Commentary from Dave Durenberger

February 14, 2008

POLITICS

OBAMA AND MCCAIN
In Madison, WI Tuesday night, Barack Obama spoke as though he will be the Democratic candidate and McCain the Republican. Despite all the pundit talk about Clinton super-delegates, he will be. Momentum is real. If that's not enough, reflect on the fact that most of these "supers" are elected political folks themselves who know popular preference when they experience it. A great Obama line with many applications is "they can choose to play the game or to end it." Right...Next big surprise: When Colin Powell expresses himself on the kind of President America needs. Now.

Conservative Republicans have Mike Huckabee to demonstrate their unhappiness with the Republican Party primaries and caucuses, but John McCain will arrive in St. Paul September 1 as the Republican candidate for President. If you look at Republican turn-out vs. Democrat. If you look at where the Romney/Huckabee/Paul votes are, you can come close to predicting how few states even an "independent" Republican can carry in November unless something really unexpected happens.

WHAT'S GOING ON HERE?
Why is Hillary struggling? In their own words: "She does not have the personality of her husband. Very few people do," says Gov. Mike Huckabee (ARK). "I really believed I had to prove in this race from the very beginning that a woman could be president and a woman could be commander-in-chief. I thought that was my primary mission." says Hillary Clinton.

Why is Obama beating Clinton? "The American people are not looking for someone who can fix a carburetor. They're looking for someone who can drive the car." Mike Huckabee observes. Barack Obama says, "You choose to play the game or to end it." Michelle Obama's role? "She's the kind of woman who would take her shoes off if her feet hurt." Conservatives for McCain: "Republicans are hell-bent on going to the left and going down in flames," says Mr. MN Conservative Jason Lewis of KTLK radio.

MCCAIN AS PRESIDENT
I know what John McCain means to the Senate. I am not sure what he might mean to the country as its President. I guess with both major parties still searching for their 21st Century, flat-world identity, he would be a McCain President not a Republican. We know his fervor for taking on threats from abroad. When John looks over a four/eight year horizon for the U.S. he sees not a shining city on a hill, but enemies against which we need to be made secure. Less well known is his adamancy about restoring some sanity to federal spending and the general consequences of eating our children's seed corn. He doesn't buy the "privatizing" solutions to entitlement reform, but would put his own shoulder to that wheel.

I suspect he would make recreating middle class jobs and reforming income security programs a high priority. The same is true of tax reform ala Reagan 1986, of strengthening anti-trust laws, market-based solutions to environmental problems, reduction of tax subsidies (remember he went into the Iowa primary opposed to ethanol tax breaks). We fought side by side with other moderate Republicans for civil rights reform and campaign finance reform in the first Bush years. He fought harder than anyone against tobacco interests and backed down only after the companies settled state-by-state.

WHY JOHN MCCAIN NEEDS ANOTHER MIRACLE TO BE ELECTED PRESIDENT
The two Democrat candidates will not hand him the election by destroying each other. The public has neither seen nor experienced any redeeming value in the Republican dominance of Washington DC since 1995. Even Newt Gingrich rails against his party in his latest book, Real Change: From the World that Fails to the World that Works.

The primaries identified the fractures in the Reagan base of the party among economic conservatives (no new taxes), values conservatives (no sex or abortion outside traditional marriage and genders, and no federal limits on tax-subsidized lobbying), faith-based conservatives (poverty, cost/value of healthcare, housing and education), and creative federalism conservatives (role of government/rules for markets). Most independents are voting against eight years of Bush and for change.

MINNESOTA GOVERNOR FOR VICE PRESIDENT
Governor Tim Pawlenty has spent so much time on John McCain's straight-talk express bus, he can predict McCain's jokes and how we will handle every reporter. He spent enough time with him in Iraq that John asked him to Munich this past weekend for the annual NATO Security Conference at which Defense Secretary Robert Gates plead with NATO countries to forget we're in Iraq and help us win the war against Al Qaeda and the Taliban in Afghanistan, now in its 6th year. Knowing John, I'd rather bet on Democratic Senator Joe Lieberman for V-P (he also ran with Al against Bush-Cheney). The other possible, former GOP Senator (TX) Phil Gramm, is too much like Cheney in public to be a helpful choice.

