CQ TODAY ONLINE NEWS
Feb. 13, 2009 – 5:57 a.m.
The HHS Choice: Burned Once? That’s Enough
By Madison Powers, CQ Guest Columnist
When President’s Obama’s nomination of former Sen. Tom Daschle for secretary of Health and Human Services fell apart, most observers were at a loss to think of who might fill the void. Some obvious names came to mind because of their knowledge of the health care system, but many were dismissed from the realm of serious speculation because they were seen as inadequate for the daunting political task at hand.
The Daschle nomination seemed a truly inspired choice. He is the consummate Washington insider with a Rolodex (Blackberry, actually) as well-stocked as any in town. He has unparalleled knowledge of all aspects of the legislative process. He’s even co-authored a book on health care overhaul.
A lesser known fact about Daschle is that he was one of the very few members of Congress who managed to get a major staffer a place at the table within the Clinton administration’s health care task force. He has first-hand understanding of what went wrong in the process that involved almost 500 people but lacked serious consultation with the key members of the legislative branch.
Ultimately, it was Daschle’s choice to follow the trend of insiders cashing in on their years of public service that did him in. The tax issue was the wedge — but the final blow to his nomination was the emerging portrait of his participation in the shadowy world of consultants and advisers whose activities are ill-defined and unregulated either by the professional norms of lawyers or the legal transparency requirements of lobbyists.
Initially, the idea of someone from beyond Washington, a governor perhaps, seemed attractive to outside observers, and if reports are accurate, appealing to the administration as well. Nonetheless, Daschle’s fall from grace was a stark reminder of how much is lost by not selecting someone skilled in the legislative sausage-making process.
One name among the list of governors to surface a week ago was greeted with instantaneous grass-roots opposition. As soon as Tennessee Democratic Gov. Phil Bredesen ’s name was reported by Marc Ambinder in The Atlantic as a serious candidate, perhaps even one of two finalists, the criticism was swift and severe.
Ron Pollack, executive director of Families USA — a national organization for health care consumers — was one prominent voice among Washington health care advocates to express profound displeasure. Tennessee health care activists and national health care advocates also jumped into the fray with sharp and even bitter condemnation of the very idea of even entertaining Bredesen as a nominee.
The health care access advocacy community, along with lawyers and health policy professionals, had for many years watched with disbelief as the drama of Bredesen’s management and oversight of Tenn-Care, Tennessee’s Medicaid program played out in great detail in the national news, academic journals, and court proceedings.
The first line of criticism is that Bredesen presided over massive cuts in Tenn-Care, stripping more than 300,000 people from eligibility and reducing coverage levels for others. While no one doubts that governors face hard choices in their Medicaid programs, almost all informed observers concluded that Bredesen opted for cuts that predictably have the greatest adverse impact on the most vulnerable citizens.
What made Bredesen’s decisions so appalling was the fact that the outcomes were avoidable, that many others offered suggestions that could have made fiscal discipline less painful to those least able to bear it, and that Bredesen silenced all of those other voices and made it clear that it was going to be the proverbial “my way or the highway.”
By mid-week, Move-On.org had joined the chorus of condemnation, sending out e-mails on Tuesday and Wednesday, making the case that this former health care industry multimillionaire would have been an ideal choice for the Bush administration, citing his record and given his almost messianic commitment to reducing entitlements and converting public programs along the lines of business models by which he made his fortune.
That same cost-cutting approach, no matter the consequences to the least well-off citizens, shows up again in his statements regarding the broader health care agenda. For years he has advocated increasing co-payments and out-of-pocket costs in order to create greater economic disincentive for health care utilization.
The advocacy of the cost-shifting approach, designed to hollow out the benefits of medical insurance coverage and impose more economic burden on patients, is not a new idea, but it has returned to fashion in conservative health policy circles.
The famous Rand Corporation study of such approaches has become a basic element of textbook knowledge in health policy circles. It showed a considerable differential impact on rich and poor patients. For low-income people, for whom increased co-payments pose a substantial barrier to access to timely and quality care, such a policy results in considerably worse health outcomes and diminished access to needed care.
Bredesen, it seems, wants to do to the nation’s already inadequate system of private health insurance what he imposed on the participants in Tennessee’s public program.
