Health Reform and Obama’s Leadership


By all accounts this is crunch time for President Obama on health care reform, and things couldn’t be more tenuous. In the past several weeks, we’ve seen unified Republican opposition to his ideas, a revolt against reform from leaders inside his own political party, and the head of the non-partisan Congressional Budget Office testifying that the only direction he is bending the cost curve in is sharply upward.

As a physician who supports the President’s vision to improve the quality, access and lower costs, I’ve been following this debate closely. I’ve also been wondering what the debate about health reform tells us about the President’s leadership style. While I see him continuing to communicate his vision eloquently, there are two key leadership qualities Obama seems to lack that may prevent him from achieving his goals for reform.

The first is the President’s unwillingness to attend to the details of his plan, a pattern we’ve seen before. During the campaign, he often outlined big, inspiring ideas that were short on specifics. This was in sharp contrast with who was then his main rival, Hillary Clinton, who recited volumes of information about policy in the primary debates. With health care, this pattern has become apparent again as he’s outlined similarly broad ideas. Yet, as the myriad of bills moving through Congress shows, he has left the details of how to cover, pay for and deliver reform to America to the other side of the Pennsylvania Avenue.

Obama’s focus on the forest instead of the trees is also the reason why his point person on reform, Secretary of Health and Human Services Kathleen Sebelius, had such a rough outing on Meet the Press last Sunday. When host David Gregory asked her basic questions about whether any of the current proposals met Obama’s goals, and whether the most important goal was cost containment, Sebelius frequently had to turf her answers back to lawmakers. “…this is still a work in progress,” she said, in non-committal fashion.

Yet if Obama’s plan is to work with Congress, recent history shows he still ought to be more assertive. When the stimulus bill went to Capitol Hill, lawmakers put so many provisions into it that to critics, it looks more like a pork-barrel bill than a shovel-ready jobs one. The latest double-digit unemployment numbers don’t contradict that criticism.

On PBS’ The News Hour last Friday, liberal commentator Mark Shields suggested that Obama’s hands-off style may be his way of avoiding what befell the Clintons during the 1990s. Most of us recall the secrecy that Hillary Clinton insisted on, behavior that upset her allies on Capital Hill and fueled her critics with enough fodder to kill reform quickly. On the other hand, Shields also noted that Obama may have “overlearned” that lesson and is giving too much away by outsourcing reform. He ought to own it instead.

Even if one supports the President’s delegating of details, he may lack the kind of powerful of influence over his Congressional colleagues that can help get things done. It’s this characteristic—his lack of influence–that could be his biggest problem in achieving reform.

As we all know, Obama’s tenure as a Senator was a quick 4 years, two of which he spent the better time of campaigning for the Presidency. It’s not likely that this in-and-out drive through the Senate provided him enough time to build a lot of clout.

To better understand this, we need to step back for a moment, and look at one of the most useful and important business books in recent years—Robert Cialdini’s The Psychology of Influence. In it, Cialdini, a professor emeritus at Arizona State University, defined 7 principles that people use to influence others. Among them is the principal of reciprocity—do a favor for someone, work with them, and you will earn the same from those who you helped. Reciprocity, whether or not you find it fair and appropriate, is the underlying principle behind political logrolling, the kind that gets deals made and laws passed.

It’s also, in my view, the reason experience, which Hillary Clinton and John McCain tried to channel to defeat Obama, is so crucial in Washington. Despite the distaste many of us have for Beltway politics, and our romantic ideals about the outsider coming in and fixing business as usual, the experience to get things done effectively is gained by those who are there, build relationships, and make deals that keep the logs rolling. It’s a big reason that Senator Ted Kennedy’s absence due to his illness is most felt now. Kennedy’s life work has been to reform health care, and he has the influence to get deals done.

This view is not without precedent—in his book, Cialdini surmises that Jimmy Carter suffered from the same problem when he was elected President. As the outsider Governor of Georgia, he didn’t owe anybody in Washington anything when he moved into the White House. But nobody in Washington owed him anything, either. We all know how that ended.

It certainly doesn’t have to be this way for President Obama—certainly, he has amazing intellectual and rhetorical strengths. He is in every way the foil of the man who preceded him in the Oval Office. And contrast the President’s vision for reform with that of the one of the most powerful Republicans in the country–Senate minority leader Mitch McConnell. McConnell, as he revealed on Meet the Press (he appeared after Sebelius), still myopically believes that “America still has the best health care system in the world” and that “we do not have a quality problem.” His comments made me want to email him a link to Atul Gawande’s New Yorker article and a decade’s worth of health policy pieces proving the exact opposite of what he believes.

