Wednesday, February 4, 2009

The Daschle Blessing

So maybe it’s a blessing in disguise, the Tom Daschle debacle. It may force some new thinking on who they want to run the Department of Health and Human Services, and why. Here’s my choice:

David Kessler. Dr. Kessler was born in New York in 1951. He graduated Amherst College in 1973, and then went on to earn a degree from Harvard Medical School (1973-1979). While at Harvard Dr. Kessler obtained a law degree from the University of Chicago (1977). From 1981 to 1984 he served as a consultant for the U.S. Senate Committee on Labor and Human Resources, and from 1982 to 1984 he was special assistant to the president of Montefiore Medical Center in New York. Dr. Kessler then went on to serve as medical director of the Hospital of the Albert Einstein College of Medicine from 1984 until President Bush appointed him as FDA commissioner in December of 1990. It is important to note that Dr. Kessler continued to serve as FDA Commissioner under President Clinton.

Dr. Kessler was one of the best FDA Commissioners we have seen in that post. As such, he knows intimately the issues facing the Nation in the areas of both drugs and food safety. He would command respect from the health care and health research scientific communities, a necessary ingredient in success there. But, further, he would bring both intelligence and firm management to a Federal department sorely in need of both.

But, could he both manage this vast department and transform the US health care system? I would submit, not.

Under the Clintons, an opportunity to transform our health care system was lost, partly due to Clinton mismanagement, and partly due to Republican demagoguery. It has been clear for some time that Republicans do not wish to give the Democrats another Medicare, or Social Security system. Those two programs have rightly been regarded as triumphs. Republicans desperately do not wish to give Democrats another such triumph. Thus, under Clinton, Republicans argued that the proposal being developed by the Clintons was too costly, too complicated, and, this is important, unnecessary—they argued that there was no health care crisis, thus no reform was needed. The Clintons failed to respond to this challenge. They continued to develop their system and then aborted it before it came to full term. Republicans had their own triumph, of sorts, albeit one for which Americans are still paying the price.

Now, we have another opportunity. I would argue that a second person is needed to manage this vast enterprise—transforming the US health care system so that it is responsive to the needs of the people, cost-effective, and efficient.  We need a single payer system, but before we leap to such a conclusion, we need to know why. Thus, I believe an initial effort, probably requiring six to 12 months, is needed to examine in detail and bring into the light of day, both the benefits and the flaws of the current system of care.  There is no question we have a magnificent system of care, for those who can afford to participate. But the system by which we pay for care is broken, and getting more ineffective daily. An employment-based insurance system can no longer be afforded or tolerated.

So, we need to detail all the features of the current system, including:

·         The system by which we pay for care;

·         The systems by which we deliver care;

·         The systems by which we attract and train the best and the brightest people into health care, and the approaches we use to compensate those people—that system is also broken, as we pay too much to specialists and not enough to our primary care practitioners. We are losing people out of primary care at the point where we need more, not fewer practitioners.

·         The systems by which drugs are developed and the companies compensated.

There are more issues than I can list here, but the point is that an analysis of the current system is complicated and must precede any design of a new system. The public must be brought to an understanding of why the current system is neither viable, nor especially effective (our current infant mortality rates are a disgrace). Once the public is made aware of the flaws in our system, they will be ready for a new system. It is also the case, that the new system can be shown more easily to fix those flaws, i.e., the design process can be made transparent to the public. This way, Republicans can argue their case, but they will be unable to demagogue the proposed approach.

I repeat, though, that this process is too complex and too time consuming for one person. The Department of Health and Human Services desperately needs competent leadership. It cannot await completion of the health care reform initiative.

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