The healthcare world learned with great sadness this week of the passing of our friend, Uwe Reinhardt. I met Uwe in 1982 at the Federation of American Hospitals meeting in Las Vegas. Uwe opened the meeting by apologizing, in his disarming German accent, for not being his usual sharp self. He had, he said, skipped breakfast because his wife May had instructed him not to pay for anything in Las Vegas that he could get for free at home. This was vintage Reinhardt, innocent and knowing at the same time. That meeting was the beginning of a long and warm friendship.
Uwe would have been acutely uncomfortable with his colleagues referring to him as a “giant” in our field, because he was genuinely humble, and had not forgotten what it felt like growing up poor in devastated post-War Germany after WWII. And there was no sterner test of humility that occupying the James Madison Professorship of Political Economy at Princeton, just about as flossy an academic title as you will find.
For many years, Uwe taught a standing-room-only undergraduate course in Accounting at Princeton. The way he taught it was as a cleverly disguised course in moral philosophy. A main trope: “how would a ‘seasoned adult’ look at this problem?” A ‘seasoned adult’ was someone who had lost his or her moral compass and sense of shame. So, where would a ‘seasoned adult’ book a bribe paid to a foreign official to obtain a contract, etc.? He was cleverly goading them not to lose their sense of outrage and their own moral compass, a tricky task without patronizing them.
Uwe had a devastating dry wit. There was the barest hint of vermouth in the Reinhardt martini.
You lived in fear of being placed on a program before him for what he might conceivably say about your talk. Please forgive the following, but I will never forget being on the program with him for the Board of Blue Cross Blue Shield of South Carolina about eight years ago. For some reason, our host had asked Uwe to talk about the current political landscape and me to talk about international health systems and what we could learn from other countries. This was a cruel thing to do, because Uwe had forgotten more about this topic than I know.
So I spent a month preparing this talk. I deconstructed the famous World Health Organization ranking of health systems, in which the US ranked 37th, behind Oman, Malta, San Marino, Switzerland etc., (largely by, effectively, double counting income inequality). And I found some great data it turned out Uwe hadn’t yet seen on WHY the US healthcare is so much more expensive than other countries (hint: ambulatory services dwarfed pharma pricing and the cost of our multi-payer system). As an almost 60-year-old “expert”, I was more nervous giving this talk than I was at my Ph.D. thesis orals at the University of Chicago decades earlier. To my immense relief, he LIKED it, and asked me to send him my slides.
Our last conversation, about a month ago, was about this very topic. We were talking about the latest round of international cost comparisons, and he said “Our colleagues need to invent a new parlor game. This one is a complete waste of time.” Most of the countries we were unfavorably compared to, he went on, were smaller than Los Angeles County, and had been doing what they had been doing for generations. I riffed on how our health system WAS a country, bigger than Germany, sort of like a successful version of Afghanistan, replete with tribal conflicts, warlords, corruption, a bad communication system, language problems, etc. That reforming the US health system was a LOT harder and more dangerous than invading a middle eastern country like Iraq. He told me to be careful with that one.
He knew when not to be careful. During the 1980’s, he served on the Physician Payment Review Commission, which was eventually folded into MedPac. So he was a fixture on the medical society lecture circuit. On a panel in front of a bunch of physicians, he bridled at a physician who argued that cutting Medicare physician fees would damage the quality of care.
Uwe asked him whether he was going to leave a sponge in a patient after closing him up at surgery because his fee was reduced. That remark put Uwe on the American Medical Association’s “do not call” list for the better part of a decade.
Uwe had a soft heart, and if you wanted him to speak for you and could get to him, he would say “yes” and deeply discount his fee. After some marital byplay, he eventually delegated the negotiations to his formidable wife, May. He met Tsung-Mei Cheng, a fellow immigrant, while studying graduate economics at Yale. May was the daughter of a Kuomintang (Nationalist Chinese) General who fled mainland China for Taiwan at the end of the Chinese Civil War. Photos of May photoshopped into Russian Commissar garb were a fixture in Uwe’s colorful presentations.
May is an improbable combination of steely, razor sharp and tough minded, but also sweet, gentle and loving. They were the most amazing couple. Delegating negotiation over speaking gigs to May was a classic economist’s move. Who better to place a value on a night away from home than his loving wife and fellow economist? She drove a very hard bargain. Later in his career, Uwe made numerous trips to Asia, “holding May’s coat” as he put it. He took immense pride in May’s role in advising Pacific Rim governments like Singapore and Taiwan on health financing, and eventually mainland China, on their financing reforms.
I talked to Uwe every few weeks or so, for decades. Whenever something happened in the world that upset me or I just could not wrap my head around, I would call him up and ask him how he felt about it. He had a calming influence on me. I do remember him remarking on what a bad sign it was that so few members of the incoming administration of George W. Bush had passports, and that they could do a lot of harm without knowing it. That was a prescient forecast. The only time I can remember in 35 years where Uwe boiled over into outraged, white hot anger was over the War in Iraq, which he felt put his son, a Marine captain, at needless risk. His son was nearly killed by an IED on a subsequent tour of Afghanistan.
I remember Uwe saying once that our colleagues in health policy weren’t going to learn so much by travelling abroad, but that they would return perhaps feeling really lucky about how much talent and resources they had to work with. Our job, he said to me more than once, was to “keep them honest”. He never lost his moral compass, but also never mounted a high horse about it. Despite its manifest flaws, he loved his adopted country. It is VERY hard to imagine this world, and this field, without Uwe in it.