Man Bites Dog: Candor in Washington, By Michael L. Millenson

Something odd happened when the health policy establishment gathered in Washington last Thursday to celebrate the 25th anniversary of Health Affairs and honor founding editor-in-chief John Iglehart on his retirement. Perhaps because so many of the participants knew each other so well, the Health Policy Summit was marked by genuine thoughtfulness and persistent outbursts of candor.

In the former category, former-Bush-administration-all-purpose-expert Mark McClellan gave a closely reasoned keynote calling for a health care system that functioned as a “learning organization” for the advancement of evidence-based medicine.  Unfortunately, the dense content was difficult to fully follow in a paper read off with the pace and inflection of a husband assuring his wife he’d remembered to pick up all the groceries.

In the candor category, Gail Wilensky, a high-ranking official in Bush I, noted that the health care reform proposals of the Republican candidates at this point in the primary season did not represent serious attempts at universal coverage. HCA CEO Jack Bovender, identifying himself as a life-long Republican, was even blunter.  Asked what he liked about the Republican proposals, he replied: “Nothing.” Bovender then rattled off a three-point plan for universal coverage that he thought Republicans could support.

Nor did the Republicans have a lock on political non-pandering.

When panelists representing the Democratic presidential candidates
were pressed to define major differences in their health reform
proposals, Barack Obama surrogate M. Gregg Bloche acknowledged that they involved the kind of details likely to be negotiated as part of the legislative process.

To be sure, political honesty had its limits. While John McCain representative Douglas Holtz-Eakin
boldly announced that the real key to containing costs involved
coordinating care and focusing on outcomes, he immediately returned to
Republican-Speak when the topic of universal coverage arose. Making
health insurance coverage “affordable,” but not mandatory, was the only
pro-choice solution, he maintained. (OK, so he didn’t really use the
term, “pro choice.” What he said was, “The American people should
choose,” but I couldn’t resist the rewording.)

The failure to make tough decisions was a consistent theme among the non-politician speakers. George Halvorson,
CEO of Kaiser Permanente Health Plan, cleverly emphasized the
simplicity of the fundamental choices by presenting slides with just a
sentence or two of black type against a white background. Chronic care
accounts for 75 percent of costs, said Halvorson, and five conditions
account for the lion’s share of that. Unfortunately, he added, while
the health care industry has an “amazingly low accountability for the
product it sells…smart people do not kill the geese who lay the golden
eggs. Health care is awash with smart people and golden eggs.”

Donald Berwick,
president of the Institute for Healthcare Improvement, similarly
deplored the lack of a “social will” to adopt such explicit clinical
goals as “no needless deaths, pain or suffering.” Princeton University
economist Uwe Reinhardt
pointed out how high-deductible health plans shifted costs or denied
care to the working class and the chronically ill, since the affluent
would not be deterred by high co-pays and the chronically ill would be
paying out of pocket year after year. Mark Smith,
president of the California HealthCare Foundation, followed by asking
why anyone thought a rational low-income consumer would “choose” to buy
an “affordable” health care policy that charged thousands of dollars a
year for coverage and then slapped on another $4,000 deductible before
he received a nickel of reimbursement in return. The belief that costs
could painlessly be shifted to some unnamed third party was the “cold
fusion” of health care, Smith added acidly.

On a hopeful note, none of the invited Dems endorsed single payer
and some of the invited “R’s” dissed HSAs. An optimist could truly
believe that the vaunted “bipartisan consensus” being assembled by AARP
(“Divided We Fail”)
and others and driven by polls showing a red state/blue state mutual
interest in health care reform will bring about that reform in our

Of course, that may depend on what you mean by “reform.” Or “our” lifetime.

On a personal note, while Mark McClellan was speaking I recalled
that he holds the recently created Leonard D. Schaeffer Director’s
Chair in Health Policy Studies. Glancing to my left, I saw that at that
very moment I was seated on an actual chair right next to Leonard D. Schaeffer!
I thought of asking Leonard, a long-time friend, to endow my chair, but
then I realized I probably couldn’t take it home, anyway.

Michael L. Millenson
, whose 25 years in
health care began in 1982, is president of Health Quality Advisors LLC
in Highland Park, IL.

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