Commentary from Dave Durenberger

September 11, 2007

There are more "frequent flyer elites" riding in Northwest Airlines' coach section between MSP and Washington, D.C. than any other destination. So I felt lucky that at 7:15 am on a beautiful September morning I was riding "up in first" while the Mayor of St. Paul rode coach. We ended that day riding with two Twin Cities' businessmen in a brand new van from Detroit to our homes in St. Paul.

Today Mayor Norm Coleman is running for re-election to the United States Senate, taking frequent trips to an Iraq I visited once in 1989, and spending 9-11-07 in Washington, D.C. listening to General David Petraeus and Ambassador Ryan Crocker predict the future. What has happened in the intervening six years I could not have imagined when we stood in the Detroit Airport World Club mesmerized by television coverage of the World Trade Center and the Pentagon in flames. Or while riding home to Minnesota with Mayor Coleman making arrangements to secure city hall and working with Governor Jesse Ventura to organize a prayer service in St. Paul the next Sunday.

I recall seeing only one clue to the future on that trip back. Starting with our first gas refill before crossing from Michigan into Illinois and ending just outside St. Paul at 11 pm, we watched the price of gasoline slowly climb from its average that day of about $1.25 gallon to somewhere around $1.60. I remember how proud I was of how people everywhere cried and prayed and promised and committed to help relieve the suffering and put a stop to the terrorism that caused it. Yes, there was some laughing and street dancing. But, on reflection, it was largely those who today are claiming to be Al Qaeda or Hamas of this-that-or the other country.

I was so proud of my new President. Of the way he captured exactly how every one of us felt and every nation's leader claimed to feel, about the threat to everyone in the world from the phenomenon that had finally hit at some of the biggest targets in America, making the most powerful country in the world as targetable as a Munich beer hall, a London subway, or a Kenyan embassy.

With three terms of experience in the Senate and eight on the Senate's Select Committee on Intelligence, I also felt a sense of relief. It was now possible to rally the American people and world leaders behind a concerted collaborative effort to root out terrorism by individuals and anarchic groups as a means of imposing their will on others. Whether you call it a war or not, the battle against national and international terrorism began 9-12-01 and the U.S. was elected to lead it.

What we know now from journalists who have covered the history of the last six years, is that we accepted the responsibility and then changed the definition of terror. We went after the Al Qaeda we knew in Afghanistan and their Taliban protectors. Then we created an Al Qaeda out of a dictator in Iraq by exaggerating or lying about his international threat. We nailed the dictator good. The war on terrorism, though, turned into something totally unexpected. The President's party lost the Congress over it and is begging the new Congress and the American people for five more years to figure out how to extract 160,000 young American men and women from a country most of them couldn't find on a map when they were in grade school.

Today I will pray. For President Bush, Vice President Cheney, and the Congress. For world leaders I know by name. For the young men and women who serve our country in the military, national and homeland security agencies, police and other state and local security personnel. They all volunteered for these jobs while others their age and circumstance chose other, presumably safer, careers. I once heard Senator Ted Kennedy say to a small group of us,"not everyone who dies for their country is wearing a uniform." He knows that from personal experience. So do the families on the four 9-11-01 airplanes and the people in the tall and pentagonal buildings. God knows America has always been like that and always will be, because he knows the real difficulties each and their families face better than I. He knows the price leaders pay and the price paid for failed leadership. So, from my heart, "God Bless America."

WHO'S NO. 1
For the last six years, Modern Healthcare has conducted a readers' poll of health care's "most powerful person." They rank the top 100 and this year the winner was Sister Carol Keehan, President of the Catholic Healthcare Association since October 2005, and a Board of Trustees member here at the University of St. Thomas. The idea of "most powerful" is a bit of a misnomer. That title should reflect ability to influence change for the better, whether it's being used or not. The President, or his HHS Secretary, or an appointee like Surgeon General C. Everett "Chick" Koop comes to mind.

I like the word "influential." There are many people I've known over three decades in this business, some in positions of leadership, whose influence on the attitudes and the behavior of others is lasting. Influence is demonstrated by changes in how people with some power use it. Now. That's why leaders like Senators Kennedy and Clinton, Governors Romney and Huckabee, are influential. They usually walk their talk and people listen. Bill Novelli at AARP is always influential on Medicare policy because of the dependence of so many older Americans on AARP's commitment to their economic interests. Healthcare association heads usually make this list, but not always because you can point to a clearly articulated set of values, walked and talked, and results that go with it.

