Health Care For America Now

Today, I had the chance to sit down with Atul Gawande (former Clinton staffer, author of this great New Yorker piece on health care) and Ron Pollack (Executive Director, Families USA), and see Paul Begala speak. Here are some highlights.

Atul Gawande on how to build on the health care system we have and still achieve transformational change:

Change is transformational when it covers everyone and medical debt disappears. Some called "universal coverage" could have such weak benefits that it doesn't achieve those two goals. Health care is the core root of our economic troubles, it's the inability of employers to cope with costs, it prevents people from shifting out of their jobs, that risk taking is being sapped by our system, so we have to change that. We have to develop a system that holds us collectively responsible for making the care better, safer, and less costly.

Those components would make transformational change. You can build on what we have in so many ways I almost don't care exactly what it looks like. If I were paid tomorrow thorough Medicare, by dealing with AETNA, or by dealing with the VA, I can see using them in ways that achieve those three things above to make transformational change.

In Massachusetts, we have coverage, but it's reaching the point that it's so expensive, that we're now in the debate - we're not debating rolling back the system, it's so popular - but are we are debating cutting benefits, raising taxes, or cutting payments. That is exactly where we need to be. Right now at the federal level, when we get into economic trouble with health care, we cut people off.

On the role of single payer supporters in the political process:

We want the energy of everyone who wants these goals pointed in the direction of fighting as hard as we can for them. The common beliefs are in these goals I talked about before, in the practicalities of how you make something real without killing people in the process. On a practical level, when they start thinking what they would do on January 1, all the idealists would suddenly become incrementalists. The abstract discussions polarizes us too much. When we imagine implementation, there actually is more common ground than we understand.

On payment reform:

I kind of imagine it will take us a long time to change the way we pay doctors and hospitals, but I'm in favor. I like the Medicare experiments that tell doctors if you spend less money this year and improve quality, we'll let you keep some of the savings.

One of the things we've come up with is a checklist for surgery. Most places don't have tools in place to let them figure out how they can provide better care, safer care, make it simple and cost effective. Kaisers or the VA can move faster because they are integrated. But I grew up in a little town in Ohio with a small hospital. They're a long way from being an integrated system, but they can use a checklist and make it a simple part of their care. If we wanted to make care better next we, we would start asking are we killing fewer people than we did before? Are heart disease deaths dropping or rising? And what can you as a patient expect when you go in for an operation? Kaiser became the 1st population in the world that made cardiac disease no longer the #1 killer. They did it by making everyone who aught to be offered certain treatments actually was. That would cut heart disease deaths in half if applied nationwide. To do it every day, you have a checklist.

That component is missing in what we fund or care about because we're all solo agents, nobody is taking a look at the bigger picture.

Ron Pollack on strange bedfellows and where the differences are between advocates and the health industry:

In the summer, we helped organize what we call a "health reform dialogue," a strange bedfellows dialogue. There are 20 organizations involved in this process, running the gamut ideologically and interest groups. AHIP, Blue Cross, 3 business groups (NFIP, the Chamber), PhRMA, AMA, AHA, for-profit hospitals, SEIU, AFSCME, Families USA, etc… We played a helpful role in getting it started, and we've been meeting a lot since the summer. One of the things I've learned from this, I know where the sharp dividing lines are.

My own view, which I feel very strongly, is that it's very unclear whether the President or key leaders in Congress are prepared to move immediately on health care reform. We're getting good rhetoric and promises, and there's sincerity, but there are real temptations to do something else first, like balance the budget, that could divert the process. Try to put yourself in the shoes of the President, deciding what are we going to do next after the stimulus. Those that are close to you will say, "Why risk your Presidency in health care reform? Look what happened to Clinton." My view is, our best chance of trying to make reform a top priority is to try and change the context. I don't for one moment think we can reach an agreement on every issue, certainly not significant ones. But I think we need to see how much we can do to achieve common ground, and show that to Congress and the President, if we're going to make reform an early priority.

Industry groups spent money last time around in 1993 and were able to move the public. To the extent we can lower the temperature this time around, I think it's a very important thing to do. To the extent we have disagreements, we have levels of personal trust so we can minimize the friction. I believe intensity trumps numbers, and generally the intensity is on the opponents side. They say, "I'm going to spend every dollar, every dime, to defeat this." To the extent we can lower the temperature and insulate some of these battles, I think that's very important.

Everyone knows the differences in judgement between business, labor, and insurance companies, but the level of personal trust there this time is something that's different than anything before. It means on the CHIP fight, we got 16 strange bedfellow organizations to sign a letter to say pass it, despite Republican opposition. We've done two multi-million dollar ad campaigns, announcing a new $13 million campaign shortly. It's true, it was a very soft message, but there are opportunities to change the dynamics.

Where are the main differences we have with the insurance industry? I would say there are three areas of differences, not necessarily intractable. One difference relates to insurance market reform. The industry has come a distance from where they were. On things like guaranteed issue [pre-existing conditions], eliminating underwriting, differences in premiums based on health status, they've moved. The industry's position, which is substantial movement, is if we have a system where we have close to universality, linked to an individual mandate, they could agree to guaranteed issue and dealing with different rate structures. They are pretty close to agreeing to community rating. The tougher question on that issue is what happens if we don't have an individual mandate. Obama does not support a mandate beyond 25 years of age. Or what happens if there aren't adequate subsidies to make a mandate feasible. What happens then? That's an ongoing conversation.