LAME DUCK BUDGET POLITICS
The President is required by law to submit the federal government budget to Congress by early February for the fiscal year beginning October 1. The one that carries the least clout, but is most revealing, is always the one for the last year of his term. President Bush's FY2009 budget is much like his predecessors'. Optimistic revenue projections and unlikely spending recommendations. Takes money from entitlement programs Congress can't touch, and programs they can't eliminate, to spend on his favorite programs, in this case national security and defense. What's revealing? The first three trillion dollar budget ($3.12 trillion) in our history, a national debt exceeding nine trillion, and deficits headed back up toward $4-500 billion per year. That means the next President gets saddled with the same kind of economic problems and entitlement spending challenges that Bush 41 passed on to Bill Clinton. But with a lot more spending on debt service and a commitment to wars on several continents.

PICK A PRESIDENTIAL WINNER
The reason the Super Tuesday presidential primary candidates spent so much time in Missouri is not convenience. The center of the country has moved to somewhere on the Kentucky-Tennessee border. It is because, with one Adlai Stevenson exception, Missouri has voted for the Presidential winner in every election since Teddy Roosevelt. Roman Catholics, who make up 25% of the eligible voters in this country, have backed the winner of the popular vote for the last nine presidential elections starting with Nixon in 1972.

SEEN AT THE NATIONAL PRAYER BREAKFAST
Being a Presidential election year, the curious among 4,000 guests of the Senate and House prayer breakfast groups were looking for candidates. What they got was a valedictory of sorts by President Bush, the sight of regular breakfast attendee Democrat Joe Lieberman bringing his friend Republican John McCain plus the first known sighting at such an event of actor Mickey Rooney (at a table next to mine). Appropriate to see Lieberman and McCain singing "Amazing Grace" with the more famous vocalist Michael Smith.

Highlight of the morning came from Minnesota businessman Ward Brehm who reflected on what he discovered of himself in 30 visits to Africa. And did it in a way that you could hear a pin drop in the giant Washington Hilton ballroom.

DAVID TYREE
David Tyree was a relatively unknown New York Giant end until he caught a desperation Eli Manning pass late in the win over the Patriots. David Tyree is another talented young man who went from a jail cell in New Jersey to the cover of Sports Illustrated because he changed his life after a lot of small things changed his heart. A must-read story by Greg Bishop and Pete Thamel which lead the sports page of the New York Times Monday morning.

NOTABLES
My dear former colleague and friend from Hawaii, Dan Inouye, who lost his wife of 57 years in 2006, will marry in May an old friend, Irene Hirano. Ms. Hirano is the CEO of the Japanese American National Museum.

Former New York Republican Senator Alfonse D'Amato, 70, announced on Super Tuesday that his new wife Katuria, 42, had given birth to a son, Alfonse Marcello D'Amato, who weighed in at 5 lbs. 14.5 oz at 7:47 am. The mother worked at Boeing before their 2004 marriage and serves on the board of the American Airpower Museum. Alfonse, a famous Giuliani-hater, backed Fred Thompson for President before joining myriads of other formers behind John McCain.

Sign on the National Parkway Humpback Bridge reconstruction near 14th St Bridge: "Fine for Speeding: Six months in jail or $15,000." WOW...that's more than corporate execs get for defrauding Medicare! Perhaps speeding in northern VA is easier to prove than Medicare fraud and involves fewer high-priced lawyers.

NATIONAL HEALTH POLICY

PHYSICIAN LEADERSHIP
As you read this commentary, I will be lecturing in Bob Galvin's class at the Yale University Medical School. Bob runs an RWJ Foundation program on Clinical Scholars for 4th year docs. My topic is the private role in healthcare, but I am actually doing a "Physician Leadership is an Oxymoron" conversation with the docs modeled a bit on a talk on Senate Intelligence (is an oxymoron) I did back when I chaired the committee. Bottom line: national policy goals will be defined and achieved only when professionals and policy-makers better understand each other.

