Senator Tom Daschle, former Senate Majority Leader and author of Getting it Done: How Obama and Congress Finally Broke the Stalemate to Make Way for Healthcare Reform.

Mark Masselli: This is Conversations on Healthcare. I am Mark Masselli.

Margaret Flinter: I am Margaret Flinter.

Mark Masselli: Margaret, as you know we mostly talk about health policy and
reform on this show but it is flu season and I am going to join the chorus of
voices of health officials in strongly urging everyone to get out there and get their
flu vaccine. I know I took my four children the other day, there weren’t too many
screams but we all got our shots and got in and out pretty quickly and there are
plenty of flu shots to go around this year and plenty of places you can go, your
local Community Health Center, your primary care provider even the chain stores
like CVS and Walgreens I have their doors open. In fact, if you go to www.flu.gov
the flu vaccine finder widget allows you to simply enter your zip code and locate
a flu clinic nearby.

Margaret Flinter: Well Mark, it seems like we are making a public service
announcement, I guess we are so we will take it all the way through and as I say
to our staff don’t be selfish, it's not just about protecting you from flu, it's about
protecting people from catching the flu from you. If everybody is vaccinated we
are all better off. But Mark what a difference a year makes if you remember the
H1N1 or Swine Flu panic last year and the lines outside the doors very different.

Mark Masselli: Certainly it was a different story from last year at this time with
this shortage in panic. It's also different flu season because you only need to get
one vaccine this year to protect you from both the seasonal vaccine and the
H1N1, last year people needed to get two vaccines, one for the 2009 H1N1 and
one for the seasonal vaccine.

Margaret Flinter: And there are other things to worry about this year and a shot
won't help them. The economy seems to be slowly and painfully covering but not
fasting up to help so many unemployed and New York Times yesterday had a
front page story telling us what the plans were to undo Health Reform Bill by
some people in the country. So well, we aren’t panicked about Swine Flu or
H1N1 this year still the lots to be concerned about as the holidays approach.

Mark Masselli: So let’s get back to the policy conversations and we turn to
today’s guest. We are very excited that Senator Tom Daschle is here with us
today. He has written a new book called Getting It Done: How Obama and
Congress Finally Broke the Stalemate to make way for Healthcare Reform.
Senator Daschle has his first hand experience with health reform and he
understands the intricacies of legislation. You may even recall his first book
about healthcare before the passage of healthcare reform called “Critical”. We
are happy Senator Daschle can join us today.

Margaret Flinter: And no matter what the story you can hear all of our shows on
our website www.chcradio.com . Subscribe to iTunes and get our show regularly

downloaded or if you would like to hang on to our every word and read a
transcript of one of our shows, come visit us at www.chcradio.com . Think about
becoming a fan of Conversations on HealthCare on Facebook and follow us on
Twitter.

Mark Masselli: I am a fan and as always if you have feedback email us at
www.chcradio.com , we would love to hear from you. Before we speak with
Senate Daschle, let's check in with our producer Lorren Bonner with Headline
News.

Loren Bonner: I am Loren Bonner with this week’s Headline News. The
government has a new plan and hopes of finally ending the smoking epidemic.
The Department of Health unveiled a comprehensive tobacco control strategy at
once warning labels on packs of cigarettes to be replace with gruesome images
covering half the front and back of packs and 20% of large ads that could include
emaciated cancer patients or diseased organs. Howard Koh, Assistant Secretary
for Health and Chair of the Working Group that developed the department’s
action plan titled Ending The Tobacco Epidemic, so these evidence-based
actions are part of a broader strategy that will create a society free of tobacco
related death and disease.

Howard Koh: While our country has made great progress in reducing tobacco
dependence, this devastating challenge remains far from solved. Tobacco use
remains the leading cause of premature and preventable death in our society. In
the United States, smoking causes almost half a million deaths a year over 1,000
people a day.

