AAPS News – Feb 2001

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Association
of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

Volume 57, No. 2 February 2001

TRANSFORMATION

A new collaboration may herald a radical transformation in
American medicine: “Hatchets buried, Newt Gingrich and Ira
Magaziner agree that the Internet could help to solve some of the
problems they battled over unsuccessfully in the past” (Rob
Cunningham, Health Affairs Nov/Dec 2000).

Possible outcomes include top-down control through public-
private partnerships (national or international fascism) -or an
explosion in innovative free-market arrangements.

In a speech at the American Enterprise Institute on Nov 4,
2000, Gingrich said: “The current system is an historic accident
with layers of protected inefficiencies and with basic flaws in
the very design. I do not believe, theoretically, [that] you can
take the current system and design a way for it to work, because
I think it violates fundamental principles of how economics …
and human organizations work. I also want to suggest to you that
the goal has to be transformation rather than
modification, … replacement rather than repair
….

“I also think, frankly, you cannot make the Information Age
medical system work if it is a doctor-centered system. I
think it has to be a patient-centered system
.”

All great breakthroughs will come through “disruptive
technology,” Gingrich believes, citing Clayton Christensen’s book
The Innovator’s Dilemma. Such technology is developed by
people who don’t get invited to Harvard and don’t make sense to
HCFA bureaucrats. Moreover, Aetna won’t be able to figure out why
to pay for it, Gingrich noted.

“You can’t plan it; you have to live it,” Gingrich said.
“And to the degree that we bureaucratize and politicize the
health system, we minimize the capacity for entrepreneurs to
invent a better future.” HCFA, with its 132,000 pages of
regulations, is “the wrong model.”

Gingrich believes that cost containment is an
impossibility. We need a method to drastically reduce
cost. That requires at least some direct customer responsibility
to pay the bills.

Gingrich and Magaziner agree on the need for better customer
access to information-and that the federal government has a major
role to play, even if they disagree on the details. Magaziner
wants to get to “consensus on universal coverage,” and to “get
the experience rating out of the system” (i.e. to abolish the
business of insurance, which concerns the accurate pricing of
risk). Gingrich favors a government-sponsored enterprise like
Fannie Mae to “share the collective costs” of bad genes or other
bad luck (i.e. socialist, coercive redistribution of wealth).
Gingrich also believes that government has to take the lead to
achieve standardization.

Gingrich at least realizes that “government can be powerful
in blocking the future.” However, while recognizing that vested
interests will resist change, he doesn’t acknowledge the
importance of government in consolidating their power, or the
dangers inherent in a public-private partnership.

In fact, massive information collection-demanded by the
vested interests empowered by “administrative simplification” –
serves the needs of bureaucratic central planning. Gingrich may
call for outcomes monitoring; the reality is compliance
monitoring of the “still highly fragmented physician office
sector.” Academic health centers and private firms-such as the
Health Care Advisory Board and a coalition that includes Duke
University, Vanderbilt, and EBMWeb-are busy devising “consensus-
care pathways.” The Federation of State Medical Boards, a highly
influential private corporation founded in 1912, is working
through licensure boards to root out non-consensus (“questionable
and deceptive”) practices. “Disruptive techology” can’t thrive if
“disruptive physicians” are delicensed.

In a skeptical counterpoint, J.D. Kleinke explains why
“vaporware” is not going to fix problems that grow from hybrid
public and private financing, cultural expectations of unlimited
access, and third-party payers whose financial lifeblood is
administrative inefficiency and the rules of the “float”
(Health Affairs, op. cit.). Moreover, federal law,
particularly the Stark and “anti-kickback” rules, stifles
connectivity. Most importantly, “medicine really is an art,”
Kleinke says, that is “too complex to be digitized.” This is one
reason why it is not necessarily amenable to methods that work in
aviation (Gingrich’s favorite example) to reduce error.

Information technology, however, might fix those underlying
problems-for the same reasons that it might thwart the social
engineers’ dreams of central control.

