Who will manage health reform once it is passed?

Editor's Note: This discussion is from the national journal online.  The post below is by Former Senate Democratic leader Tom Daschle.

It is increasingly likely that Congress will pass meaningful, comprehensive health reform this year. But that is the beginning, not the end, of changing the way our health system functions. Over the next 10 years, our country will continue to spend perhaps $35 trillion on health care with a new infrastructure that we hope will cover all Americans by providing greater access, better quality and lower cost. The big question is: Who will manage all of this? While the Center for Medicare and Medicaid Services manages the two largest federal health programs, we have no overall management authority. Imagine an aviation system without the FAA. Or our monetary system without the Federal Reserve Board.

Today, we have three big problems. First, our system (such as it is) is laden with stovepipes with little real integration. Federal health agencies have little or no coordination with each other. And there is even less between federal and commercial entities. Second, Congress is largely left with the virtually impossible responsibility of making managerial decisions that require extraordinary expertise and political courage. This is something that Congress is not equipped to do well. Third, as a result of the first two problems combined with a lack of transparency and no systemwide effort to address the need for quality enhancement, we have no systemwide infrastructure management. In large part, the lack of any coordination and integration of our massive health care labyrinth has led to massive inefficiency, a loss in quality and higher costs. How disappointing it would be if, after we pass meaningful change in health care policy, we fail to develop the infrastructure to implement and manage it.

We need a federal health board with the political autonomy, the expertise and the legal authority to make the tough decisions and to manage our system far better than it is managed now. The best time to do this would have been decades ago. No one knows how much quality improvement and cost reduction we could have experienced.

But the second best time is now.

This response is by John Goodman, President and CEO, National Center for Policy Analysis

With all due respect, Sen. Daschle has gvien us the wrong diagnosis and the wrong solution.

We are in trouble because every single actor in the health care system faces perverse incentives. That includes 300 million patients, about 800,000 doctors, every nurse, every hospital administrator, every employee, every employer, every insurer, and every government agency (did I leave out anybody?). The incentives are not just a little bit perverse. They are very, very perverse.

No amount of "management" can make things work as long as social cost exceeds social benefit for every actor at every margin. True reform does not start at the top by trying to select a manager. True reform starts at the bottom -- by systematically correcting all the perverse incentives we have created.

Finding practical ways to do this, by the way, are what I and my colleagues at the National Center for Policy Analysis have been trying to do for two decades. We welcome constructive input from others.

This response is by Newt Gingrich, Founder, Center for Health Transformation

Tom, you are onto something when you wonder if our federal agencies are up to the task of implementing real change in healthcare. The public sector's track record of measuring whether policy changes, new strategies, etc. actually work as envisioned is not encouraging. In the private sector, people are held accountable if their plans do not succeed. This rarely happens in government.

But would a federal health board help this? Healthcare is simply too complex for one group to “manage our system.” While I understand the conceptual advantages, such as avoiding politicians’ micromanaging, the dangers of a centralized health board are too great. Just look at the Federal Reserve and the almost unaccountable power it has wielded since last fall.

What I recommend is to 1) include specific goals in any regulatory or legislative change, so that we know exactly what we are working toward. 2) make relevant federal agencies publicly report their progress online so that the American people can see where things stand in real time. 3) release taxpayer-funded data from government health programs, like Medicare, so the public can assess and compare the performance of providers, hospitals, insurers, and others.

Despite our differing views on a federal board, you and I agree on more than most people think when it comes to healthcare. In fact, if you could put up all the ideas and “options” that have been discussed so far, I bet Republicans and Democrats agree on 75% of them, especially on delivery reform and promoting better health. Unfortunately, the 25% where they don’t agree gets the headlines, like a government insurance plan and employer mandates. Moving forward, we should continue to focus on those areas of agreement.

We look forward to discussing this and many other priorities this week when you join us at our Center for Health Transformation member meeting on Thursday.