Loren Bonner: The FDA will gather public comment on 36 proposed images now
th nd
through January 9 and 9 will be selected by June 22 after reviewing the
scientific literature the public comments and a study involving 1800 people.
Beginning in October 2012 cigarette makers that do not put the new warnings on
their packaging will not be allowed to sell their brands in the United States.
Doctors are rebelling against a 23% cut in Medicare fees that go into effect
st
December 1 unless the lamed up congress staves it off. The scheduled cuts
are the consequence of a 1990s budget balancing law whose requirements
congress has routinely postponed. Republicans and democrats and congress
are still unable to come together on an agreement. Health and Human Services-
Secretary Kathleen Sebelius said, “The administration is committed to working
with providers to avert the scheduled cuts.” However she did not specify her
th
remarks where congress should look for funds to pay for either the 13 month fix
or a long term remedy. A reprieve of a few months may be the likeliest outcome.

Mark Masselli: This is Conversations on Healthcare; today we are speaking with
Tom Daschle former United States Senator and Senate Majority Leader and
author of Getting It Done how Obama and congress finally broke the stalemate to
make way for healthcare reform. Welcome Senator Daschle.

Tom Daschle: Thank you very much Mark.

Mark Masselli: In the opening red book you posed the question why do we
undertake such a massive bill to spike the economic situation that the country
faced and you framed your answer around three points first the problems with
our healthcare system are so serious that we have to address them in order to
have a full economic recovery. Second the law was written to pay for itself and
finally if it didn’t happen now it would be another generation before we could try it
again. With the November elections behind us it would seem that the country
might not have grasped the importance of those three drivers. What was the
disconnect?

Tom Daschle: Well, I think the disconnect in part was a lack of appreciation of
what the bill and the law now may do for so many Americans in terms of access
in cost and quality. We have a very slow ramp up to pull implementation and the
down side to that is that people aren’t going to see results initially and I think
people are in America somewhat impatient who want to be able to see things
before they can come to any conclusion. The other thing I would say is that we
were outspent those of us who advocate before the law were probably outspent
seven or eight to one, dramatic imbalance in terms of the tremendous campaign
which regard to the characterization of this new law versus the other side those
of us who supported it with limited resources and very little ability to counter.

Margaret Flinter: Senator you summarized the many goals of a 2000-plus page
bill in very simple language really address rising cost, uneven quality and gaps in
excess and six months or more than six months now after the passage of the act
the initial implementation phase has taken place I think perhaps more than many
Americans appreciate their government has set up their consumer website
healthcare.gov it's established the temporary high risk pool with people with pre-
existing conditions, establish new rules for minimum benefits for new plans
including prevention and funded most of the states to begin working on the health
insurance exchanges and at the community level we see really unprecedented
support for community health centers, school health centers, public health. So
that is a lot of progress but easy administration effectively tying these successes
and these advances to those very clear goals so I don’t think most Americans
would disagree with addressing rising cost, uneven quality and the excess gaps.

Tom Daschle: Well I think that’s right Margaret my feeling is and has been for
sometime that we haven't done a very good job with messaging that is explaining
what it is this law is designed to do and how well it’s already done it. I give the
Department of Health and Human Services, high marks for implementation so
far. They have made most of the deadlines, they have done it without any major
screw-ups and as you say it's already expanded the scope of our opportunities to
serve in addressing all three of those challenges. Now I wish we could go faster,
I wish there was more we could do in a more visible and comprehensive way but

the law prescribes this slow implementation in large measure for one reason, we
want to get it right.

Mark Masselli: Senator given the magnitude of what health reform represents,
it's not surprising that reading your book, getting it done how Obama and
congress finally broke the stalemate to make way for healthcare reform, it’s
sometimes like reading the Tom Clancy novel, victory seems to be within reach
than the unforeseeable and unthinkable happens republicans Scott Brown wins
th
the late Senator Kennedy’s seat. In the 60 senate vote disappears there are
epic blizzards, negotiated deals that blow up the emergence of formerly obscure
rules for proceedings like reconciliation in the face-off between government
leaders. As always it's largely a story of people and their ability to lead others, as
we move forward who are the individuals you see as ensuring the success of
health reform and who are the once most likely to achieve what Ted Kennedy
called “keeping the dream alive.”