Information technology smashes the monopoly on knowledge
heretofore held by academic centers and guilds. It empowers pati-

ents, who are already voting with $27 billion out-of-pocket
annually for non-consensus-based medicine-an amount that
equals out-of-pocket expenditures for all physician
visits. It can drastically reduce transaction costs. It can
create a true marketplace by making cost information as well as
clinical information widely available.

Privacy concerns have impeded certain applications of
information technology and are the pretext for a vastly expanded
regulatory regime. The rules, contrary to their stated purpose,
greatly increase access of government and its private partners to
sensitive patient information. The occasion for such information
gathering is the submission of a claim for third-party payment-
the quid pro quo for surrendering privacy.

And that is the key to radical transformation. Empowered
customers may ask: why is payment for medical services
so different from paying for other necessities? Why
should one have to file a claim subject to bureaucratic scrutiny?
Why should one have to pay a third party’s overhead,
plus a sickness tax to cover other people’s care, to buy a
medical service?

Technology coveted by the minions of Big Brother could yet
be the means for making his mission impossible.


Administrativectomy

In 1999, at the age of 41, with 6 years’ experience in
private practice, AAPS member Michael Harris, M.D., of Michigan,
a solo urologist, had had enough. His patients were brainwashed
into a “lotto mentality” and an “entitlement attitude.” Insurance
companies were hassling more, and paying less, while “trying to
reduce medicine to high school cookbook formulas.” Instead of
complaining, Dr. Harris took out his knife and performed some
radical surgery.

In early 1999, Dr. Harris departicipated from all private
insurance plans, and in December, 2000, withdrew from his
participation agreement with Medicare. Patients are provided with
all necessary information and submit their own insurance claims,
except for Medicare. Elective surgery is prepaid-by cash, check,
or credit card. Local banks provide loans with just a phone call
for those patients who prefer to finance their surgical charge:
“I am not a low/no interest loan agency.” The one patient who
financed his surgery last year was paid in full by his
insurance company 2 weeks later.

“When we submitted claims electronically,” Dr. Harris
writes, “patients were isolated from the hassles inflicted on me
by their insurance companies…. It took 6 to 8 weeks to complete
an uncomplicated insurance claim for companies with whom I did
not participate. Companies with whom I did participate questioned
my professional judgment and denied payment at will. When medical
societies or individual physicians complain about payment
hassles, nobody cares…. To my amazement, most patients are paid
in full within 2 weeks of submitting their own claims and usually
paid in full for my charges. I believe that insurance companies
are more sensitive to policyholders than to doctors. The patients
bought the insurance; therefore, the company has a duty to the
insured. Doctors should never get in the middle of that
relationship.”

Patients are informed of the billing policy when they call
for an appointment. Dr. Harris’s rates are low; he cannot afford
to hire a collection officer and must be paid for his time, all
the time. He will care for the downtrodden free of charge but
does not waste time or money submitting a useless Medicaid claim.
Some patients are incensed because the doctor will not “honor”
their insurance. That is fine with Dr. Harris: “This is
a urology service, not a capitated/number game/health care
avoidance scheme.”

Dr. Harris reports that his overhead is down, and income up.
He has never been happier practicing medicine.

Other cost-cutting measures include an simple electronic
medical record and very efficient practice accounting. With a
laptop computer in every room, Dr. Harris can keep detailed,
typewritten notes without paying a 12-cent-per-line transcription
charge. He took over the bookkeeping himself, after streamlining
it with effective software, and saw accounting fees drop from
$1,900 per month to $2,000 per year.

Dr. Harris’s advice: “If you are unsure of the radical
approach that I took, then start slowly, but with determination.
Change for the better, against current thinking, is not always
immediately satisfying. Look at your worst third-party payers and
departicipate. If you lost 20% of your patients but made 20% more
on half the remaining patients-and if your billing and collection
headaches evaporated-you would have more income and more time.
Imagine that! You could go sailing, golfing, or fishing. You
could spend more time with your family…. You could see more
patients who appreciate your time and effort. Now is the
time to enjoy your practice!