These are not policies one would associate with the stated ambitions of the new administration. Breseden’s promotion of these ideas from the position of HHS secretary would interject into health care overhaul debates just the kind of distractions that would fracture the fragile coalition for change.
Bredesen, however, struck back at his critics this week, telling the Wall Street Journal that his reputation was being unfairly maligned. He noted that “advocacy groups don’t matter nearly as much as the pharmaceutical groups, the hospitals, the doctors’ groups. There’s a lot of very powerful interest groups that will play in this thing.”
His defensive remarks are revealing. He is willing to entertain the ideas of advocacy groups who represent the interests of constituencies for whom he has respect, but the ideas of those who speak for ordinary citizens of modest means are dismissed as unimportant.
Bredesen’s name as a contender has drawn unusually pointed attacks, and it is not all about his policies. It is bad enough that Bredesen is out of step with the humane values that inform the commitment to universal, comprehensive health care.
But those who have followed the Tennessee saga through legislative hearings and voluminous court records know that his response to criticism is vintage Bredesen behavior. Over the years, first as mayor of Nashville and then as governor, a clear and consistent picture emerged of a political figure who is arrogant, autocratic, and seemingly allergic to legislative accountability.
His characteristically belligerent attitude to those who disagree with him, along with his misplaced confidence in the lessons from his own experience in the commercial health care sector, make him a singularly unsuited candidate for the job.
In fact, Bredesen has a head start in denigrating Washington politicians who disagree with him. In a June 24, 2005, National Press Club address, he chastised Democrats including Senate Majority Leader Harry Reid of Nevada and House Speaker Nancy Pelosi of California, by saying their commitment to Medicaid was “like beating a dead horse” while he lives “in the real world.”
Critics are right to hope that Bredesen’s potential nomination will turn out to be the only dead horse around by the end of next week.
Madison Powers is Senior Research Scholar, Kennedy Institute of Ethics, Georgetown University. His column appears each Friday in CQ Politics.
Comments
While it is laudable to express concern for the access to health care of people of modest means, it isn't very realistic. Health care spending will NEVER get under control so long as we entertain the notion that anyone should have access to all the health care they want with minimal contribution on their part and regardless of cost ... UNLESS you impose some form of rationing (waiting lists, permitting only those treatments "approved" as "cost effective") on everyone. Our economy and our society cannot shovel ever more money to satisfy the unlimited wants of people who view their health insurance (private as well as public) as a "use it or lose it" proposition. Lift the legislative mandates on what private insurance must provide. Allow people to shop for the kind of health insurance they want (no more employer-paid-provided health care; give people a tax deduction or even some tax rebate on what they pay for health insurance), and return the decision-making to the doctor-patient relationship.
This is a 'velvet hammer' and you hammered him good. I'm convinced. I knew nothing really about the man, but the background presented and his own record is very telling. Looks like a skunk, smells like a skunk, must be a skunk. We don't need any more 'bad picks,' and health reform is too important to cede to the least-best candidate in the running.
