Howard Dean? Kansas Gov. Kathleen Sebelius? Former NIH director Harold Varmus (now at Memorial Sloan-Kettering Cancer Center)? Dr. Atul Gawande? Former Oregon Governor John Kitzhaber? John Podesta, founder and president of the Center for American Progress, formerly chief of staff to President Bill Clinton? These are a few of the names being floated in the mainstream press and the blogosphere as possible replacements for Tom Daschle as Secretary of Health and Human Services and/or healthcare czar.
But before replacing Daschle, let’s consider why he is stepping out of the game, and what this means for healthcare reform. In announcing his withdrawal, Daschle put his finger on why he must leave: “If 30 years of exposure to the challenges inherent in our system has taught me anything, it has taught me that this work will require a leader who can operate with the full faith of Congress and the American people.”
Daschle was not, as some claim, undone by the Republican nomination. Nor should Obama be blamed for “conceding defeat.”
As Daschle himself acknowledges, he did himself in by undermining the full faith and trust that anyone who hopes to guide health care reform must have.
When explaining his departure, most pundits emphasize the fact that he failed to pay about $128,000 in back taxes mainly for the use of a limo and driver over three years. No question, anything that gives headline writers a chance to pair the word “liberals” and “limos” is truly unfortunate. But Daschle is not the only government official who has ever had to explain an “oversight” regarding his taxes. (Though the fact he was the second cabinet appointee who found himself in that position posed a serious problem for the administration.)
Still, what is more troubling is the recent disclosure that Daschle had taken more than $200,000 in the past two years speaking to members of the health care industry that he was assigned to reform.
The speaking fees were just a portion of the more than $5.2 million the former senator earned over the past two years as he advised health insurers and hospitals and worked in other industries such as energy and telecommunications, according to a financial statement filed with the Office of Government Ethics.
Among the health care interest groups paying Daschle for speeches were America's Health Insurance Plans, $40,000 for two speeches; CSL Behring, $30,000; the National Association of Boards of Pharmacy, $16,000; and the Principal Life Insurance Co., $15,000.
Daschle knew that he wanted to become a leader of healthcare reform. What was he thinking? Perhaps he had spent too many years in Washington. Here, I must quote Bob Laszewski, editor of the Health Care Policy and Marketplace Review:“ I have a friend who says that when you first come to Washington you see it as this ugly political swamp but after you are here awhile it begins to seem like this wonderful hot tub. He says that's when it's time to get out of town and go back home.”
Many would argue that it is difficult to find a senior federal official who has not moved in and out of the industry he oversees. Perhaps. And perhaps we need laws to block—or at least slow—the revolving door.
In any case, it is essential to remember that healthcare is not just another industry. It is an industry charged with protecting our health. Any suspicion of graft within Health and Human Services would be like a hint of corruption with the Federal Aviation Administration: lives are at stake.
How would you feel if you heard that the new head of the FAA had taken large speaking fees from various airlines—and now he was being appointed to an oversight position where he would be responsible for overhauling the industry and making sure that airlines did not continue to cover-up the causes of major airline catastrophes?
Fortunately, our airline industry has not shown a penchant for scandal. By and large, it is quite forthcoming when it comes to co-operating with accident investigations. The same, unfortunately, cannot be said about our healthcare industry.
With some regularity, drug companies are accused of repressing evidence that their favorite blockbusters are causing heart attack and strokes or device-makers forget to inform the FDA about heart devices that implode inside a living heart. Over the past 15 years, for-profit hospitals have found themselves the target of FBI raids that revealed they had been lying to Medicare, lying to insurers, lying to shareholders—or, in the worst cases, performing unnecessary surgeries on perfectly healthy patients, leaving some dead, others maimed.
As I have documented in Money-Driven Medicine: The Real Reason Health Care Costs So Much, this is an industry fraught with conflict of interest. This is why reform needs to be overseen by someone who is perceived as being above suspicion—purer than Caesar’s wife.
When it comes to his dealings with the industry, Daschle may well be pure of heart—but, as he acknowledges, the way that the public will perceive him has been muddied. An experienced politician, Daschle knows, all too well, how the opponents of reform would use this. Moreover, it is time for the Obama administration to make it very clear to all that it means what it has said about change in Washington.