Methodology for Change Agents

The GrantWatch section of Health Affairs outlines
the thinking of the Robert Wood Johnson Foundation, one of the
ten largest U.S. philanthropies, which controls about $7 billion
in assets, including $4.4 billion in Johnson & Johnson stock.

The Nov/Dec issue looks at the RWJF’s “end-of-life”
projects, which began as the foundation was “making a greater
effort to examine more strategically the factors leading to
social change and how the tools of grantmakers might affect
them.”

The foundation began with a study of deaths in hospitals and
has built a Last Acts coalition that now has 510 partners. RWJF
has dispensed nearly $84 million in related grants. The
bellwether train-the-trainer program, called Education for
Physicians on End-of-Life Care (EPEC), began at the AMA. Multiple
projects are designed to “improve the questions on licensing
exams, support residency and faculty training, provide online
curriculum modules, and influence the content of textbooks.”
Encouraging nurses to consider pain as the “fifth vital sign” is
an RWJF initiative. RWJF cofunded the PBS series On Our Own
Terms: Moyers on Dying
, and the outreach program. The Last
Acts campaign also aims at influencing entertainment television
(such as ER), and sponsors panels at meetings of
producers and directors.

Most people, notes RWJF, want a cure, rather than a “good
death.” The goal is to “help [them] understand that palliative
care may be something they want”-and at an earlier point in the
“chronic care continuum.”

The overall objective can only be surmised. Linda Gorman of
Colorado’s Independence Institute writes: “Judging by its grants,
the foundation’s mission appears to be the promotion of policy
initiatives that create the institutional framework required to
replace private medicine with government-controlled managed care”
(Foundation Watch, 11/00). Docile acceptance of
rationing would facilitate that agenda.

Robert Moorhead, R.I.P.

Robert Moorhead, M.D., of Yazoo City, MS, died on Dec. 9,
2000, at the age of 92. He joined AAPS in 1948, served as
President in 1961, and was an active member until just before his
death. In his illustrious 47-year career practicing private
medicine, he delivered thousands of babies, including Haley
Barbour and Judge William Barbour. At the 1961 annual meeting, he
explained, with great prescience, the pitfalls of the Relative
Value Scale-the Marxist Labor Theory of Value (see AAPS
News
Nov 1987 and the pamphlet on the RBRVS.) He
faithfully and lovingly served the people of the rural
Mississippi Delta in the highest tradition of Hippocrates and
also represented his profession in countless ways, including as
President of the Mississippi State Medical Association and the
Southern Medical Association.

AAPS Calendar

Feb. 3. AAPS Board of Directors, DFW Marriott North.

Feb. 8. Belden hearing (rescheduled), Milwaukee.

Feb. 9-10. Chaos in Medicine: an International
Perspective, Oakland, CA. Contact: Dr. Vincent Cangello, (510)
834-4282, [email protected].

Feb. 20-21. Arizona chapter hosts Don Boudreaux of FEE.

Oct. 24-27. 58th annual meeting, Cincinnati, OH.


Organized Medicine for Universal Access

The AMA has given preliminary approval to a change in its
Principles of Medical Ethics, adding an ethical obligation for
physicians to “support access to care for all people.” Dr.
Herbert Rakatansky, chairman of the Council on Ethical and
Judicial Affairs (CEJA), denies that this implies support for
“single payer” or other specific delivery system.

The American Academy of Family Physicians (AAFP) is seeking
member reaction to a draft proposal that declares health coverage
is a “social good” in which participation must be
mandatory
(http://www.aafp.org/unicov
). Glen Dewberry, Jr., M.D., of Oklahoma City has supplied an
analysis, which is available on request (800) 635-1196.
The deadline is Feb. 28.

