Mark McClellan and that effort held the previous record. (2)  Unlike the GOP’s MMA, which spent record amounts of money expanding Medicare coverage, much of it unpaid for, and was not an issue in the 2004 election, the ACA 2010 was  successfully used by Republicans  to target its Democratic supporters.

(3) Obama Administration officials charged with the implementation effort appear reluctant to engage publically on ACA specifics. That includes those responsible for keeping Don Berwick from a confirmation hearing before Senate Finance. (4) Insiders (including the White House) and journalists believe that only those who know the law best – the administration and most of the health care provider community – can make the ACA repeal an issue which will backfire on Republicans. (5) Never has any policy change this comprehensive passed into law.  Because all health care is local, the lynchpin for successful implementation will be a “race to the top” on improving population health, developing a quality strategy, and making value for money systems a reality.

My advice is to start as soon as possible in 2010 holding individual hearings on each of the ten titles of the ACA law.  Secretary Sebelius and CMS Administrator Dr. Donald Berwick should be lead-off witnesses followed by the leadership of the health care provider and consumer community.  Hearings should cover implementation status and funding requirements, authority needed to improve administration of the law (recall there was no Senate-House conference committee which usually does this), new policy authority that would improve the law, and the role of states and local communities in assuring the success of the law in reaching its goals.

CENTER FOR HEALTHCARE INNOVATION
Republican opponents of ACA have focused their attention on the law’s provision for an Independent Payment Commission which would recommend public payment policy changes which would become law unless vetoed by Congress. They haven’t considered the fact that the key to making ACA work is the ability of CMS and private employer and health plan payers to finance real innovation in population health, health care design, delivery and financing, health care quality, safety, efficiency and effectiveness. This is what physician-led health systems all over the country have done for decades, usually in co-operation with local employer coalitions and local health plans.

The ACA might more aptly recognize the nation’s “centers for healthcare innovation” as the key to the future. Not of a national health system like other countries, but of a nation of health care “systems” unique to the genius of an America. When he was Secretary of HHS, former Utah Governor Mike Leavitt criss-crossed the country looking for examples of community-based innovation. Mike had no trouble finding them.  In fact, he spoke about the possibility of as many as 100 distinct regions worth recognizing for their ability to innovate playing to the strength of local practice cultures and civic leadership involvement.

MINNESOTA LEADS THE NATION IN HEALTH CARE INNOVATION
Or so many people involved in health system and health policy change have long believed. As a member of the Senate, I was always told my Minnesota health reform ideas were great. For Minnesotans. But they wouldn’t translate nationally.  Minnesota has been a national leader in expanding coverage to nearly all residents (although there has been a lot of slippage the 8 years of the Pawlenty administration). We are leaders in care quality and safety initiatives and applying health plan and delivery system cooperation to bending the cost curve. In employer involvement in fostering employee choice, health management, and care coordination systems. In leadership in dealing with mental and behavioral health and long-term care. And in dealing with reducing the consequences of poor health on medical costs.

Listening to our Governor Tim Pawlenty run for president against this kind of health system and policy is appalling. As he said Sunday on national cable TV:  “I think Obamacare is one of the worst pieces of legislation passed in the modern history of the country….It is a top down, command and control, bureaucratically run entitlement program.” “I like people being in charge of their decisions.” This is outright bull. Unworthy of the governor of a state that has been working hard to create many of the care system and access innovations that the ACA will help to fund with federal dollars as an example to the rest of the country.  All on his watch. Much with prodding from the DFL legislature and from health provider groups in Minnesota who, by the way, endorsed “anyone but the Pawlenty heir” for governor last month.

OBAMA IS THE TARGET
This is not a post-election Wal-Mart ad.  It’s an assessment.  Starting with U.S. Senate leader Mitch McConnell (R-KY) who declared the number one goal of Republicans in Congress to be the defeat of President Obama by 2012, the nation is in for the policy divisions it seems to prefer.  And the world is left to wonder how the free world wins at least three wars started by a discredited (by two elections) predecessor plus end our national over-dependence on foreign crude oil while struggling to get Israelis and Palestinian leaders to leave their right wings behind long enough to make a deal.