As the nation's politicians approach another major round of health policy reform, I am reminded of the day shortly after the Congress passed the DRG legislation in 1983 when I presented at the Texas Medical Center at Baylor. After the chair of the powerful Senate Finance Committee's health sub-committee (me) finished explaining DRGs and their policy purpose, there were lots of detail questions and finally a question by a gentleman who was then the age I am today and dressed in green scrubs with "DeBakey" in script. After telling me he was called to lecture all over the world on medicine and health systems, he nicely told me what my colleagues and I could do with our latest financing policy.

LESSONS FROM CALIFORNIA and other places as well, like Massachusetts and Colorado. Yogi Berra gets credit for describing it well, "Unless you know where you are going, any road will get you there." Some just take a lot longer than others. If you think universal coverage is the goal you can get there more quickly from Minnesota than you can from California, largely because of the nature of the populations. That reminds me of another Yogi Berra, "When you come to a fork in the road, take it." When state Governors recently decided the federal government was not going to do a thing to improve coverage, some decided to do it themselves. A couple successes emboldened others and eventually Arnold Schwarzenegger decided to take it on. Bush Republicans in Washington opted for consumer driven health care in busses driven by private health insurance plans and fewer Americans have coverage today than when President Bush took office, and the costs of coverage have nearly doubled. The uninsured are a problem for the uninsured and for all the rest of us.

What happened last month in California and to five aborted reform proposals in Colorado is actually GOOD news. Buying people into or politicians mandating them into a dysfunctional healthcare system with its unchecked medical cost inflation creates more problems than it solves. Minnesota House Democratic health leader, Tom Huntley, put it better than Yogi when he declared: "It is easier for me to provide health insurance for the 7% without it, than to assure the 93% with it they are getting value for the money they spend." While Hillary Clinton and Barack Obama debate the effectiveness of their universal coverage proposals, one will soon be debating John McCain on the effectiveness of either UC (with or without mandates) or consumer driven health care.

Eleven months from now one of them will be preparing a budget message and, hopefully, a health reform strategy speech. The "plans" and the "promises" will be gone and the serious work begins. He/she has but one chance to get it right.

IN MINNESOTA UNIVERSAL COVERAGE and cost containing policy recommendations have come from two commissions involving legislative leaders and others. The Star Tribune on the first day of the legislative session calls 2008 "a rare opportunity for landmark change" in health care and coverage in Minnesota. I would call the commission recommendations "directional" - gets us off "any road will get you there" and starts to bite the tough bullets. State Senate DFL health power Linda Berglin calls the recommendations "not a multiple-choice exercise. We have to move forward on all parts of this at the same time." But our Republican Governor has already rejected Commission recommendations for even higher taxes on tobacco, and his Republican legislative allies reject individual mandates for coverage out of hand. If you ask me, landmark change may best be saved for 2009 when health policy reform is a critical national priority as well, and Minnesota can focus 2008 on its long-delayed infrastructure needs including transportation.

BADGERCARE PLUS
While the gopher state debates coverage and quality, Wisconsin last week began a program to enroll 25,000 children in a streamlined version of existing Medicaid, Healthy Start and Badger Care programs. Families with incomes up to 300% of poverty can buy private HMO coverage, including prescription drugs, for their children for a premium from $10 to $90.74 per month plus some co-pays. This comes after a long fight between the Democratic Governor Jim Doyle and the Bush Medicaid director as a consequence of which the feds will be paying about 60% of the $50 million cost over the next 18 months.

Consumer-driven Badger-state pols have yet another scheme to improve quality and reduce prices. Senate Bill 337 would require all health care providers to list prices they usually charge, they charge uninsured and they are paid by Medicaid for their 50 mostly provided services. Insurance companies would have to give policy-holders information about what they pay per procedure. The authors' stated presumption is that those providers who specialize will provide better value for money. While researchers have yet to establish that fact, Wisconsin health care professionals seem to agree it might be worth the try.

