Is Congress the Problem with Health Care?


The first thing you notice when you sit down with Tom Daschle is that he's got some really funky glasses. Like, surprisingly funky. Fire-engine red with odd edges and varied trim, the sort of eyeglasses you'd see perched on the nose of an art dealer, not a former Senate majority leader.

But despite the incongruent accessorizing, Daschle is a former Senate majority leader, through and through. After losing his South Dakota Senate seat to John Thune in 2004, he halfheartedly attempted to return to private life, joining a law firm and taking some teaching gigs. But soon enough, he was pulled back into public policy by the Center for American Progress, which convinced him to become a senior fellow. Soon after that, he began working with well-regarded health-policy researchers Scott Greenberger and Jeanne Lambrew on a book about the health-care system.

Critical: What We Can Do About the Health-Care Crisis, is now out, and most of it is fairly familiar. Costs are up, and coverage is down. Taxes are up, and quality is down. Anxiety is up, and access is down. We're paying more than we can afford for a system no moral person could countenance and no disinterested researcher could praise. As Daschle and his co-authors conclude, "Health-care is a complex topic, but we have to face a simple truth: We're paying top dollar for mediocre results."

If the analysis is standard, however, the solution is considerably more surprising. As a longtime veteran of Congress, Daschle has watched the proverbial sausage being made, and concluded that complicated health-care decisions shouldn't be left up to butchers. "We have to look harder at the exceptional nature of the health-care problem," he writes, "and reconsider the political process we've followed in trying to solve it. The stakes are extraordinarily high in health-care -- literally life and death -- and the issue is incredibly complex. The number of stakeholders and special interests involved is extraordinarily large, and their influence is immense ... perhaps it isn't surprising that the traditional legislative process has failed to deliver."

Daschle's solution is something he calls a Federal Health Board. I sat down with him recently to talk about his proposal and his vision of the future of health-care.

Ezra Klein: So, to begin, the Federal Health Board. Why is it needed and what does it do?

Tom Daschle: I ask audiences frequently, what would have happened if the Congress had been the ones responsible for trying to figure out what to do with the Bear-Stearns crisis, the sub-prime crisis? Or what would happen if Congress were asked to raise or lower interest rates once a month? That's why we have a Federal Reserve. We need an insulated, accountable and credible decision-making board to take that responsibility.

The Federal Health Board would have some of the same roles as the Federal Reserve board, in that it would create a management infrastructure to integrate our public and private health-care systems. About 45 percent of the people in our country get their health-care from public sources, 55 percent from private sources, but there's no integration, either among the public programs or between the public and private sectors. Somebody has to do that. We need a board -- just as we have needed commissions in the past for base closing or Social Security -- to focus and to create the kind of decision-making process that allows us to make the tough decisions. That's why we have these commissions, and that's why we need the Federal Health Board. It also has a secondary purpose, which is that as we pass the legislation, it precludes the need for Congress to get too far into the weeds and be getting so mired in the minutia of details that would never really get to the larger questions. It allows us to stay out of the details. We delegate that detail to the board.

EK: But when you have a history, like you did in 1993, when people had bumper stickers saying, "If you like the DMV, you'll love government health-care," how do you sell both the politicians and the public on the idea that what we're going to do is turn health-care decisions over to a government-appointed, semi-accountable, vaguely shadowy institution? How do you make them comfortable with that?

TD: Well, first of all, that's not what we're doing. And so if we've not gotten our message better out, we will have failed. I don't think we have a government-run banking system. Most people believe we have a private banking system. But somebody -- the Federal Reserve -- is there to help set the guidelines within which this private banking system functions. Banks are free to do almost anything on banking practices if they want, just as long as it fits within those guidelines. And so it would be with the Federal Health Board. We would try to streamline the tremendous bureaucracy that exists today in our federal government when it comes to health-care. So this would really mean far less bureaucracy, not more. And I would simply ask the question, if you think our banking system today is reasonably regulated, why not try the same type of model for our health-care system?