This is why Daschle had to step down.
This is a loss because he seemed uniquely positioned to serve as the Obama administration’s liaison to Congress. Among his Congressional colleagues he is reported to be well-liked on both sides of the aisle. Arguably, this is because he is not the strongest leader Democrats have ever had. When it came to controversial issues such as standing up to President Bush on the war in Iraq, or the tax cut for the very wealthy, Daschle was timid.
The recent vote on what should have been a slam-dunk for the Democrats—expanding healthcare for poor children—turned into a sometimes bitter battle, an indication that the ideological opposition to reform remains fierce. Perhaps the administration will need a liaison made of stronger stuff—here John Podesta comes to mind.
Nevertheless, Daschle seemed sincerely dedicated to the cause of providing health care for all Americans. And, without question, his departure will slow the process—though I expect Senate Finance Chairman Max Baucus will continue to push ahead in Congress. And Baucus’ white paper is not very different from the President’s, so in that sense, the administration will still be well-represented within Congress.
But it will take time to find a replacement for Daschle, more than a week or two, I would wager. Here are a few of the names being bandied about, and the reasons why they might, or might not, be viable candidates:
Howard Dean: The fact that Dean is an M.D. makes him an attractive candidate. We need a healthcare reform leader who understands that medicine is not a business, but a profession—which means that it must put patients first. Dean might be able to rally doctors; their support is, I believe, crucial because patients will listen to their doctors. As Governor of Vermont, Dean expanded health insurance to children, and faced the challenges of health care reform. (He also paid off the state's public debt, signed civil unions into law, and delivered a balanced budget every year.) To cap off his resume, as Chairman of the DNC he implemented the 50-state strategy that many say gave Obama the foundation for victory. On the other han, Rahm Emmanuel, opposed the 50-state strategy; rumor has it this is why Daschle’s name was never on the short list for Secretary of HHS. There is also the fact that many media pundits simply don’t like Dean. Whether that should be counted as a point in his favor or a point against him is open to question.
Dr. Atul Gawande: The American Prospect’s Ezra Klein threw Gawande’s name into the ring. But in a private interview at the Families’ USA conference last week, Gawande said twice “I know nothing about politics.” He said it cheerfully, smiling, a man happy that he knows nothing about politics. He also has a job that he clearly loves as a surgeon and brilliant writer. It is hard to believe he would give that up.
Former Oregon Governor John Kitzhaber: Kitzhaber is dedicated to health care reform. An M.D., he is extremely intelligent, honest, articulate and charismatic. In many ways he would be the ideal candidate. But Kitzhaber hates Washington. Many years ago, when the Democrats tried to draft him to run for the Senate, he told me that after visiting the city, he had determined that he would never work there. Too many lobbyists, too much intrigue, too much graft— impossible to get anything done. Perhaps he would view Obama’s D.C. differently, but I’ve been following Kitzhaber’s career, and I doubt it.
Kansas Governor Kathleen Sebelius: Former insurance commissioner in Kansas, she knows the issues, and has a good relationship with Obama. Sebelius is a well-respected politician, but since she is coming from outside the beltway, she wouldn’t make as much sense as Obama’s liaison to Congress. Still, she might well be an excellent choice as Secretary of HHS. It’s quite likely Obama will replace Daschle with two people. But I have no idea as to whether she wants the job.
Former NIH Director Howard Varmus: The Wall Street Journal’s Healthblog mentioned Varmus (along with Dean and Daschle) as one of three candidates for the post when the short list was first being prepared, and mentioned him again today. Clearly the Nobel Laureate has the ability, but does he have the temperament—and again, would he want the position?
CAP president John Podesta: As a politician he is more than Daschle’s equal—and a stronger figure. Moreover, Podesta understands both the policy issues and the politics involved in healthcare reform. The most liberal reformers might object that Podesta is too much of a centrist. On the other hand, when it comes to healthcare reform that may be what is needed, not just to achieve consensus, but to avoid disaster. See my recent post on Dr. Atul Gawande’s prescription for what I call reality-based reform: Gawande stresses that when it comes to universal coverage we need to proceed in a way that allows for continuous learning from mistakes, constant tinkering with reform.