© 2007 Schillerstrom, Modern Healthcare

That's why Carol Keehan is my definition of the most influential person in healthcare and health policy in this country. I doubt she's ever won a popularity contest. But no one who has ever worked with Carol Keehan has come away with anything but the greatest admiration for her. She is someone you want to be with and to work with. You know together you're going somewhere. A dozen years ago an EVP at HCA told me that "the most powerful competitor to HCA in the hospital field are the Catholics, if they can ever get their acts together." A lot of merging helped. But not until Carol Keehan took over the CHA reins, and especially since she laid the ethics of mission-driven hospital care on the not-for-profit "community benefit" table, have Catholic hospitals begun to be appreciated - and emulated.

Her position on tax-exempt community benefits and transparency is simple. Hospitals need to earn the right to the exemption. By being held accountable to the communities they serve to meet the health care needs that for-profits cannot because of their fiduciary responsibility to shareholders. That's one reason why CHA disagrees with AHA's position that hospitals can use the difference between what Medicare pays and what the hospital "charges" as a "community benefit." Were that the definition of "benefit" to community, then most for-profit hospitals could claim the tax exemption as well.

DR. MARK MCCLELLAN is a "hot" name in health policy today. An MD/MBA who has Harvard, Stanford, and a mother who ran as an independent for Governor of Texas in his background, Mark worked in the Clinton Treasury Department and in the Bush FDA and CMS. Today he heads up a center for non-partisan health reform at The Brookings Institution which is funded by philanthropy from WellPoint's Leonard Schaeffer (after whom it's named) to RWJ. He aims to be a non-partisan problem definer/solver for policy-makers who are challenged by the bad "politics" of change. The FDA is already on his list and others will follow, including facets of Medicare.

DIAGNOSING THE MEDICAL ARMS RACE SYNDROME
The NIHP will host Columbia University professor and former Aetna, Inc. CEO and Mount Sinai NYU Health CEO Dr. Jack Rowe at the Minneapolis campus of the University of St. Thomas on September 20 at noon. Rowe will speak to the role of healthcare financing in improving the value of medical technology from the standpoint of both private insurance plans and public insurance like Medicare and Medicaid.

Rowe's former colleagues on the Medicare Payment Advisory Commission have recently begun an analysis of physician and hospital relationships with an eye toward Medicare payment changes that would foster improved beneficiary and trust fund value from both collaboration (as in things like gain-sharing) and competition (as in physician-owned imaging and surgical facilities).

MedPAC analyst Jeff Stensland will appear along with former CMS administrator Dr. Mark McClellan, CMS' Dr. Barry Straub, and representatives of medical device, hospital and specialty hospitals at a joint NIHP/Medical Technology Leadership Forum October 14-15 on the campus of the University of Minnesota in Minneapolis.

For more on MARS, or to register for either event, see the NIHP website.

OVERTREATED
Sharon Brownlee writes stories and essays about medicine, health and biotechnology for Atlantic Monthly, New York Times Magazine, New Republic, and Time. A senior fellow now at the New America Foundation, she has written an excellent critique of American medicine subtitled: WHY TOO MUCH MEDICINE IS MAKING US SICKER AND POORER. It is well-described as the "American Health Care System's Addiction to Over-treatment." That is you and me and they.

If you laughed at Michael Moore's portrayal of your own experiences with the health insurance industry in Sicko, reading Overtreated may get you asking questions of the delivery system as well. After reviewing it, I came to think of this 300 page book as a multi-volume set of references. There's "The Most Dangerous Place" (hospitals); "The Desperate Cure" (our cancer cure and lower back crazes); "The Limits of Seeing" (the Imaging Industry); and one of my own favorites, "The Persuaders". A story I haven't read elsewhere of how marketing genius has created hundreds of new diseases, and disease organizations, to persuade us we need to buy $200 billion a year in new drugs. This chapter is followed by one called "Money, Drugs, and Lies."

Those of us who have long admired Jack Wennberg and his colleagues at Dartmouth will quickly realize that this is the book Jack and Elliott and Jonathan and David and Jim and others couldn't write because they are the researchers on whom Brownlee draws for her "too much medicine is harmful to your health."

