I just finished reading Tom Daschle's book:

Daschle, T., S. Greenberger, and J. Lambrew, Critical: What We Can Do about the Health-Care Crisis. 1st ed. 2008, New York: St. Martin's Press. 226.

Given that Mr. Daschle is the new Secretary of Health and Human Services by President Obama, this book, which outlines his beliefs on what should be done to mend our "broken" health-care system, is required reading for anyone hoping to understand and anticipate the changes coming our way.

I would like to therefore submit my “book report”, for those of you who may not have time to read the book and who don’t mind my take on things. There are only 5 chapters, so for simplicity and brevity I am presenting an outline using the chapters as the main points. For those of you who have even less time, I refer you to the final part of the outline, section 6. This is where I highlight what I consider to be the main points of the book.

  1. The Crisis
  2. To begin, Daschle outlines why he believes we are in a health care crisis. He starts with a quote from a certain President of the United States:
  3. “Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.” And
  4. “People with low or moderate incomes do not get the same medical attention as those with high incomes. The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.”
  5. He then points out that while we might believe that President Clinton uttered those words, they were actually spoken by Harry Truman, 64 years ago! (Truman’s speech can be read in entirety at

  6. He then goes on to quote the figures we are all familiar with:
  7. 47 million Americans without health insurance
  8. 16 million “underinsured”
  9. Only 65% of people earning less than $10 an hour are offered health insurance at work.
  10. Skyrocketing costs
  11. Direct to consumer advertising by pharmaceutical companies
  12. Pathologic supply-side forces such as the fact that physicians both diagnose and treat illness – they thus can create and satisfy demand
  13. Unpaid bills become hidden taxes
  14. Inflated hospital bills that punish the uninsured while rewarding large insurers
  15. Many states have begun to act on their own, frustrated by inaction at the Federal Level
  16. Massachusetts in 2006
  17. Vermont – 2006
  18. California – proposed
  19. The History of Health Reform
  20. 1914 – labor reformers tried to get states to legislate free medical care, sick leave, and a death benefit
  21. Even though the measures didn’t pass, they scared employers
  22. Hospitals, looking for revenue in the Depression, set up pre-payment plans for groups such as teachers and firefighters – start of the Blue Cross Blue Shield
  23. After WWII, employers added health insurance as a benefit to attract workers, since they were forbidden to increase wages by federal price controls
  24. Health Insurance was ruled not taxable when provided by employers
  25. Clinton campaigned on health care and was elected
  26. Managed competition
  27. Use regional alliances to purchase or provide health care
  28. Offer subsidies to the unemployed and small businesses
  29. Pay-or-play
  30. Employers either join the state-sponsored plan or pay a fee to the government for each worker
  31. Problems with Clinton plan
  32. Did not involve Congress from the beginning – he convened a task force that excluded and thus offended many legislators
  33. Size of task force got to be too big
  34. Managed Chaos
  35. Tried to keep deliberations secret
  36. But they had so many members, leaks killed them
  37. Size and complexity of bill was too much – 1,342 pages
  38. 90 new councils, commissions, and other bodies
  39. “A big, fat, ugly bill”
  40. The embarrassment of the incident in Somalia (think: “Blackhawk Down”) and NAFTA diluted the power of the issue
  41. Health Insurer’s association and the small business association mightily opposed and carried out a successful grassroots campaign
  42. Harry and Louise ads
  43. As the decision on the issue was delayed until the mid-term elections were nearing, Republicans saw a chance to use the issue to seize control of both houses of Congress
  44. Sen. Mitchell pulled the plug on the bill on Sept. 26, 1994
  45. Since then, Congress has done little to help the situation
  46. Health Insurance Portability and Accountability Act (HIPAA)
  47. State Children’s Health Insurance Program (SCHIP)
  48. Medicare Modernization Act of 2003
  49. Handout to drug and insurance companies
  50. What went wrong and models for making it right
  51. Timing was bad
  52. Waited too long after president took office to mount a major push for reform
  53. KEY POINT: Daschle here is signaling his intent to push for reform as soon as possible- possibly attaching the health reform act to the federal budget
  54. Wasted time trying to craft their own plan, rather than bringing in congressional leaders almost immediately
  55. Opponents capitalized on fears and lack of knowledge
  56. Congress finds it difficult to deal with health care issues because of the nature of politics and the political process
  57. At this point, laying the groundwork for the main proposal of the book (a Federal Health Board) he goes into a description of the Federal Reserve System, describing how its creation in 1913 separated and insulated the governance of our monetary system from the vagaries of Congress and federal politics.
  58. The Federal Health Board (FHB)
  59. Despite its merits, asking for a single-payer system is unrealistic
  60. Individual insurance market for everyone is similarly unrealistic “High-cost sharing leads to reduced use of both needed and unneeded care”.
  61. Build on the model we have
  62. Expand the Federal Employee Health Benefits Program (FEHBP) and make it available to everyone without job-based insurance
  63. Thus everyone would have access to health insurance – either through:
  64. Their employer
  65. Medicare
  66. Medicaid
