The job of Secretary of Health and Human Services will be a particularly important one in the Obama Administration, because the President-Elect is strongly committed to health care reform. Among those who have been suggested as contenders for the post are former South Dakota Senator Tom Dashle, former Vermont Governor Howard Dean, Rep. Rosa DeLauro of Connecticut, and Kansas Governor Kathleen Sebelius.
While DeLauro and Sebelius are little known nationally, Dean has been prominent since his 2004 run for President, and he has also been Chairman of the Democratic National Committee since 2005. When he was Vermont’s Governor, Dean, who is a physician, expanded health care coverage to nearly all of the state’s children, and he also expanded Medicaid to cover prescription drugs for a third of the program’s recipients. As a Presidential candidate, he proposed enlarging Medicaid and the State Children’s Health Insurance Program to cover all uninsured children and young adults up to age 25. (Obama, too, wants to cover all children but would make some parents responsible for buying the insurance.) Dean also wanted to bring poor adults under the SCHIP umbrella.
Tom Dashle is familiar from his years as Majority Leader and later Minority Leader of the Senate when it was dominated by Republicans. In that stressful, difficult role, he showed a remarkable equanimity under pressure while keeping the beleaguered Democrats together. Since leaving the Senate, he has been fighting for health-care reform, trying to achieve consensus across party lines with the help of fellow ex-Majority Leaders George Mitchell, Bob Dole, and Howard Baker. Their Leaders’ Project (part of the Bipartisan Policy Center) has held forums across the country this year. Dashle has also written a book called Critical: What We Can Do About the Health Care Crisis.
In that book, Dashle makes a number of proposals that are close to Obama’s health care platform, including more emphasis on preventive and chronic care, a shared responsibility approach to financing, and changes in how doctors and hospitals are paid. Like the President-Elect (and many other Democrats, past and present), he also wants to create a national insurance pool, similar to the Federal Employees Health Benefit Program, that would allow individuals and small firms to get lower insurance rates.
Dashle’s major proposal is to create a Federal Health Board that would oversee and set the rules for government-funded and government-subsidized health programs, including Medicare, Medicaid, and the expanded FEHBP. Together, these programs might eventually cover the majority of Americans; in any case, private insurers would be likely to follow the policies of this Federal Health Board, as they follow Medicare in many areas.
Comprised of government-appointed experts, Dashle’s Federal Health Board would, among things, decide which benefits would be covered, supervise comparative effectiveness research, and recommend infrastructure investments. It’s a smart plan from the viewpoint of protecting rational health policy decisions from the assaults of special interests. In fact, in terms of drawing up standard benefit packages, it’s the only way to go. But I have serious reservations about how well it could run the health care system—even a system that might, in the future, be increasingly government-financed.
For starters, all health care is local. While Dashle does propose an advisory role for regional health boards that would include business and consumer representatives, his model is too centralized to respond to the differences in how health care is delivered at the local level. One size does not fit all in health care.
Second, even if experts could agree on what should be in a benefit package or on how doctors should be compensated, that doesn’t mean that the stakeholders would abide by the outcome. Interestingly, Dashle points out that the Federal Reserve’s power rests on its support from Congress. The same would be true of a Federal Health Board. Simply punting the decisions to a group of experts would not remove their political impact. Also, at a time of economic meltdown, let’s not forget that neither the Federal Reserve nor the SEC—both models for Dashle’s plan—have functioned very well in terms of oversight. We can’t depend on a Federal Health Board to make the right decisions for health care any more than we can rely on regulatory agencies to keep our financial system on the tracks.
That said, either Daschle or Dean would make a fine HHS Secretary. Daschle would have excellent relations with a Democratic-controlled Congress, and Dean would be able to apply his proven executive abilities. Obama might also consider Dr. Mark McClellan, who heads the Brookings Institution’s Engelberg Center for Health Reform. As a former head of the Food and Drug Administration and of the Centers for Medicare and Medicaid Services in the Bush Administration, McClellan knows the levers of HHS well, and he also has a detailed knowledge of the policy issues. Among his accomplishments: He implemented Medicare Part D. Whatever you think of that program, it was a monumental job to put it into place. If Obama wants to bring a Republican into his Cabinet, McClellan has a lot to offer—including his recently stated belief that the time for healthcare reform is now.