IS UNIVERSAL COVERAGE THE ANSWER TO HEALTH CARE COSTS?
The American Cancer Society may be the first of the big disease organizations to commit its entire 2008 marketing/advertising budget ($18 million) to the campaign to enact universal insurance coverage nationally. No surprise here. Cancer and other disease groups have joined with other beneficiaries of disease research funding in getting Congress to double the NIH research budget every two years for the last couple decades.

Perhaps ACS can be successful in joining oncologists, Cancer Centers, and every other health care provider and insurance plan in getting public subsidies for health insurance doubled every five years or so. That would help keep pace with the rising incomes of everyone engaged in the medicalization of disease.

In the alternative, they could join embryonic public efforts to finance research for the evaluative sciences we need to inform cancer patients and lots of others about the comparative effectiveness, and the cost effectiveness, of the choices with which physicians and surgeons present them.

SCHIP - TOO EXPENSIVE OR TOO EXPANSIVE?
We all know that the State Children's Health Insurance Program (SCHIP) must be reauthorized by September 30th or states will not receive federal SCHIP money and 6 million children currently covered by SCHIP may be at risk of becoming uninsured.

The SCHIP program is expensive - about $5 billion annually and would need almost $3 billion more per year just to maintain current enrollment levels. But unlike other public health care programs, the expense of the program doesn't appear to be the key sticking point for SCHIP reauthorization. The House has passed a bill that would increase SCHIP spending by $47 billion above current baseline over the next 5 years and the bill passed by the Senate increases new spending by $35 billion over the same period.

©2007 The Washington Post Writer's Group

While there seems to be bipartisan support for some expansion of SCHIP, there is still some consternation about the appropriate level for this expanded funding. Immediately after Labor Day, as Senate Majority Leader Harry Reid (D-Nev.) was trying to appoint Senate conferees for the SCHIP conference committee, Minority Leader Mitch McConnell (R-Ky.) objected (and blocked the process and the appointment of committee members) because he had not received assurances that the Senate would stick with the lower spending levels in its bill and not try to pass the more expensive House version of the bill.

The White House has made it clear that President Bush is likely to veto either version of the SCHIP bill and not simply because of the expense or likely funding mechanism (an increased tobacco tax). The White House seems to be preoccupied with the expansion of SCHIP as a government program and the extent to which government coverage might replace or "crowd out" private insurance. In fact, the Administration is so concerned with the issue of crowd out that, at the end of August, CMS issued a letter to state Medicaid officials requiring several strategies be implemented in state SCHIP programs to prevent crowd out. State Medicaid directors have since responded to CMS and asked that these restrictions be lifted.

The controversy about crowd out is real, although most economists agree that at lower incomes, families and children don't have significant access to private coverage and that SCHIP or Medicaid is likely the only option for these families. The controversy remains, however, for the very population of children in lower income working families targeted by the SCHIP program. Last week CMS denied New York's request to expand its SCHIP program, thus taking on Ways and Means Chairman Charlie Rangel. They're also taking on a NY Medicaid program with well publicized fraud and abuse.

A detailed analysis of the SCHIP program and the current House and Senate Bills can be found at the Kaiser Family Foundation Website.

COMMENTS ON OBESITY
The Trust for America's Health's report on obesity put Minnesota above average for the problem and below for good health (made me wonder how we keep getting ranked no. 1 healthy state with 23.7% of Minnesotans considered obese). For kids, we are among the states with the lowest rates of childhood obesity, with 10.1% of Minnesota children considered overweight.

One of my first impressions of northern California from our second home in Marin County, was how fit everyone appeared to be. Earlier this summer we took in an Oakland A's game and I swore I was back home in Minnesota. Guess it depends on where you look. Last week we took two grandsons to five hours at the Great Minnesota State Fair. By the end Susan and I came independently to the same conclusion: About 50% of Minnesota - not 23.7% - is obese or kids that are headed there given a look at their parents and their eating habits!

The Economist reports that America's elementary and secondary schools may have to take some responsibility for the failing health of young people. In an August 23 article headlined "Fat and getting fatter," the Economist reports the U.S. has no national guidelines for food sold outside school lunch and no physical education requirements. The GAO reported that 99% of U.S. schools sell snacks and other foods as well as providing lunch. The CDC reports the number of kids taking part in daily exercise in high school has dropped from 42% in 1991 to 28% in 2004. The National Institute on Aging warns this may be the first generation ever to have a shorter lifespan than their parents.

