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Critical: What We Can Do About the Health-Care Crisis

Critical: What We Can Do About the Health-Care Crisis By Tom Daschle (with Scott S. Greenberger and Jeanne M. Lambrew) 226 pp, $24.50 New York, NY, Thomas Dunne Books, St Martin's Press, 2008 ISBN-13: 978-0-3123-8301-5 Seldom has a volume appeared on the bestseller list, only to be banished days later as literary (and political) tastes and preferences changed. But that is what happened to Tom Daschle's Critical: What We Can Do About the Health-Care Crisis. As the former Senate Majority Leader's nomination as Secretary of Health and Human Services came and went, so did the fortunes of this slim volume—a blueprint of what might have been, had Daschle not come under tax scrutiny. Senator Daschle's misfortune is a loss for all interested in meaningful health care reform. As Critical demonstrates, he was a student of and participant in earlier reform efforts and learned invaluable lessons. His departure from the political spotlight makes it all the more important to heed his words as an author. Most important, Daschle learned to couch the lack of access for 47 million persons in the United States as a moral question. Unlike the Clinton Plan, which was motivated by economic concerns, the Daschle Plan would have been informed by an ethical obligation to a citizenry facing the consequences of a lack of coverage. Making the moral argument, Critical begins with heartbreaking stories. Consider the saga of Donna S. Smith, a South Dakota journalist Daschle met when he was on the campaign trail. Smith and her husband declared bankruptcy after they both fell ill and lost their jobs as well as their employee-based health coverage. As Mrs Smith put it, “the life we worked so hard to build and the life we fought to save was lost. The health-care system had crushed us.” Mrs Smith held Congress responsible for her pain and anguish. At a Congressional hearing she railed, “ . . . You left me broken and battered because you failed to act on health-care reform . . . others will come forward to hold you accountable. Remember the hard-working people who elected you. Their bankruptcy shame due to medical crisis is really your shame.” Daschle, the former legislator, takes Mrs. Smith's indictment of Congress personally. Critical is his attempt to understand Washington's collective failure to achieve universal access to health care in the time since Harry Truman first attempted it in 1945. With an eye toward penance and constructive atonement, Daschle recounts decades of history with a keen appreciation of the politics behind the fatal omissions, compromises, and polemics that continue to make reform so elusive. For example, Daschle suggests that Truman did not succeed in part because Southern politicians “feared that federal involvement in health care would lead to federal action against segregation.” Presidents Kennedy and Johnson overcame fears of an expanded federal role and worries about socialized medicine because they were savvy enough to appreciate the increasing political power of the “elder vote.” Their efforts would culminate in Medicare, a bill Johnson signed at Truman's Independence, Missouri, home with the former president at his side. A critical opportunity was lost when President Carter replaced his entire cabinet mid term. This included Secretary of Health, Education, and Welfare Joe Califano, who would have been critical to implementing a compromise reached between Senator Ted Kennedy and the administration guaranteeing universal coverage while preserving a role for private insurers. Achieving such a workable public-private balance has been a perennial challenge. Most recently it led to the ill-fated Clinton-era compromise of “managed competition,” a strategy no one liked but that was “one of the few options that could unite liberals and conservatives.” Daschle knows this history well and recounts it masterfully, drawing lessons that remain relevant. From the Clinton Plan, he learned that Congress is the wrong place to make allocation decisions. He knowingly writes that “In my experience, the challenge of passing a bill is directly proportional to its size.” This is precisely what Ted Sorenson, President Kennedy's closest advisor, told me in 1994 after the demise of President Clinton's 1342-page Health Security Act. When I asked him what Kennedy would have done, he pointed upward, toward an imaginary Capitol Hill, and said he would have sent a 13-page bill up there and then worked out the details. Instead of making comprehensive and potentially dated coverage decisions, Daschle suggests that Congress create a “public-private infrastructure similar to the one we have constructed for our monetary system” under which “our health-care system would function.” To that end, Daschle proposes the creation of a Federal Health Board (Health Fed), modeled on the Federal Reserve. As envisioned by Daschle, the Health Fed would be constituted by presidentially appointed governors confirmed by the Senate for 10-year terms. Each would be a health policy expert or clinician of high stature. Collectively they would be charged with making coverage decisions for all federal programs based on the best available evidence, much like Britain's National Institute for Health and Clinical Excellence. The Health Fed would be complemented by regional boards, analogous to regional Federal Reserve banks, which would bring national priorities to local markets. Although this analogy might be a tough sell amid collapsing markets, the demise of the financial sector has not been a result of the failure of regulations but rather of the failure to regulate and to do so intelligently. Much the same could be said for the patchwork of US health care. As Daschle points out, even the 100 million persons in the United States who are covered by the federal government receive differing benefits. Daschle argues that the Health Fed could yield more coherent and consistent policies. It would set the rules for an expanded Federal Employee Health Benefit Plan—available to all US citizens not covered by employee or individually mandated coverage—and likewise serve as a benefit benchmark for private insurers. Finally, it would also help to align incentives with quality care, focusing more on outcomes than on the volume of services delivered. Daschle's plan is novel and remains worthy of serious attention. One can only hope that President Obama will take a page from Critical: What We Can Do About the Health Care Crisis, realize Truman's dream of universal access, and sign historic legislation with Daschle at his side. Back to top Article Information Financial Disclosures: None reported. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA American Medical Association