Tom Daschle: Well that’s a great question Mark and I think it starts with the
President. The President has to continue to make healthcare and this law a high
priority in his administration. There are some who are concerned that given the
tremendous competition for the president’s time and attention that it's hard to do
that, hard to keep coming back to healthcare now that the legislation is passed
but that’s exactly what has to happen. He has to continue to be the messenger
in chief and the implementer in chief and that will determine a good deal of our
success or lack of it. But beyond that of course it's the secretary I think that the
secretary and her organizational efforts at the Department of Health and Human
Services is really going to be key and then finally in some ways I would say that
the governors are going to be every bit is important is the secretary or the
president because so much of what has to be done has to be done at the state
level with the leadership with the governors and here I have some concerns. You
have a lot of governors who have campaigned in opposition to the law and have
even talked about illuminating Medicaid all together in their state, that’s a
problem. But at the same time we have a very important default opportunity here
if the states for whatever reason choose not to implement the secretary has the
ability to step in that’s going to be a tough, tough and very confrontational
environment but nonetheless at least you have that fallback as maybe as
inadequate as it may be.

Margaret Flinter: Senator as a long time veteran of health reform efforts, you, of
course you are of course are very familiar with the Harry and Louise ads that
helped derail the Clinton administration efforts on health reform and in your book
you described really the sea change that took place during the Obama reform
efforts Chip Kahn who headed the hospital or the Health Insurance Association of
America during the Clinton era was now at the table as the Head of the
Federation of American Hospitals and some of America’s best known and largest
insurers like the Aetna were on record as supporting the need for health reform.
Why the shift do you think 30 million potential new insured customers or a once

in a lifetime opportunity to really do some fundamental reforms that addresses
again those rising cost on even quality and the excess gaps?

Tom Daschle: Well I think it's really one of those cases where it’s all of the above
Margaret, you have got, you clearly have an opportunity for the stakeholders to
benefit from this law in just a number of ways, you mentioned one of course
insurance companies accessing potentially 30 plus million more customers.
Doctors are extremely frustrated with the current system especially Medicare
reimbursement. This provides an opportunity for a paradigm shift in
reimbursement, hospitals the same way with the real possibilities of medical
homes and there maybe bundled payments where hospitals have more control.
There are a lot of different pluses here. But I think also it's the flip side. All the
stakeholders know that our current track is unattainable. When it comes to
excess cost and quality we can't sustain the many, many problems that are
multiplying by the year in our current system. So they realize as we all do, as
many of us do the importance of changing our circumstances and creating a new
marketplace that allows for us to address these problems much more seriously.

Mark Masselli: This is Conversations on Healthcare. Today we are speaking
with former senator Tom Daschle, author of the new book “Getting it Done” how
Obama and congress finally broke the stalemate to make way for healthcare
reform. Senator I asked you a little earlier about who are the people most likely
to keep the dream alive and one of your current projects is serving as co-chair
along with the late senator’s widow Victoria Kennedy on the Health Information
Center, a democratic-led effort to defend and explain the Patient Protection and
Affordable Care Act, and what it means to Americans. You laid out that there
were really 3 drivers, it seems like there might be a fourth in terms of voices from
the public what’s your strategy for communicating and informing Americans about
the bill but sort of handling the misinformation in the era where the phrase is
Obama Care & Government or overreach are part of the public psyche.

Tom Daschle: Well Mark just one more clarification, Vicky Kennedy and I don’t
have any formal relationship in that effort. We are very informal along with many
other advisors who are hoping to help the administration and others who share
our determination to continue to see the law implemented as was planned and,
but here question the first and foremost I think it’s critical that the president and
the administration step up its visibility efforts, its messaging and do what it can
from the White House, from the congress, from the Department of Health and
Human Services to make sure that people fully appreciate the magnitude of good
that can come from this bill. Secondly, I think it's also important for the
stakeholders to be as engaged. I worry a little bit I am very appreciative of the
stakeholders cooperation and the kind of effort that they have made so far since
implementation, their attitude about the importance of making sure that it is
implemented but I would love to see the stakeholders step up and become even
more vocal and more visible than they have been to date. I think that’s critical.
Third, I think it’s you know you have a lot of advocacy groups, groups that

understand why this is so important. And they too need that to join the course
and become more engaged.