EK: You mention in your book a couple of other examples where Congress has ceded authority on politically troublesome issues to commissions in order to pave the way for better decisions to be made. Can you talk a little bit about them?

TD: Well I think that probably the best example is the, in some respects, besides the Federal Reserve, which I think was the best model, is the FAA. You know, we don't make decisions on flight safety, the FAA does. We've designated the responsibility to create an infrastructure that I would say works pretty well. I knock on wood as I say that, we've gone a long time without an accident, in the FAA system. But you know, we lose the equivalent of one 747 everyday every two and a half days in our health -care system. Every two and a half days, the equivalent number of people, somewhere around 450 people, die because of medical mistakes in our health-care system, and we don't even hear about it.

That would never happen in our aviation system. Well we need the same thing with our health-care system. There's also the base closing commission, probably less consequential, but that one worked as well. There've been so many, I would even say the Social Security commission back in the '80s that took on the responsibility of making the tough choices in order to save the Social Security system.

EK: The base closing commission is an interesting example because it's a more direct example of politicians giving up something they often saw as in their interests to protect -- the bases in their home state or district -- because they recognized that if everyone was going to do that, the entire system of base-closing would devolve to utter gridlock.

TD: That's exactly right. This was also Congress recognizing its limits, recognizing its capacity for making tough decisions in a timely way. The same is exactly true on health-care. These are tough decisions, and there are limits on what Congress is able to do on a routine basis as they deal with these issues. So in the case of base closing, Congress was actually prepared to turn over some of that responsibility to the commission, knowing that there was a sort of a safety hatch they could revert back to if they had to, they could override. And obviously with health-care, Congress always ought to have the opportunity to override as well. That would be the safety hatch here.

EK: But health-care is so personal. Inflation, though it has globalized effects, is really a macro phenomenon. And base closings hit much smaller numbers of constituents. Health-care feels very visceral to people. And they won't be used to this sort of model. How do you convince them of its legitimacy?

TD: Well, I would say three things. First, the Federal Reserve board maybe doesn't get some of the credit it deserves for dealing with some of these issues that are very personal. You know, whether a homeowner pays 5 and a half or 8 and a half percent interest is a big deal. That's very personal. Now, whether or not you gain or lose $100,000 on the market because of what we did in the subprime system in bailing out Bear Stearns is a big deal, that's very personal. So I do think that these decisions are very personal. This does have a very real presence in the lives of most Americans. Secondly, I think it's important to say who's going to be on the board. I would like to have people who reflect the common, daily concerns of average working Americans on that board, making sure those consumer voices are heard. This shouldn't be made up solely of insurance executives, retired congressmen, or surgeons that never leave the operating room. This ought to be a combination reflecting the eclectic mix of health-care participants we see today. That's very important. The third is also important, and that's what I said before. It is always the prerogative of Congress on some of these things to overturn these decisions that are not in keeping with the expectations of the law. And that would always be the right of Congress in this case as well.

EK: Many of these ideas, some similar, some not, have fallen by the wayside, when they stepped into the political realm. Why would this get to 60 when so many others have failed?

TD: This would only succeed if we learn lessons from the past. And there are so many lessons to learn. You know, one of the lessons of the past that we should learn is we've got to broaden the coalition as much as possible. I think our potential for broadening the coalition this time is really great. I think there's a lot more interest in it. Secondly, I think we've got to realize that there are not one but three categories of health problems: access, quality and cost. All three have to be dealt with, and all three have different constituencies. And so we have to address the constituencies where the political problems lie. With the doctors, it's going to be malpractice. With patients, it should be quality and cost. With businesses, it's going to be cost. So we've got to go right to the heart of what is the core concern for these core constituencies and try to address it. Third, we've got to have a lot more transparency. We have to break the myth, we have to put opponents of change on the defensive. In the past, it's been proponents of change who've been on the defensive. We have to turn the tables.

Reprinted with permission from Ezra Klein, "Is Congress the Problem with Health Care?," The American Prospect Online: May 14, 2008. The American Prospect, 2000 L Street NW, Suite 717, Washington, DC 20036. All rights reserved.

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