© 2007 Dayton Daily News

HHS AND IMPORT SAFETY
Sense a rising concern about the prevalence of "Made in China" products in our consumer markets? Do you not laugh at the "Leaded or unleaded?" cartoon? With $2.2 trillion in imports last year, HHS Secretary Michael Leavitt last week assured Americans that "We will not be able to inspect our way to food and product safety." He chairs an Interagency Working Group which started in July to develop a strategy other than inspection. The announcement by Mattel, followed by a few other toy manufacturers, reminded me that perhaps that obligation belongs with the American companies whose failure to adequately inspect work place, production and transport facilities abroad or product content before shelved in American stores subjects us and our children to risks that our law prohibits. Chinese trade official suicides are nowhere near as effective as a penalty banning Mattel - or anyone else - from US sales for a period of time.

SEX AND THE CITY
The District of Columbia has given out 650,000 free condoms since February. Its campaign to slow the rate of HIV-AIDS in the city with a million free condoms a year is apparently slowed down by resident objections to "shoddy packaging" of the condoms which are made in India, China, and Japan.

UNITED NO MORE
Two of the top three officials at United Health Group have left or are leaving the company. Richard Anderson, who came to UHG three years ago from his post at pre-bankrupt Northwest Airlines, is off to Atlanta as CEO of Delta. Anderson gets high marks for his leadership in the technology side of United, including its worldwide businesses, but obviously couldn't resist the chance to return to a first love; and perhaps to a Northwest-Delta merger one of these days.

Lois Quam built the government side of United's business into one of the most reliable and innovative of managed care companies in the Medicare, Medicaid and long-term care business in the country. Quam is also responsible for the special deal United has developed with AARP giving them a big advantage in the Medicare drug market. Quam will move to a top deck office at Piper Jaffray as Senior VP in charge of health and energy investments. She is also in charge of Hillary Clinton's health care policy run and is guaranteed a top spot in a Clinton cabinet.

WAR IN IRAQ
Like many Americans I have decided that little I say or do will make any difference. I am not one of the 160,000 U.S. military service personnel mandated to serve in Iraq and to believe that their lives and sacrifice make a difference. I am also not one of the 100,000 mercenaries working in Iraq hired at an average annual income of $300,000 (compared to the average service persons' $44,000). Nor am I an Iraqi still living in Iraq because I can't get out. I can afford to wait out the Bush presidency and hope for the better. It is quite clear to me that nothing I say will make a difference.

©2007 Tribune Media Services, Inc.

I can tell when I talk to a Senator just back from a visit to the "surge protectors" in Anbar province. So why bother. This week Petraeus and Crocker and Bush and Gates and Rice will do their thing in Washington, DC. My elected representatives of both parties are powerless to do anything but talk. The good guys I know like John Warner and Chuck Hagel are bailing. I'm getting used to it. Maybe too used to it. I hope not. The only date that counts for average Americans today is November 4, 2008. Unfortunately the only American who doesn't care about that date is President Bush whose plan is simple: "Go replenish the old coffers."

NEWT GINGRICH is reportedly testing Fred Thompson's water to see whether Republicans have a greater Presidential appetite than can be satisfied by John McCain, Rudy Giuliani, and the Ronald Reagan/James Dobson impersonators. In the meantime, he continues his own "heath care transformation" motivational speakers' circuit. Audiences respond gratefully to someone who can give them an anecdotal vision of what their instincts tell them should be an American health system. "Non-partisan," however, is not part of his definition.

MINNESOTA SENATE POLITICS
At the Great Minnesota State Fair, former comedian Al Franken had the longest lines (many of them autograph seekers) and his DFL opponent, anti-tobacco lawyer Mike Ciresi, the most promises. Incumbent Republican Norm Coleman started the fair by suggesting his colleague Larry Craig quit the Senate and followed that with a trip to Iraq, which preceded President Bush by a couple days, but resulted in the same policy strategy.

