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The Big Challenge Now Is Implementing Health Care Reform

First, a word about Stewart Udall, who died last week. I admit I have a very soft spot for the Udall clan, including not just Stewart’s son Tom and his nephew Mark, both now serving in the Senate, but also their cousin, former Sen. Gordon Smith (R-Ore.). This family has an ethos of public service, combined with immense civility and decency, and a collective sense of humor that was best typified by Mark’s late father, Mo, whom I was proud to call my friend. Stewart demonstrated those qualities in his service in Congress as well as his time as secretary of the Interior and his landmark lifelong efforts to improve the environment. He will be missed, but he leaves a hell of a legacy in his family.

[IMGCAP(1)]Now on to the topic of the day and year. Of course, passing health care reform was a huge victory for President Barack Obama and his White House, Speaker Nancy Pelosi (D-Calif.) and her leadership team, House Energy and Commerce Chairman Henry Waxman (D-Calif.) and the substantive gurus who found the right formula and also showed how the bill would benefit each and every Congressional district, and to the memory of the late Sen. Edward Kennedy (D-Mass.). It was also a huge tribute to Rep. John Dingell (D-Mich.), who finally achieved the goal of his life and played a pivotal role in the critical endgame through his relationship with Rep. Bart Stupak (D-Mich.).

I will assume that the Senate will get through this by the weekend or very soon thereafter. I was skeptical that the Senate Republicans’ main point of order, challenging the reconciliation bill on the grounds that the changes in taxation of high-end health plans affect Social Security outlays, would prevail — after all, many prior reconciliation bills included tax changes that had an indirect effect on Social Security and passed parliamentary muster. I also suspect that the tactic of offering unlimited amendments to do a filibuster by amendment will be limited in duration; after the House action and the public belief that this issue is effectively decided, any interminable delay for delay’s sake will create a significant backlash.

After that comes the hard part. This reform plan is neither socialism nor a government takeover of the health care system, and its sweep in some important ways has been overstated — the outlays here over 10 years amount to less than 4 percent of what the nation will spend on health. But it is complicated because it makes significant changes in the public and private components of the health care system, and the complications extend to all its efforts to “bend the cost curve.”

Its promise to save money over the next 10 and 20 years has real potential; every idea for cost control that health specialists have suggested is in the bill in one form or another. But the reality will be shaped by the implementation of the program, and that in turn will be shaped by the people in charge of implementation.

The skepticism about the projected cost savings here is based in part on a misconception — that every health plan enacted by Congress has exaggerated potential savings and underestimated costs. That is false, and the best example is the Medicare Part D program enacted in circumstances at least as controversial as this reform bill. That bill passed the House in the dead of night after the infamous three-hour vote, which included the attempted shakedown on the floor of then-Rep. Nick Smith (R-Mich.) that earned then-Majority Leader Tom DeLay (R-Texas) and Rep. Candice Miller (R-Mich.) rebukes from the ethics committee. It also included a conference committee that locked out both Senate Minority Leader Tom Daschle (D-S.D.) and Sen. Jay Rockefeller (D-W.Va.) from the deliberations. And it included an effort to silence the Medicare chief actuary before he could give cost estimates for the bill.

The Medicare prescription drug bill was the poster child for violations of the regular order and brought with it dire predictions of huge cost overruns, magnified even more because the bill included no offsets to pay for it. But the fact is that the program has consistently produced far lower costs than either the Congressional Budget Office or its critics predicted and projected. Why? One reason was that the elements that then-Ways and Means Chairman Bill Thomas (R-Calif.) built into the program to enhance competition and reduce costs actually worked. But I believe the most significant reason for this program’s success at cost control was the skillful implementation of the program by Mark McClellan, then-director of the Centers for Medicare and Medicaid Services.

McClellan got the program off to a smooth start, figured out the best ways to communicate the essentials of it to seniors — not the easiest audience to reach using modern communications or to adapt to change — managed to coordinate the efforts of Medicare, pharmaceutical companies, pharmacies and the other key actors, and made sure that loopholes and glitches were kept to a minimum.

I raise this issue now because the mastery of the Obama administration in achieving the passage of health care reform has been paired with inexcusable ineptitude when it comes to putting into place the key player to implement this new and pivotal program. Fourteen months into the Obama presidency, we have no director of the CMS — and we don’t even have a nominee! Cost containment in Medicare and Medicaid is in sight for the first time because of some laudable reforms in the health care bill, but achieving them will depend on leadership in this position.

The presidential nomination and confirmation process is seriously broken. Dozens of worthy and competent nominees are twisting in the wind in the Senate, delayed for months by holds that are often petty, shortsighted and even wholly unrelated to the poor people waiting to be confirmed. It is no way to govern, and the Senate should be individually and collectively ashamed at this shortsighted abuse of power — and should act on reform of the process.

But there is plenty of fault to aim at the White House, which has itself been inexplicably slow at picking nominees for key posts. None is more important than the head of the CMS. The president and his Congressional allies deserve a victory dance over the remarkable achievement of enacting major health care reform. It could well be a pyrrhic victory if the president doesn’t get his team in gear and get a CMS team in place pronto.

Norman Ornstein is a resident scholar at the American Enterprise Institute.

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