We’re very pleased with the expected nomination of Senator Tom Daschle to the position of Secretary of the Department of Health and Human Services (HHS). Sen. Daschle brings a wealth of knowledge and experience to HHS, and has a proven track record of building bipartisan consensus on some of our nation’s most difficult challenges. During his nearly three decades of representing his state in the U.S. Congress, South Dakota’s hospitals always found Sen. Daschle to be accessible and understanding of the issues facing America’s hospitals. We commend this great choice for Secretary of HHS and look forward to working with Sen. Daschle upon his confirmation.

The federal health agenda has become so dominated by managing the high costs and treatment of health problems, that preventing disease and helping Americans stay healthier get only a small fraction of attention and funding support. The current way the federal health agencies are structured and funded, they do not have the resources or jurisdiction they need to reach our national objectives for improving health. In particular, the public health service is underfunded, understaffed, and often uses out of date technologies to combat today’s modern health threats.

The next Administration should appoint a Secretary of HHS who has a strong understanding of public health as well as health care, and public health expertise should be represented on the staffs of the Domestic Policy Council, National Economic Council, and National Security Council, in addition to the expertise already housed in the Office of Management and Budget.

At HHS, the next Administration should elevate the current Assistant Secretary of Health position to be an Undersecretary for Health (USH). This office should oversee a strategic approach to prevention, preparedness, and public health to increase coordination and accountability among agencies, including all Public Health Service agencies, the Assistant Secretary for Preparedness and Response, and the Centers for Medicare and Medicaid Services. The USH is not meant to disempower agencies or add another bureaucratic layer, but to help coordinate and provide leadership. Further, the USH and the Secretary would have integrated budget and policy analysis staff so as not to have two layers of review. The new USH and new public health experts at the White House should be charted with convening a sub-Cabinet Working Group across all federal agencies to encourage consideration of the health impact of all policies and programs. In addition, an Office of Health Policy should be created in all Cabinet departments to evaluate the health impact of policies and programs within each department.
Also, a strong, independent Surgeon General should be appointed, who would be given authority and resources to strengthen the Public Health Service Commissioned Corps. The Surgeon General must be given the independence to speak directly to the public on matters of health, be given the resources needed to ensure those messages are heard, and support the visibility of state and local health departments as critical parts of the public health system. The Surgeon General could chair a new National Public Health Board, charged with setting broad national priorities for public health, convening both governmental and private sector leaders to take responsibility for achieving these priorities, and assessing the nation’s progress in meeting them. A strong leader must also be appointed to the U.S. Centers for Disease Control and Prevention to help focus the agency on clear prevention goals that would help improve the health of Americans.

The next Administration must also finally clearly define public health emergency and response roles and responsibilities. Many experts have called for more clarity around the roles and responsibilities of federal agencies involved in public health emergency preparedness -- both among cabinet agencies -- the Departments of Health and Human Services (HHS), Homeland Security (DHS), Veterans Affairs (VA), and Defense (DOD) -- and for offices within HHS -- the Assistant Secretary for Preparedness and Response (ASPR), the Centers for Disease Control and Prevention (CDC), and the Health Resource and Services Administration (HRSA). Under the current structure, ASPR functions as both a policy arm and operating division. Roles must be clarified. With support from a new Undersecretary of Health, ASPR should focus on consistency in policy among programs, to assure that all HHS agencies follow the policy guidance of ASPR.

The next President has the opportunity to appoint a team that will be able to fulfill his campaign pledge to prioritize public health and prevention. Americans are not as healthy as they could be or should be. We will only be able to improve the health of Americans if our next health leaders focus on prevention and preparedness, starting on Day One.

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Ideal Job Description:

1. Knows economics.

2. Knows nothing about health care.

3. Knows about insurance, but nothing about health insurance.

4. Knows nothing about health policy.

5. Does not even have any friends who know anything about health policy.

I'm actually half serious about this.

President-Elect Obama will need a balanced and savvy team he can trust to keep their eyes on the prize of health reform. The good news is Tom Daschle is going to be a key counselor and spokesperson, whichever specific position he takes. Former Senator Daschle has just the right equanimity, knowledge about the health system's strengths and flaws, Congressional leadership experience, plus a genuine passion for getting comprehensive health reform done, so as to be invaluable in private and in public to a new President with an ambitious agenda and intense competition for his time and attention. I also know that Senator Daschle is committed to attracting genuine bi-partisan support for the final package, a sine qua non to the long run sustainability of the reform effort.

With Senator Daschle as either Secretary of HHS or the key White House health advisor, the five other positions that matter most will be: the head of CMS, the head of the FDA ,and the head of the NIH, and the head of the Agency for Healthcare Research and Quality, and hopefully the new Comparative Effectiveness Institute.

The CMS administrator, the point person for Medicare, Medicaid, and most importantly, the interface between these key public insurance programs and system reform plans, must be someone who is deeply knowledgeable about the current delivery system and its perverse payment incentives and how those incentives impact cost, patient care and health, especially for the most vulnerable among us. The perfect background for this would be a physician and CEO of a successful integrated delivery system with a coherent vision about how to use payment reform to transform our system into a far more efficient and sustainable one. This person will need credibility with professional colleagues and societies, system stakeholders, as well as with key Congressional leaders. So someone with high professional standing and an academic record of distinction who can explain health care to civilians would be an ideal candidate.

For FDA, an academic with pharmaco-economic knowledge and intimate experience with clinical trial design, financing, and execution seems about right. A current or former medical school dean who has had to balance drug trial funding streams and competing research agendas, and who understands the need to reform the FDA to yield far better comparative effectiveness information at the point of marketing, would be ideal.

For NIH, I would want a successful academic researcher with a vision for how to reallocate existing funds to yield more immediate knowledge and clinical effectiveness from translational and comparative effectiveness research. We desparately need someone who can raise the prestige of this kind of research without denigrating the search for serendipitous knowledge that has served us well in the past.

I think of AHRQ and the new Comparative Effectiveness Institute (CEI) as complementary. AHRQ could take on the new functions of the CEI, but for prestige and impact reasons, it may be better to create a new CEI that is not subservient to the Secretary of HHS and competing with other agencies within HHS for budget and clout. Congress and the President, and the many stakeholders with a vested interest, will work that out. The kinds of people we need running both are those who are knowledgeable about and committed to learning and teaching best practices, nationwide, as soon as possible. We have tolerated mediocrity and delay in the diffusion of best practice information far too long, and part of the reason to make a new CEI is to raise the profile of our commitment to producing more best practice knowledge and disseminating what we do know far faster. These functions, along with incentive realignment through payment reform and information sharing with patients and other payers, are essential if we are to improve value and bend the cost growth curve in the long run. So, physicians who have run large multi-specialty groups, have had stellar research success, and are committed to making the US health care system performance #1 in the world by 2020 are perfect for these jobs.

On balance, given the skill sets identified and with Senator Daschle's presumed role, I don't think anyone else necessarily has to come with lots of prior Washington experience, though that should not disqualify an otherwise qualified candidate.

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