Commentary from Dave Durenberger

April 30, 2009

SPECTER SURPRISES
Five-term Pennsylvania Senator Arlen Specter announced this week he intends to enter the Pennsylvania Democratic primary in 2010, thus making him the 59th Democrat in the U.S. Senate. He cited John F. Kennedy to the effect that "sometimes Party asks too much" and that his independence as a Pennsylvania Senator was more important than the demands being made of him by Republicans and the Republican base in this country.

Vermont Senator Jim Jeffords said something like that back in the spring of 2001 when he left the GOP caucus in a 50-50 Senate in which Dick Cheney held the 51st vote. Jeffords was being hounded by the GOP caucus to toe a line he had never been able to toe in a long House and Senate career, President Bush and Karl Rove were running the party from the White House and Trent Lott (R-MS) and Tom DeLay (R-TX) running the Congress. There were times, he told me, when he was being asked to surrender his own beliefs for the good of the Party and he finally found that impossible.

Specter carried a great deal of water for President Bush and Republicans because of his role as chair or ranking member of Judiciary where all Bush';s judicial nominations would go. Specter was under enormous right-wing party pressure, especially from the social values base the Party was building with whom Specter rarely agreed. It was his Democratic counterpart Pat Leahy (D-VT) who helped Specter weather the storm and get through some really tough decisions, especially regarding the Supreme Court.

Illustration from The Hilll by Wayne Weyant

REAGAN/SPECTER AND THE GOP
As President, Ronald Reagan defined "Republican" as "a belief in restraining government spending, economic growth, tax reduction, sound national defense, and maximum individual liberty." As a moderate conservative Congressional party, we Republicans came to understand what that meant. Beginning in 1981 we cut spending by cutting price inflation and federal programs. We debated some on the margin like Legal Assistance for the poor and civil rights enforcement.

We reduced the marginal income tax rate on individuals from 70% to 28% and eliminated a whole lot of "tax spending" favored by business/investment interests. We put together bi-partisan majorities to de-regulate substantial parts of the economy to grow competitive markets in finance, transportation, and energy. We spent unashamedly on national defense (all but pie-in-the-sky missile shields), while reducing and reforming welfare and Medicare.

We proposed a "new federalism" by devolving responsibility for certain spending, taxing, and regulating from national to state governments, thus clearing the public lines of accountability. We honored Reagan's "maximum individual liberty" choice by reducing the liberal tendency to make behaviors of choice constitutional rights in every case, and by refusing to allow our votes to be dictated by religious or moral fundamentalism.

MEANWHILE OVER IN THE HOUSE
Newt Gingrich and his followers were busy building a cadre of "new Republicans" bent on reaching majorities in Congress by tearing down the Democrats and "left-leaning Republicans." With the help of Senator Jesse Helms of North Carolina, they built formidable legislative strategies that identified members as good/bad on votes against the National Endowment for the Arts, civil rights enforcement, AIDS prevention, flag burning, communists in Africa, abortion and family planning, and for prayer in the schools, and faith-based federal spending, They encouraged the development of "moral majorities" starting with southern fundamentalist church leaders and Catholic pro-lifers, used direct mail and Jesse Helms'; right-wing radio base to rev up "the troops."

Over time they sent southern Republicans from the House to the Senate and reduced or eliminated Democrats from office in the old confederacy. They took on the State Department in international affairs and squishy Republicans in Congress. As public dissatisfaction with government's performance grew, the anti-government message got traction. Other than the early Clinton-Gingrich days when Clinton trumped Newt on some of his own reform schemes, Congress has been notably unproductive. The record on the first eight years of this decade is abysmal. Little or nothing gets done in Washington until October when spending bills "to keep government operating" come due. And we're paying the bills on these and blaming whoever happens to be president. Bush or Obama.

SECRETARY SEBELIUS - FINALLY
The Senate finally comfirmed the President';s nomination of Kansas Governor Kathleen Sebelius as Secretary of HHS. Why did it take so long? Because there are those in the Senate who can';t seem to get over the fact that Barack Obama was elected President and has the right to appoint cabinet members. Subject to the right of the Senate to determine whether they have the requisite experience in the field and in public service to carry out the executive';s responsibility to implement legislative policy.

