Commentary from Dave Durenberger

May 16, 2007

PAUL ELLWOOD
He's a bright-as-ever, happy, policy guru at 83. He took his first airline flight in nearly two years to come to Minnesota for a few days, and a group of us enjoyed a couple hours talking past, present and future. The “road to value” as healthcare cost containment, which Paul and colleagues at Interstudy designed 3-4 decades ago, still runs through Minnesota, says Paul. The road, however, and some of the policy vehicles designed for it have taken less-than-productive twists and turns over the years. But the destination is the same. Lower costs by delivering high value health care.

But reaching this destination requires consensus outcomes (medical and health), and the ability to measure and reward them. The "pay-for-performance" products Paul has seen so far "are a crock," according to him. We must replace everybody's proprietary health records with more universal electronic medical records. The ideal delivery system is still integrated health systems with providers held accountable for financial risk as well as health outcomes. The growing dependence on public financing creates so many “one guy’s costs is another guy’s income” interests. That makes policy consensus difficult without a natural political leader. The “federal reserve” approach to institutionalizing the on-going success of policy change is critical.

CONVERSATION ON COVERAGE
Every week a new “unlikely coalition” of business, labor, retiree, employer and financial services associations commits to reforming U.S. income security programs. Two weeks ago a group of us formally re-launched Americans for Generational Equity (AGE) with an international Alliance for Generational Equity committed to re-examining national policies around income security.

The AGE Board includes major players in financial services, international relations and former members of Congress. Last week the Aspen Institute announced a public-private program that was multi- generational. This week it is 45+ organizations and associations focused on retirement security. Behind all this is decades of work by organizations like the Concord Coalition and the current messianic work of the Comptroller General, David Walker. Nothing this big or this broad can fail. Particularly if its leaders come together at some point to focus on a single long-term policy goal.

UNIVERSAL COVERAGE
Universal coverage and access cannot be accomplished at the state level. Another story from Florida where Jeb Bush’s 2005 plan to expand Medicaid by lowering provider payments has resulted in a substantial increase in the number of physicians unwilling to see Medicaid patients. Across the country we see dentistry becoming the most serious of access problems.

States like Minnesota and Massachusetts can come close to universal coverage by raising taxes on income – either everyone’s income or the physician/hospital/nursing home income. Up here we think it improves our quality of life. The majority of states cannot do it, and won't do it.

But even Minnesota and Massachusetts can’t do universal coverage without federal money. It makes so much more sense to develop a national policy on income security for middle and low-income Americans that provides affordable access to health, medical and long-term care. A whole new plan or program, not simply “modifications” to the existing Medicare/Medicaid and SCHIP, or tax subsidy programs that pass for income security policy, which they aren't because so much of the benefits end up with Americans who don’t need them – and aren’t asking for them.

THE WASHINGTON DC INFLUENCE BUSINESS
I commented recently about the power of information to influence health policy. I always use the decades-old National Health Policy Forum at George Washington University, headed by Judy Miller Jones, as a model for which to strive. I implied that the integrity of impartiality is potentially weakened by the invasion of DC by information/conference/research/consulting enterprises like Newt Gingrich’s Center for Health Transformation and Dan Mendelson’s Avalere Health. One leans right, the other leans left. But both lean in the direction of those who fund their “research/consulting” work. Danny has an edge on Newt because (a) he has a much lower profile, (b) he has a pedigree and practice as a researcher/analyst, and (c) he gets contracts not only from private health care interests, but from CMS, Kaiser and like institutions.

However, when Mendelson starts saying things like he did last week in the Wall Street Journal, "A cut in private fee-for-service (PFFS) is a cut in rural health," it might make anyone go looking for a client (maybe an AHIP member or CMS) that is wedded financially and ideologically to the profit-sucking sound of PFFS Medicare Advantage.

THE WASHINGTON DC INFLUENCE BUSINESS - PART TWO
A long-time Washington lobbyist and one of the recognized pros on health policy and politics recently told me, “There is little real legislative action in health policy these days. One reason is there are so few members who want the job. So 70% of my business is on the regulatory side.” Meaning of course, we have CMS, FDA, and like agencies which can move millions (or billions) one way or the other with very little of the public oversight that’s part of the Congressional committee process. Fortunately for us, my friend doesn't do Appropriations, which is where "earmarked" spending makes a joke of good health policy.