BUSINESS INFLUENCE ON HEALTH CARE POLICY
For whatever reason, and it may be the millions of dollars available to do health services research and policy research from BCBS "Conversion Foundations," the San Francisco Bay area business community has always made strong contributions to improved health policy. My colleague on MedPAC, Dr. Arnie Milstein, has a deserved national reputation in the area of improving system performance policy. Peter Lee, who is a part of a famous health care delivery family in the south bay area, recently moved from CEO of Pacific Business Group on Health to a new position as their Executive Director of National Policy. This reflects the tremendous amount of work, and contributions, Peter has done and is making on the quality front nationally.

One of the persons whose name has become associated with quality in health care, David Lansky, was just selected as PBGH third CEO. Lansky was President of the Foundation for Accountability (FACCT), which Paul Ellwood had a role in founding. Most recently he has built a deserved reputation for quality accountability at the Markle Foundation where he led its Personal Health Technology Initiative.

DISEASE MANAGEMENT was an idea with a purpose when created by health maintenance organizations and pre-paid group medical practices as a way to prevent chronic illnesses and reduce premium costs to consumers. But Medicare, for one, didn't make this benefit financially rewarding to the "health managers." When the Consumer-driven-health-care folks arrived a few years ago they created for-profit disease managers who sold their package DM products to insurance companies. They formed lobbying organizations like the Disease Management Association (DMAA) in Washington D.C. They divided up America into "territories" for American Healthways or Health Dialogue.

Then, like HMOs in the 1990s, they began to merge with and acquire each other until only a few remained and the others went off with their hundreds of millions of dollars. Then they changed their name to correspond with the latest "health-talk". They became the Care Continuum Alliance. In late January, the Bush CMS, which helped finance these folks with the 2005 Medicare Support Program, announced that a pilot program designed to improve the health and satisfaction of sick patients and save taxpayers money (care coordination for diabetes and congestive heart failure) had failed. Five health insurance companies will lose lucrative contracts. And what started as a really good, cost-saving, health-preserving idea is in some trouble.

RETAIL MEDICINE
Because the medical industrial complex has never had to meet the value purchasing requirements of consumerism in the U.S., behavior change in individual producers will come very slowly. In fact, it may take forever. Especially when we don't know how to reward the really high performers in the system or in our communities today. The advocates of CDHC have impressed us with their entrepreneurial ability to pick the medical market apart. Everything from specialty radiology and surgical hospitals to retail clinics and medical malls for primary and cosmetic surgical care. Target and Wal-Mart are catching on to the fact that six-sigma applied to primary care and some chronic care can be achieved in non-traditional settings like theirs where you can do value purchasing and accountability for near-perfection every time.

Last week Wal-Mart announced its intent to launch several hundred new clinics in its stores starting in Little Rock and moving through the South. Former Bush HHS Assistant Secretary for Health, Dr. John Agwunobi, is in charge. He says, "We have learned that people are willing to receive their health care from the front of a store or the back of a drugstore. But customers have also said they would rather it be delivered by a trusted name, a local health care practice, a trusted local provider of care."

So Wal-Mart isn't quite at value purchasing unless they can tell us whether other local providers can compete for the Wal-Mart business opportunity by consistently demonstrating higher levels of outcomes, process performance in their local practices as well as in their store-fronts. Agwunobi and Wal-Mart dodge the bullet they aim at every other product producer when the good medical director says, ""The quality of care is within the domain of the provider. The customer will always be able to trust that the partner we have chosen is fully licensed and in compliance with all local and regulatory rules and standards."

Can we expect more from TARGET when their retail clinics come on line next year?

LOOK WHO'S WORKING AT THE FDA
The new British ambassador to the U. S. is Sir Nigel Sheinwald who serves in career foreign service. His wife Dr. Julia Dunne has worked for the British government and the European Union in pediatric health. At the FDA she will be employed part-time in FDA's office of pediatric therapeutics where her specialty of testing and regulating children's medicine will add substantial value.