How diligent a Cabinet Secretary must be in complying with the law relating to reporting income and expenses for tax purposes is one of those "who is willing to cast the first stone" questions to be decided by each Senator. Whether a governor who vetoed two bills relating to abortion offered up by anti-abortion advocates makes Secretary Sebelius unqualified for office as Secretary of HHS, is an issue decided by the presidential election. The public has already judged Obama on this issue and their representatives need not judge Governor Sebelius. Members of the Senate will have opportunity in the future to debate and resolve these issues around legislative or regulatory specifics.

COMPARATIVE EFFECTIVENESS RESEARCH
The same should be said for Senator John Kyl';s (R-AZ) inexplicable ranting on the subject of comparative effectiveness research and his opposition to Sebelius on these grounds. The Congress has already decided to invest $1.1 billion in the effectiveness science research that for many years drug and device companies have lobbied against or diluted with Republican votes. Republicans lost in 2006 and 2008 and again on the Stimulus Bill of 2009. So let';s get on with improving the health care system.

Molly Ann Brodie reports that 55% of adult Americans support "a panel to determine which treatments are most cost efficient and effective" but only 41% like the idea if the federal government appoints the panel.

It is interesting to learn how many of us want our physicians to be our "trusted advisers" when it comes to what';s best for us, and are really not ready to make those decisions on our own even with the consensus advice of some of the best minds in the country. Especially if those minds were asked to serve by our government. Republican Senators are betting that';s a judgment on our trust in government. Other polls show that to be the case as it relates to the current economy. Obama is up, but government is down.

DR. CAROLYN CLANCY
Is the administrator of the Agency for Healthcare Research and Quality (AHRQ). She spoke to our University of St. Thomas MBA in Healthcare students in Washington DC last Tuesday. She provided them with a synopsis of the 20 year history of efforts to research quality in healthcare in which I was much involved. The history includes early efforts by surgical specialty organizations (especially spine surgeons) to fight "what works best" research. Plus the recent efforts of drug and device companies to kill comparative research by under-funding it. The stimulus bill provides Clancy';s AHRQ with $1.1 billion, much of it to be committed to research by NIH along a research protocol developed this summer by the Institute of Medicine.

I myself have always believed importing N.I.C.E. from the U.K. to the U.S. will never work in an American health system. We love pluralism and choice too much. Even when it';s unbelievably confusing and occasionally unproductive. Effectiveness science is a discipline that exists in most industries and it needs to come to medicine. It will get here most quickly if the research grants go to clinical settings which have demonstrated the greatest capacity to put clinical knowledge and research to work immediately and to take responsibility for it.

We don';t need this research money added to the cancer money and divvied up among the richest of our academic medical establishment. We need to it to go out into primary, secondary and tertiary settings for a variety of effectiveness and efficiency purposes. We need the involvement of the medical specialty societies in this work more than we need "the academic enterprise." We all point with some pride to the Society of Thoracic Surgeons and their nearly 20 year effort to use data to improve their outcomes even though we aren';t paying them to do it. Let';s start paying them - for the results we believe are possible.

"ASK YOUR DOCTOR" DRUG ADS
Why go through alluring marketing followed by rapid fire/small -print warnings only to be advised to ask our doctor';s opinion? My first reaction is that is CYA by drug companies. Then I was at an event in Florida when an emcee my age held up a cigarette ad from our younger days when "6 out of 10 doctors smoked Camels." This made me think about what it took to get doctors to say they smoked camels in the old days and what it takes to get doctors today to prescribe certain drugs rather than comparable alternatives. Does every doctor rely on up-to-date comparative research, including comparable prices and effectiveness? If not, how do I?

DAVID BRODER MEASURES EARLY PARTISANSHIP IN CONGRESS
Like so many of us who have watched Washington at work over the years, Washington Post pundit Broder wants President Obama to stick with his efforts at bi-partisanship. Republicans have been most unhelpful to the President. In fact, no help at all. Right-wing radio/TV has been unmerciful in its attacks on the President's spending and tax policies. And the GOP in Congress has marched in rhetorical lock-step through economic recovery, appropriations, and budget bills.

But Broder says the independent voters want bi-partisanship. Now more than ever. He believes Congressional districts have been gerrymandered to prefer partisans over independents. Which accounts for the way Congress, especially the House, measures public opinion. The evidence: 88% of Democrats approve Obama policies; 27% of Republicans do. His advice to the President is to not use his Democratic majority to muscle legislation through Congress as George Bush did. But to focus on the ability of the Senate, on the margin, to better reflect the majority of popular opinion.