Correct Coding Fraud

As explained in the Sept/Oct issue of Now Hear This
from the League of Physicians and Surgeons, HCFA, in its dual
role of single payer and regulator of the Medicare system, is
barred from implementing changes in physicians’ billing practices
without first obtaining input from the medical community.
Accordingly, HCFA officials claim that policy on “correct coding
combinations” (bundling) is developed by AdminiStar, a Part B
contract agent, and then submitted to the AMA for distribution
and input.

In the course of investigating carotid Doppler edits, which
were the impetus for the carrier to vilify Dr. Lawrence Huntoon
in letters circulated to his patients [see AAPS News May and July 2000],
it was found that AdminiStar Federal is apparently just a
smokescreen. It appears that HCFA develops the Correct Coding
Initiative on its own through the National Technical Information
Service, in secret. A call to the AMA revealed that there is a
committee to review the bundling of codes, but its input is often
overridden without explanation, reports Yvonne Archer. This, she
claims, is illegal.

HCFA routinely trashes “guidelines and regulations …
designed to act as checks and balances against what otherwise
becomes a runaway bureaucracy,” states Mrs. Archer.

A court challenge to the CCI process may be feasible. “This
could potentially destroy one of HCFA’s most effective schemes to
cheat physicians out of proper payment for work done,” writes Dr.
Huntoon.

***Your input is needed.***

**Please brief us on problems with CCI bundled
codes.*

Sanctions Worse Than They Admit

At a HCFA-sponsored conference call with provider advocates,
OIG Chief Counsel “Mac” Thornton reportedly said that
“inaccurate, excessive rhetoric is leading [physicians] into
harmful behavior,” such as undercoding, failing to return
overpayments for fear of provoking an audit, or opting out of
Medicare altogether (Medicare Compliance Alert
12/11/00). The OIG stated that “only” 21 physicians were
convicted of criminal fraud in 1998 and 1999, and fewer than 25
had civil penalties imposed. In 1999, 1,078 providers were
referred to the OIG by HCFA for fraud investigations, and 723 in
2000.

Convictions don’t tell the whole story. Some attorneys say
that Medicare’s real weapons are threats of false claims suits
and suspension of payments, which help to extract settlements. In
FY 2000, the amount taken in health care fraud settlements
reached an all-time high of $840 million. The number of excluded
providers was 17,271 as of Nov, 1999, and 20,196 as of Nov,
2000).

While pressure might ease under the new Administration,
don’t count on it. Attorneys interviewed by Medicare
Compliance Alert
(1/1/01) predict more scrutiny of
Evaluation and Management (E&M) codes; more searching for
evidence of denial of care; and an increase in anti-kickback
enforcement, which may emanate from compliance activities.
Smaller physician practices may be prosecuted just to show that
“no one is too small to escape notice.” More asset freezes are
likely, even in civil cases.

Star Chambers Make Coverage Decisions

According to a letter from Stephen Northup, Executive
Director of the Medical Device Manufacturers Association (MDMA),
HCFA should abolish Medicare work groups made up of contractor
medical directors (CMDs), which he calls “latter-day Star
Chambers.”

CMD groups “are not specifically authorized by law or
regulation, do not meet publicly, and are not required to
disclose the nature of their deliberations or to justify their
decisions. Nevertheless, the work of these CMD workgroups is the
basis for hundreds of local medical review policies that
determine what medical procedures and technologies are available
to Medicare beneficiaries.”

[See
http://www.medicaldevices.org
.]

Guidelines Don’t Follow Guidelines

As pressure mounts to evaluate physicians for compliance
with guidelines, the methodologic quality of clinical practice
guidelines in the peer-reviewed medical literature is highly
pertinent. Of 279 guidelines published from 1985 through 1997,
mean overall adherence to standards was 43%, with no difference
between guidelines developed by medical societies compared with
government agencies. The biggest deficiency was in the
identification and summary of evidence (JAMA
1999;281:1900-1905). Only 7.5% described formal methods to
combine evidence and opinion. The evidence relied on by guideline
developers was “modest in rigor, discordant, or nonexistent”
(JAMA 1999;281;1950-1951). Few of the guidelines were
evaluated in practice before dissemination.