If Obama is the target, then “Obamacare” or the Accountable Care Act of 2010 (ACA) is the bulls-eye.  Nothing the president and the Democrats accomplished in 2009-10 is easier to shoot at and score big points on than the ACA.  The election campaign proved that Americans remember the process by which the ACA became law, they understand little about its actual content or its policy potential.  Other than universal access if we can afford it, which a majority seem to believe we cannot. Really rough times lie ahead and neither the president nor his appointees have yet demonstrated the capacity for explaining what I know to be the vast potential for good in the ACA.

OBAMACARE AND THE 2010 ELECTION
The president and his party were ”shellacked” by the legislative environment, not the policy content, of health policy reform. The ACA reform law is mostly bi-partisan policy developed over the last 15-20 years. Much of what appears in the law appears in narrative form in a bi-partisan report from the Senate Finance Committee in December 2008.

The last time the Congress attempted such sweeping policy reform was in 1993. The presidential campaign of 1992 was fought over health reform and the winner, Governor Bill Clinton of Arkansas, believed he had a mandate to pass reform legislation, even though some leaders in his own party suggested the timing wasn’t great. Clinton wasn’t successful because he misjudged the economic environment, the conservative message of cutting spending and taxes in a down economy, and the willingness of moderate Republicans to help if Clinton would moderate the terms of his reform.

The 2008 election was not about health reform, even though costs had risen so much higher and faster than in the years preceding 1992. McCain, Clinton, and Obama all proposed some health reform and President Obama decided it was the time to do it. All of it. If not now, never. The near collapse of financial markets and the national economy and the emergency spending response of both President Bush and President Obama changed the public willingness to take on great big changes. The president didn’t sense it.  Republicans did. Unlike 1993-4, not a single Congressional Republican dared offer support for health policy change. A majority of conservative Democrats who did lost their re-elections.

SO IT IS NO SURPRISE THAT REPUBLICANS MUST DO WHAT THEY CAN TO DELIVER ON REPEAL PROMISES
. . . And President Obama must do what he did in 2009 when he took the fight to the Republicans in Congress – at the GOP House Retreat in Virginia; at a special address to the Congress and the nation right after the infamous town hall meetings of August; and at the day-long dialogue with more than 40 Republican and Democratic leaders of the Senate and House at Blair House in February, 2010.

In addition, he must find a way to capture the essence of what a uniquely American health care system could mean to every American.  And repeat it every day if possible.  His task could be eased considerably if he would get comfortable describing where you can go in this country and actually see that American future.  Like Hawaii, or northern California; Portland, OR; Grand Junction, CO; or Ogden, UT.  LaCrosse, Marshfield, and Appleton, WI.  Just for starters.

HOW MANY MILLIONS OF MINNESOTA TAX DOLLARS CAN BE SAVED BY IMPLEMENTING THE ACA?
That should be the first question MN legislators ask the MN Department of Revenue. For example, up to now it costs us one million dollars to get one million federal dollars into our Medicaid program. Under the ACA reform (“Obamacare,” let’s say) we can get $1.4 billion in new Medicaid dollars by spending only $430 million MN dollars. Now why wouldn’t that be a better deal?

Minnesota has been on a 20-year course to cover all Minnesotans by raising Minnesota income taxes and charging doctors and hospitals a 2% tax on every dollar of medical services they provide us. Which, of course, we also pay. When fully implemented, the ACA commits the feds to fund 90% of all dollars required to subsidize access up to 133% of poverty and, on a declining percentage of income scale, up to 400% of poverty.  Wouldn’t that be a better deal for MN taxpayers and medical patients?

SOCIAL DETERMINANTS OF HEALTH
Back when presidential candidate Tim Pawlenty was a fledgling governor, I talked him into appointing an 18-member commission to ask Minnesotans how to reduce health care costs. It became the best experience of my long life because we had no difficulty at all in finding the answers to “bending the cost curve” from ordinary Minnesotans. The first thing everyone agreed on was the best way to lower costs was to encourage everyone to stay as healthy as our marathoner governor. Next was advice that we focus on community services in the beginning and the end of life, and on reforming both the “This-is-not-a-bill” risk avoiding insurance system, and the health care delivery system it perpetuated.