Separation of powers and checks and balances all come too late in this game as Congressman Henry Waxman is demonstrating with his spate of “oversight” hearings. The result: too much power in the Executive Branch. And in the appointment process. Two Supreme Court Justices turn the Court. Two dozen Federalist Society acolytes in the Justice Department replace a like number of Republican U.S. District Attorney’s “who have lost their focus.” And the deletion, or watering down, of one provision in a CMS regulation retains or makes multi-millions for a favored healthcare provider.

HILLBILLY HEROIN
Since OxyContin came on the legal narcotics market it has become a drug of choice for the young, especially in rural America. Earlier this month Purdue Pharma, the corporation which peddled the product into millions of homes and bodies - and pocketed nearly $3 billion for its efforts - paid fines totaling $600 million for misleading doctors and patients. The executives responsible paid much smaller amounts and got off with misdemeanor pleas for “misbranding” the drug.

This in the same week that U.S. district attorneys were nailing Bristol-Meyers Squibb for Plavix, and that a growing number of studies suggested the comparative ineffectiveness of cancer drugs and reports on the widespread financial interest of doctors in anti-psychotic drugs. It's also the same week that Senators Ted Kennedy and Mike Enzi were praised for agreeing on re-authorization of the FDA, which former Congressman and $2 million-year PhARMA President Billy Tauzin applauded, saying it "will preserve and even strengthen the FDA’s ability to do its job.”

Wall Street Journal editors, however, call this "painkiller hysteria" and use Dr. Sally Satel at the American Enterprise Institute (AEI) to blame the problem on the abuses of the drug.

MISBRANDING
It might be a smaller crime, but it's still a crime. Much like speeding or double parking. Or direct-to-consumer marketing that may be less than truthful. Is it advertising or addiction-inducing? Is there any difference in today’s world of life-style drugs?

By legal definition, “misbranding” makes it a crime to mis-label a drug (such as the drugs from China that are killing people in various parts of our world,) or to fraudulently promote or market it for an unapproved use. Take your choice. With $3 billion at stake in your “misbranding,” is it not possible for lawmakers to consider a more egregious penalty? Or does the prosecutor bar say defense attorneys for drug companies are just too good at defending anything but misdemeanor cases? That’s another story that bothers Congress about the Justice Department's hiring and firing policy. No headlines as long as the corporate fine money keeps rolling in.

By Don Wright ©2007 Tribune Media Services, Inc.

HYBRID HEALTH
Minnesota's famous General Mills announced a new line of breakfast foods it is marketing with Curves, the women's fitness company with 8,000 U.S. work-out stations. The new partners launched a marketing campaign theme of fit and healthy to women who want to lose weight. We can be assured that the promise is greater than the reality. "Healthy Food" depends entirely on source and content, not on consumer opinion. It reminds me of the AARP partnership with United Health Group to bring a comforting, trustworthy "Medical Home" to as many of the 70 million Americans over 50 who succumb to the notion that, if sick, they need only clip one of those famous AARP coupons to use on the nearest available hospital or medical clinic.

CORPORATE WELFARE
Many years ago 3M put a plant in Wahpeton, ND, across the border from Breckenridge, MN. A decade ago Imation split from 3M and took over the Wahpeton plant. In 2000, it decided it needed to upgrade its Wahpeton facility. They threatened to move, and locals found that the government subsidy trough could give Imation $3.5 million in federal grants, $7 million in federally guaranteed loans, along with millions in local tax forgiveness, among others. Today Imation says it’s sorry, but it has to cut costs and is moving out of Wahpeton, leaving us holding the bag. Perhaps we will see the day when government sticks to its business and America’s business corporations try to stick to theirs rather than playing silly politicians against each other, while spending other people’s money.

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2008 PRESIDENTIAL ELECTIONS
As states like Florida start pushing the first primary elections closer and closer to Christmas 2007, there is growing concern that the Presidential candidates of the two major parties will be selected before Minnesota and Iowa have a chance to shovel out next winter’s snow. The feverish pace of campaign fund-raising would lead you to believe that even candidates live in fear of early elimination or a too-long campaign for front-runners. I have a different take on this.

