National Institute of Health Policy - Advancing health policy dialogue

Commentary from Dave Durenberger
Monday, August 22, 2011

What to Make of the “Week From Hell”

We were enjoying life at the foothills of the Teton Mountains of Wyoming while the stock market reacted to S&P’s reaction to our national political leader’s reaction to the Tea Party demands we lower federal spending in exchange for increasing our borrowing. Or maybe it reacted to the decision to delegate the future of federal spending/taxing policy to 12 members of the Congress.
In any event, no one in a position of leadership in this country seems to have the foggiest idea about what the U.S. economy of the future may look like compared to the one that was knocked for a loop by the “great recession of 2008-09.” We aren’t just mad at Washington or at political polarization. Or tired of listening to a president explain away his apparent inability to understand the leadership challenge he inherited in November 2008.
We know that the “old economy” on which we’d built hopes for our retirement and for our children and grandchildren’s education and “lives better than our own,” is over. We know instinctively there will be a new, leaner, more competitive and productive American economy. That it is likely to require us to change our expectations and our behavior. What troubles most of us is not knowing whether any of our business, professional or political leaders know this. Or, if they do, why are they so reluctant to cut us in on it?

Is There Enough of This Economy to Go Around?

That might explain why politicians won't speak out. That the economic benefits will be disproportionately allocated to those with the means to invest in change? Rather than to those whose efforts are essential to making it work? That the nature of a “job” and its compensation benefits will have to change so there may be more jobs for more people? American business and the industry that finances it, with rare exceptions, has come out of the recession fairly well off.  But their employees have not, and these are the consumers upon whom much of the business economy depends. 
So blaming Washington, D.C., or polarized politics or government deficits, regulation, spending, taxing for the slow reformation of the American economy is unhelpful. Americans are in the grips of uncertainty and insecurity right now. The old economy is as dead as persistent unemployment. Whether delivered to political markets by Democrats and Republicans or to stock and commodity markets by business leaders. The key to certainty is restored confidence in persons in positions of leadership. That means leaders who will take the heat for tough news, stop blaming others for our problems, and who can articulate a vision of the future. 

A Really Good Crisis is Too Important to Waste

Because the real ones are rare. We had one in January 2009 when a Democratic president succeeded a two-term Republican and had to make immediate and decisive decisions. We were losing 800,000 American jobs every month. He was forced to rely almost entirely on his own majority in the Congress to deliver policy product that first year, because within six months, it was clear the new Republican minority was committed to making him a one-term president.
It's a rare American crisis that does not bring us closer together. Financial crisis, national security crisis, the assassination of a president or the attack on our homeland. This crisis did not unite us. We were already divided. Sarah Palin proved that from the day she was announced as John McCain's running mate. It was clear on Election Day 2008 that we needed a president who generated hope in our mutual future. One of those "If not us, who?  If not now, when?" moments.

An Underperforming President

“Is he shrewd, or simply weak?” says The Economist of President Barack Obama (8-6-11). That's a question we've been asking a lot lately. The answer seems to be coming in Obama approval ratings as low as 39% and "wrong-track" opinions of America near 80%.  Drew Westen, a professor of psychology at Emory University has our pulse with his Aug. 7th New York Times opinion. “The stories our leaders tell us matter, probably almost as much as the stories our parents tell us as children, because they orient us as to what is, what could be, and what should be, the worldviews they hold and the values they hold sacred.”  
In my lifetime I recall John F. Kennedy and Ronald Reagan as presidents with a gift for this kind of “story-telling.” Neither of them was dealt as challenging a hand as the one we dealt President Obama. Because of the “promise” inherent in “change we can believe in,” our expectations of a relatively inexperienced president were high. We cut him a lot of slack in his first year or two. While we waited for him to deal with this new economy and the realities of old wars, natural and corporate disasters, and democratic revolutions.
Remembering the 2008 campaign, however, we expected that each time we faced a crisis together and he spoke to us with the weight of his new office, he would explain “what is, what could be, and what should be.” Not once, however, has he touched us as he did in 2008. So we have come to doubt whether this president has a principled belief system and a set of personal values on which to rest his office, his views on the role of government and of America at this time in our history.

"If Clinton wanted to be president 25 hours a day, and we wanted to be president 4 hours a day, Obama wants to be president about 14 hours a day. And that's fine, as long as you don't look like you're phoning it in when the country is dialing 911."  Maureen Dowd, New York Times, August 21, 2011

Life is 20% What Happens to You, and

80% how you deal with it,” to quote the late Nick Charles, founder of CNN Sports. I think of that a great deal lately. Because I live in a world in which a lot of people are hurting and most others have come to judgment on what passes for leadership in this country. They are letting us all down, but taking care of each other. Because a lot of Americans have chosen to second guess their choice of Barack Obama as our president in 2008 and I can’t imagine how any other choice could have done much more with what we all handed Obama in January of 2009.  And, because I celebrated the 77th anniversary of my birth back in the Great Depression, and I know from a lifetime of experiences just how right Nick was.