What I like to demonstrate to my health policy students is how much the ACA titles conform to the 2003-04 recommendations of Minnesotans. Often overlooked in the political debate over “Obamacare” is the incentive to reduce health care costs by reducing the incidence of preventable poor health. Every county commissioner, school superintendant, and police chief in Minnesota knows that poor health and poor people are no coincidence. Cheap processed food is poor nutrition and food stamps as agriculture policy that allows purchasing of crap food. Dependence on public housing and church housing makes good education and relationships nearly impossible. The list is a very long one and everyone knows, just in Minnesota, nearly a million people are headed for serious health problems that can be avoided.

WHERE IS AMERICAN BUSINESS ON HEALTH POLICY REFORM?
It’s a mystery to me. I think they’re in China or India or Mexico. And their unions, if they still have them, are in the 1960s. No one has as much at stake in reducing health care costs as the employers of American workers and the employee unions. The way to reduce costs, as major employers and unions know, is to reward healthy productive workers, leverage change to high quality, high value production in the health care system, and use public resources to expand access to all Americans so the burden of meeting the high cost needs of low income, poor health Americans doesn’t always fall on insured workers. The ACA sets us on a course to do just that.

The U.S. Chamber of Commerce, the National Federation of Independent Business (NFIB), and the MN Forward (MN Chamber of Commerce and MN Business Partnership) have spent millions supporting nothing but “repeal” candidates. I don’t get it. I broke into this game years ago as part of an effort to create employer coalitions in communities across the country to leverage employee purchasing power to bring down the escalating costs of health care.

I can only surmise that employers buy the notion that high deductible health plans alone will make informed consumers of American workers, and change the medical industrial complex’ habit of selling us goods and services that we can’t afford and often don’t need.

Business is also counting on Republicans in Congress and in the MN Legislature to divert public resources away from access to care for the poor and disabled to funding Health Savings Accounts that provide much larger individual tax subsidies to support the choices made by the high bracket tax payer than the low to middle income folks.

WE KNOW WHERE PATIENTS ARE
Tim McGuire, 61, is the Frank Russell Chair for the business of journalism at Arizona State University’s Walter Cronkite School of Journalism.  From 1979 to 2002 he was employed at the Minneapolis Star and the Star Tribune retiring as editor and senior vice president.  Tim writes at http://cronkite.asu.edu/mcguireblog/?p=204.  I was moved by “My medical sojourn maddened me and strengthened me” which reflects on the period of his life between September 25 and its writing.

McGuire, whose young body required 13 surgeries before age 16, had surgery to fuse his left ankle on July 23 this year. On September 26th he was back in the hospital with an apparent impacted kidney stone which created a massive bladder infection, which traveled to his surgery site and undid the ankle surgery. “Four surgeries, nine days in the hospital, massive infections, even more massive anti-biotics, vague conversations about amputation and anemia can conspire to create an emotional maelstrom,” says McGuire, who was back teaching his class on journalism ethics October 19th.

“I could write a chapter or more on how the medical system works during a crisis like this. I was never satisfied with the level of coordination between the various doctors on my case. I got the terrible feeling I had to prove myself worthy of being dealt with straightforwardly. The cost of this ordeal was huge. Despite good insurance the out-of-pocket price tag would devastate normal families. Without insurance the catastrophe is too horrible to think about.”

“The real delight medically for me was meeting all the men and women who do the important nursing and technical jobs. Customer service and comfort seem high on their list.  I constantly felt that these people were my advocates and at a time of trauma that’s incredibly important.”

“The next time you hear a friend is in the hospital go see the person or at least call.  Illness is a profoundly lonely time. Visiting, calling, or even a note, are valued more than you know…all I could think about was the friend who was very sick this past spring. I never visited him. I felt bad about that every time a visitor came to see me….Support goes so far beyond visitors. I do not understand how anyone without a loving partner and spouse like my Jean could deal with something like this.”

