President Barack Obama’s healthcare reform initiative, after what many had seen as a badly compromised and possibly debilitating start when the nomination of Tom Daschle as Dept. of Health and Human Services secretary crashed and burned in early February, seems to be moving forward smoothly and inexorably toward a Congressional vote before Labor Day. Daschle had seemed to be an essential lynch pin to the reform effort, combining a policy perspective remarkably close to that of the President with an undisputed ability to work closely and constructively with the Congress. But Obama recovered from the initial setback with a canny succession of key policy personnel appointments, and never skipped a beat. In retrospect, it is hard to imagine a stronger health reform policy team than the one currently in place — with one glaring omission we’ll get to below.
First, Obama installed Nancy-Ann Min deParle, former Office of Management and Budget analyst (assigned to the Clinton healthcare reform effort), CMS administrator and all-around health policy star, as head of the White House Office of Health Reform — a title Daschle would have held in addition to his cabinet position. Along with the March nomination of eventual DHHS Secretary Kathleen Sebelius (confirmed by the Senate at the end of April), deParle gave Obama a top-level health care policy team with a rare combination of political, administrative and analytical talents — far surpassing what Daschle would have brought to the job — except for his Senate “member of the club” connections.
Sebelius, for her part, has now assembled a large and talented team to staff the DHHS Office of Health Reform (not to be confused with the White House Office). Perhaps most noteworthy is Sebelius’ selection of Michael Hash as senior advisor. Hash — among the most knowledgeable and experienced practical health policy experts in Washington — has been a hospital industry lobbyist, a key House Energy and Commerce Committee staffer (where he worked for Henry Waxman on Medicare issues) and the deputy administrator of the Health Care Financing Administration. His connections to key health reform stakeholders inside and outside of government run broad and deep. His principal assignment is to be the liaison between the DHHS office and the White House Office, but Hash’s substantive contribution to the details of health reform is likely to be very important.
Other critical administrative positions in DHHS have also been filled — notably Dr. Margaret Hamburg as commissioner of the FDA (confirmed by the Senate May 18) and Dr. Thomas Frieden — New York City’s much respected commissioner of health — as director of the Centers for Disease Control and Prevention. Neither of these appointments will contribute directly to healthcare reform, but both with help immeasurably to stabilize and energize agencies critical to protection of the public health.
More than dozen DHHS positions requiring Senate confirmation remain vacant— largely due to Sebelius’ relatively recent assumption of formal responsibility. But only one of those vacancies — that of CMS Administrator — is obviously and directly critical to the eventual success of the health reform initiative. And while there is surprisingly little information or even speculation in print or on the web about likely nominees and/or the status of the search, there are indications that it has been difficult to find a willing candidate with the attributes most sought after by the President.
As far back as January 28, the In Vivo Blog reported being told by multiple sources that selection of the CMS Administrator had been made, floating a number of names, including:
— Denis Cortese, Mayo Clinic CEO;
— Donald Berwick, CEO of the Institute for Health Care Improvement;
— Robert Berenson, former head of Payment Policy and Group Contracting at CMS, member of Obama’s transition team, a Medicare Payment Assessment Commission (MedPAC) commissioner, and Senior Health Policy Fellow at The Urban Institute;
— Hamburg (recently named to the top FDA post);
— Judy Feder, Clinton health policy advisor, member of Ira Magaziner’s ill-fated Clinton administration health reform task force and former DHHS assistant secretary for planning and evaluation;
— and David Blumenthal, director of the Massachusetts General Hospital’s Institute for Health Policy.
At least one Washington insider has told me that it is widely believed that at least two of those candidates, Berwick and Berenson, have been offered and have declined the administrator’s position. That same source added the name of Glenn Steele, head of Pennsylvania’s Geisinger Health System, to the list of candidates — but In Vivo reported just last week that Steele had withdrawn from consideration.
Finally MedPAC chairman Glenn Hackbarth’s name has surfaced in a number of places as a candidate; Hackbarth has ties to Berwick (both were important leaders in the early development of the Harvard Community Health Plan — Massachusetts’ once-seminal, now late and lamented staff model HMO), and has served as a HCFA Deputy Administrator. Among all those named here, he is probably the most deeply knowledgeable about the financial and quality impacts of Medicare’s various payment methodologies.
Why the apparent reluctance of well-qualified candidates to serve and why is the process taking so long? There are no definitive answers to those questions as yet; no one — neither the insiders nor the reluctant candidates — is talking. But there are some highly plausible reasons to consider.
It may be the choice had been made — and the offer accepted — for an administrator to serve under secretary-designate Daschle; but with Daschle off the board, the key players changed and the pieces rearranged, that nominee withdrew and the process needed to start from scratch.
The multitude of strong-minded, creative and assertive health policy leaders that makes up the Obama reform team, and that is driving the initiative toward a successful policy conclusion, is a turn-off to the best potential CMS administrator candidates. Running CMS is an enormous challenge in routine times; changing the direction of the CMS bureaucracy in order to initiate real policy innovations is incredibly difficult under any circumstances. Who would want to take on the task with an entire village of people who think they could do the job equally well or better sitting in the White House and the secretary’s office and second-guessing every move?
Perhaps the candidates have assessed the potential for success in introducing real innovation in the Medicare program and have concluded — based upon the legislative straight-jacket that has encumbered the program through its history — that the opportunity isn’t real. A reasonable person might conclude that there are too many restrictive program elements that can only be changed by the Congress, and too little administrative room to operate, to effect meaningful quality improvements and cost reductions.
Finally, until a candidate knows whether he or she is going to be developing and managing a public health insurance program to compete with and/or supplement private insurance offerings, there is no way to assess the challenges and opportunities of the job. What is potentially the biggest, newest and most difficult piece of the CMS administrator’s job remains an unknown. Maybe it is too early — not late at all — for an appointment.