Life Begins at 50

Governor Tim Pawlenty ended his quest for the presidency last week, and opened a door on a life beyond politics. Those who knew him during his 30 year career in politics in Minnesota liked him, admired his intellect and character. His Republican colleagues in the Minnesota House made him their leader as soon as possible. An even more competitive bunch, his fellow Republican and Democratic governors, chose him during his first term to be their national leader. Only GOP kingmaker Karl Rove misfired when he demanded Pawlenty end his 2002 race for the Senate to allow Norm Coleman to run for the Senate; and Sen. John McCain (R-AZ) lost it when he dropped Pawlenty as his vice presidential choice in favor of Alaska Governor Sarah Palin.

The Tim Pawlenty I learned to know and respect, after giving him his start in public service, enjoyed public service and the difference one person could make in public policy. The Republicans who will decide which person takes on President Obama next year are not the kind of Minnesota Republicans who brought Pawlenty to work for me, or him to work for others in this state. I know times change, and I know the definition of conservative changes. But candidate Pawlenty wasn’t the Republican president this country needs right now. And he knew it.

The Iowa State Fair straw poll campaign and debate proved one thing clear as a bell: If people today prefer Michele Bachmann to Tim Pawlenty, it’s no wonder Republican power brokers keep looking for new candidates. Ryan Lizza (The New Yorker) did a good job summarizing who brought Michele Bachmann to elected office and what kind of base Republicans have been building under the future political leadership of this country.

Business Needs to Make People a Priority As Well As Profits

My friend Dr. John Wennberg is famous for 40 years of pioneering research into health care practice variation, its cause, its effects, and its changes. On our visit to Jackson Hole, Jack asked me how difficult it would be for business and government to agree on changing the statutory definitions of work and a work week. For the same reason that the 1935 retirement age of 65 no longer represents the norm for economic security policy, why is work and its compensation uniformly defined by hours? Jack suggested the Germans have already begun to figure this one out – allowing employers to employ more workers, for shorter periods of time, without reducing benefits by more than a small percentage.

Is There a Chance for Bi-Partisan Change of Obamacare?

The politically painless way for a Super Committee to reduce government spending is to reduce fees for health care services for those in Medicare, Medicaid and other public entitlement programs. The more profitable approach would be for the committee to recommend changes in how the A.C.A. reform law is being implemented and the role that states and communities in this country can play in bending the cost curve by improving care quality and health maintenance. 

We all know that Republicans en masse want a Republican president to support repeal of the law and its replacement with tax voucher-financed high-deductible private health insurance.  There is a better way. Regionalizing the Medicare program to take advantage of the ingenuity and professional innovation of health professionals and health plans in communities across the country.

The Centers for Medicare and Medicaid Services (CMS) already has authority to create regions for administrative purposes. Seventy-eight of them, to be exact, which are designed to help run the program out of Washington/Baltimore. Health researchers have long demonstrated that health care is practiced differently in different parts of this country. There are probably at least 78 of these distinct practice regions in which CMS should be authorized to delegate authority to a private health plan(s) to measure and pay for health care improvement and to share savings with providers and beneficiaries. As soon as the results come in the money goes out. As does information on how care providers and systems achieved quality improvement ad cost reduction – to other professionals and beneficiaries in other parts of the country.  What’s not to like for GOP ideologues in a system like this?

Tax Policy or Economic Security Policy?

Many seem to believe that only half of American income earners “pay any taxes.” A popular myth at a time of partisan attack tax reform. But it’s not true. Practically every employed person, and most others, pay taxes on earned income. In the form of a wage tax for economic security programs like Social Security, Disability, and Medicare. Our employers contribute similar sums plus pay taxes for our unemployment and workers compensation program protections as well. 

Where there’s a sales tax or a property tax, we pay these as well, of course, but for different public purposes. As to the income tax, the nonpartisan Tax Policy Center last month informed us that only 46% of us pay taxes on our income in addition to these other taxes.  So rhetorical radicals now claim “we are approaching nearly half the U.S. population that doesn’t pay any income taxes” (Rick Perry, Mitt Romney, Michelle Bachmann).

Tax Reform

Former CBO Director, McCain campaign adviser, and director of the American Action Forum, Douglas Holtz-Eakin argues that 95% of the income tax is paid by 5% of U.S. households. “We’re going to have to have tax reform, because the system is broken,” he says. So what are we waiting for?  Rick Perry, Mitt Romney, Michele Bachmann, the Tea Party, the Club for Growth (started by now Sen. Pat Toomey who sits on the Super Committee), and Grover Norquist, the tax pledge guru who claims to control the tax policy votes of 95% of the elected Republicans in the country.

