The Players Who Will Shape Health Care Reform in 2009

A number of key advisers will shape the health care reform debate following the Presidential Election. Here are some of the top players who will engage in the reform debate-and play important roles in health-in 2009.

Health care reform is coming, whether a Republican or Democrat is elected president in November. So who’s going to do it?

By Ramsey Baghdadi

Everyone loves a good horse race. Hence, speculation is starting to grow louder as to who will play key roles in the next administration, depending on who wins the November presidential election, Illinois Senator Barack Obama or his Republican counterpart, Arizona Senator John McCain.

Health care will be one of the top domestic issues for the next US president. Both parties agree that the election will presage reforms of some sort—whether they be a push for universal health coverage under Obama, or for a transfer of tax incentives under the employer-sponsored system to individuals and families to buy their own insurance, which McCain advocates.

Either way, Obama or McCain will rely on a handful of policymakers to craft their vision for health care. In fact, they already do: Both campaigns have health advisors helping to shape their plans in the context of the election. The profile of those advisors signals where health care reform stands on the totem pole of priorities for each candidate, as well as the preferred approach So it is no coincidence that McCain counts a number of economists as his top health policy aides. McCain’s approach to health care reform begins with tax policy, after all, with the candidate advocating a tax credit-transfer strategy to provide incentives for Americans to seek coverage. And of course, McCain, the fiscal conservative, is eager to lift the hood of the current health system to identify all the possible areas to garner savings.

Perhaps more importantly, the handful of McCain’s health advisers pale in comparison to the number of foreign policy advisers working with the Senator’s campaign, indicating the relative importance of the two issues.

Obama, on the other hand, has a number of health advisors who have been pronouncedly more visible during the campaign. While Obama’s plan is less of a radical change to the current employer-based health care system, it is significantly more ambitious in attempting to cover the approximately 47 million Americans without insurance. (Also see "Preparing for Health Care Reform: Why Big Pharma Thinks it Can Avoid Another "Hillarycare"" - Pink Sheet, 1 Jan, 2008.)

But, of course, the winning candidate’s health care team will expand after the election. It has to, and not just because there are so many jobs to fill. When it is time to tackle health care reform, the new Administration will need to bring in plenty of outsiders who have the right expertise, connections or public image to help move the issue.

Whether it’s McCain or Obama in November, health experts on both sides of the aisle and opposite ends of the debate are gearing up for a debate over major changes to the health care system—and many believe the time is right for significant reform to be enacted under the next president.

Here are just a few of the advisors who are currently tied to each campaign, and a sprinkling of other policy experts who could play a role in the next White House.

The Obama Players

David Cutler: The Harvard health economist is a top health adviser to Obama. Cutler is considered the primary architect of Obama’s health care reform plan and would be a prime candidate for any number of positions, with the top spots at the Centers for Medicare and Medicaid Services and the Congressional Budget Office a strong possibility. The Office of Management and Budget would also be right up Cutler’s alley. That position, however, has gone to former elected officials recently (Jim Nussle and Rob Portman; Mitch Daniels went from OMB to be elected as governor of Indiana).

Under the Clinton Administration, Cutler served on the president’s Council of Economic Advisers and was director of the National Economic Council; he’s also a member of the Institute of Medicine. Cutler has advised the presidential campaigns of Sen. Bill Bradley (D-NY) and Sen. John Kerry (D-Mass.).

Cutler has co-authored health economics papers with former FDA commissioner and CMS administrator Mark McClellan and shares some of McClellan’s views on the inefficiencies in the system that are the cause of higher-cost, lower-quality care.

David Blumenthal: Also a Harvard professor and director of Massachusetts General Hospital’s Institute for Health Policy, Blumenthal will be a high-profile player if Obama wins, whether it’s a formal position in the Administration or as an outside adviser.

Blumenthal has conducted research on the future of academic health centers, quality management and access to health care, and the extent and consequences of academic-industrial relationships in the health sector.

Although it was a long time ago, Blumenthal was a professional staff member on Senator Ted Kennedy’s Subcommittee on Health and Scientific Research during the 1970s—a plus for any candidate for a top Senate-confirmed health spot in a Democratic Administration. And he’s an MD to boot.