Because there is so much at stake, and so much money on the table, and because of the phenomenal support for Barack Obama and even Fred Thompson, I will suggest the campaign for the parties' presidential candidate will go on much longer than we think. The money will hold out longer than we think because in close contests at the primary level, early investors will keep hoping for a pay-off that can survive both early and later primaries. That is certainly true of the Edwards-Clinton-Obama race where the future of the Democratic party is at stake. Investors in Republicans, dragging the problems of the Middle East and the war in Iraq into a national race, have much less at stake in a long election campaign.

By Dan Wasserman ©2007 Tribune Media Services, Inc.

NEWT GINGRICH
A “transformer” in health care and policy is taking the political tremors around former Senator Fred Thompson seriously. On ABC he formally announced he’ll be in the GOP presidential race after his national, internet-based "American Solutions for Winning the Future" workshop in September. Doesn't make the already-declared Republican candidates feel very good about their efforts! But then a good friend who viewed the line-up of candidates at the first debate said, “I didn’t think Republicans believed in cloning.”

IRAQ: WHOM TO BELIEVE?
A few months ago Minnesota’s new Republican Congressmember Michele Bachmann told us that it was critical to increase our investment of troops and dollars in Iraq because of a secret strategy by Iran. Now Minnesota’s senior Republican Senator Norm Coleman. who like Bachman, is up for re-election next year, informs us that he knows U.S. troops will be out of Baghdad “sometime during 2008.” Either the surge works, or a "Rwanda-style bloodletting” occurs. But, in any event, it won’t involve U.S. troops who will be busy fighting Al Quaeda in Anbar province and other parts of Iraq outside the capital to make sure the U.S. is safer and the war on international terrorism can be won. Not sure exactly where the Hutu genocide against Tutsi Rwandans comes in here, but there you have it. Sounds like the GOP in Congress may be setting us up for an election to decide who is responsible for genocide in Iraq.

THE THIRD WAY
Somewhere in my basement files is a bulky set labeled "The Third Way of Politics," which I started drafting midway through Ronald Reagan's term as President. Later in the 1980s it became a term adapted to a movement among Democrats focused on the Democratic Leadership Council and bright politicians like Senator Sam Nunn of GA and Governor Bill Clinton of Arkansas. In the early 1990s, a brash young Labour party member in UK's House of Commons spoke to "a third way" so incessantly he blew by Labour's obvious next leader, Gordon Brown, to secure the Prime Minister position he held for 10 years and gave up last week.

Tony Blair may well have made a mistake when he gave President Bush a blank check of Britain's support after Sept. 11, 2001. But he never stopped exuding a common touch for the potential of political leadership in a world starved for a "third way" of governing. Reagan was the best of the second way. Clinton blew his chances to launch the Democratic Party as a U.S. third way, but Blair was highly successful at most that he chose to lead. Much more of a Clinton than a Bush (41 or 43), Tony Blair would have made a great successor to the Democrat who couldn't succeed himself as President of the U.S. Instead, the most likely successor in this country will not be his friend's wife, Senator Hillary Clinton, but a new member of the Senate who reads very much like the Labour back-bencher of the early 1990s, as he promises you a "third way" without using the words.

GEORGE TENET AS BOOKEND
How do we explain the popularity of Iraq exposé books and their authors, and the resounding denunciation of former CIA Director George Tenet and his new book “At the Center of the Storm?” I think the title captures the feeling of journalists, political types, and the public. As CIA Director under both Clinton and Bush, Tenet was visibly at the center of the storm that both preceded and followed 9/11. When he could have made a difference he sat stone-faced behind Secretary of State Colin Powell and endorsed the faulty intelligence on which the U.S.-U.K. went to war against Saddam Hussein. With his vast experience, we wish Powell had been the one to stop the neo-con express. At least he didn’t take his whitewash medal and then do a “don’t blame me” book.

At the beginning of 1985, George Tenet came to serve as chief of staff to ranking Democratic minority leader Patrick Leahy on the Senate Select Committee on Intelligence. I was then serving as Barry Goldwater’s successor as chairman. Director of the CIA was Bill Casey, a man Ronald Reagan put in charge of the intelligence necessary to lead him out of the cold war. Casey was a man whom Goldwater distrusted and discounted at almost every turn in his “covert action wars” in Central America, Africa, and South Asia. 1985 turned out to be the year 9 or 10 Americans were caught spying on their own country for foreign powers, and the Democrats thought Casey was to blame. In 1986, he added fuel to their fire with what we remember as the Iran-Contra affair. I found Tenet then, and during his service to Leahy’s successor David Boren (D-OK), to be a sound and reliable supporter of both the intelligence mission and the legislative oversight to keep it in the public interest.