Minnesota's premiere news analyst, Lori Sturdevant of the Minneapolis Star Tribune, spent last Thursday with Coleman (and 128,000 people) at the State Fair. She couldn't find anyone taking the Senator on on the issue. What did they care about? Bread, butter, and the cost of government. Biggest issues involved transportation issues, especially highway bridges and the taxes (or no new taxes) to resolve them; followed by droughts (and then floods) and what Norm was doing about each.

I rode NWA back from a MedPAC meeting in Washington last Friday with Senator Coleman and challenger Ciresi. We spent most of our two hour 20 minute trip in books: the Senator in Richard North Patterson's latest thriller Exit; challenger Ciresi in Emory University professor Drew Westin's Political Brain; and me in Blessed Unrest by Paul Hawken. Our pilot said he remembered flying me to Crookston, MN 30 years ago. Reminding me that what I love most about having served in public office is that people want to remember what you have in common.

DEAR LARRY
I want you to know that I'll remember you for the classy way you dealt with our differences in the six years we served together, and for the special affection you showed for your wife Suzanne. In time, I will also remember you for your willingness to deal with the reality of your execution by your best friends in the U.S. Senate and House. I say "in time" because I know the shock takes time to wear off. You reach for the little "hope" there is in the best of them -Republican Senator Arlen Specter - telling the world they haven't a legal leg to stand on. But your closest friends tell you that when the Republican leader says whatever you did is "unforgivable," your seat's been pulled out from under you and no lawyer or PR flack can get it back.

© 2007 Star Tribune

Misdemeanor disorderly conduct should be no grounds for expulsion from the U.S. Senate, especially when it occurred in an airport 961 miles from the capitol and unrelated to Senate duties. But for a 21st century Republican officeholder to be publicly charged with soliciting same-sex relations anywhere is a crime against a political party which insists on making itself increasingly irrelevant. The Senate's ethical standard is conduct which brings discredit upon the institution. What we know of Larry Craig's conduct in the Minneapolis-St. Paul Airport is that it mainly brings discredit on a party which cannot seem to discipline its members' voracious appetite for campaign financing, appropriations from the public purse, and single issue politics. The claim of institutional discredit wrings hollow when only Republican Presidential candidates, the Republican leader who ran Bob Packwood out of the Senate, the Republican Campaign Committee chair, and the Republican ethics co-chair demanded Craig's immediate resignation.

THE WASHINGTON POST finds it ironic that last November when Alaska Republican Senator Ted Stevens, a former member of the Capital Yacht Club in Washington D.C., wanted to rejoin the exclusive club so he could more easily enjoy his 38-foot Chris Craft motor boat, his application for membership was sponsored by Senator Larry Craig and a former Craig assistant and energy lobbyist. Apparently Craig owns a 42-foot Bertram yacht and docks it at the club. Larry was also the first Senate member to blast the FBI for "Gestapo tactics" when it raided Ted Stevens home in July. Stevens, who chaired the Senate Ethics Committee for several years when I served on it in the 1980s, says he won't comment on Craig's dilemma after talking to his lawyers "and they advise that I make no comments about any investigations right now."

DON'T GET CAUGHT
While the political world focused this past week on Senator Larry Craig, Atlanta Falcon quarterback Michael Vick's mother worried her son was being mistreated. Lou Gelfand, who does ethics for the Minneapolis Star Tribune, tells us she is quoted on AOL Sports as saying: "I gotta be strong for him. They are trying to put my baby in jail, and for what? Everybody makes mistakes. Everybody deserves a second chance. He has given his life over to God." And reacting to both Michael and brother Marcus' behavior: "Everybody does it in the NFL and college football. He just got caught doing it."

ELECTION 2008
There are nearly twice as many current Republican Senate seats up for grabs in the 2008 election as there are Democratic seats. It is a Presidential election year which usually favors Republicans, but, after 2006 and eight years of Bush politics, few in D.C. will bet against the Democrats taking a filibuster-proof 60 seats in the U.S. Senate 14 months from now. Sad, but true.

©2007 Times Picayune

SENATOR CHUCK HAGEL of Nebraska made it official today. He'll not run for certain re-election in Nebraska. Thus leaving the seat to former Democratic Senator Bob Kerry who currently is President of the New School in Greenwhich Village in New York City. (One of whose trustees is fund-raising fugitive Norman Hsu). Both are decorated veterans of Viet Nam with serious independent streaks born of both Nebraska and Viet Nam experiences. Each is wise beyond his job description. Both are respected by members of both parties, making them loved by journalists and constituents, but not admired within their own caucuses. If there is such a thing as a "New Democrat" both might fit that description since politics today makes it easier for a Democrat to move off "the base" than for a Republican.

