Friday, February 26, 2010

Blogging for Newt

As some of you may know, yesterday I was asked to participate as an expert commentator on the President’s Health Care Summit by the Center for Heath Transformation (CHT). The Center is the brainchild of Newt Gingrich, former Speaker of the United States House of Representatives. You remember Newt, right? Contract with America? Anti-Clinton firebrand? Academy Award for best performance as a public servant named for an amphibian?

Since his departure from Congress, the Speaker has developed a keen interest in health care reform. Adopting the role of “elder statesman,” he tries to bring a thoughtful prominence to the issues, and in this era of polarization the more constructive views we can have out there the better. That’s not to say that I agree with everything he says. The private sector can’t solve everything, because the very nature of capitalism is to maximize profits, not to do what’s right. And as I’ve mentioned before, a career in public health gives one the chance to be a paid professional liberal on someone else’s dime. So participating in the live blog yesterday made me feel like a CONTROL mole in CHAOS headquarters (with all apologies to the classic Get Smart, which was infinitely funnier and nowhere near as dangerous).

But the Speaker is, if nothing else, a force of nature; and its great fun to get caught up in his wake. I’ve heard him speak on several occasions. Even though much of which he says is pure rhetoric, he has the gift of being able to lock on to whatever idea or belief you hold most dear, and then to build his argument around you, not him. He’s a master of the analogy, talking about how Fed Ex can find anyone across the globe, but we can’t seem to find illegal aliens in our country. And in front of a large group he can out-bombast them all.

But with an audience he comes off as a politician. He’s really at his best in a small group. His voice drops in volume, he sometimes squints to see; he looks less polished, more like a weathered country boy, and the cut of the tailored suit can’t disguise the portly waist and the occasional heave of his chest when he sits down from walking too fast. He tells personal stories in small groups, stories about things we all experience, like trying to decide if his mother-in-law needs nursing home care. He becomes an old man, sadder but wiser, a thinking person reflecting on his life and sympathizing with yours. You don’t just want to like him…you do. But don't ever think the private Newt is a different person. The content of the thought, and the beliefs behind it, are exactly the same. But up close he becomes human, and that makes all the difference in the world.

I’ve actually met him only once. I was invited by my friend Julie Eckstein, the former State Health Officer in Missouri, to attend a meeting of the CHT in Washington, DC this past fall. It was a fantastic opportunity to see how the Center worked and to eat really good food at a fancy Washington hotel. And at first I was somewhat taken aback by the invitation…I even asked Julie if I was invited to be a token liberal, as every organization needs one. (Polite to the end, she still hasn't answered the question.) The conference itself…attended by the CHT's major funders…was by and large a meeting of the pep squad, with sponsors touting their own programs and roundly condemning any change in the current health care system. And both the Speaker and those working with the Center rolled with tide, as well they should. However, when you would speak to CHT staff individually, their view of the health care debate was much more nuanced and much less vitriolic, and was underpinned by a firm conviction that the status quo is unequivocally broken. They espoused conservative views, absolutely, but not ones that were overly doctrinarial. Speaking with them felt more like I was having a gentleman’s disagreement, and our conversations featured a surprising number of issues where, in the words of Rodney King and every parent with kids fighting in the backseat, we could all just get along. (You could make the case that the mannerisms exhibited by CHT staff were simply polite cover for a rabid right -wing agenda, but inherent in being a liberal is a large degree of doe-eyed optimism.)

But back to Newt. I was introduced to him at a breakfast meeting. We talked about racing, of all things…his former congressional district included the Atlanta Motor Speedway…and he mentioned that he was good friends with the French family, the owners of NASCAR and fairly big wheels in the life of Daytona Beach. This statement of his posed a grave problem for me. The family of NASCAR are the Frances, not the French (I suppose one could make a case that if you got more than one France family member in the room they could be called the French, but that’s like my contention that if you get more than one Belgian in a room you could call them the Belch, and that more than anyone from Wichita should be called a Wiccan, because Wichitan, Wichitonian, and Wichitite just sound silly.)

I literally had a meltdown on the spot. What do I do about this? Do I correct the former Speaker of the House, a possible future Presidential candidate and the man who was paying my hotel bill? Do I respect his position and not reveal his error? Does he want me to correct him as a test of my manhood? So instead of taking a stand, I broke out onto a sweat and murmured a very definitive and authoritative, “Uh-huh.” He looked at me curiously, cocked his head to the left, and moved on to a person who actually mattered.

So that’s one of the reasons I was so surprised to be asked to participate as an “expert” on the live blog during the Summit on the CHT website. (I already mentioned in yesterday’s blog that one definition of “expert” is a guy form out of town with a Power Point presentation. The other one I recall is that is “x” is a qualitative unknown, and a spurt is a forceful expulsion of liquid, than an expert can be considered as an “unknown drip under pressure.”) The folks form the Center asked me for some initial comments which they featured on their website (and which I’ve posted on this blog yesterday), and I pretty much had free reign to comment on whatever I wanted. The staff (thanks, Amy) could not have been nicer or any more facilitating about the whole thing. What I found most interesting was not the direct interaction with the frankly hostile right-wing extremist bloggers actively commenting on the Summit, but with the wider but unseen world of more moderate people seeking knowledge in a sea of polemics. I had been told that for every person on a web chat, there are at least ten people watching. The blog was not for those on line; it was for those other ten. (And yes, Fox News, I am fair, balanced, telegenic, and available.)