Madison Powers' Feb. 13 column on the future of the U.S. Department of Health and Human Services amounted to an intellectually dishonest attack on Gov. Phil Bredesen of Tennessee, whose name has been mentioned as a possible candidate to lead the agency. While Bredesen is not campaigning for the Cabinet post, those of us around him are loath to let attacks on him go unanswered. Powers' critique of Bredesen is startling, both for its ferocity as well as its lack of understanding of events surrounding the Volunteer State's Medicaid restructuring in 2005. Powers' treatise is beset by major errors of both commission and omission. He mischaracterizes Bredesen's longstanding philosophy on the need for universal health care at the federal level. And he altogether ignores, or at least distorts, the facts about what happened in Tennessee's Medicaid program, known as TennCare. Because Powers failed to put the situation in proper perspective, please allow me to do so. When Bredesen took office in 2003, he inherited what undisputedly was the most financially troubled Medicaid program in America. With 1.3 million people covered, Tennessee had the highest Medicaid enrollment in the nation on a per-capita basis relative to its population. Meanwhile, it had one of the lowest per-capita revenue collections. Total cost of the pharmacy benefit alone in TennCare had grown greater than the total cost of Tennessee's higher education system. At that time in the United States, the average number of prescriptions each year was 10. In the South, it was 11. In TennCare, it was 30. A study by McKinsey & Company found TennCare was on track to consume virtually all new state revenue, leaving little additional for education, public safety and other vital priorities. On top of its unsustainable growth, TennCare faced fundamental operational problems. Prior to Bredesen's taking office, the program had been dramatically expanded under the premise of managed care. But most of the managed-care organizations (MCOs) responsible for administering the program had become insolvent. Fueling problems was the fact that the program was hamstrung by pre-existing legal settlements in federal courts that made it impossible to effectively administer the program and bring costs under control. To save TennCare from the brink of collapse, Bredesen worked overtime to negotiate with legal advocates. He sought relief from federal legal settlements so adult disenrollments would not be necessary. When advocates refused to grant relief, he kept working hard to hold adult disenrollments to a minimum, while maintaining and later expanding full coverage for children and establishing a series of safety-net programs to provide continued assistance to adults. It is important to note that the adults who lost coverage would not have qualified for Medicaid assistance in virtually any other state. That does not diminish the difficulty that enrollees experienced during that period. But it underscores the fact that TennCare was and is unique among U.S. Medicaid programs, which will always complicate efforts to finance it. When Bredesen scaled back TennCare, he did the only thing he could do to keep the program from bankrupting the state. Tennesseans approved, resoundingly. In 2006, voters returned Bredesen to office for a second term with the largest re-election support in Tennessee history -- mainly on his record of bringing TennCare under control in a responsible and humane manner. Today, TennCare is financially stable for the first time. The program's managed-care organizations are solvent, and TennCare is the first Medicaid program in the nation to require its MCOs to earn accreditation from the National Committee for Quality Assurance. Working through the federal courts, the state gained limited flexibility inside the pre-existing legal settlements. Fraud and abuse are being aggressively attacked, with savings going back to the program. Following enrollment reductions, TennCare remains one of the most comprehensive state health plans in the nation, with approximately 1.2 million enrollees, or about 100,000 less than it had in 2003. Unfortunately, none of this context is mentioned by Powers in his column. Additionally, he makes several statements that are patently inaccurate. For example, he suggests that Bredesen opposes universal comprehensive health care. To the contrary, the governor has for years said and reaffirmed as recently as this week that he believes in a national solution for health insurance. Powers claims that Bredesen's support of patient co-payments -- fairly standard practice in most financially sound health plans -- is somehow part of a conspiracy to create an "economic disincentive for health care utilization." In perhaps the most outrageous portion of his column, Powers actually inserts words in Bredesen's mouth and claims he denigrated Senate Majority Leader Harry Reid and House Speaker Nancy Pelosi in a 2005 speech to the National Press Club. The entire text of the speech, which can be found easily online, reveals the governor leveled no such criticisms -- not to mention the fact that neither Reid nor Pelosi were even in their current leadership positions at that time. Instead, the Press Club speech demonstrated the kind of thoughtful approach to healthcare reform that is emblematic of Bredesen's approach to governing in Tennessee. Finally, most troubling is Powers' visceral attacks on character and values despite not knowing the governor and likely never having met him. He certainly made no effort to contact the Governor's Office to solicit differing viewpoints or even confirm the veracity of his claims prior to publication. As a Georgetown academic and a CQ Politics columnist, he demonstrated either a total lack of intellectual curiosity or, worse, a complete disregard for the facts. In Tennessee, we've got thick skin. Bredesen, in particular, is used to criticism, which obviously comes with the territory when you're making tough decisions. But Powers' commentary amounts to one of the more irresponsible and inaccurate attacks we've seen. Not long ago, New York Times Public Editor Clark Hoyt wrote that opinion pages are, quite properly, "home to a lot of provocative opinions." But he added: "All are supposed to be grounded on the bedrock of fact." Unfortunately, Madison Powers' column is built on shifting sands of half-truths and distortions about what actually happened in Tennessee.
