In the debate over a replacement candidate for Tom Daschle at HHS, some well known (but dumb choice) names have surfaced, like ex-MA Gov. Mitt Romney (who thinks the MA experience would fail) and TN Gov. Phil Bredesen (a Democrat, but the architect of draconian cuts to TN's health system in 2005-6. See Ezra for the scoop on Bredesen's health care industry ties, which are more profound than Daschle's ever were.) Well known and not-so-dumb choices that are making the rounds are Ron Wyden (Sen from OR, has his own health plan and experience building a coalition for it), Howard Dean, KS Gov. Kathleen Sebelius and Bill Bradley (each of whom has their plusses and minuses - Bradley's finances, for example, are likely more complex than Sebelius'.) But as the HuffPo article on Bradley notes, the intriguing name is John Kitzhaber.
Who? Well, this guy.
In 1978 Gov. Kitzhaber was elected to the Oregon State House of Representatives. In 1980 he was elected to the first of three terms in the State Senate and served as Senate President from 1985 to 1993. His legislative career was marked by active leadership in the areas of public education, community development, environmental stewardship and a wide variety of health care issues including: long-term care, resource allocation and uncompensated care. While Senate President he authored and implemented the groundbreaking Oregon Health Plan. In 1994 he was elected Governor of the State of Oregon and was reelected to a second term in 1998.
The Oregon Health Plan is famous because it introduced rationing of care.
The state of health care in Oregon first came to prominence in 1987 with the case of Coby Howard, a 7-year-old boy diagnosed with leukemia. Howard required a bone marrow transplant. The Oregon legislature, however, had decided earlier that year not to fund transplant operations, which were an optional service at the discretion of states under the Medicaid program that provides insurance to low-income Americans. The state consequently refused to pay for the operation. The case drew substantial media attention, and private efforts to raise money for the operation were undertaken, but Coby Howard died later that year before sufficient funds were raised.2 In response to the Howard case, an Oregon state representative introduced legislation to restore Medicaid funding for bone marrow transplants. However, the bill was opposed by John Kitzhaber, a former emergency medicine physician and then president of the state senate who later became Oregon's governor. Kitzhaber noted that in Oregon, as in all other US states, substantial segments of the population were uninsured and lacked coverage for even the most basic medical services. Kitzhaber contended that, in this context, it made little sense for the state to pay for costly services, such as transplants, that would benefit relatively few Medicaid recipients. He argued that, although Oregon could not conceivably afford to pay for every medical care service for every person, it could expand insurance to cover all the uninsured while controlling expenditures if it was willing to ration care.2
In 1989, the Oregon legislature enacted a health reform bill sponsored by Kitzhaber that aimed to extend insurance coverage to all Oregonians. The bill contained 2 major provisions: a mandate for private employers to provide their workers with health insurance and an expansion of the state Medicaid program to cover all people in the state below the federal poverty line. At the time, Medicaid covered only 42% of low-income Americans, and other states had been tightening eligibility requirements in response to growing program expenditures, thus adding to the already substantial ranks of the uninsured in the United States. In contrast, Oregon pursued a "pincer strategy" of expanding both public and private sources of medical insurance to produce a system of universal coverage. Oregon's employer mandate, which was beset by business opposition and hampered by the election of a conservative Republican legislative majority in 1994, never received the federal waiver necessary for its implementation. Consequently, Oregon's aim of achieving universal coverage, which is something that no US state has yet attained, was not met. Yet the state's Medicaid reforms, after considerable national debate, were approved by the Clinton administration, and the OHP began operation in 1994.
Note that the background includes "former emergency room physician", a good perspective to see some of what ails the health system, such as overcrowding and the need for surge capacity (although I would maintain that, as with Dr. Dean, having an MD is a very useful but the least valuable of the experience factors. Simply being an MD does not train you in public health or to run HHS. Consider the job description of a plastic surgeon, for example, or a July 2008 med school grad, to stretch the point of what's needed to manage a 737 billion dollar budget. Executive experience is a much bigger plus, hence the string of Governonrs who are recent or prospective job applicants.)
More to the point, Kitzhaber has published a "health framework" that emphasises (gasp) fairness and practicality.
- We cannot solve the health care crisis by simply giving everyone insurance coverage (i.e. this is not just an insurance problem).
- We are all in this together and have challenged the whole concept of "categorical eligibility."
- All Americans should be eligible for and have timely access to effective treatment for at least the same set of essential health conditions ("core benefit")
- The core benefit should be portable and not tied to employment.
- In terms of financing, we believe the first emphasis should be on the public resources already being spent on health care. We are not trying to dictate what people do with their private after-tax dollars, but rather to ensure that public resources are spent in a way that is equitable, efficient and effective in producing health.
- Market competition should be based on cost, quality and outcomes, not the avoidance of risk.
- We must explicitly recognize the reality of fiscal limits and that we cannot purchase everything for everyone.
- We must acknowledge the inevitability of at least a two-tiered system; that people with more disposable income will always be able to purchase more than people with fewer resources. People should be able to purchase additional services that may not be covered in the core benefit. The challenge is to ensure that the core benefit (the "floor") is adequate to provide for the health of all Americans.
- All medical interventions are not of equal value and effectiveness in producing health, and therefore a prioritization process must be established to decide what will be financed with the public resources.
- Individuals should be more directly involved in their own health care treatment decisions.
- It is important to promote healthy behaviors through strategies that focus on both individual choices (responsibility) and environmental influences.
- Co-payments should be used not simply to shift costs to individuals, but rather to influence individual behavior by placing lower co-payments (or no co-payments) for highly effective procedures backed by good scientific evidence and higher co-payments on lower priority interventions.
He's been interested in health reform for some time. And I love that he's a blogger, a tradition at HHS. He's a Democrat (elections have consequences, and after Judd Gregg to Commerce, that needs to be emphasized).
He doesn't specifically address single payer, and his ability to work with the Senate is an unknown.
A down side may be his (potential) unfamiliarity with other issues that HHS has to deal with (like BARDA and other research dollars, the National Response Framework, CDC and the public health side, etc.)
Presumably, he pays his taxes (let's hope so.) And he's the exact opposite of a creature of DC. So, while this is short of an endorsement, he's a character that would be worth learning more about.
And get familiar with the Oregon Health Plan debate, because sooner or later, scarce resources will lead to a discussion of limits, rationing and ethics. Agree or disagree, Kitzhaber has had a jump start on all of that. And, more to the point, familiarize yourself with what HHS does and consider the qualities needed to lead it (including a sensitivity for research dollars and how they are spent, as well as the role of public health in our lives.) This isn't a patronage job or a reward for service. And this is not an era where anything less than outstanding is acceptable.
Update [2009-2-5 12:5:47 by DemFromCT]:: Kitzhaber seems uninterested
Former Oregon Governor John Kitzhaber says he’s flattered by being mentioned as a possible cabinet secretary in the Obama Administration. But he says he’s not interested in heading the U.S. Department of Health and Human Services.