The Super Committee to the Rescue

I’ll believe it when I see it and I don’t expect to see it this year. Or next. Democrats and Republicans loaded the committee with their political leaders, not their policy leaders. That is to be expected in a presidential election year when everything is on the line. To add to the problem for even the thoughtful like Sen. Rob Portman (R-OH), is what happened to the stock market over the last two weeks since the debt ceiling deal was announced. A majority of House Republicans believed the country’s credit and its economy would not fail if the debt ceiling wasn’t raised. Wall Street’s melee and the return to normalcy has convinced them they’re right. They also believe that forcing austerity on the economy will create jobs rather than the more likely alternative. Where is business leadership in this country? Do they all believe that ideology trumps economic common sense and self interest?

Minnesota Health Care Successes

Hospitals have not been the leaders in employee health management and chronic illness/accident prevention. Witness overweight professional staff and the “smoking lounge” outside the hospitals. So it’s news when Allina Health System provides reduced health insurance cost-sharing to employees/families who can prove they do not use tobacco products.  Read more:  Chris Snowbeck , The Pioneer Press, August 19, 2011.

Park Nicollet Health Services finally received a check from CMS for its share of the savings generated by keeping patients healthy and away from expensive healthcare services. Like hospitalization. It’s part of a Medicare/Medicaid pilot project begun in 2005 which the government finally got around to rewarding! At this rate, it may take ten years to see shared savings under the CMS Center for Innovation programs!!

UnitedHealth Group (UHG) decided to end its Evercare program in Minnesota, saying it was a “victim of its own success.” Evercare started in Minnesota 25 years ago as a program to substitute nurse practitioners for doctors in coordinating care for frail elderly. The model has moved around the country, thanks to UHG, but been adapted by enough care systems in Minnesota who no longer need to depend on Evercare/UHG to administer it.

Policy and Politics: Informed or Inflamed?

Senator Pat Moynihan (D-NY) has never been more frequently quoted than during our current national struggle over defining the role of government in America. "We are each entitled to our own opinion, but not to our own facts," is the way he informed my work over three terms in the Senate. He'd then reference research on a topic, perhaps done 30 years earlier but never disproven, to make his point. On occasion, Pat would also remind his colleagues of a study on the amount of time Congress members have to think about a policy problem they faced. Like 24 hours a week in 1960 vs. 24 minutes in 1990.
Republican presidential candidates this year provide us clear examples of rhetorical opinion clashing with factual analysis. Our own Cong. Michele Bachmann is the hands-down winner of the fact-checker prize for zealotry and rhetoric and inflamed passion winning out over reality. But Texas Governor Rick Perry wins the prize for how facts can be bought and policy results sold in today's political environment. And the Romney-Pawlenty debate over "Romneycare" and what Tim did in Minnesota is another example of partisan politics trumping real policy leadership in campaigns.
Teaching American health policy-making gives me a chance to share my previous experiences with politics and policy-makers from across the country, and argue for non-partisan approaches to dealing with complex problems and their policy solutions. "What each member sees depends largely on where they stand," is my favorite.  In other words, experience is usually confined to anecdotal and relational (with our half of the doctor-patient relationship). Because medicine is practiced very differently in different parts of the country, and healthcare "reform" has been a tradition in some communities, but not in most others, policy "reform" depends heavily on using facts, not opinion. Both in defining the problem, and reaching consensus policy solutions.
The role of the media in fact-checking is critical today. Because most Americans form opinions based on the opinions of "experts" rather than their own effort.  Energy and environmental policy are closely linked because fossil fuels generate serious air, water, and land resource problems.  People who live in states like Minnesota are dependent on others for energy, but have staked our futures to the natural environment. Is global warming for real?  Is "fracking for gas" a harmless, though costly, endeavor? Listen to the dominant opinion media in our state.  Or the dominant opinion of political partisans and of energy businesses that buy election campaigns and the elected. And, hardest to take, check the growing dependence of public radio and television on "America's 9.2 million job-producing oil and gas industry" version of the facts.


Having trouble seeing this message? View it online:

This message was sent to %%EmailAddr_%% based on previous engagement with the National Institute of Health Policy. To unsubscribe, please send a blank email to: %%email.unsub%%

For regular updates or to subscribe, visit our website:

National Institute of Health Policy
Terrence Murphy Hall 440 • 1000 LaSalle Ave
Minneapolis, MN 55403
1-651-962-4630 •
NIHP is part of the University of St. Thomas