I spent almost 20 years dealing with TN Medicaid policy, including being closely involved in many of the TennCare battles during Gov. Bredesen's tenure. Mr. Powers is absolutely correct - both factually and with regard to the approach taken by the governor toward both the issue and people who desperately need health care. The bottom line is that the cuts Bredesen made - in both eligibility and benefits - were completely unnecessary. And it became clear to me that the governor did not believe American (or at least Tennessean) human beings had any "right" to health care (as he now says they do - since he's running for HHS secretary). I can't really add much else, except a heartfelt AMEN to the truth. Unfortunately, it's a reality few people in TN or across the country could ever fully appreciate. Powers captures it perfectly. And I've met the governor and talked with him about TennCare - MANY times.
The article, and comments, ignore the obvious choice for head of HHS: Dr. Howard Dean UPSIDE * Long-time practicing physician: content knowledge * Repeatedly re-elected VT governor: admin experience * VT covered all kids and pregnant women with health care * He balanced all annual budgets, in a state where not required to do so, important considering previous * * As former DNC chair, he knows everyone, get stuff done DOWNSIDE * Emanuel hates him: They clashed while he was head of DCCC over Dean's 50-state strategy (which turned out great for the Ds in '08). This makes him a non-starter. While the O admin can countenance a R mole like Gregg who did them damage, they cannot handle a member of a "team of rivals" who has delivered the Ds a great deal of benefit, and who is fit for the job?
We certainly needed this assessment of Bredesen. The rarity of its appearance speaks volumes about the torpor of the USA's "news" industry. The suggestion for Dean at HHS is excellent if only because Obama, Inc.'s, unwillingness to include dissident voices inside their ranks is becoming alarming. Will we see anyone in the punditry willing to take this on? I believe in miracles, but am not fool enough to count on them when we most need one. Mr. Powers at least sets a standard for presenting a comprehensive, poignant assessment of wannabe initiates into upper administrative ranks. It would still be very redeeming to have such an assessment of Obama's economic team. It boggles the mind to see the administration so enthusiastically following the advice for finding an exit from our political economy's woes from the very creators (theories and people) of these woes. But what the bleep can anyone outside the inner circle know about anything intelligent? Judging from (afar, of course) how rapidly Obama, Inc., is consolidating administrative powers, and how rapidly our supine as well as anarchic congress is falling in line, and how historically marginal in relevance the court system loves remaining (so long at the system's chief clerics continue getting treated like first rank celebraties), one need not be devoted to Hannah Arendt's writings to suppose the nation's future non-totalitarian coherence can be numbered in months because years no longer count as units of measure held in common by we provincials and our rulers (who used to be public servants). Is it vain to refuse to become cynical?
Mr. Pinkston's arguments about Governor Bredesen's dismantling of TennCare center on secondary questions of causation and responsibility. What is of primary concern in evaluating the Governor's qualifications for a cabinet post is a reality that even Mr. Pinkston cannot deny: Mr. Bredesen failed to deliver on his promise to save and strengthen Tennessee's public health insurance program. Tennesseans now have less health coverage. The health care infrastructure of the state is more precarious. Infant mortality has risen in the state, in contrast to the rest of the nation. Tennessee is dead last in support for families trying to care for frail loved ones at home. Tennesseans lead the nation in personal bankruptcies due to medical debt. The failure to manage TennCare has exacted a tragic human toll. (See http://www.nashvillescene.com/2005-11-24/news/the-faces-of-tenncare/) Governor Bredesen's supporters defend his failure to save the health coverage of hundreds of thousands of Tennessee's most vulnerable citizens by arguing that cutting their coverage was the only thing he could do. Like Mr. Pinkston, they blame financial problems left by Governor Bredesen's predecessor, spiraling costs, poor performance by government contractors and the opposition of those who disagreed with his policies. (Judge for yourself: http://www.tnjustice.org/tenncare/tenncare%20chronology.htm.) The next Secretary of Health and Human Services will face the very same problems, in spades. How does Governor Bredesen's failure to overcome those obstacles in a small state qualify him to try again on a national stage?