DECISION POINTS: THE BOOK…FAIR GAME: THE REALITY
President George W. Bush has regained a lot of respect by the role he chose to play during the first two years of the Obama administration.  Reminds me of something his dad told me during the third year of the Clinton administration from his office in Houston, about the presidency, and about how we have but one at a time and, if lucky, a few good ex-presidents doing very well, thank you.  Crown Publishing this week released President Bush 43’s first book on his presidency.  Aptly entitled, for the man who claims to be “the decider,” Decision Points.

President Bush may have been the decider, but Vice President Dick Cheney influenced those decisions in ways that have had disastrous consequences. None more so than the manufacture of WMD in Iraq as an excuse to finish the job Cheney wanted Bush 41 to finish in 1991.  And the destruction of an excellent CIA officer named Valerie Plame because her former ambassador husband Joe Wilson called the president’s statements involving him fabrications. The story is told vividly, thanks in part to Minneapolis producer Bill Pohlad, in the new movie Fair Game which opened here last week. The movie reminds us that not only reputations but lives are sometimes lost. When the end justifies the means. And no one takes responsibility.

I’ve know Joe Wilson well since meeting him in Baghdad in 1989 when he was deputy to the U.S. Ambassador there.  Joe was also the last American out of Baghdad in January 1991, after taking my phone call and persuading me to vote to “kick Saddam Hussein the hell out of Kuwait.”  There was a full house at a 5 pm showing of Fair Game in one of the largest old theatres left in Minneapolis. At the end of the movie the audience clapped and cheered loudly at the Scooter Libby sentence and the changed lives.

NANCY PELOSI WANTS TO DEFEND HER RECORD
San Francisco won the World Series after re-electing the first woman speaker of the U.S. House of Representatives. Historic.  Nancy Pelosi won another re-election the day after the Giants whipped the Rangers. But she won’t get to be speaker thanks to “a shellacking” her party and her president took after two very successful elections.

Nancy Pelosi is a genius at the legislative process and she proved it in health reform. She is also, and always has been, the face of the liberal side of the Democratic Party nationally and that she can’t help.  She looks it and sounds it and does it (as in ACA). Although I once heard Howard Dean at a book party in San Francisco say to the 200 plus in attendance, “I know you are all to the left of Nancy Pelosi” – which I found astounding.

Republicans poll-tested the face of Nancy Pelosi and she appeared in every House race, and some Senate races, in America this fall. And, well, you know the result. To expect Democrats to fare any better in 2012 if she’s their House leaders isn’t great politics.

QUOTES
“Thank God that one week from today we can all go to the voting booth and put an end to these ads.” Cong. Michele Bachmann (R-MN) who spent more money on her race than any other member of Congress.

“My thing is, ‘Hey, just get it right. Just get it right.”  MN Viking coach Brad Childress 10-27-10

“Not only the message is important, but the messenger.” Peggy Noonan reporting on President Obama’s 11-3-10 press conference which caused her to refer to him as “human depression.”

“It’s not coming from the taxpayers, but from resources.” Alaska GOP Senate candidate Joe Miller about the $32,000 a year he receives for his family of eight children from taxes Alaska levies on Prudhoe Bay crude oil that is piped across Alaska and Canada to the lower 48 states.

“I will fight for Kentucky’s share of (earmarks and federal pork) as long as it is doled out transparently at the (Appropriations) committee level and not parachuted in the dead of the night.” Libertarian Republican Senator-elect Rand Paul M.D. (after criticizing earmarks in the campaign).

“You have to earn your way into politics. You should go have a life, build a string of accomplishments, then enter public service. And you need actual talent. You have to be able to bring people in and along…you have to be able to persuade.” Peggy Noonan, former Reagan speechwriter in WSJ 11-06-10

“There’s a lot of potential for not just mischief, but serious undermining of the intent and hope for improving our health care system…Republicans could make a mess out of what will already be a very difficult implementation process.” Robert Reischauer, President, Urban Institute and former director of the Congressional Budget Office.