Yet, as I said, this is crunch time, and the President needs to take ownership of health reform with more than just his vision. Americans (including many doctors like me) truly believe that the status quo in medicine must change—we believe—and are inspired by– the words of our President. But in Washington, words don’t herd Congressional cats—details and deals do. So the President best roll up his sleeves to craft some details of his vision—access for all, real quality, modern IT systems—so that they can be turned into law. And though he may not have the “experience” to have earned some reciprocity, in order to bend the health care curve, he is going to have to exchange tough promises with fence-sitters to line up the votes. He may owe those folks something later, but if the President believes what he says about health care being the pivotal issue for us and our economy, he best get a little ornery. Otherwise, I fear, we will have missed the best opportunity in decades to change medicine for the better.

Dr. Rahul Parikh is a Pediatrician in the San Francisco Bay Area and a frequent contributor to and THCB. Dr. Parikh practices with the Walnut Creek Medical Center and Kasier Permanente.

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13 replies »

  1. I am a German citizen who lived in the US in 1973/74. In spite of the Green Card I left the States because there is no healthcare system worth the name. I suffered from bad toothaches then, and every time I had 50 Dollars together, I went to the dentist, and he did 50 Dollars worth of work on my teeth. I was so frustated and disappointed, I tore up my Green Card and left the US. That the health system is still in the same – and worse – shambles than it was back then is something I do not understand. The German system is far from perfect, and sometimes I mind paying with my premiums for those who do not want to work at all or not legally, but I would not exchange our system for anything. Even in Cuba – where I have visited several times – people are better cared for than in the US. And that in a country that does not have enough medication or modern equipment etc. But even that is better than a system where the rich get any treatment they want, and the poor just have to suffer and die. I sincerely hope that Obama will succeed. Once an effective health care system has been established, people will not want to go back to the old ways, which is no different from third world countries.

  2. Excellent thoughts. But I have two comments. First, leaders are supposed to see the forest, which President Obama does, but his lieutenants should see the trees. Maybe he has failed to instill that thought in them. Second, I have a feeling that he is giving the bipartisanship an honest try, an idea he promulgated during the campaign. A time will come, maybe within the next few weeks, when he will discard all hopes of bipartisanship and hold the dissenting Democrats’ feet to the fire and go it alone. I am sure of that. The healthcare will pass with a public option.

  3. I’ve lived in three countries one without a National Health Service (the USA) and two with National Health Services (Germany and currently Britain). In Germany I was in a serious road traffic accident which put me in hospital for 2 months and intensive physio therapy to 18 months. The care was world class. I had a dedicated team of specialists that saved my leg, today I don’t even limp. It cost me nothing. I am convinced that if this accident had happened in the USA I would be an amputee and my family would have gone bankrupt. I was an artist at the time and paying into the German health service based on my income. I could not have afforded private health insurance. I am forever grateful to this system.
    I now live in the UK. While I think the German system is more efficient, the NHS in Britain works for most people most of the time. I was recently offered private health care for a hefty monthly premium, which I was very happy to be able to turn down. The NHS provides an excellent level of care and is constantly being improved.
    I hope that one day in the USA doctors will be able to care for all US citizens and I believe that Americans are capable of creating the best National Health Service on the planet.

  4. Innovation that radically improves the quality of care, thus reducing utilization, is the way to go about health reform. An innovation for infectious disorders has been available since 1981, but suppressed by unethical vested interests. One for cancer has been available since 2001, but suppressed by similar interests.
    Lieb,J.”The immunostimulating and antimicrobial properties of lithium and antidepressants.” J Infection (2004) 49 88-93. The eighth of nine reviews I have published since 1981.
    Lieb,J. “Defeating cancer with antidepressants.” ecancermedicalscience DOI.10.3332/eCMS 2008.88 The fourth of five reviews I have published since 2001.
    Anyone may verify this by accessing Medline or Pubmed, and entering “antidepressants” and “cancer.”

  5. I feel people need to take more responsibility for their health. They cannot expect government and the tax payers pay for their own mistakes. The biggest health concern in US today is obesity by all estimates this is going to be the biggest health care cost in the coming years. And why should the government pay for that. If at all we need the government to pay for health care it should also come with some penalties for people who don’t take responsibility for their own health.