  67. FEHBP
  68. KEY POINT: The FHB would determine coverage
  69. Mental health parity
  70. Dental care
  71. Quality
  72. KEY POINT: FHB would measure quality of providers. ASCs must obtain the quality outcome data to back up our claims- we need to publicize it and make sure it gets into the hands of these policymakers.
  73. Develop national quality standards
  74. Pay for performance
  75. Coordination of care
  76. Develop Infrastructure
  77. EMR
  78. Community health centers
  79. Develop Rational System
  80. KEY POINT: “If there were a single standard of care and coverage in all of these programs, it would be a model for every other provider and payer”. We need to make sure that ASC services are fully covered.
  81. The Federal Health Board
  82. Quasi-governmental organization
  83. Board of Governors
  84. Clinicians
  85. Health benefit managers
  86. Economists
  87. Researchers
  88. Appointed to 10 year terms
  89. Would also have Regional Boards
  90. Regional Boards would focus primarily on promoting best practices and quality of care locally
  91. Staff of analysts “Charged with assessing and producing the research required to make sound decisions”
  92. Board and its staff would have unparalleled resource, and would produce work that would become part of the public domain
  93. Functions
  94. Set rules for proposed expanded FEHBP
  95. Promote “high-value” medical care – recommend procedures backed by solid evidence.
  96. Align incentives with care- “would counter the smoke and mirrors with hard facts on the value of devices, drugs, and services”.
  97. Pay providers based on outcomes, rather than services
  98. Make the health-care system more transparent
  99. KEY POINT: Guide resource investments. Here we should push to address the resources devoted to ASCs vs. hospitals
  100. Enforcement
  101. Power would come because all federal health programs would have to abide by its recommendations.
  102. Prospects for Health Reform
  103. Increasing costs are the main driver for reform – business interests, an opponent of earlier attempts, are crying for help
  104. KEY POINT: here again he says that the bill should be attached to the federal budget to prevent it being stalled by Senate protocol.
  105. Again he touts the possible benefits of the FHB, comparing it to the Federal Aviation Administration, which has responsibility for airline safety
  106. Health care consumers, like airline passengers, have little clout in Congress- think of the power of airline manufacturers like Boeing and McDonnell Douglas matched up against the unorganized concerns of the average airline traveler. Similarly, health care consumers as a whole have a difficult time gaining the influence held by the massive lobbying of Big Pharma, hospitals, and providers.
  107. KEY POINT: “The Federal Health Board would serve as a public framework for a private health system. It would make tough coverage decisions, collect evidence, identify weaknesses in our system, and align federal health programs.” I am thinking of decisions such as coverage of ASC services.
  108. He finishes with another quote from Truman’s speech referred to at the beginning of the book (see above):
  109. “By preventing illness, by assuring access to needed community and personal health services, by promoting medical research, and by protecting our people against the loss caused by sickness, we shall strengthen our national health, our national defense, and our economic productivity. We shall increase the professional and economic opportunities of our physicians, dentists and nurses. We shall increase the effectiveness of our hospitals and public health agencies. We shall bring new security to our people.”
  110. My summary
  111. Here again, excerpted from the outline above, are the key points for ASCs and the ASC Association that I identified in my reading of the book:
  112. Daschle intends to push for reform as soon as possible- possibly attaching the health reform act to the federal budget. We must gear up now for the massive lobbying effort that will soon be taking place on Capitol Hill.
  113. The new Federal Health Board (FHB) would measure the quality of providers. We have the quality outcome data to back up our claims- we need to publicize our favorable outcome studies and progress in quality data collection and make sure it gets into the hands of these policymakers.
  114. “If there were a single standard of care and coverage in all of these programs, it would be a model for every other provider and payer”. We need to make sure that ASC services are listed on that standard.
  115. The FHB would guide resource investments. Here we should push to address the resources devoted to ASCs.
  116. “The Federal Health Board would serve as a public framework for a private health system. It would make tough coverage decisions, collect evidence, identify weaknesses in our system, and align federal health programs.” Again – we must insure coverage of ASC services.

I hope I have given you a clear summary of the important ideas contained in the book. This is important information for all of us. We have 100 days from the start of President Obama’s term- this is often seen as the key time for newly-elected Presidents to get policy implemented, as they can use the impetus of their recent victory to help them drive legislation. We must get our message of the unequalled quality, access, and cost of ASCs into the hands of our legislators as they deliberate on these massive policy issues.

And at the same time, we need to prepare ourselves for the possibility of a Federal Health Board, as well as Regional Health Boards, and make the connections necessary to see that ASCs and their allies are strongly positioned on these new policy-making bodies.

With change comes opportunity. Change is upon us- let us take advantage of the opportunities!

Dan Simonson, CRNA, MHPA

3 January 2009