Gregg Bloche: The Georgetown law professor and Brookings Institute non-resident senior fellow has publicly represented Obama on health care issues.

Bloche brings an international specialty on health law and policy; he has been a consultant to South Africa’s Truth and Reconciliation Commission on human rights in health as well as an adviser to the World Health Organization. He has also served on the Institute of Medicine’s Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care.

Wendell Primus: Primus served as deputy assistant secretary at HHS between 1993-1996, where he focused on conduct and coordination of research and evaluation on child development, welfare and employment, among other issues. Before that, he was chief economist for the House Ways & Means Committee.

Primus is most known for resigning from his HHS position in protest of President Clinton’s compromise with Republicans on a welfare reform bill that drew fire from the liberal wing of the Democratic Party. He now serves as a senior adviser on budget and health issues to House Speaker Nancy Pelosi (D-Calif.), and could be a candidate for a prominent position if Obama wins in November.

Paul Starr: It’s hard to imagine Starr won’t be involved in some capacity if Obama makes a real run at transformation health care reform. The co-founder and co-editor of the liberal American Prospect magazine, Starr was a senior adviser to the Clinton Administration in 1993 on the president’s plan for universal health coverage. The Princeton professor won the 1984 Pulitzer Prize for Non-Fiction for his book "The Social Transformation of American Medicine" and has publicly lamented the missed opportunity to reach a compromise on a universal plan. If Obama wins, he may get a second chance.

Mark McClellan: The current-and-former-everything-in-health-care, McClellan could be considered for any number of high-level positions in a McCain or Obama White House. He’s headed up FDA, CMS and serves as director of the Brookings Institute’s Engelberg Center for Health Care Reform. That’s not all: McClellan is also chairman of the public-private Reagan-Udall Foundation, which was established under the FDA Amendments Act. (Also see "Building the Right Foundation: An Interview with Mark McClellan" - Pink Sheet, 1 Apr, 2008.)

The only major health policy position McClellan hasn’t yet held is HHS secretary; however, that job seems to be reserved for a governor or top campaigner. Former Arkansas and Massachusetts Governors Mike Huckabee and Mitt Romney, have been thrown around as possible HHS secretary nominees in a McCain cabinet, but McClellan would be an intriguing choice for Obama or McCain.

Rare is the policymaker in this partisan environment who could be considered such an attractive candidate for any number of high-profile roles in both a Democratic and Republican administration. But McClellan has accomplished just that.

McClellan’s family has a history of breaking with convention. Two decades as a Republican wasn’t enough to stop McClellan’s mother and Texas Comptroller Carole Keeton Strayhorn from breaking with the party and running against President Bush-backed incumbent Rick Perry for governor in 2006 (she would eventually lose to Perry).

And of course, McClellan’s brother Scott, who served as press secretary for George W. Bush, didn’t make any new friends in the Republican Party with his book "What Happened: Inside the Bush White House and Washington’s Culture of Deception." And don’t forget, Mark McClellan served as deputy assistant secretary of the Treasury for economic policy under President Clinton from 1998-1999. The high regard for McClellan from both sides of the aisle would be a plus for a McCain Administration just as much as an Obama Administration.

Steve Nissen: Yes, Nissen is a possibility as FDA commissioner, albeit somewhat of a long shot for a number of reasons. The job is essentially Ted Kennedy’s choice and Nissen may be too much of a controversial pick for the senior senator from Massachusetts, who has a large and important drug industry constituency in his home state.

Nissen also may not want the job given the challenges. The Cleveland Clinic cardiologist knows all too well the drug industry would put all of its resources behind a campaign to block his nomination, plus, his very public criticisms of FDA would mean he would be tasked with fixing "the problems" under a very public microscope.

Still, expect him to at least receive public consideration for the post.

Dan Mendelson: President and founder of the successful health consultancy firm Avalere Health, Mendelson could play an important role at CMS or OMB, where he served as associate director for health under the Clinton Administration from 1998-2000. At OMB, he focused on the development of a federal pharmaceutical benefit and the broad application of health information technology.