PARTISAN POLITICS AND POLICY
Concern in Washington DC about the need to use budget reconciliation and its 50 votes rather than the 60 required to pass health policy reform this fall. Democrats like Amy Klobuchar in MN favor bi-partisanship and its value to achieving public support for one of the President's key initiatives. Because of the reach of the legislation into every home, hospital and medical clinic, and pocketbook in America, the opportunity for the Democratic Party to demonstrate its new center-left makeup is enormous. Question: Is the Democratic leadership in the Congress up to it? Harry Reid, Nancy Pelosi and their long-time Chairs from California and New York?

RANKING SENATE PARTISANS
Each Congress, The Hill newspaper polls every Senator on which of their colleagues they are most eager to work on legislation with and which are the most difficult. Ted Kennedy, Tom Carper (Del), Chris Dodd (CT), Evan Bayh (IN) and Tom Harkin (IA) were the best Democrats with whom to work. Patrick Leahy (VT), Charles Schumer (NY), Chris Dodd (CT), Dick Durbin (IL) and John Kerry (MA) were the most difficult.

Among Republicans the 99 colleagues wanted most to work with are Susan Collins (ME), Olympia Snowe (ME), Orrin Hatch (UT), Dick Lugar (IN) and John McCain (AZ). Republicans to avoid were Jim Bunning (KY), David Vitter (LA), Tom Coburn (OK), Jim DeMInt (SC), and Lamar Alexander (TN).

RIGHT TRACK - WRONG TRACK
Both national polls and this week';s Minnesota poll show a steep rise in optimism in the country. 39% of Minnesotans (compared with 14% a year ago) believe America is "on the right track." National polls show that from February 09 to April 09 right track opinion rose 22%. President Obama';s job approval ratings are 62%. Noteworthy, though is the fact that 88% of Democrats approve of the President';s performance, but only 21% of Republicans. These are comparable to national figures illustrating why Congressional Republicans seem confident in their "just vote no on everything" stance.

Unfortunately for Republicans, this ignores the fact that the percentage of people who identify as Republicans has dropped substantially in the last 3-4 years. Plus, the number of Republican seats up for grabs in the Senate in 2010 is double the number of Democratic seats. Plus, the fact that neither the new President nor the relatively new, and more conservative Democrats, have yet been able to play their more moderate policy hands.

Republicans in Congress may have another strategy in mind. To force the Democrats in the Senate to come up with 60 Democratic votes on everything. Thus making it particularly difficult for centrist Democrats from swing states by making them take votes on everything from trillion dollar spending to expanding healthcare coverage without the dollars to pay for it to union check-off.

My former Senate colleague Jack Danforth (R-MO) appeared on the Jim Lehrer Newshour this week in a Gwen Ifill interview of political leaders in St. Louis. The occasion was President Obama's 100 days in office. Danforth gave the President an A plus for articulating and achieving the goals he set out for himself and the country. Then sternly opined through is very gray visage that those policies, which shift so much power to the national government, are "dangerously close" to running the country off course. This comes very close to explaining why public opinion polls show such clear difference in the President's approval ratings between Republicans and Democrats.

by Wayne Stayskal

MORE DOCTORS - MORE MONEY
Must be time for health care reform!! It';s like "if the sun sets it will also rise." Every time we get close to real healthcare policy reform that might drive system reform, we are told the U.S. does not have enough doctors or nurses or whatever to serve us now, to say nothing of in an improved care system. Or, comparative effectivess and payment reform in drugs and devices will drive technology companies out of America. It gets repeated to every generation of reformers. It's in the nature of much of the American medical system (and education as well) for the professionals to tell us that if we want them to do better we have to pay them more.

The same holds true with our thinking about healthcare quality. If my doctor prescribes more treatment and sends me a larger bill, he or she must be doing more for me and better for me. Not true. He or she is doing more, but it's not necessarily good for me. Just for him or her. That's what he or she is trained to do in most practice cultures. So when policy makers or insurers insist in getting better care for patients and insureds, the reaction is" pay me more."