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TAX ON THE WEALTHY
Minnesota Democratic legislators are bound and determined to fulfill public expectations by raising the money they need to balance the state budget with substantial increases in income taxes for the top 50,000 Minnesota income earners. This would not include the many in this bracket who have already moved their residence to non-income tax states to avoid just such insanity. Public opinion polls reflect that the other 5 million Minnesotans support such an effort. Any question as to why?

STAR-TRIBUNE’S REIGN IS OVER
Just when we thought a strong east wind would fold the St. Paul Pioneer Press into the Minneapolis Star Tribune (Strib), the Strib’s owners start throwing staff off the former Cowles flagship. While there was a day I’d have enjoyed the sight of that ship sinking, that isn’t the case today.

Owners apparently don’t intend to sink it either, but put a lot of staff to work harder now that they haven’t much of a cross-metro rival to go to. Rumor has it, though, that the old liberals on the editorial staff are out – starting with Susan Albright, the editor of the editorial pages who came to town from Phoenix with a chip on her shoulder and never lost it. Marketing says the editorial page needs the right to hire opinion pieces that will appeal more to the conservative centrists in the suburbs who will still read a newspaper that can reflect current and future policy thinking.

DFL MUSEUMS
In Minnesota we honor the elected officials of our majority Democratic Party (called Democratic-Farmer-Labor) in as many ways as we possibly can. When they die they have public facilities named after them. Most large facilities (airport-stadia) are named for Hubert H. Humphrey. Small parks and buildings are named for Senator Paul Wellstone and Congressman Bruce Vento. Now we are into honoring the living ex-politicians and even some still in office, like Walter Mondale and Minnesota Rep. Jim Oberstar.

The most interesting stories came this week with the announcement that Ford Bell, who lost a primary race for the U.S. Senate to Amy Klobuchar, will become President of the American Association of Museums. Judi Dutcher, former State auditor (and former Republican) who also lost a 2006 race for Lt. Governor, will become President of The Museum of Russia in south Minneapolis.

NOTHING TO FEAR BUT FEAR ITSELF
Roman Catholics in the Archdiocese of St. Paul and Minneapolis, along with their 495 priests, received the news that New Ulm Diocese Bishop John Nienstedt will succeed Harry Flynn as Archbishop in a year with some amount of trepidation. That's putting it mildly. Much of the "news" was sourced to newspaper accounts. But a large amount came from priests in this diocese who claim to know Bishop Neinstedt well. University of St. Thomas (UST) Catholic Studies professor Robert Kennedy says the local dailies "for some reason have decided to take off after this guy, and I think what they've reported is deliberately skewed and unfair."

Kennedy also said the role of the Archbishop as chair of the Board of Regents at UST, one of less than a dozen diocesan Catholic Universities in the U.S., "is more ceremonial than administrative." UST President Dennis Dease, on the other hand, refers us to Bishop Neinstedt's doctoral thesis on medical ethics. When the St. Thomas Board and the Allina Health System Board agreed last Thursday to work jointly toward creating a new medical school in Minnesota, a lot of people went looking for copies of the new Bishop's doctoral thesis, which can be ordered on Amazon.com. His public statements and commentary can be found on the Diocese of New Ulm's website.

In much more conservative St. Louis, MO, an invitation to Senator Claire McCaskill to speak at her daughter's Catholic high school graduation was withdrawn because of the Senator's position on stem cell research and abortion.

While reported that St. Louis Archbishop Raymond Burke was not the one who made the final decision to rescind the invitation, it is in-line with his policies. In April, Archbishop Burke approved a memo sent to Archdiocesan schools urging the re-examination of support for the Susan G. Komen foundation because of their support to Planned Parenthood. In early May Bishop Burke resigned from the board of directors for the Cardinal Glennon Children's Foundation, because of its decision to have singer Sheryl Crow headline a benefit concert for the organization.