To get market reform, you're probably going to need a mandate, to get a mandate, you need subsidies, to get subsidies, you need financing. Reform's biggest potential for breaking apart is the subsidies and how you pay for it. If we don't get a mandate, or we don't get adequate subsidies, then what do we do about market reform? We're trying to think through ways that can be dealt with, things like automatic enrollment.

Issue #2 is Medicare Advantage. This is a program that Obama and all of us have identified as a windfall to private insurance. The industry recognizes this is a losing fight. There is really a lot of flexibility on this, even though publicly they will resist it.

Issue #3 is the tougher nut, the public plan. That's where the hard line is. I don't think it's the health insurance industry, it's also the doctors, hospitals, PhRMA, device makers, business, everybody. The cost shifting report was their opening salvo. That is going to be a really tough issue. When you hear questions of bipartisanship, that's the toughest thing to achieve as part of a bipartisan package.

On timing and political will:

When Clinton left the White House in 2000, there was a small gathering, and it was perhaps the most revealing conversation I've had with Clinton on what he thought his mistakes were. He felt he made a mistake during the health care fight by not taking the hand of some Republicans who were offering to negotiate at the early stages of the process. At some point, because of Bill Kristol and Newt Gingrich, there no longer was a hand to take.

That dynamic teaches me one of the biggest mistakes in 1993 was that the health care reform speech wasn't given until September of 1993, and the proposal wasn't dropped until November. Before that, you had the debate about NAFTA, balancing the budget, and the debate about gays in the military. By Sept of 1993, whatever capital Clinton had brought in, a lot had been expended. At the very beginning, after he was elected, there was this aura of inevitability. That dissipated over time, and by the time September rolled around, that was gone. This had a huge impact on how Republicans handled the fight. At the beginning, you had Dole and John Chafee and a bare majority of Republicans saying they were ready to work with the President.

The more this thing gets put off this time around, well, time is against us. The more that aura dissipates, the worse our chances. And it's not simply with the Republican party, it's opinion leaders and others. Timing is absolutely essential.

My prediction the biggest fight on health reform to get to "yes" is going to be on subsidies and how you pay for it. That's the fight, that's where we'll win and lose.

On holding together the Democrats:

It's very hard to achieve discipline in the ranks of the Democratic party. I'm not sure Clyburn's position had been carefully thought through before he made it. That is not a slam on Clyburn, I respect him very much. The same thing happened with Pete Stark. He sent out a statement right after modifying his position. The leaders on the Democratic party on health care reform all want to happen immediately. All of them. Whether it is Baucus, Kennedy, Waxman, Rangel, Miller, they all, and I mean all, strongly believe it has to happen and happen quickly.

On bipartisanship:

Max Baucus, who's chairing the committee with the biggest say, has been saying for months now that he wants to pass reform with 70 to 80 votes. I don't know how he feels about it today after the bruising battle on SCHIP, mainly over the immigrant issue which shouldn't have caused such a rupture.

The media is talking as if bipartisanship is a virtue all to its own. I believe in it, but it's not the top value. Obama will make a sincere effort, and Baucus works closely with Grassley. Whether the differences between the leadership of the two parties can be bridged, it's too early to say.

Paul Begala on the mistakes of the Clinton health care reform battle:

Why did we fail? First, money. More money was spent opposing that bill than any bill in the history of America - over $100 million. Supporters of the bill spent $15 million. Today, Obama just spent $600 million running for President, and the average donation was $86. He has the capacity to meet or beat the spending of special interests.

Second, we put policy ahead of politics. We set up task force, met behind closed doors, there were all sorts of smart people in the room. But fundamentally, the issue a legislative problem, not a policy problem. It's about the best way to pass a bill. Today, we have retired Senate Majority leader Daschle in charge. Daschle is both White House staff and part of the Cabinet, which means there will be a unity of purpose between agencies and the White House.

Third, we left the Hill out. Obama will not make that mistake. He will come to the hill with principles but start engaging them earlier.

Fourth, we favored complexity over clarity. We had a 1,000 page bill.

Fifth, we allowed the perfect to be the enemy of the good. A President aught never to say he'll veto a bill for what is not in it.

Sixth, we had some feckless Democrats in Congress in 1993. The Chairman of the Senate Finance Committee said there was no health care crisis! Max Baucus is not saying that. This new President has a higher class of Democrats working with him. Some of that is just the changing times.

Seventh, we completely misunderstood the communications challenge. Everything in the memos we wrote was about press events that we did. The press did its job. But they couldn't do it enough. The essence of communications is repetition - you have to advertise. The money Obama can raise and the new media he has, this is completely new. He's at the center of a community of 15 million people. He understands the iterative, interactive nature of this. He listens and learns from the feedback loop.

Finally, we had a different opponent then. I don't hear many people in the health care industry saying just say no to a bill this time. They made a decision in 1993 to kill anything and everything. That was a big risk, and it paid off. The nature of industry is different now, they're looking for reasonable compromise. Gingrich has said, social security isn't the third rail of American politics, the real third rail is health care.

And yet, I'm endlessly optimistic, because the moment, the man, the message, the media environment are coming together.