Margaret Flinter: Senator Daschle, the republicans are the new majority in the
house and many have pledged a commitment to repealing the bill, even though
repealed would seem to be well not impossible. We are hearing a lot about the
republican strategy to defend parts of the law, can you clarify for our listeners
what has already been funded and is really protected in the reform bill and
conversely what are the possible provisions in the law the republicans could
block or tamper with through with holding appropriations are even defunding?

Tom Daschle: Much of the bill is entitlement funding that is, it’s legislated and not
appropriated so those areas that are provided for in the log under Medicaid and
under Medicare in particular that our enhancements of the entitlement systems
are not one that could be defunded with simply withholding funds because
Congress doesn’t have that authority and there are also other provisions that are
given to the secretary to implement without further congressional involvement
and she has a great deal of flexibility in providing the funding necessary. So it’s
those areas that are more directly tied to annual appropriations that could be a
challenge and they could of course attempt to legislate a no-funds shall be
provided for phrase and the appropriations to take away the secretary’s authority
to do some of that but that would take a presidential signature as well. So the
bottom-line they don’t have nearly the autonomy, the authority that they might
think they have with regards to complete defunding. Some of it, yes but I think a
large portion of it will go through regardless of what congress does.

Mark Masselli: Senator Daschle of cost quality in excess, the most difficult
maybe raining and cost which is clearly tied to quality and access, you described
in your book possible approaches, bundle payments, accountable care
organizations, beefing up primary care and putting a new emphasis on
prevention some would say a lot of this is more hypothetical than real. What’s
your response to that?

Tom Daschle: Well Mark I have always felt that what we have to do is to come
up with a better decision making capacity. We don’t have that today the ongoing
debate about the sustainable growth rate for doctors reimbursement under
Medicare is a good example. And so that’s one reason why I have strongly
supported to be independent payment advisory board concept and the other
mechanisms that are in the bill that allow us a little more streamlined and a little
more insulated decision making capacity than we have today or that we had
before this law was passed so I think it starts with that. Secondly, I think there is
a fairly good appreciation that there is so much more that has to be done in part
because Congress didn’t have the capacity to get tougher on cost containment
because of the politics and complexity involved and in part because we really
aren’t sure which is the best approach to use. As you know there is going to be a
number of demonstrations, pilot projects and studies with very significant

opportunities for review and ultimate decision making within the law itself that will
allow us a more consequential cost containment strategy as we go forward. In
that regard I would say we are probably at best on a 10 or 20 yard line, we have
got a long way to go, 80 to 90 yards before we can really achieve the cost
containment but I think we have got the team on the field and now the question is
to move that ball down the field and I think we can do that.

Margaret Flinter: Senator you wrote that President Obama had concluded that
the only way to spread the cost of covering everyone around to ending lifetime
limits and preexisting condition denials to ending the practice of dropping people
when they got sick, was to require that everybody had health insurance so there
would be enough healthy people paying premiums to offset those higher costs of
less healthy people. But you can’t do that without providing subsidies to help the
people who can afford it, which is of course what we saw ultimately as a part of
the bill. That seems both obvious and rational and yet the individual mandate to
have health insurance is one of the most hotly contested provisions. Why do you
think when people accept mandatory no fault car insurance so easily, is this such
a tough one for Americans to support?

Tom Daschle: Well I think this whole debate has been about the role of
government and what is the appropriate role of government. It plays itself out in
just about every one of the issues what is the role of government and this was
another illustrative example of a deep division that exist within our country with
regard to the answer to that question. In large measure it's not the individual
mandate but it's the government telling people to have to buy insurance as you
say Margaret there is plenty of precedence for that, all through society. And
ironically many of those who have argued that there shouldn’t be an individual
mandate are the same ones who have argued for the need for personal
responsibility, taking more responsibility as individuals. Well I can't think of a
better demonstration of personal responsibility than to take care of yourself, first
to stay healthy and secondly to pay for your illness if you get sick. That’s what
the individual mandate is about as well. It's partly an effort to make sure
insurance concepts can be applied across the board including everybody, but it's
also partly a personal responsibility. Is healthcare a right, I happen to believe it is
a moral right, but along with that right comes a responsibility and that’s what we
are talking about here.