On achieving consensus before back-up disks:

“As soon as Winston had dealt with each of the messages,
he clipped his speakwritten corrections to the appropriate copy
of the
Times and pushed them into the pneumatic tube.
Then, with a movement that was as nearly as possible unconscious,
he crumpled up the original message and any notes that he … had
made, and dropped them into the memory hole to be devoured by the
flames.

“What happened in the unseen labyrinth to which the
pneumatic tubes led, he did not know in detail, but he did know
in general terms. As soon as all the corrections … had been
assembled and collated, that number of the
Times would
be reprinted, the original copy destroyed, and the corrected copy
placed in the files in its stead…. In this way every prediction
made by the Party could be shown by documentary evidence to have
been correct; nor was any item of news, or any expression of
opinion, which conflicted with the needs of the moment, ever
allowed to remain on record.”


George Orwell, 1984


Members’ Page

The Motive. Our hospital brought in an attorney to give
a presentation that was supposed to “scare all of us real good”
so that we would become better documenters and more compliant
with government regulations. He apparently talked with an FBI
agent in Buffalo recently and was told that four or five more FBI
agents had been added in this area for the sole purpose of
investigating health care fraud. The main reason is not that
there is necessarily a lot of fraud, but that health care is a
major part of the economy in western New York State. In other
words, there is a lot of money that the government feels it can
get its hands on.

Lawrence R. Huntoon, M.D., Ph.D., Jamestown, NY

Spending Levels. Who is to say what the “right” level
of spending is for a given purpose? The U.S. spends much less on
food as a percent of GDP than many other nations. Does that mean
that we are starving? We spend a lot more on entertainment than
most ($495 billion). So what? Who cares?

If we look only at government (involuntary, coerced)
spending on “health care,” the U.S. is at about the same level as
other developed countries. The rest is voluntary, private
spending that we choose over other uses of our money. Who dares
to say that we should be forbidden to spend our own money for
medical care-other than the World Health Organization, of course?

Greg Scandlen, National Center for Policy Analysis

Where Bills Come From. Many Republicans were surprised
to find language in nearly every health care reform bill passed
since 1994 that is identical to provisions of the Clinton health
plan, which failed in 1994. When confronted with that fact,
members responded that they didn’t read the bill.

The bill came from the computer files of staff members. The
party of the committee chairman may have changed; but the
language in the computers didn’t.

Ernest J. White, Alexandria, VA

Ritalin Abuse. Congratulations to AAPS for the articles
on drug abuse, Ritalin, and ADHD [see AAPS News Jan 2001]. You bring out a very serious
public health problem that has been largely ignored by physicians
and the public. The scientific validity of ADHD has been taken
for granted. So has the need for Ritalin and other psychotropic
drugs for young children whose school behavior is considered
pathological. Perhaps the worst part is that the state, with all
its enforcement powers, is behind the whole operation….

Note that the use of the term (Mental) Illness is inconsis-

tent with the DSM classification of the APA, which speaks of
“disorder” (the last “d” in ADHD)….Medical student Winston
Chiong has written an important reminder that the use of the term
“disease” should be reassessed (MS-JAMA, 1/3/01, p. 89).
Diagnoses are often given too liberally without regard to the
social and economic consequences [to the patient]….

Nelson Borelli, M.D., Northwestern Univ. Medical
School

Peer Review Abuse. AAPS is the only organization I know
of, except for the Semmelweis Society, that has ever taken any
interest in the terrible problem of sham physician peer review. I
am dismayed that there is virtually no avenue of redress for the
physician targeted for bad-faith peer review. By the time the
process is well underway, he is probably doomed. I suggest that
at the first hint of an attack on a physician’s staff
privileges or medical license, he should go into a state of
general alarm and spare no expense or effort at immediately
attacking the process. Waiting and hoping that things may not be
so bad after all seals the doctor’s fate-just as delay in the use
of potent antibiotics in the face of a serious bacterial
infection leads to sepsis and death.

