Before his withdrawal from consideration Tuesday, Daschle was slated to become both HHS Secretary and director of the new White House Office of Health Reform (a position popularly known as the “health czar”). Since his 2004 Senate reelection defeat, Daschle has spent considerable time – and received a small fortune – advising the healthcare industry. You can imagine what kind of healthcare reform Daschle would recommend. Actually, you don’t have to imagine: Daschle published a slim book on the subject last year (Critical: What We Can Do about the Health-Care Crisis), written “with” coauthors Scott Greenberger and Jeanne Lambrew.
In an obscure footnote to one of the chapters, Daschle says that his ideas stem from a 2005 article cowritten by Lambrew as well as “conversations with numerous experts and practitioners, especially the leadership of the Mayo Clinic, on whose board I serve.”
As follows from this background, Daschle calls not for a healthcare overhaul but a structural tinkering. With hardly a glance to alternative health systems, he argues for maintaining the current employer-based insurance while expanding the Federal employee private health insurance system and Medicaid to cover the otherwise uninsured. Daschle also advocates for more preventive medicine, incentives for higher quality, parity for mental health care, increased emphasis on continuity of care and on chronic care, care integration via computerizing health records and more rural clinics.
The proposed Federal Health Board really is not much like the Federal Reserve Board. The Health Board would set guidelines for insurance company practices that promote fairness and efficiency. It would also make recommendations about medical procedures and treatments that are justified by their health and economic impacts. It would have no enforcement power outside of the federal government programs.
That still leaves the proposed FHB with a wide area of authority. All the federal programs together already cover a third of the US population, and Congress on Wednesday made another 4 million children eligible for the State Children’s Health Insurance Program (SCHIP). Although Daschle claims it is unfeasible in the current political climate, the US does indeed have creeping national healthcare, albeit for the poor and aged. The healthy and affluent ironically have more healthcare choices to fill their lesser needs, though let’s not underestimate the constraints of private insurance.
The core problem with Daschle’s stance is that he views health politics as a battlefield of competing special interests – from insurance and drug companies to hospitals and doctors to patients and advocacy groups. He treats each of these as having equivalent standing. It’s a matter of negotiating a compromise. That might seem reasonable to Daschle, the industry consultant, but it ignores the fundamental asymmetry between these groups.
The only true measure of the success of the healthcare system is whether it keeps patients alive and healthy. It has nothing to do with how many people or corporations it makes rich. Yet patients are the least powerful component of the system. At the other end of the spectrum are the drug and device makers. With the rest of the health hierarchy in increasing financial trouble, these companies have stood out as the one sector gaining in wealth and influence. They have corrupted the entire system through their ceaseless promotional activity. Even scientific findings are reshaped to be on message.
Daschle’s Federal Health Board would have to confront this paucity of objective research right from the beginning. Daschle does recommend that the Board be able to advise the NIH on its research agenda. But the NIH is a central part of the current system. It has never undertaken research that challenges the structure of current healthcare delivery.
More fundamentally, the NIH as well as Daschle passively accepts the way knowledge is used in modern medicine. Modern medicine does not seek to create a class of wise practitioners – i.e., a medical staff that works to understand each patient as a unique organism with a complex internal and external environment. Wisdom at the clinic level would express itself as highly flexible, personalized prevention and treatment services. Instead, wisdom is more and more encapsulated in the products marketed by the pharmaceutical industry: drugs, assays, devices, and soon even genes. The result is a dumbing-down of the human staff, which is expected to uniformly apply the guidelines issued for each product’s use. Therapy only departs from the routine when it fails. You’d better have a smart doctor lined up for that all-too-frequent eventuality.
Patients inevitably suffer from the medical system’s mediocrity, its bureaucratic rigidity and rampant materialism. Both insurers and the government support a reimbursement structure that makes acute care of specific disease incidents more easily billable than long-term health maintenance. One suspects that this state of affairs continues precisely because it increases overall costs and therefore income. The pharmaceutical industry is key to this type of care, and it charges the most it can get away with (it’s the marketplace).
Daschle and his kind promise at most some attenuation of the financial burden. Let’s be clear: the change he represents will help Americans considerably. Patients will find care more accessible and efficient. Still, Daschle could have been more audacious. He leaves in place the current public and private players as well as their basic philosophy. He might have at least proposed using the weight of the US’s enormous national health programs to control healthcare costs, but it is not for him to challenge the industry. There are parallels here with the new Medicare drug benefit, a government-subsidized private patchwork with no real cost containment despite large gaps in coverage.
From gaps in coverage to gaps in courage: In his Inaugural Address, Barack Obama spoke of a new era of responsibility, about Americans willingly embracing their duties to their communities, their country and their planet. Healthcare reform is a good starting point to give substance to this sentiment. We have to recognize that we are all going to get sick someday, very likely sooner than we imagine. Let the healthy support the ill until they too become ill and need the help of a new generation of healthy Americans. Daschle thinks that Americans are not receptive to appeals to their sense of collective responsibility – or to any fiscal arrangement that would reflect such responsibility. Yet experience should have taught him that structuring healthcare finances around a hodgepodge of individual plans, some cheaper and with healthier members than others, is not financially sustainable. The more comprehensive plans are forced to shed benefits and chronically ill members to stay competitive. We don’t necessarily need a single payer, but we do need a common health fund.
So now that Daschle is gone, will the outlook for healthcare reform improve? Well, no. Among the people mentioned as Daschle’s replacement is his coauthor Jeanne Lambrew. Still, you have to recognize that a necessary reform process has started. The Obama administration will make some progress in attacking the twin problems of affordability and quality. Real change, as always, is up to the pressure that we, the outsiders, can bring to bear.