WHEN ALL ELSE FAILS
News from 73rd/74th Streets and Broadway in New York City that an apartment tenant is suing a next-door neighbor to stop her cigarette smoke from entering their common hallway and endangering the life of his 4 year old son. Galila Huff admits to being a chain smoker who is "racked with guilt over her inability to quit smoking" but she has two Oreck XL air purifiers in a 635 sq. ft apartment plus a Chihuahua named Bobo who shows no ill effects from his mistress' habit.

My Senate office was next door to Utah Senator Orrin Hatch's suite. I had no idea who occupied the Hatch office next to mine until his health LA, Tricia Knight, one day met me in the Russell Building hallway outside our offices to say that she knew that any night the Senate was in late, "Senator Health" from Minnesota would stoke up a stogie and she was left to inhale the fumes. How I'll never know, but I should have told her to get an Oreck XL. Instead I quit smoking.

TROUBLESOME TRENDS

Chuck Agerstrand oversees benefits for the Michigan Teachers Association which has saved over $40 million on care for retired teachers and other employees simply by moving them all into private Medicare Advantage plans. "My jaw dropped when I heard the kind of moneys that were following these programs. A question arises as to how long will these subsidies last, and if they disappear tomorrow, what will happen?" The L.A. Times tells us a lot of public and non-profit employers are following the same course. Next year AHIP will campaign against legislative change by using this new batch of folks in addition to the racially profiled lobbyists they recruited this past year to preserve their 13 - 30% financial advantage over traditional Medicare.

HealthPartners headed off a planned strike by their nurses led by Universal Coverage Champ SEIU this week by agreeing to a contract settlement which increases pay by 3% and preserves health benefit packages which require little or no cost-sharing on the part of the employees. Thus fewer incentives the rest of us are supposed to have to maintain healthy lifestyles and shop carefully for high value medical services.

HCA, the former Hospital Corporation of America, now a $33 billion leveraged buy-out, reports that its bad debt expense is rising to 11.7% of revenue because of lower collections rates, more uninsured patients, and increase in hospital charges. To offset this, the company's local hospital executives are increasing their visits with physicians to "drum up more hospital business", spending more money on selective niche medical specialty markets, and increasing their outpatient services. Not a good sign for health care costs in the HCA market place.

One in ten Minnesotans suffer some form of mental illness. Depression is number one by far, followed by attention deficit disorder (ADD). This from a report by MN's seven largest insurers follows national patterns. It suggests that children and elderly are much over-medicated for some causes of mental illness and other adults under-medicated. Add to this study the fact that 80% of all prescriptions for drugs to treat mental illness are written by time-pressured primary care physicians, and you begin to wonder whether advocates for building more psychiatric hospitals have the best answer to the problem. They might want to read Joseph Malins' famous "A Fence or an Ambulance" which ends "Better put a strong fence round the top of the cliff than an ambulance down in the valley."

AHRQ announced its list of America's ten most expensive medical conditions with hearts at $76 billion, cancer $69 billion, diabetes and osteoarthritis at $34 billion. Experts quickly agreed on two things: Healthy life styles are great preventatives and coordinating or managing diseases to avoid complications are a great money-saver.

The "new" Wall Street Journal
You might suspect the New York Times of jumping to conclusions about what publisher Rupert Murdoch and Editor Robert Thomson plan for the WSJ. But columnist David Carr is a Minnesota boy and he walks not jumps to his conclusions. In a recent column he alerts those of us who value both publications, for very different reasons, that the ability of American daily newspaper journalism to sustain in-depth analysis of events may be undermined as much by publishers as by readers who have choices all day of "instant analysis" which passes for journalism.

The WSJ is expanding its political coverage brightening its headlines and is headed for sports and other reporting left to others in the past. "There is no reason that people should have to go to another news source beyond the Journal to find news of consequence to them in any sphere - politics, economics, even culture and the arts," says Marcus Brauchli, its managing editor. The New York Times has been challenged by shareholders to improve its performance. Directors James Kilts and Brenda Barnes are leaving because of "outside commitments."