Edwin Day, M.D., Lafayette, LA


www.semmelweissociety.org

MSAs Catch on Slowly. Within my 20-employee company, we
implemented an MSA option in 1997. An employee can pick the $500
deductible “traditional” plan or the MSA. Initially, I was only
able to persuade half to pick the MSA, but as the MSA enrollees
have experienced significant accumulations and better coverage,
all but one have converted to MSA.

Proposals that require the employer to pick one or the other
plan, but not both, create too much tension. Not wanting to rock
the boat, the employer picks the traditional plan. Giving the
employee the option enhances the market penetration of MSAs.

Art Jetter, Jr., Omaha, NE

A Corrupt System. I belong to the Christian Brotherhood
Newsletter, a group of people who agree to donate a certain
amount each month to help other members pay real medical bills.
It is not insurance, so we are considered self-pay. One member
broke her hip, incurring $40,000 in hospital bills. The financial
department said the best they could do was a 10% discount. She
balked, knowing that HMOs or Medicare would never pay that much.
They encouraged her to apply for “charity” care. Here is the
zinger: “We would prefer government payment to your cash, so we
will qualify for more government aid in the future.”

We will pay the bill, but not until we make some big waves.
We will negotiate a better discount for cash.

Alieta Eck, M.D., Somerset, NJ


Legislative Alert

Adults Are Taking Charge of The
Agenda

President-Elect George W. Bush presented the American people
with a strong and remarkably detailed policy agenda, ranging from
substantial reform of Social Security and Medicare to ambitious
education and tax-reduction initiatives. His Cabinet choices-from
General Colin Powell and Donald Rumsfeld to Governor Tommy
Thompson and John Ashcroft -demonstrate that he is serious and
that he understands a crucial fact: Personnel is Policy. You
can’t get a solid agenda for change enacted unless you have
capable and committed people to promote it.

When the President-Elect met with Congressional leaders on
December 2, 2000, he said: “I’m going to remind both the Speaker
and the leadership about the agenda that I’ve talked about. I
feel one of the reasons why I’m sitting here is because of the
agenda, and it was a clear agenda” (Washington Post
12/14/00). Likewise, Ari Fleisher, the President-Elect’s
transition spokesman, also told The Post, “The governor
is committed to the programs on which he ran. The ability to
govern and enact an agenda derive more from the actions of the
officeholder than the margins of an election.” The President-
Elect’s Cabinet choices reinforce his commitment to honor the
promises he made to the American people.

Advice from Opponents

The newly elected President will be deluged with advice
on how to “hit the ground running”; how to manage the government;
whom to appoint; whom not to appoint; what is and is not in his
best political interest or the national interest. He will be
counseled on how to exercise the time-honored political virtue of
“prudence,” the need for “temperance” and “restraint” in the
pursuit of his policy objectives, and the wisdom of accepting
lower expectations. Remarkably, he will be given “friendly” and
ample advice and counsel from policy analysts, foundation
representatives, journalists, and politicians who, feigning good
will toward the incoming Bush Administration, deeply regret that
he has been elected to the Office of the Presidency in the first
place. The new President realizes, of course, and so should his
advisors, that such counselors can also be relied upon to wish
him little or no success in making major policy changes,
particularly in domestic policy.

While “bipartisanship” in a closely divided government is
often a political necessity, it is equally true that the spirit
of bipartisanship can only remain vital within the contours of
the new President’s promises-his public trust-to the electorate.
In their solid and candid assessment, the editors observe, “Mr.
Bush’s main campaign promises remain anathema to many Democrats,
and the things Democrats like least about them tend to be
precisely those that many Republicans like most” (Washington
Post
12/19/00).

The Presidential nomination and clearance of Cabinet
officials is complete. The burden of quick confirmation should
rest with the Senate. It appears that Senator John Ashcroft,
nominee for Attorney General; Gale Norton, nominee for Interior:
and Linda Chavez, nominee for Labor will all run into left-wing
opposition. Wisconsin Governor Tommy Thompson can also be
expected to generate at least some heat: the hard Left will never
forgive him for welfare reform, and the abortionists’ lobby is
not known for its moderation.