KARL ROVE
What difference has he made? Kind of a James Carville without a snarl, Rove is credited with "making" George W. Bush, the Texas Governor and the President. Where he failed is in making the country into his kind of Republicans. The party is weaker today in most states than when Bush won the Presidency in 2000. The Republican Congress has little to show for its six years of legislative efforts with a Republican President. Its public respect has declined, some of its highest potential candidates have lost elections they could have won, and "conservatives" fight each other to define the meaning of the term. Karl Rove belongs on Fox News panels with the 1990s Bill Kristol and Fred Barnes, who continually prove that the brightest Republican pundits are much better as the loyal opposition than as the party in power.

THE PRINCE OF DARKNESS
Washington, D.C. pundit Robert Novak loves that title. But in his new book by that name, he comes out into the light in a way that DC "insiders" rarely do. Never a great fan of Novak's, I enjoyed the 638 page visit to his 50 years inside Washington politics and the politicians and the peddlers who make it newsworthy. The best the book has to offer is candor. Not a Washington staple. Novak takes us through "eras" like Clean Gene, Bobby and LBJ; Amnesty Abortion and Acid; Reagan's Rebellion; Will Success Spoil Newt Gingrich; the Rise of George W. Bush and, of course, the role he played in each. Novak depends heavily on "being used" by information peddlers, but he readily acknowledges his occasional bad judgment. He talks openly about his drinking and related bad habits, about his many hospitalizations, and his conversion to Catholicism. And he puts today's prices on the value in Washington of his kind of "insider" info so we can watch his income rise from a couple hundred bucks a week to $1.2 million a year with the rise of television talk shows and "celebrity" speaking appearances.

PROPHET NOT PROFIT
68 year old Edward M. (Ned) Gramlich died of acute myeloid leukemia after falling ill on a March 2007 trip to Africa. He and his wife have announced he was off experimental therapies because the survival rate is already so low. Gramlich was appointed Governor of the Federal Reserve Bank by Bill Clinton in 1997 and has served as the Dean of the University of Michigan's School of Public Policy and acting provost since leaving the Fed in 2005.

Gramlich is most famous for predicting the fall of the easy money housing market for 10 years, having earned the right not to be ignored as chair of the Neighborhood Reinvestment Corp. Bob Reischauer of the Urban Institute recently introduced him in terms we can all relate to: "Ned is to the policy community what an Olympic gold medal decathlete is to sports." You can read what Gramlich has predicted for years in his June book: Subprime Mortgages: America's Latest Boom and Bust.

PRIVATE EQUITY ENTERPRISE
Jim D'Aquila, CEO of Mercanti Group, a boutique mergers and acquisitions firm in Minneapolis and LA, reminds us of a "private equity" example that occurred in Minnesota 20 years ago when a small group of money men from Marriott and Disney did a heavily-leveraged buyout of a near debt-free company called Northwest Airlines. Some would say it's been down-hill every day since then. Even an ill-advised "bail-out" by Minnesota Governor Arne Carlson and the MN Legislature in the mid-1990s could not save the company from bankruptcy, its employees from either job loss or job lock, and millions of the rest of us from the torture of flight delays and cancellations. The so-called "investors" who did the deal are all doing quite well, thank you.

The Century Foundation, along with The Commonwealth Fund and AARP, will host a September 14th conference in Washington, D.C. to discuss Business and National Health Care Reform. Contact The Century Foundation for more information.

This event will be held at the University of St. Thomas' Minneapolis campus from 12:00 - 2:00 p.m. on September 20th. Register before September 12 to receive the early registration discount.

Continue following the MARS series on October 15th as Dr. Mark McClellan, former FDA Commissioner and former Administrator of the Centers for Medicare and Medicaid Services, addresses the impact of government regulation and payment systems on the Medical Arms Race.

This event will be held at the University of Minnesota's Coffman Memorial Union from 2:00 - 3:30 p.m. on October 15, 2007. The NIHP has teamed up with the Medical Technology Leadership Forum to host this event. Space is limited, so register early for this event.

Registration and detailed information for both events can be found at NIHP's website.

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