HARVARD ASKS THE QUESTION
What is a Harvard education? Is it attending a university at which world famous researchers are recruited to contribute to the faculty to revolutionize knowledge? Or is it giving Harvard students the opportunity to actually meet and learn from (even attend classes taught by) these revolutionaries? Sociologist Theda Skocpol, well known for her views on health policy and a very good teacher to boot, has chaired a faculty committee raising the question. In light of the amount of money demanded of students, alumni, and other philanthropists to finance undergraduate education today, it sounds like both university regents and accrediting bodies could well focus on answering the same questions.

This may well be a policy question which both Congress and the Executive, whose higher education financing policies are deservedly under fire today, should be asking of the larger community which makes up the United States in a shrinking New World. In this case, higher education in the U.S. may be too important to be left to “educators” whose focus too long has been on "who" and "what" brings money in the door.

"Demand for top-flight Democratic lobbyists is outpacing supply, leaving trade groups, associations and firms with holes on their staffs as they try to make in-roads to the new majority."
--- Journalist Jim Synder, The Hill, May 2, 2007 on K Street

"The slice (of British life) I was enjoying yesterday on the ambassador's lawn, as hundreds of Washington power broker types directed their rapturous attention toward Her Majesty, is the Britain that doesn't often fall for ludicrous ideas. It's the Britain that has revitalized its economy even while France struggles, and has mostly preserved the pillars, like the monarchy, of its distinct national identity. It's the Britain still too well bred to mention, as a few ex-pats and Yanks did yesterday, that the Queen looks a bit shorter than Helen Mirren."
--- David Brooks, New York Times; May 8, 2007, on his visit to Britain last week

"Advisers say his advice to her can be boiled down to a few broad themes. He urges her to remember that the biggest person gets elected (in other words, the one who rises above political pettiness) and that the most optimistic candidate wins. He has encouraged her to talk about average people who work hard and play by the rules, classic Clintonian language. And she has, using those phrases and other themes in telling, for example, about regular Americans who are "invisible" to the Bush administration (Advisers say Mr. Clinton did not devise the invisible line.)"
--- Journalist Patrick Healy, New York Times; May 14, 2007, on Bill Clinton's role in Hillary Clinton's presidential campaign.

"But now the agency (CIA) is in perhaps the worst funk in its history. Requests by agents to publish books are running at 100 a month. Congress has hopelessly botched intelligence reform. And the public has almost no confidence in intelligence reports. Mr. Tenet's book would have had a better reception if he had spent less time justifying a phrase and more time explaining how to repair his damaged agency."
--- Lexington (The Economist), on George Tenet's "At the Centre of the Storm"

"Most people believe [healthcare reform] does not get done without good business support, and we've assembled a coalition of people who believe business has a responsibility to make sure people get the healthcare coverage that they need."
--- Steve Burd, chairman of Safeway grocery, on the newly formed coalition for healthcare reform in California.

"The party you belong to is a powerful brand. If the brand is damaged, it drags down all of the product line."
--- Larry Jacobs, University of Minnesota political scientist, on campaign strategy

MOTHERS DAY 2007
We had many moms, a grand-mom, and assorted grand kids over for the weekend and loved almost every minute of it. Especially celebrating the successful mothers in our family, and the 13th birthday of our oldest grand-daughter, Sara Marie Durenberger. At Catholic Eldercare in NE Minneapolis my 95-year old mother was surprised to learn she was the mother of five, and I was one - about which she seemed a bit dubious. She often is these days.

The biggest surprise was discovering that the widow of Minneapolis Lakers (Now LA Lakers) coach Johnny Kundla, Marie Kundla, has just moved in to a room on my mother's floor. Each recognizes her own name, but not others. So I couldn't tell either how my father, George, and Johnny Kundla played semi-pro basketball against each other in the 1929-32 period, how they later coached against each other, and how they considered themselves as "best of friends."

The Senate last week approved a bill last week allowing pharmaceutical and medical device companies to pay user fees in the amount of $393 million next year in hopes their new treatments and products will pass through the approval process much more quickly and efficiently.

The Commonwealth Fund Tuesday released "Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care," a study revealing international comparisons of healthcare systems. As in previous studies, the comparative analyses show the United States underperforming "relative to other countries - Australia, Canada, Germany, New Zealand and the United Kingdom- on most dimensions of performance."