Left-wing groups and their allies on Capitol Hill are
girding for battle. While nobody yet seriously thinks that the
congressional Left will be able to defeat these Cabinet nominees,
nobody seriously thinks that the Left is simply going to fold.
And, of course, don’t expect Washington’s liberal leaders to
offer avuncular advice to NARAL et al to defer to the recently
heady spirit of bipartisanship. In official Washington, one is
quickly educated to the fact that this thing called
“bipartisanship” is a one-way proposition: it means that Bush
should surrender and refrain from pushing either his conservative
agenda on tax cuts, for example, or nominating conservatives to
carry out conservative policies.

Recruiting the Lieutenants

Moving a major agenda for change-including a rollback of
excessive taxation, promoting accountability and performance in
America’s educational system, and improvement in the pension and
medical coverage for the next generation of retirees-will not
only depend on the ability of the President to work cooperatively
with Members of Congress, building alliances across party lines
and accommodating the legitimate interests of competing factions
in a closely divided national legislature. It will also depend on
the quality and commitment of his own political appointees below
the Cabinet level-the Assistant Secretaries, the Deputy Assistant
Secretaries, and the non-career senior executives and program
managers.

The new President must make a serious determination on the
number of political appointees he will need. Obviously, no
President can advance his agenda with a small handful of staffers
in the White House or the federal departments. His political
opponents on Capitol Hill and elsewhere, of course, understand
this, and hostility to the Administration will sometimes take the
form of Congressional attempts to limit his appointing power.
Likewise, the new President should expect that any increase he
makes in the number of political appointees will draw fire from
opponents in Congress, liberal foundations, and the “public
administration community,” who will complain that he is
“politicizing the civil service”. The new President should be
prepared for this kind of self-serving propaganda, recognize it
for what it is, and remain undeterred by it. He needs a full
cadre of personnel, personally loyal to him and fully committed
to his agenda, in the federal agencies that execute the details
of national policy. Once again, appointing a sufficient number of
political appointees to staff key agencies and subunits in the
agencies and departments will enable the new President to suffuse
his authority throughout the executive branch of the government,
enhance cooperation among political appointees in the agencies,
promote teamwork among his appointees, and prevent their
isolation.

Depending on the Career Civil Service-to a Point

Career staff in the federal departments and agencies
also have a civic duty. They must give new political appointees
solid information concerning not only of the issues requiring
immediate attention, but also of current policies, priorities,
and programs. In this respect, briefing books can be an
invaluable tool, and an excellent point of reference over time.
These volumes can provide detail on the history of these
programs, how they work, and why they are structured the way they
are. They may prove truly enlightening. More importantly, they
can provoke the right questions from political appointees. New
political appointees are likely to find out that agency
priorities, or the way programs are organized, reflect the
political agenda of the outgoing Administration.

Clinton Administration loyalists, not universally known for
their own bipartisan spirit, understand this. Upon taking office,
President Clinton quickly, by executive order, reversed many of
the first Bush Administration policies in the first days and
weeks of the Clinton Administration. It was change-big time. Mr.
Seth Harris, a policy advisor for President Clinton at the
Department of Labor, in a remarkably candid article kindly
advised Mr. Bush to rely more on the advice of career staff and
dispense with the bulky briefing books: “Forging early and close
relationships between each department’s new political leadership
and its career staff will moderate any ideologically driven
agendas and produce a better functioning government. The briefing
books will hardly be missed” (Washington Post 12/20/00).
Translation: Look, you dim Republicans, don’t you worry your
little brains about all that hard, dull, dry-as-dust and mind-
numbingly detailed program and policy stuff; we’ll tell you what
you need to know.” Can’t you see it now; the old gang over at
HCFA telling all those newly arrived conservative health policy
team coming into HHS to just, well, relax and take it easy. Don’t
worry. Be happy.