George Halvorsen at Kaiser Permanente tells the story of the transplant center that was charging $200,000 per transplant. When asked if they'd consider doing them for $100,000, they replied, "Only if you pay us for consistent results, and don't tell us what and how we have to do in order to get there." Now that's what Glenn Steele at Geisinger, and hundreds of other physicians who have the privilege of leading integrated medical groups across the country have been trying to tell organized medicine for decades, and Congress for the last few years. "Organized medicine" just doesn't want to organize!

The other reaction is, you can't reduce payments to surgeon Smith to improve the payments for family doc Nelson. Of course not. American subspecialty medicine is by far the best paid in the world. Japan has a higher cost of living than U.S., but world class sub-specialists in Japan earn incomes (in Japan) a third of their U.S. counterparts. Technology-dependent sub-specialties like radiology and much surgery, are highly dependent on medical technology to improve productivity and performance and so they react just like the device companies. Unfortunately for us, the profit from innovation that should be shared among patient, device company, device inventor and investor, physician/surgeon, and hospital is not split five ways, but is first multiplied by four and then paid by the patient or her insurer to all four "beneficiaries."

WHERE';S THE NURSES SHORTAGE?
For several years we have wrung our healthcare hands over the need to pump more money into nursing school faculties so the pent-up demand for nursing education can be relieved. In a difficult economy nurses who have left the profession are coming back for the extra family income. To the point where in many communities there are no openings for RNs. So the question arises here, as it does with doctors, how much is it worth in public expenditures
to relieve "shortages" which may exist because of life style preferences (many fewer hours and selective times) or other personal and family "choices." Maybe full tuition and large debt is an incentive to get the most out of education?

THE AMERICAN HEALTH SYSTEM
30 years ago primary care physicians'; income was on average 30% less than subspecialists. Plus they worked much longer hours. Today the disparity is 200% on average and the hours worked are roughly comparable. Four years of medical school in Minnesota today costs $325,000 per student. The average student graduates with $150-200,000 in debt. One half of all the medical school "slots" for primary care go unfilled.

Health Insurance Reform…We can save a great deal of money in the system if informed consumer choice of health insurance plans worked to create market competition. Consumer choices are driven by marketing and premium prices, not by financial rewards for reducing exposure. National rules on risk assumption, risk pooling, and product and benefit comparison are essential. The individual insurance market is a result of the medical/insurance/banking combine to preserve status quo at public expense. It is funded by tax subsidies like the HSA. Everyone takes a piece of the premium payer';s dollar without returning anything of value other than a temporary price advantage which goes away with a couple costly claims.

Health Insurance Reform - 2…Malpractice Insurance. Minnesota happens to be the second lowest cost malpractice premium state in the country after Nebraska. Juries don';t make big-dollar awards here. However, unlike group health insurance companies, which pay 90 cents on the premium dollar to care providers, malpractice insurance pays only 54% of premiums to patients who have been injured by the negligence of the medical system. The rest goes to insurance companies and lawyers.

UNINSURANCE KILLS
Minnesota has the highest percentage of insured citizens in the country next to Massachusetts. We do it with a variety of public and private insurance programs and with state taxes of various kinds including on healthcare services income. Most everyone else gets hospitalized if they need it and hospitals make up the costs somewhere. When the economy is as tough as it is this year, there are hospitals that can';t handle the increased financial impact of uninsured and uncompensated care. At our largest quasi-public institution - Hennepin County Medical Center in downtown Minneapolis - Dr. Michael "Mick" Belzer, the Chief Medical officer says, "If uninsurance were classified as a disease, it would be the third-leading killer of the near- elderly from 50 to 65."

NOT EVERYONE IS HURTING
HCA Inc. in Nashville is the nation';s largest owner of health-care facilities, owned by a private equity firm, and very profitable. Its first quarter 2009 net profit was up 92% on revenues which rose 4.3% to $7.43 billion, despite a drop in the number of surgeries. Obviously insurers and employers in the south are picking up the higher prices HCA charges and passing them on to the rest of us.

Health insurer Humana in Louisville, KY also saw 1st quarter income double on larger Medicare Advantage and Prescription Drug enrollment, higher premiums, and improved margins. Humana expects revenue close to $32 billion this year. My son lives in a third tier suburb of Louisville in which two of the major hospital systems in the city have finished or are finishing major new hospitals, and the third is about to start. Along with a dozen new physicians'; office buildings surrounding the hospitals.