Great post, Maggie.
Let’s hope the Obama team learns from this debacle. It was beginning to look like all this talk about change during the campaign was nothing more than empty political rhetoric. In my view, any serious attempt at U.S. healthcare reform is going to take a leader who is not a quintessential Washington insider, and is not so hopelessly conflicted by his financial ties to corporate healthcare interests.
What about David Satcher? He is as clean as the driven snow and very, very knowledgeable from a public health perspective. He may be too old for a/the big fight though!
How about the best HHS Secretary we’ve ever had …. Donna Shalala?
DEAN 🙂
Rick Lippin
How about Dr. Pamela Mitchell, the outgoing president of the American Academy of Nursing? Personal bias here, but I think a nurse might bring a much-needed fresh perspective to healthcare reform.
Aren’t states required to have a balanced budget? It’s my understanding that, unlike the federal government, individual states can’t run a deficit, so praising Dean’s performance on the subject is not particularly noteworthy.
That said, I like the idea of appointing an MD, but I’m not sure if Dean’s the best choice.
I’ll second Bob Lazewski’s suggestion of Senator Ron Wyden for all the reasons he outlined.
Billy Tauzin
Thanks, Rick, Heather, Abby,
Barry and Jim for your comments and votes!
Abby–
You are absolutely right– states are required to balance their budgets. I should have taken that out of the tout sheet put out by Dean’s backers. (“balanced budget each year”)
Though the fact that Dean managed to spend money on some very good things (expanded healthcare for children) while keeping his budget balanced is to his credit.
Patrick:
You write: “It was beginning to look like all this talk about change during the campaign was nothing more than empty political rhetoric. In my view, any serious attempt at U.S. healthcare reform is going to take a leader who is not a quintessential Washington insider, and is not so hopelessly conflicted by his financial ties to corporate healthcare interests.”
Thank you. I agree– this does seem a signal that the talk about change was not just “empty
political rhetoric.”
And to me, this signal is exremely reassuring.
I also think that picking Daschle to lead the crusade for health care reform beause he was such an insider in Congress may have been a flawed strategy, from the outsete. His insider, liked on both side of the aisles, (and a consultant to the industry) almo meant that he was compromised in vsrious ways.
I like the idea of an outsider: at the same time, it will be very, very difficult for a beltway outsider to accomplish this task.
I don’t have a candidate: it’s impossible to know how well various outsiders would “play” with Congress.
But at this point, I’d rather see Obama just play it straight: pick someone who knows the issue, knows how to negotiate, and does not suffer from tunnel vision focusing on some particular aspect of reform (or dead set against some aspect of reform.)
On the votes, I’m not going to comment. At this point, I honestly don’t have a good sense of who would be a good replacment for Daschle. There are people who I like, but that’s quite different from
nowing who would be politically effective, and there, I either don’t know enough about the people in question, or don’t know how Congress would react them.
But Please, Continue to send in Your Nominations.
As it becomes clearer who the administration might favor, this thread–and your reactions to the administrations’ rumored pick–will beocme more and more interesting.
That said:
Patrick:
You write: “It was beginning to look like all this talk about change during the campaign was nothing more than empty political rhetoric. In my view, any serious attempt at U.S. healthcare reform is going to take a leader who is not a quintessential Washington insider, and is not so hopelessly conflicted by his financial ties to corporate healthcare interests.”
Is anyone with me on Atul Gawande, MD? Did anyone hear him speak at The Families USA conference? Have any of you read his books?
He reminds me of Obama; very bright, inspiring, likeable, down-to-earth, and he really seems to want whats best for patients/healthcare consumers.
He’s proven that he’s willing to put his neck on the line for patients just by the bold books he’s written and the research he’s done about health care quality issues.
I like the fact that he’s in the trenches in healthcare, yet has proven himself on the national stage on healthcare quality and access issues. (he’s not very popular with some MD’s because they don’t like the fact that his simple checklists have proven to save thousands of lives in hospitals).
