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What do Obama's first weeks tell us about health care reform?

From the March ACP Internist, copyright 2009 by the American College of Physicians

By Robert B. Doherty

Evaluating how a new president is doing based on the first few weeks in office is akin to predicting that a baseball team will win the World Series based on its performance in the first few games of April.

Still, hindsight tells us that a president's first 100 days provides clues to how effectively he will govern.

Learning from Clinton

We now know that President Bill Clinton made serious missteps in the earliest days of his administration that contributed to the failure of health care reform.

He developed his health plan in secrecy. He relied too much on policy experts and not enough on skilled political hands. His choice of Hillary Clinton to run the effort is now widely regarded as a mistake. He waited too long to release his plan, and by the time he did, he had used up much of his political capital.

President Obama and his team started out determined not to repeat Clinton's mistakes. They vowed to be transparent and inclusive in developing their proposal, encouraging public participation on the Internet and in town hall meetings.

They decided to move without hesitation to jumpstart health care reform. They asked Congress to act immediately to reauthorize and expand the State Children's Health Insurance Program (SCHIP). They asked for tens of billions of dollars for health care to be funded out of the economic stimulus bill.

How is it going?

President Obama scored some early victories in achieving some of his "down payment" on health care reform.

SCHIP, which handily passed both the House and the Senate, was sent to the President for his signature on Feb. 4. Four million more children will now have access to coverage; an estimated 5 million children will remain uninsured. This expansion is paid for by raising the cigarette tax from 39 cents to $1. Last year, opposition to the tobacco tax increase by President Bush and congressional Republicans, and the level of spending on the program, made it impossible for Congress to pass more than a short-term extension of SCHIP (Most Republicans voted against this version as well).

As this column went to print, the U.S. Senate was debating the President's economic stimulus package. A similar package had passed the House of Representatives a week earlier. The House-passed stimulus bill advances the President's goal of funding a "down payment" on health care reform by authorizing billions of dollars for health information technology, research on the comparative effectiveness of different treatments, assistance to unemployed workers to help them afford COBRA coverage, temporary help to the states to prop up their Medicaid programs, and training more primary care clinicians through the National Health Services Corps.

Whether the Senate would retain these health provisions remained in doubt. Several fiscally conservative senators-Republicans and Democrats alike-insisted that the stimulus bill should pay only for things that would provide immediate benefit to the economy and create jobs. Based on this standard, some of the President's health priorities, such as funding of comparative effectiveness research, might not measure up.

President Obama, though, re-iterated his view that the final bill must include a substantial down payment on health reform, including funding for health information technology and comparative effectiveness research.

The Daschle debacle

Despite the back-and-forth on the stimulus bill, President Obama has already scored victories in his initial efforts to reform health care. He achieved a major expansion of coverage for children. He appeared likely to get tens of billions of dollars of funding for health information technology.

Along with these wins, though, he experienced one huge loss: the failed nomination of Tom Daschle over unpaid back taxes.

When the former Senate majority leader withdrew his name from nomination for secretary of the Department of Health and Human Services, President Obama lost the one person he was counting on to help bring him success on health care reform. Mr. Daschle offered a unique combination of skills: an unparalleled understanding of Senate politics, political connections going back decades and a passionate belief in health care reform.

Now, with Mr. Daschle's departure from the scene, Mr. Obama is in the unenviable position of trying to figure out who he can turn to now to run his health care reform initiative, knowing that if he picks the wrong person, he can do major damage to his chances for success. Just ask Bill Clinton.

Every administration makes mistakes, especially in its earliest days. Some of those mistakes end up being precursors to larger failures, others do not.

Mr. Obama has achieved some early and impressive victories on health care, and he appears able to learn from his own mistakes. How he moves forward after the Daschle debacle will foretell much about how successful he will ultimately be in achieving meaningful reform.

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