Eli Y. Adashi, MD: Hello. I am Eli Adashi, Professor of Medical Science at Brown University and host of Medscape One-on-One. Joining me today is former senatorand senate majority leader Tom Daschle to discuss his latest book, Getting It Done, a highly informed account of the process leading to the passage of the Affordable Care Act and thus the launch of healthcare reform. Now approaching its first anniversary, the law remains the center of attention and contention. Welcome.
Senator Tom Daschle: Thank you Dr. Adashi.
Dr. Adashi: It's especially wonderful to have you with us.
Sen. Daschle: Thank you very much.
Dr. Adashi: What led you to undertake this rather demanding project?
Sen. Daschle: I've had an interest in healthcare for a long time, going back as early as my first years in Congress in '78 and '80. I was involved with the first effort to pass health reform in 1993 and '94 so this is a natural extension really. I thought that the passage of this legislation after a hundred years of effort really should be documented. We should try to tell the story. How did it happen? Why did it happen? What does it mean? That's really what I attempt to do in the book Getting It Done.
Dr. Adashi: Was Getting It Done to be a follow-up to your previous book, Critical: What We Can Do About the Health-Care Crisis?
Sen. Daschle: It really was in some respects sort of the sequel to Critical. In Critical I talk about why we have the problems we do in health and how we might address them. Getting It Done is what the Congress actually did to do just that, to address the challenges of cost, access, and quality in a meaningful way.
The Affordable Care Act's Role in History
Dr. Adashi: You already commented on it briefly, but viewed against the backdrop of other historic statutory accomplishments, how do you think about the Affordable Care Act in perspective, considering our recent -- perhaps even entire -- legislative history? Where does it rank?
Sen. Daschle: I believe that the passage of the Affordable Care Act ranks up there with the passage of our monetary system in 1913 or the Social Security System in 1935. I believe that there is every reason to believe this will be viewed as one of the most historic and transformational moments in public policy domestically that we've seen in decades if not generations.
Dr. Adashi: One wonders whether the abundance of attention this bill is getting is, in fact, a reflection of the fact that it is a significant legal accomplishment and that it does, in fact, matter.
Sen. Daschle: Just as we've seen with other historic moments, there have been efforts to pass it that have failed and efforts to repeal it once it is passed that have failed. I believe that will happen with the Affordable Care Act as well. It took us a long time to get to this place. It, I believe, is going to be permanent law. I don't think efforts to repeal the legislation will be successful. There are other questions constitutionality-wise and implementation-wise that are going to have to be addressed, but by and large I think what you see now as part of the official statute will stand.
Many "Near Death" Experiences of the Affordable Care Act Passage
Dr. Adashi: Going back to the book now, you describe cogently a whole series of events that ultimately led to passage. Reflecting on that series of events, which one do you think was most surprising to you, perhaps even jolting, along the way?
Sen. Daschle: Even though I fully expected that this was going to be very difficult, I never dreamed in my wildest imagination that we would have so many near death experiences; really to rise up after having virtually completely collapsed legislatively not once, not twice, but again and again and again was probably the most jolting experience. For those of us who care deeply about this legislation, it was beyond nail biting. It was really a very, very tense experience that kept repeating itself until March 24, 2010, when the legislation was finally signed into law.
Dr. Adashi: Speaking of near death experiences, you described several low points in the process. One wonders whether there was one particular low point when you felt that success was all but beyond reach.
Sen. Daschle: There were several where I became very concerned, but I'll tell you one that really stands out to me. I had the good fortune to have lunch with the President in early September right after the August recess when all of those town meetings were being held that ended up as screaming matches and even worse, real confrontational experiences for so many members. I was lamenting to the President how painful it was and how concerned I was for him that we were going through all of this. He reminded me that August was never his month. Politically, he went through several of these August experiences back to back over time, but he said what he found through that experience is that as bad as August is, fall gets much better. He said: I think it will here too, so we've got to keep our strength and keep our stamina and think positive thoughts about the future. He was right.
Dr. Adashi: This is hypothetical, of course, but because you have delved into this process so deeply, if we had to do it all over again, what would you have done differently?
Sen. Daschle: I think the hardest thing to do is to explain this complicated subject in ways that people could better understand. While we won the legislative war, I think almost from the beginning we've lost the message war. We've lost the ability at least temporarily to have the kind of high ground I would have hoped when I wrote these 2 books. My concern all along has been how we can make this more understandable for the average person. Why should they care and why should they believe this is a good thing for them? Using those questions I think we could have done a lot better job in creating the kind of appreciation, the education, the message it takes for people to better understand why this is important to them.
The Key Role of Medical Liability
Dr. Adashi: Although it is undeniable that with the huge number of items in the bill, condensing it into an elevator speech, if you will, is a challenge and perhaps hard to fault the message or the messenger. Moving forward now, it is very clear that American physicians are especially interested in the outcome of various elements that are in the bill or that are not in the bill. One that is not in the bill is the medical liability issue. Many of us are following closely a bill that was sponsored by representative Phil Gingrey, himself a physician, and we were wondering how would you rate the likelihood of the passage of a medical liability bill, be it this one or perhaps another one?
Sen. Daschle: The prospects for addressing medical liability at the national level over the course of the next several years continue to increase. As you know, this has always been viewed as more a matter for states than the federal government. We have a number of states, well over 30, that have taken on this issue of medical liability. My feeling is that as we begin to examine ways to address unnecessary care, defensive medicine is going to be one of those issues for which there could be little disagreement. The question is: how do we fix it? My view all along is that we should connect medical liability and safe harbor with best practices. The more we could encourage doctors to employ best practices, giving them immunity if they did, the more likely it is that I think we could find some resolution.
Dr. Adashi: The President's 2012 fiscal year budget is reported to include funds that would offset the long disputed cuts in Medicare reimbursements to physicians. Here again, given your deep background in all of these issues -- and I know you don’t have a crystal ball, still -- how do you see this particular issue evolving in the current political mix?
Sen. Daschle: There is broad recognition that the Sustainable Growth Rate (SGR) problem is one that has to be addressed. It's unfair to physicians and providers that we do this on a short-term basis constantly with so many questions outstanding with regard to how this is going to play out. It's unfair to virtually everybody involved. Congress has not done a very good job, and that's a reflection on me while I was there just as it is now on those who are there today. I believe we've got to fix it, and I would like to see it fixed as we consider payment reform. We have to address meaningful payment reform as we go forward. The Secretary of Health and Human Services is given a great deal of latitude, but we've got to move away from the volume-driven fee-for-service approaches that we've had in our federal system for too long and create new ways, whether it's globalized or bundled or perhaps even capitated approaches that would allow us to incent value rather than volume. It's in that context that I believe we can finally address SGR.
Dr. Adashi: On a personal note, is there another book in the cards and thereby the possibility of a before, during, and after trilogy?
Sen. Daschle: That's very kind to ask. I love to write, and I love the issue. I wouldn't be surprised if down the road we come up with another matter. I joke with audiences these days, though, that I hope there isn't a sequel because that would imply that we've had to start all over. I'm not prepared to do that, but there will be so many, many things to talk about with regard to health as we go forward on the cost side, on the quality side, even on access in the new infrastructure that we're trying to set up. The endless opportunities to write more are there, and I would like to find ways to continue to do the research and to share good information with others.
Dr. Adashi: Thank you Senator; we look forward to it. On that note, sincere thanks to Senator Daschle and to you, our viewers, for joining Medscape One-on-One. Until next time, I am Eli Adashi.