The McCain Players

Douglas Holtz-Eakin: McCain’s policy director will surely serve in some sort of senior role in a Republican administration. Holtz-Eakin served as director of the Congressional Budget Office from 2003-2005 and was the White House’s chief economist on the President’s Council of Economic Advisers from 2001-2002. Here’s what Holtz-Eakin had to say about health care in a March 2008 editorial in the Washington Post:

"[Sen. McCain] would propose comprehensive health-care reforms that would change the practice of medicine to reward quality, high-value care, as well as tax credits and insurance market reforms to stop the erosion of health insurance. Such a combination would attack spiraling costs, ease pressure on family budgets, permit firms to pay better wages and reduce the number of the uninsured."

In an April Q&A with US News & World Report, Holtz-Eakin explained the problem with universal health care coverage:

"The fundamental problem with health care is rising costs. The focus on the Democratic side is covering everybody. That’s a laudable goal, but the reality is even if you were to snap your fingers and cover everybody who was uninsured...and in exchange for their insurance you had them pony up $3,000 apiece, you would raise $150 billion, which is a lot of money, and now everyone would be in the system and given 6 to 8 percent cost growth a year, you would chew up that $150 billion within a year, and now everybody is in and it's getting more and more expensive every year and that is why companies drop insurance and people can't buy insurance. The Democratic formulation solves the wrong priority first."

Holtz-Eakin could play a wide and varied role if McCain were to be elected, whether it be in the White House or in a high-level position at HHS.

Mark McClellan: (See previous.)

Thomas Miller: A senior fellow at the conservative think tank American Enterprise Institute, Miller is already working with McCain on health care issues; he specializes in the Medicare Part D drug benefit and health savings accounts. Miller’s most recent published articles have related to understanding and improving health disparities.

Miller has diverse experience: a current member of the National Advisory Council to the Agency for Health Care Research & Quality, a senior health economist for the Senate Joint Economic Committee from 2003-2006, and a journalist (print and TV with a stint as a sports director in radio).

Gail Wilensky: Wilensky has kept her name circulating in Republican circles and would have to be on any short list of McCain advisers or Administration positions. Wilensky represented McCain at a Washington event hosted by the Health Central Network in April, where she dedicated much of her presentation to comparative effectiveness and value-based purchasing. That’s no surprise considering Wilensky has taken a public lead on the issue of a national comparative effectiveness center. (See "Comparative Effectiveness: The Next Gatekeeper to Commercial Success," The RPM Report, September 2007.)[ A#2007500151]

Currently a senior fellow at the non-profit Project HOPE, Wilensky’s resume includes a two-year stint as administrator of the Health Care Financing Administration (now CMS) from 1990-1992 under Bush I and a subsequent position as deputy assistant to the president for policy development. She also chaired the Medicare Payment Advisory Committee from 1997-2001. If a new center for comparative effectiveness were to be created during a McCain presidency, Wilensky would almost certainly shoot to the top of the list of candidates to lead the government entity.

Dan Crippen: A former head of CBO, Crippen’s ties to the Regan Administration make him an attractive candidate for a health slot in a McCain White House. Crippen, who is working with the Republican Senator’s campaign, has been a vocal advocate of health IT and changing physician practice patterns to foster better, more efficient care. In a March 2005 editorial in the Washington Post, he wrote: "Doctors should have incentives to assume the role of care coordinators for the chronic users of Medicare in an effort to improve care and hold down costs. We should start reducing the utilization of hospitals to curb costs without lowering the level of care provided....With proper incentives, we can have physicians coordinating the entire care regimes of the chronically ill, regulating the prescriptions and doing everything in their power to provide the best treatment without using the hospital as a default. The patient will get better care, and Medicare will recoup big savings....We can no longer ignore the elephant in the room that is Medicare. It’s too important for everybody."Crippen, who was domestic policy adviser to President Reagan from 1988-1989, could be a strong candidate for an advisory role in the McCain White House.

Kevin Hassett: Another AEI scholar, Hassett is director of the conservative think tank’s economic policy studies. The former Columbia business school professor was an economic adviser to the 2004 Bush campaign and, prior to that, acted as McCain’s chief economic adviser during the2000Presidential Republican Primaries. Hassett’s most likely landing spot in a McCain Administration would likely be the President’s Council of Economic Advisers.