Critical: What We Can Do About the Health-Care Crisis

JAMA , Volume 301 (13) – Apr 1, 2009

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Publisher
American Medical Association
Copyright
Copyright © 2009 American Medical Association. All Rights Reserved.
ISSN
0098-7484
eISSN
1538-3598
DOI
10.1001/jama.2009.382
Publisher site
See Article on Publisher Site

Abstract

By Tom Daschle (with Scott S. Greenberger and Jeanne M. Lambrew) 226 pp, $24.50 New York, NY, Thomas Dunne Books, St Martin's Press, 2008 ISBN-13: 978-0-3123-8301-5 Seldom has a volume appeared on the bestseller list, only to be banished days later as literary (and political) tastes and preferences changed. But that is what happened to Tom Daschle's Critical: What We Can Do About the Health-Care Crisis. As the former Senate Majority Leader's nomination as Secretary of Health and Human Services came and went, so did the fortunes of this slim volume—a blueprint of what might have been, had Daschle not come under tax scrutiny. Senator Daschle's misfortune is a loss for all interested in meaningful health care reform. As Critical demonstrates, he was a student of and participant in earlier reform efforts and learned invaluable lessons. His departure from the political spotlight makes it all the more important to heed his words as an author. Most important, Daschle learned to couch the lack of access for 47 million persons in the United States as a moral question. Unlike the Clinton Plan, which was motivated by economic concerns, the Daschle Plan would have been informed by an ethical obligation to a citizenry facing the consequences of a lack of coverage. Making the moral argument, Critical begins with heartbreaking stories. Consider the saga of Donna S. Smith, a South Dakota journalist Daschle met when he was on the campaign trail. Smith and her husband declared bankruptcy after they both fell ill and lost their jobs as well as their employee-based health coverage. As Mrs Smith put it, “the life we worked so hard to build and the life we fought to save was lost. The health-care system had crushed us.” Mrs Smith held Congress responsible for her pain and anguish. At a Congressional hearing she railed, “ . . . You left me broken and battered because you failed to act on health-care reform . . . others will come forward to hold you accountable. Remember the hard-working people who elected you. Their bankruptcy shame due to medical crisis is really your shame.” Daschle, the former legislator, takes Mrs. Smith's indictment of Congress personally. Critical is his attempt to understand Washington's collective failure to achieve universal access to health care in the time since Harry Truman first attempted it in 1945. With an eye toward penance and constructive atonement, Daschle recounts decades of history with a keen appreciation of the politics behind the fatal omissions, compromises, and polemics that continue to make reform so elusive. For example, Daschle suggests that Truman did not succeed in part because Southern politicians “feared that federal involvement in health care would lead to federal action against segregation.” Presidents Kennedy and Johnson overcame fears of an expanded federal role and worries about socialized medicine because they were savvy enough to appreciate the increasing political power of the “elder vote.” Their efforts would culminate in Medicare, a bill Johnson signed at Truman's Independence, Missouri, home with the former president at his side. A critical opportunity was lost when President Carter replaced his entire cabinet mid term. This included Secretary of Health, Education, and Welfare Joe Califano, who would have been critical to implementing a compromise reached between Senator Ted Kennedy and the administration guaranteeing universal coverage while preserving a role for private insurers. Achieving such a workable public-private balance has been a perennial challenge. Most recently it led to the ill-fated Clinton-era compromise of “managed competition,” a strategy no one liked but that was “one of the few options that could unite liberals and conservatives.” Daschle knows this history well and recounts it masterfully, drawing lessons that remain relevant. From the Clinton Plan, he learned that Congress is the wrong place to make allocation decisions. He knowingly writes that “In my experience, the challenge of passing a bill is directly proportional to its size.” This is precisely what Ted Sorenson, President Kennedy's closest advisor, told me in 1994 after the demise of President Clinton's 1342-page Health Security Act. When I asked him what Kennedy would have done, he pointed upward, toward an imaginary Capitol Hill, and said he would have sent a 13-page bill up there and then worked out the details. Instead of making comprehensive and potentially dated coverage decisions, Daschle suggests that Congress create a “public-private infrastructure similar to the one we have constructed for our monetary system” under which “our health-care system would function.” To that end, Daschle proposes the creation of a Federal Health Board (Health Fed), modeled on the Federal Reserve. As envisioned by Daschle, the Health Fed would be constituted by presidentially appointed governors confirmed by the Senate for 10-year terms. Each would be a health policy expert or clinician of high stature. Collectively they would be charged with making coverage decisions for all federal programs based on the best available evidence, much like Britain's National Institute for Health and Clinical Excellence. The Health Fed would be complemented by regional boards, analogous to regional Federal Reserve banks, which would bring national priorities to local markets. Although this analogy might be a tough sell amid collapsing markets, the demise of the financial sector has not been a result of the failure of regulations but rather of the failure to regulate and to do so intelligently. Much the same could be said for the patchwork of US health care. As Daschle points out, even the 100 million persons in the United States who are covered by the federal government receive differing benefits. Daschle argues that the Health Fed could yield more coherent and consistent policies. It would set the rules for an expanded Federal Employee Health Benefit Plan—available to all US citizens not covered by employee or individually mandated coverage—and likewise serve as a benefit benchmark for private insurers. Finally, it would also help to align incentives with quality care, focusing more on outcomes than on the volume of services delivered. Daschle's plan is novel and remains worthy of serious attention. One can only hope that President Obama will take a page from Critical: What We Can Do About the Health Care Crisis, realize Truman's dream of universal access, and sign historic legislation with Daschle at his side. Back to top Article Information Financial Disclosures: None reported.

Journal

JAMAAmerican Medical Association

Published: Apr 1, 2009

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