Wanted: A Tough and Loyal Team

Political appointees are in the spotlight all of the
time. They must be constantly aware of how a Presidential
initiative will play in the media. They must understand this in
the formulation and the implementation of policy. The price of
failure in this respect can be high. So it is essential that
among the criteria for selection of executive appointees should
be their experience in dealing with the media, including
television. It would certainly help the President and his team if
the men and women who are expected to speak on behalf of the
Administration, especially on controversial issues, be given the
appropriate media training for doing so.

A serious agenda for change is always difficult, and nowhere
more so than in official Washington. The new President should
realize that many attractive candidates, for all of their fine
personal and professional qualities, education, and experience,
may not fill senior positions well where they are charged with
being agents of change. Such a role inevitably invites conflict,
on Capitol Hill and in the media, and it requires personal
perseverance, stamina, and, as the occasion demands, raw
political courage. Some otherwise highly qualified candidates are
simply not cut out for that kind of role. In the past, there have
been cases of political appointees “going native” in the federal
bureaucracy or enriching their resume, while losing sight of
their primary mission and the very reason for their appointment:
the advancement of the President’s agenda, rather than their own
future career prospects or the institutional interests of their
departments or agencies. It is an old, and sad, Washington story.

Secretary Thompson at HHS

The nomination of Wisconsin Governor Tommy Thompson is
the appointment of a strong leader in what is shaping up to be a
very strong Cabinet. Elected three times by comfortable
majorities in a state historically cool to conservative
politicians, Thompson brings strong political skills with his
well-established administrative ability. At HHS, he will need
both. The point to remember: HHS is a huge bureaucratic Empire
with many kingdoms-including HCFA and its financially troubled
Medicare and Medicaid portfolios, the Public Health Service, the
National Institutes of Health and major welfare and social
program responsibilities.

Thompson brings to the big job a solid track record of
achievement. He was the first governor in the nation to apply on
a broad scale what Bush has identified as “compassionate
conservatism.” His pioneering welfare reform program, based on a
waiver from HHS, resulted in a stunning 91% reduction in welfare
caseloads, and against all of the dire predictions of the Left,
low-income residents in Wisconsin were not left starving in the
streets, but many found themselves with jobs and a new sense of
self-respect. It is not too much to say that without Thompson’s
performance, the revolutionary 1996 welfare reform act would
never have been enacted. Not only does Thompson match Bush’s
profile of a “compassionate conservative”-a social contractarian
who offers government assistance laced with a strong dose of
personal responsibility-he is strongly pro-life, a backer of
parental consent for abortion for minors, and a vocal opponent of
partial birth abortion, the horrendous practice which was
routinely protected from a Congressional ban by Clinton’s veto.
And of course, he achieved some of the biggest tax cuts in
Wisconsin history.

If the past is prologue, Thompson, like Colin Powell,
promises to be a high-profile cabinet member, as well as a team
player, and very possibly a household name in America. He has a
passion for action, and has stated his intention to fight
vigorously for “meaningful changes,” not just tinker around the
edges of the status quo. In his acceptance remarks, please note
that Thompson stated his admiration for Bush’s willingness to
take on Social Security, the “third rail” of American politics,
and ignoring “safe,” stale, and conventional political wisdom. So
it looks as if Thompson is going to be a tough and relentless
battler for the Administration’s agenda. Thus, Thompson will
either be taking point or riding shotgun for the White House in a
major efforts to tackle the troubled financing of Medicare and
Social Security. Hopefully, he will be putting into place an
improved system for both, working out the inevitable wrinkles,
well before the retirement of the 77 million baby boomers.

Please note: The transition team, now at work at HHS, is
headed up by Sally Canfield, a top legislative staffer with the
brainy Congressman Jim McCrery (R-LA), who has emerged, with
House Majority leader Dick Armey, as one of the top Congressional
champions of tax credits and consumer choice as the pillars of
health care reform. It’s very early, but the initial signals are
impressive.

Robert Moffit is a prominent Washington health policy
analyst and Director of Domestic Policy at the Heritage
Foundation.

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