Being an outsider gives him another mark on the plus side.
Over at HCB they are talking about Ron Wyden? I said he could get help from Dr.(former Gov of Orgegon) Assuming they share common basic views?
Someone said Don Berwick would be good for HHS? Don is excellent but his expertise is hospital based medicine which is NOT the future of a sustainable US health care system.
Dr. Rick Lippin
Southampton,Pa
Lori and Dr. Rick– thanks for your comments.
Lori–
Gawande is one of my favorite people in the world of healthcare–and probably the best writer.
Coincidentally, I interviwed him last week.
But he would never take the job. He has a brilliant career as a surgeon and writer, and loves his work. Why give that up to become a bureaucrat?
Moreover, twice during the interview he said “I know nothing about politics”–he said it smiling, making it clear that he’s happy not to be involved in politics
Dr. Rick–
Wyden is a pawn of the insurance industry. His
turncoat vote was key to
the passage of the Medicare Modernization Act
which gave the insurance industry a windfall bonus and stated that Medicare could not negotiate for discounts on drugs.
His healthcare reform plan would hand healthcare over to the for-profit insurance industry.
I think Don Berwick would be excellent. Yes, his area of expertise is reducing waste and errors in hospitals–and this is something that needs to be done. But mroe importantly, he understands what is wrong with the whole system—that it is competitive rather than collaborative, and that it is profit-driven.
And he knows a great deal about healthcare in Europe. Which is very important. (I urge everyone to read Berwick’s book, Escape Fire, it’s very, very good.)
That said, it’s not clear that he would take the job.
The problem is that the best people always seem too good for Washington because Washington is such a cesspool of graft, conflict of interest, etc.
In time, one hopes that
may begin to change under an Obama administration,
but right now it’s still a
town where a person of intergrity will have a hard time . .
Lori!!! So happy to see you here. Did you catch the screening of Maggie’s film at the Families USA event?
I’m sticking with my nomination of Dr. Elizabeth Smith, Founder of the Community Medical Founation in Houston.
It is clear Dr. Berwick needs to be in a national leadership role and every patient safety advocate and organization in the country would support him in any capacity. I’m not sure this is the one, though. You know where I see Berwick? Heading the new “Whatever” that regulates and oversees our healthcare system. Eventually PSO’s will be mandatory, this is where I see Berwick in the future. I’m sticking with Dr. Elizabeth Smith to replace Daschle.
Berwick for President!!
Thank you, Maggie. 🙂
In place of Daschle I like Kathleen Sibelius — fmr insurance commisioner, current governor (therefore knows about Medicaid issues and balancing budgets), highly articulate, coolheaded, an outsider, and most importantly not beholden (as far as I know) to corporate healthcare interests.
It also occurs to me that with all the close ties between the Obama admin and Daschle that he will still play some role, probably behind-the-scenes, in shepherding whatever reforms are proposed by the Obama team.
Lisa and Patrick–
Good to hear from you both.
Lisa,
I, too, could see Don Berwick heading a Nat’l Health Board. He would be superb.
Patrick,
I don’t know much about Sebelius except from what I hear from others. But what you say confirms what I have heard.
And I do think, at this point, that it would make
sense to have someone from
outside the beltway.
As for Daschle, I suspect you are right–
we could have his help in talking to friends in Congress, smoothing the way, informally, even if he isn’t offically on the team.
My impression is that he does truly care about the issue, and so would probably be happy role.
.
This could mean a “win” for everyone.
I have an outsider recommendation. This guy knows the health care industry inside and out. He reads volumes of manuals for breakfast. Insurance companies call him to explain their own policies to them. He is one of the chosen few who go around the country doing medicare audits. I don’t know anyone else who knows more about healthcare then this man, but he has not political experience. His name is Bellinger Moody and he lives in Augusta, GA. When I first met this man in 2003, he had me at hello.
I think we ought to support Maggie Mahar to replace Daschle. Why not have somebody who actually KNOWS what’s wrong with health care and what to do about it?
Darrell–
Thanks much for the kind words.
Marion–
Thanks for the recommendation.