Truth be told, and all politics aside, it was fun. I had a chance to make a few points, say a few things I believed in, and provide what I thought might be some useful information. I even got to send out some kudos for Health and Human Services Secretary Kathleen Sebelius, my former employer in Kansas and the rare politician who actually “gets” health care. In the end, I have no idea if I influenced the discussion. I don’t even know if I’ll get invited to blog again, let alone partake of their truly tasty meals in our nation’s capital. But if the Center needs an official liberal conscience, I’m happy to oblige. The food was really that good.

Thursday, February 25, 2010

The President's Health Care Summit

My friend Julie Eckstein, the former State Health Officer of Missouri, now works with the Center for Health Transformation led by former Speaker of the House Newt Gingrich. She has asked me to participate as a "expert" (which I always thought was a guy from out of town with a Power Point presentaiton) in a live blog on the proceedings of the President's Health Care Summit. As part of this, I was asked to write an introductory commentary. I encourage you to join the discussion at

When I was asked to think about today’s Health Care Summit, I kept thinking of Santa. When you’re a kid, you make a wish list and tell Santa everything you want. What Mr. Kringle actually brings is whatever, in close consultation with your parents, he actually wants to stuff into the sleigh. (For the record, you might also get whatever your relatives have an inclination to purchase, especially if said gifts are particularly annoying to your parents. This is why my nieces and nephews have metal drums, carpet-adhering Play-Doh, and bow and arrow sets.)
The Health Care Summit should be my opportunity to tell Santa my wish list. But unlike the list of my twelve-year old son, an endless roll of specific items originating from the television and the internet, my list is that of a practicing emergency physician looking to see if we can at least share a baseline understanding of our systemic health care problem. So here are four things I would like to hear:

Health beats health care. Health is defined by the World Health Organization as "a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” It is a factor of not only medical care, but of genetics, culture, economics, education, and environment. By way of contrast, health care refers to system of delivery of medical treatments (doctors and hospitals), while health coverage refers one view of how such services are mediated between patients, physicians, and external payers (public and private insurance plans). This distinction is critical to understanding the true impact of the current debate, which has started to address the problem of health care coverage. We have not yet begun to address issues of health except in the most peripheral fashion. Decreasing smoking rates, preventing obesity, and mandatory seat belt laws can do more for the health of the nation than expansions of Medicaid or individual mandates to purchase private policies. And while I firmly believe that every citizen of this country deserves access to the health care system, there is a relative paucity of evidence to suggest that changes in health care alone will have a major impact on overall health.

Health care cannot, by its nature, work by free market rules. I've always had a problem with looking at health care as a marketplace subject to the same market forces as buying a home appliance. Health care is accessed differently than other markets...for example, your doctor or insurance plan often tells you where to go for care, as opposed to choosing any appliance dealer of your choice...and if your need is emergent rather than elective, your choices are often circumscribed by geography, urgency, or the need for specialty services. The specialized nature of health care means that individual often cannot make an informed consumer choice of costs, products, and services. I don't know that I can support the idea of heath care operating as a free market system, not because there's anything wrong with the free market, but because health care cannot, by its very essence, operate in that way except in a very limited realm of choices and services. An employer choosing which health plan to offer employees can operate according to free market principles; the employee's use of that policy cannot.

Health care is a doctor-driven process. Trying to figure out who’s in charge of the health care system is a great game, almost as fun as Parcheesi. But from a day-to-day, operational view, physicians still actually run the show. It’s the physician who provides an entry point into the health care system through the office or clinic. It’s the physician who provides the assessment, orders tests, requests consultations, and order drugs and other treatments for acute or chronic medical conditions. It’s the physician who has to balance clinical realities, resource management, consumer demands, and societal expectations while keeping the patient’s welfare first in mind. It’s the physician’s actions (or lack thereof) which drive the medicolegal system. Health care costs are driven by the process of establishing the diagnosis and providing care, all of which are under the expert control of the physician. And while physicians are unquestionably subject to, and necessarily react to, all the outside influences upon their practice, the fact remains that nothing gets done, care is not provided, costs are not incurred, and paperwork is not completed without the doctor starting the chain of events. So it seems to me that if we really want to reform health care, we need to concentrate on the role of the physician. For example, we already know that it’s difficult for Medicaid patients to get into physician’s offices due to reimbursement and medicolegal concerns. While it’s true that expanding Medicaid gets more patients “coverage,” what makes anyone think that simply expanding Medicaid means more patients will actually get to see a physician?

Access x Quality = Cost. I’ve always thought that out of every relationship, good or bad, you find something of value. And so I must thank the worst boss I ever had for introducing me to this equation, one which effectively summarizes the entire problem of any health care system.

• Access is the number of people who have entry into the health care system.
• Quality represents the number of services provided.
• Cost is, well, cost.

It’s a zero-sum game. If you increase health care access while holding service level stable, costs go up. If you increase the services provided to a constant population, costs rise. The only way to hold costs down is to limit access or limit services. Both of these are unpopular, which is why costs will continue to rise. Either decide to place limits to control costs (personally, I’d rather see greater access to a limited scope of services) or just accept that health care reform is going to cost more…a lot more. I’m less worried about the details or direction of change than I am about simple honesty.

Why are these thoughts on my wish list? Because acknowledgement of these basic facts is the first step towards real improvement. Failing to recognize these tenets as true is easy, and allows plenty of room for argument, planning, and policy without requiring any hard decisions. But hard decisions are what we need if we truly want to arrest what all parties acknowledge is a precipitous decline in the health of the nation.

This being said, I will be pleasantly surprised if any of these things are mentioned at the Summit today. I might even be tempted to take a nibble off my Stetson. My expectation, however, is that instead of an open and challenging dialogue about the root issues of health and health care, we will simply hear more political posturing from both the left and the right. None of which, unfortunately, will take us any closer to repairing a system that is irrevocably broken.