Mark Masselli: Senator Daschle we would like to ask all of our guests when you
look around the country in the world what do you see in terms of innovations and
who should our listeners at Conversations be keeping an eye on?

Tom Daschle: I would suggest a book by TR Reid called Healing of America
which is an analysis of that very question as it applies to health. Mr. Reid, I think,
does an exceptional job of pointing out where other countries have done better
than we have. The old myth is that we have the best system in the world, but we
have some of the best institutions in the world, and certainly some of the finest

doctors, and the best technology, but we aren’t anywhere close to being the best
system or marketplace in the world. And I think we can learn from other
countries on prevention, on wellness, on the whole notion of making sure that we
as a community take a greater responsibility for wellness than we do in United
States. Obesity continues to be a huge problem. Other countries are beginning
to understand that little more quickly and put in place implementations of plans
and programs that will allow them to address it. Great Britain is a good example.
But I think that we have a lot of work to do in that regard and as your question
suggests, we can learn from other countries.

Margaret Flinter: And I think we interviewed TR Reid on the show not too many
months ago so we could agree with you more. That was a fascinating book.
Today we have been speaking with Tom Daschle the former Senator and Senate
Majority Leader from South Dakota. His new book published by Thomas Dunne
Books is called, Getting It Done: How Obama And Congress Finally Broke The
Stalemate To Make Way For Health Care Reform. Senator, thank you so much
for joining us today on Conversations.

Tom Daschle: My pleasure. I enjoyed it a good deal.

Mark Masselli: Each week Conversations highlights a bright idea about how to
make wellness apart of our communities into everyday lives.

Margaret Flinter: This week’s bright idea comes to us from Afghanistan where a
new midwifery training program is making child births safer in a country with a
second highest maternal and infant mortality rate in the world. The program was
created by Jhpiego, an international health organization affiliated with The Johns
Hopkins University. This non-profit has a track record empowering frontline
health workers for almost four decades and its efforts have improved healthcare
for women and children in more than 140 countries worldwide, Afghanistan, just
one of 50 international efforts currently going on. Six years ago Jhpiego
developed a plan to provide remote mountain villages in Afghanistan often very
far away from health clinics, with the resources that they needed to stop
preventable deaths in child birth. Jhpiego has worked with Afghanistan’s Ministry
of Public Health to increase the number of village health clinics and to establish
accredited midwifery schools in every province of the country. Now young
women can attend an 18-month midwifery training course in their provincial
capital. And although women are not typically allowed to have jobs or travel
alone in traditional Afghan society, the new system has been developed, where
village health councils enable the community leaders to choose which women will
receive the training based on their aptitude and interest and their relationship
with the community. The women returned as midwives to their villages respected
and ready to provide a full spectrum of prenatal delivery and postpartum health
services. These new midwives are usually based at the closest health clinics, but
many travel high into the mountains everyday to visit patients who are unwilling
or unable to travel to the clinic. While the presence of a midwife is a new

experience is a new experience for many Afghan mothers, most welcome the
reassurance that these health workers provide. In just over six years Jhpiego’s
midwifery training program has already begun to transform the reality of
motherhood in Afghanistan where women have an average of seven children in
their life times. The percentage of deliveries attended by skilled birth attendants
has increased from 8% in 2003, to 19% in 2006, by training midwives to provide
the delivery support and the infant care education that new mothers need,
Jhpiego is strengthening Afghanistan’s healthcare system and improving
maternal and infant survival rates across the country. Now that’s a bright idea.
This is conversations of healthcare I am Margaret Flinter.

Mark Masselli: And I am Mark Masselli, peace and health.

Conversations on Healthcare broadcast from the campus of Wesleyan University
at WESU streaming live at www.wesufm.org and brought to you by the
Community Health Center.