TIME FOR A NATIONAL CONVERSATION ON HEALTH CARE
There is little or no evidence in Washington DC that genuine health policy reform will happen in 2009. Given President Obama's commitment - and yours and mine - to make it a reality soon, I suggest he encourage us, and lead us in a national conversation, dialogue whatever you want to call it. The subject: What it's like to live in an American health system.

Obama leads off and thousands of Americans who live in communities that are already trying to create this system take it from there. Health reform is not a job for the Congress. They really aren't up to it. Not without persuasive examples growing right here in the USA - from Hawaii to New England. I watch community leaders like Glenn Steele of Geisinger, George Halverson of Kaiser-Permanente, and Dennis Cortese of Mayo go to Washington where they get four minutes apiece with Congress members. And none with the 305 million people who would love to know what they're talking about.

The purpose of health policy change, especially healthcare financing reform, is not just coverage or access or quality or cost containment. It's health and healthcare system change - the American way. Health goes up, care quality goes up, costs come down, access improves. For everyone. It's worked that way in every other American industry except healthcare and education. Where we still play to our weaknesses rather than to our strengths. Because those who benefit are reluctant to change.

People I respect a lot suggest we start a consumer-driven health care campaign involving Republicans and Democrats, liberals and conservatives, politicians and professionals. A campaign to demand "low cost healthcare" in America. A colleague of mine at UST put it simply: "I live for the day a device company sales rep walks into a hospital with a defibrillator and says, 'Ours works just as well as the others in the market, and costs half as much. What's your excuse for not buying? Or, better yet, patients are equipped to discuss alternative therapies that cost them less in time, pain, income loss and out-of-pocket expense. There are a thousand examples to change their R and D and marketing policies and practices in real competitive markets.

WHAT DO SUSAN BOYLE, RICHARD PHILLIPS, AND ADAM MAKI HAVE IN COMMON?
Ordinary people doing extraordinary things with the gifts and opportunities they've been given. Susan Boyle went from ridicule to the most easily recognized new name in the world in just seconds. Thanks to the gift of an unusual voice and a TV talent contest. Richard Phillips did much the same this month thanks to nameless, faceless Somali pirates. We'll remember Phillips as the merchant marine captain who offered his life so his men could save theirs. Pros say he was heroic "but he was just doing what sea captains are supposed to do, paid to do, and expected to do."

Who is Adam Maki. Twenty plus years ago he was a student in a northeastern Minnesota high school who asked me for help getting into the Air Force Academy. He was more than qualified, but that year Air Force wanted hockey players so Adam went to Annapolis. Graduating from the Naval Academy he went straight to the Navy SEALs program and 16 years later is a Lt. Commander about to become Commander. Stationed in Bahrain, Lt. Comm. Maki commanded the SEAL team of three sharp-shooters dropped into the Indian Ocean next to the Bainbridge. A flawless operation directed by a kid from Minnesota who wanted to serve his country. Boy did he ever. Just doing with his gifts and an opportunity what we all help pay him to do extraordinarily well. Thank God. Thank you, Adam.

THE MINNESOTA SENATE SEAT
In Washington with our Healthcare MBA students a couple weeks ago, it was a delight to see Minnesota';s only Senator Amy Klobuchar hard at work. She took time for lunch with our students and faculty and then sent them off to visit with President Obama';s health policy counselor Nancy Ann DeParle at what used to be called the Old Executive Office Building next to the White House. Later that afternoon we all toured the Capitol and ended by watching three Senate votes from the gallery of the Senate. There was our Senator engaging everyone on the floor, giving a big hug to recent Viet Nam traveling companion Lindsay Graham (R-SC), and then being advised by the chair to "take conversations to the cloakroom."

Back home in Minnesota, Norm Coleman has asked the Minnesota Supreme Court to review the decision of the three-judge panel finding that opponent Al Franken won the election by over 300 votes. The Court agreed and set June 1 as the date for oral arguments by Coleman and Franken attorneys. Only 28% of Minnesotans (me included) consider Norm';s appeal "appropriate." 73% (me included) say he should give up if he loses at our State';s highest court. 64% percent of us believe that Minnesota always learns from experience and that we need to re-examine our election law to maximize the accuracy of every vote.

QUOTABLE
Lloyd Leverins quoting his grandson "Grandpa, you did so much with so little; why can I do so little with so much?"

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