The risk in all this, according to Carr: "People don't read The Wall Street Journal to find out what happened when a bridge collapsed in Minneapolis, but they might be interested in an article about why it did." Which of course reminded me that, but for the WSJ reporting curiosity, the folks in Minneapolis who saw another local icon nearly collapse in 2007, might never have known how millions of dollars were moved out of UnitedHealth Care earnings by executive and director back-dating of stock options.

THE NEWS FROM LAKE WOBEGON

BRIDGE POLITICS
Contractors on the $400 million replacement for MN's I-35W bridge say they are ahead of schedule despite one of the coldest winters in MN recent history. But a serious blogger, and former DFL activist, Rob Meek is keeping the heat on the public officials responsible for bridge maintenance. Rob's very effective reporting on bridge collapse/inspections/replacements/repairs in other states in recent years makes for an interesting insight into the issue of public accountability for public infrastructure.

2008: THE 75th ANNIVERSARY OF THE REPEAL OF PROHIBITION
This is an event worth getting excited about. Andrew Volstead was a MN Congressman so we are the focus. A new book, Land of Amber Waters, from the MN Historical Society describes a rich heritage of Minnesota which features beer and German heritage. National Beer Wholesalers are spending lots of DC money to convince members of Congress.

WHO ME MEDIOCRE?
Minnesota took a blow to the solar plexus this week when the new President of the state's largest philanthropic foundation declared, "What I am learning after less than a year is that the Minnesota Miracle is moving toward Minnesota Mediocrity. We're losing ground on so many things." To try and prove her wrong I turned to the sports section and found Aaron Ness, a 16-year old hockey player from Roseau, MN, who is taking his junior and senior year in high school between 7:30 am and 3:30 pm each day so he can enroll at the University of Minnesota to play hockey this fall. Everyone agrees he's the best player in MN today and bound for the NHL.

Then the not so good news: Moose Lake police are conducting a criminal investigation into a fight at the end of a girls hockey game which left a 15-year old Moose Lake player temporarily paralyzed and with a concussion. Believed to be a first for MN, the injury occurred when Moose Lake ladies, trailing International Falls ladies by 3-2 with seconds left tried to storm the IF goal and goalie.

But good news: Despite legal challenges to their claim from Fraser, CO, the same International Falls, MN just received Reg. No. 3,375,139 from the U.S. Patent and Trademark Office declaring it is legally, rightfully, and officially the Icebox of the Nation. Proof came in photographs of the 1955 International Falls PeeWee hockey team in Boston wearing jackets boasting its national icebox claim.

This week's BIG news on the GOP Convention in St. Paul September 1-3, 2008: The St. Paul Grill in the historic St. Paul Hotel is stocking a 55-year old Macallan single-malt scotch whisky which it plans to sell to Republicans for $525 per "pony" - a 1 ounce shot. To quote an early sampler from Phoenix, "Eighteen and 25-year old scotch - you're splitting hairs. At 50, you're just showing off." So what else do we want to do at a national political convention in our little old capitol city?

Biggest news in town this week was that our football genius Adrian Peterson will bring a brand new red car home with him from Hawaii. Adrian was named the MVP in the Pro-Bowl game gaining 129 yards and scoring two touchdowns.

UPCOMING EVENTS

Former Senate Majority Leader Tom Daschle will discuss his new book and bi-partisan approach to health care reform at the University of St. Thomas on March 12, 2008.

In his new book, Critical: What We Can Do about the Health Care Crisis, Senator Daschle traces how skyrocketing costs, crumbling coverage, and failed national policies have given us stories of the casualties of America's so-called health system. He draws upon more than twenty years of experience in Congress to remind readers why health policy change is so daunting and to present his vision for how, despite these obstacles, future progress in health care reform can be achieved.

This event is filling up quickly, so reserve your space by registering online at NIHP's website.

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