Which Picture Is Really Me?

9 Hours and I am Still Standing

This year just gets better and better. Yesterday, we had 9 hours of solid seminar, with views ranging from a left-wing Yale economist who favors single payor to a representative of ALL of the moneyed interests in the health care debate, who wants nothing to do with the public option. The latter was interesting; she was as pleasant as can be, and yet stood for large amounts of what we are all (I suspect) against happened. It was the most interesting exchange of the day. Mary Grealy, her name was. She came on after John Iglehart and Harvey Finberg- two of the nicest and smartest doctors in the US- representing the Healthcare Leadership Council. She spent a lot of time explaining how her group wanted to deal with the problem of the uninsured, but not by expanding public insurance, and was very interested in stories of people who were eligible for public insurance refusing it because of the stigma of "welfare". Of course, she saw nothing wrong with the stigma- her response to that was to assert that it showed the need for more private insurance in America. Sje spoke of Jacob Hacker's work as "voodoo", (Hacker is a nobel-prize winning economist who feels stringly about the plan) and really thinks that the public option is creeping socialism. Sheldon nailed it by appearing to be confused- "So, am I reading this to mean that your group supports the public option?", and her "everything's fine" manner quickly dissappeared- "Show me where it says that" in a sharp manner. The other speakers spoke more of the process- ways Fellows can get in over their heads and the like. One quote stuck with me: "You have to be cynical to survive in the Capitol. You have to use cynical means in order to achieve altruistic ends.". That sounds an awful lot like "All the King's Men". I am indeed in the right place.

Quote for the day: On Reform

To judge from his faltering campaign for healthcare reform, President Obama, well-read as he is, appears to have neglected to read Machiavelli. If he had done so, the American president would have learned this from the Florentine statesman and philosopher in "The Prince":

"It must be considered that there is nothing more difficult to carry out, nor more doubtful of success, nor more dangerous to handle, than to initiate a new order of things. For the reformer has enemies in all those who profit by the old order, and only lukewarm defenders in all those who would profit by the new order, this lukewarmness arising partly from fear of their adversaries, who have the laws in their favor; and partly from the incredulity of mankind, who do not truly believe in anything new until they have had actual experience of it. Thus it arises that on every opportunity for attacking the reformer, his opponents do so with the zeal of partisans, the others only defend him half-heartedly, so that between them he runs great danger."

From Howie Foreman

I clearly need to read "The Prince"

Beginning of Second Week

Today is a really busy day:

Monday - September 14, 2009 | ^ back to top
8:00 AM-12:00 PM	Howie Forman - Primer on Healthcare Expenditures
12:00 PM-1:00 PM	John Iglehart, Founding Editor of Health Affairs
1:00 PM-2:00 PM	Harvey Fineberg - President of the IOM
2:00 PM-3:00 PM	Mary Grealy - Healthcare Leadership Council
3:00 PM-4:00 PM	Beth Fuchs & Lisa Potetz - Health Policy Alternatives
4:00 PM-5:00 PM	Jim Jensen - Director, Office of Congressional and Government Affairs, NAS

I have been delinquent is blogging about Friday- let me just say that I have begun to feel like I understand ERISA for the first time. All of Friday continued to convince me that I know nothing. I may update this later, and try to say more about it, but there is too much information coming into my ears this morning.

This was my view walking to work today. It is still truly amazing to be here. And Comcast did show up.

End of the First Week: Politics in DC

So, I am sitting in my apartment, waiting for Comcast to come and install my wireless. It wasn't hot outside, so I opened my windows, which allows me to hear the crowd of people on the Mall today, angry that Obama is President, and that "big government" is back. Actually, it turns out that it actually never went away. Still, it is work reflecting a bit on the second and third days of our Fellowship experience. I took notes.---------------------