  6. There are some well thought out replies here!
    This “socialist correction” stuff is scary. Can anyone point out a government-introduced, temporary program that was actually temporary?
    I do think our health care system needs to be tweaked – even overhauled in some areas. But the system needs reform because of the inconsistent policies and government red tape already in place. We need reform because we’ve raised four generations of welfare indigents who don’t work…and still need someone to provide healthcare to them. We have illegal aliens coming across out borders in need of health care. We don’t have enough healthcare assistance for our elderly who spent all their lives struggeling to make a living – going to work everyday and now can’t afford their medications.
    The quality of health care provided in the USA is excellent! The biggest problems I see are in providers not being adequately reimbursed for the care provided, challenges in delivering that care to rural areas…and even getting the uninsured and undoctored to GO TO THE doctor to begin with, and in navigating the health insurance regulations (not to mention Medicaid and Medicare regulations). Socialized medicine (and socialist economic policy) have no business in the land of the FREE AND THE BRAVE.
    Here’s a thought. How about directing even 1/8 of this proposed budget to academic medical centers (through the NIH already in place and already well run) who work everyday to help remove the barriers to healthcare for the states they serve. How about providing more money to these centers (who by the way are the only places these days who will even touch indigent/uninsured patients) to do what they do best – train the best physicians, provide care to people regardless of healthcare status, and seek answers to the most pressing medical problems we face. Just because we need tweaking, don’t go and throw the baby out with the bath water.
    There is still much to discuss here…but we need to pay attention to the details of this and any plan!

  7. I am sure there are many on this forum have reported “dissidents” to the official White House “Snitch Brigade,” where Obama has called on his supporters to report any dissenting opinions that oppose his Health Care plan. What a bunch of hippy-crites you are for trying to squash to 1st Amendment you claim to defend!!
    I wish to be reported for the following dissenting opinion:
    Obama’s plan is nothing short of the Nationalization of 20% of the American Economy. He has already made the taxpayer into an unwilling car dealer, now he wants to go into Nationalized Healthcare.
    The government is overstepping its’ bounds and is reaching far beyond what the Founding Fathers ever intended. If this sort of government takeover would have happened even 50 years ago, there would be armed Revolution in the streets. Now the Welfare Nation is so complacent, their vote paid in full with thick slices of government cheese, that they no longer care if their rights are taken from them.
    This “Health Plan” is not about caring for those less fortunate, it is not about wanting to overhaul a system in need of a change, it is about grabbing power over your life and your right to live as you see fit, which includes keeping my money in my own pocket. I do not want to sacrifice “for the greater good.” I want to reap the fruits of my own labor and not be FORCED to be my brother’s keeper by the government. NO HEALTH CARE REFORM!!!! REVOLT AGAINST THE TYRANNY!!!!

  8. As an Obama supporter, I decided I needed to better understand his health care plan. Your article has helped tremendously; in fact, as I read I thought, “President Obama needs to read this!” You managed to point out major weaknesses and flaws in both the man and his ideas without venomously attacking either. I have read some extremely hateful, incredulous comments in the past few days (no, our President is not secretly a communist!)
    Thanks for your clear thoughts on a complicated subject.

  9. Don’t be a guinea pig for Obamas healthcare expierment. Call your Congressman , Senators anyone that will listen make it known how you feel.

  10. Hey listen if the insurance companies make money let them. If you can’t get healthcare then you should die and so should your family. If you make money doing what ever it is that you do then we should let you. You take care of yours I take care of mine simple.
    If you believe in Jesus you will be fine either way.

  11. Maybe I am being too naive, but I do not know why it is so hard for President Obama to understand that our Healthcare system in the United States just needs tweaking. If clear directives are delineated by the President to health insurance carriers, pharmaceutical companies, hospitals and doctors to promote fairness with charges, I believe all people in the United States would benefit. Am I being naive? Carol Heckelmann

  12. President Obama is challenging one of the most corrupt systems of the world: The US healthcare system.
    That’s it! Only it!
    But guess what? He’s not alone!
    Have a good one.

  13. Thank you Dr. Parikh-
    But I posit that some reform of health care is a done deal.Why? Because the status quo is simply not economically sustainable.So we will have reform for the wrong reason – that being avoiding economic calamity.
    Obama knows this and states it repeatedly. Others seem to be wiling to take the nation down to avoid necessary long overdue change.
    To me here are the two questions uppermost in my mind-
    -What will the final bill that gets to the president’s desk look like?
    – Does continuing to “trade” human health in a for profit market meet the test of the morality of any civilized nation?
    Dr. Rick Lippin