As an attorney who has represented at-risk children and families in Tennessee for many years, I have closely followed Governor Bredesen's many unwarranted "reforms" of TennCare. In fact, many of my clients, including poor grandmothers and between-the-cracks teens, were directly and catastrophically impacted by his unfounded and senseless actions. I call them that because well-considered cost-savings alternatives were offered and dismissed by the governor out of hand. In doing this, Bredesen would always go out of his way to deride and belittle consumer advocates, health care policy experts, and real people who were really getting hurt. All that said, I am a person who is confident that our new president aims to deliver real change I can believe in, and wouldn't possibly pick Bredesen. Moreover, I am certain he has learned his lesson from the Judd Gregg incident: You can't rely on someone whose views on key issues are diametrically opposed to your own. That is certainly the case with Bredesen.
On the federal level, we need an HHS secretary whose first concern is the delivery of health care, NOT one whose "business model" makes money for the HMOs and insurance industry by denying health care. The health of the nation would suffer under the approach Bredesen has taken here in Tennessee.
In 2004, I was in a meeting with other advocates with Governor Bredesen. The advocates came to this meeting with the understanding that we would discuss solutions to fixing TennCare. There was no discussion. The Governor came in and berated the advocates for not agreeing with him. He said that he believed that everyone should have health care. However, there was no discussion. Initially, the governor said that he only had 5 minutes. Thirty minutes later, he was still berating the advocates and then left the meeting. Since that time, 170,000 Tennesseans lost their health care in 2005. In January, 2006, another 25,000 low-income elderly and disabled lost their TennCare. And from June 2005 to October 2008, another 90,000 people who were in the Medically Needy category lost their coverage. This is not to mention the benefit restrictions the governor has placed on the program, limiting drugs to no more than 2 brand drugs per month, reducing home nursing services, and weakening people's appeal rights. However, what makes Bredesen most unfit for the job as Secretary of HHS is the disdain and callousness that he shows for adults on TennCare. An example of this was in order to win public support for cutting the program, he characterized the program as riddled with fraud. Advocates would point out that these problems are manageable and no worse than in other states. This was ignored. In the same breath, he made a big deal out of not cutting the Medically Needy Program, giving the public and the medically fragile on TennCare the impression that those with serious medical needs would not be cut. However, the Medically Needy Program is a narrow eligibility category that only helps a few. Since the announcement that he would keep this program, in 2005, the program was frozen and never opened again. The 97,000 adults who got TennCare through this program now number about 5,000 adults. In 2005, the governor reluctantly established a very limited safety-net with state-only money. However, people still died because of lack of care and the health of hundreds of vulnerable people was compromised because of losing their TennCare coverage. When people spoke up about the possibility that people would die, their concerns were dismissed as "reactionary". We now know that these cuts in eligibility were not necessary and there were better ways to deal with these challenges. And to top this off, the eligibility cuts did not save the state any money . Additionally the state has lost the 2/3 federal match, over $2 billion dollars in three years. So, Governor Bredesen got his way, over 300,000 adults have lost their care, and Tennessee's Medicaid/TennCare program is now more restrictive than it was in 1993 before TennCare was created. This is not much of a record for a nominee for Secretary of HHS to lead the country in a new direction to provide coverage for all Americans.
In the course of his campaign to justify cutting coverage for TennCare recipients, Gov. Bredesen gratuitously vilified the health care advocates. They are among the most conscientious and honorable people I know. Bredesen's attacks diminished himself, not the advocates. He promised to reform TennCare, but instead he slashed access to care without making any effort to contain rising costs charged by for-profit hospitals, private practitioners, pharmaceutical companies, medical equipment and supply vendors or insurance companies. It was clear his main interests were aligned with shareholders and campaign contributors, not the sick.
Madison Power's thoughtful analysis seems to highlight two major issues with Gov. Bredesen. One is his substantive views on health care reform - he may have cut costs, which certainly needed to be done, but his Tennessee record shows that he has failed to pursue reasonable alternatives to the draconian measures he imposed. Second, his disdain for the health care advocacy community means he has already alienated a major - really the major - constitutency in health care reform. If Gov. Bredesen's decisions and governing style have already started the blame game and engendered such a backlash, how could he possibly have the skills and support to tackle this problem on a national level? There aren't many people out there with Tom Daschle's credentials, but there are certainly far better and less controversial choices than Gov. Bredesen. I'm too old to have stars in my eyes, but I feel that his appointment will dispel so much of my hope and excitement about our new Administartion.
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