Thursday was a late starting day and we began some more discussion of the mechanics of what is to come. Then we learned about the Institute of Medicine. Chartered in 1971, the IOM joined the NAS and the NAE as an advisory body, funded a lot by Congress to present them with considered opinions about important stuff, like why are there so many medical errors and what do we know about vaccine injuries. They answer the questions that they are asked, and they do very little original research (ex

cept in military medicine, where they are an indespensable the repository of data). We met five of the Boards:

Children, Youth and Families, Health of Selected Populations, Health Sciences Policy, Food and Nutrition and Population Health and Public Health Practice. There were a number of different studies that relate to children, particularly in CYF and Food and Nutrition. They have some stuff on Children's Mental Health going on, along with obesity stuff and vaccine stuff and - you name it. In a lot of ways, it was overwhelming, and I wasn't able to ingest it all enough to ask a competent question, a sure sign of being overwhelmed. How will I be able to hang onto that many contacts and names? How will I learn what is going on?

Anyway, after 3 hours of Boards and studies, Marie began a talk on the current state of the health reform debate, using it as an means of explaining how our government works. She was brilliant- low key, yet full of facts and interesting stories about how work actually get done around here. I took notes on her slide set- I really want to use her slides. The most important ones, I think, are these:

We look at problems as a way to ask interesting questions- we then collect fresh data and look

to see what questions it raises. Medicine and engineering tend to be bit more practical than the pure scientists, but still, we are interested in a "deep" understanding of things.

Political folks approach problems with a legal eye: What are the Issues? What are the Rules? How have the rules been Applied in the past? What is your Conclusion? A lawyer's notion of fairness, then, is heavily biased toward the status quo. Takes a supple mind to say- we need a different applications. Politicians have more free to change the Rules, but, if they are not going to support the status quo, they have to have a real keen sense of how the power balance is playing out. And always, they have to figure out who will pay for whatever the change is (and does that person or entity have the power to strike back)?

My challenge is to be able to take the stuff we have learned through science and help that information inform the decision process. Not an easy task.

The flip side of this is that I will be functioning in a system that has a completely different value system than the one that I am used to. Marie gave us some ways to think about it, that lend themselves to stereotyping, but are true at the core. The interesting one to me was the high value placed by decision makers on the power of the press. Given everything that has been said about the decline and fall of the media, it is not clear who the media are, only that they are feared.

The other interesting thing about Marie's contemplation was here assessment of the decision making apparatus. There's the Executive Branch, with the POTUS and his many Executive Offices, the Legislative Branch, with its committees and chairman, and the interest groups (Special Interests, Stakeholders) which she parses into Voluntary Health Groups (ACS is king among those), Professional Societies, Trade Associations, and Academe/Think Tanks. The latter is how science intercolates itself into the debate. The key to the process is understanding the players in this complex multimodal process.

What have I gotten myself into?

^^^^^

6 hours waiting and no Comcast. They now say that he has a flat tire. Not sure I believe it.

Privatizing a Blog: What's Up with that?

Orientation has begun for the RWJ Health Policy Fellowship, and I finally understand a bit of what I am supposed to be doing here. It seems my job is to provide Congress with cogent and pristine policy analysis on issues related to health policy. My position at the IOM gives me great credibility; in Washington, that allows us unprecedented access to information and people. Indiscriminant DISTRIBUTION of that information, however, is the kiss of death in this town. Hence the closing of the blog, and it's transformation into my private diary. I may open this to a few people (e.g. my wife and sons), but not a lot more. Makes sense.

Some salient quotes from yesterday:

What makes a great experience? An office that makes it feel like you are part of the team, you have a front seat, that you have a portfolio, and that you present stuff to a legislative team that you love and admire. You spend long and hard hours, working from 6 AM to 11 PM, and you feel like you are making policy. You become part of a process that makes it happen. The Rose Garden ceremony is the icing on the cake.

What is success? Success is making not one enemy and learning to handle information in a very strategic way. This is a marathon, not a sprint. Don’t do anything that will interfere with your ability to go forth into the future. You are playing for the long game.

That seems a tall order to me. Our charge is to be indispensable, yet invisible. I see many ways in which this can go wrong. We'll see how it goes.

More later.