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Bill George

Harvard Business School Professor, former Medtronic CEO

Category: Health Care

US Health Care and Obama’s Janus Problem

Just eight months into his term, Barack Obama is facing a severe crisis that will define his leadership as president. The immediate challenge is health care reform, but the deeper issue is whether Obama the Leader or Obama the Politician will dominate.

Like the Roman god Janus, with two heads facing in opposite directions, Obama the Politician pulls against Obama the Leader. This identity crisis is eroding the President’s political capital, hampering his chances for legislative success on health care, and alienating recession-stricken Americans.

We have always known there were two Obamas: one, the idealistic and compassionate community organizer whose service changed lives; the other, the skilled operative who emerged from the political wars of Chicago’s south side. During the long, brutal presidential campaign, Obama did a brilliant job of integrating these two facets of his persona. Many who supported him hoped and trusted that once elected to the nation’s highest office, Obama the Leader would retain his passionate commitment to certain ideals over and above political considerations. Since January, however, politics has seemed to dominate many of his decisions, with health care being the most recent example.

Rather than provide the leadership he promised on this crisis by presenting a comprehensive, integrated health care policy to the American people, Obama is instead playing politics by ceding leadership to Congress. In leaving the details of the reform bill to Congress, he has effectively abdicated, removing himself from substantive Capitol Hill discussions. Congress, in turn, has focused on only one aspect of this complex problem: health insurance reform that will provide guaranteed access. The other essential aspects of health care — cost, quality, and consumer focus on wellness and prevention — are being virtually ignored. All three must be addressed in an integrated fashion before the health care crisis can truly be resolved.

This will require real sacrifices and concessions from everyone, and a politicized executive cannot make that happen. What’s needed here is realistic and, above all, forthright leadership. How can the President shed political pretense and become the same galvanizing leader on health care that he was during the 2008 campaign? How can Obama the Leader predominate over Obama the Politician and take full ownership of this process?

As leader of this all-important reform effort, he must immediately face the reality that the debate is going in the wrong direction, acknowledge the mistakes he made in abdicating and ceding leadership to Congress, and put the legislation on hold until early 2010. In my recent book, 7 Lessons for Leading in Crisis, this is Lesson #1: Face reality, starting with yourself.

Then he needs to go on offense. Obama should introduce an integrated plan that focuses first on wellness and prevention, develops detailed programs to incentivize quality outcomes and reduce costs, and offers affordable access. Most important, he must take his case to the American people and convince us that this plan is the only way to resolve the health care crisis for the long term.

During the campaign President Obama delivered a remarkable, uplifting speech on race in Philadelphia that elevated our level of national discourse. As president, he has demonstrated strong leadership in the Middle East peace process, and he has guided us away from financial collapse. Here is a man who is capable of authentic leadership.

Now, on health care, the United States needs Obama the Leader to step up again.

Rights, Dignity, & Death: Palin Propaganda Disrespects the American Patient

On August 7th Alaska Governor Sarah Palin warned that Congress and the White House will create bureaucratic health rationing panels – aka “death panels” – to decide whether America’s sick, aged, or disabled are “worthy of healthcare.” In other words, Palin predicts the government will decide if you live or die, should pending legislation become law.

In the same breath that she mentions death panels, Palin asserts that “[h]uman rights and human dignity must be at the center of any health care discussion.” I wholeheartedly agree. “Rights” and “dignity” are central to the health care discussions we have with our doctors, particularly end-of-life consultations about our future care.

A wide range of media have delivered over forty reports refuting this warped and unfounded claim but shockingly, it is still believed by many, much like last year’s charges that President Obama is a Muslim. Conservative pundits and fringe elements are using it as a call to arms to oppose reform.

Spare us the pain, and examine the facts.

Proposed legislation provides Medicare funding for voluntary end-of-life counseling, also known as advanced care planning consultation. This permits American citizens to visit their doctor once every 5 years to discuss issues like hospice care, health proxies, living wills, and appropriate future pain medications. There are no provisions for bureaucratic health boards, no mentions of care rationing, and no allusions to anything resembling a “death panel.”

Despite all this evidence, arguments to the contrary pervade the blogosphere. The misinformation just won’t stop. Those who hype the “death panel” argument continue to distract attention away from an already confusing debate on healthcare. We need to focus on the framework and details of an integrative, preventative healthcare reform approach, and not get lost in the mire of deficient, inflammatory rhetoric.

Regardless of how irrational their basis, “death panelists” are having a very real impact on healthcare reform. The New York Times reported on August 14th that the Senate will likely drop end-of-life care provisions because they “could be misinterpreted and implemented incorrectly.” Furthermore, USA Today reported on August 18th that while end-of-life counseling “started out as a rare example of congressional bipartisanship,” the measure has effectively zero chance of passing. Not only has Congress been forced to ignore one potential building block for consensus, but many American citizens may be forced to enter a very trying period of life with little to no guidance from their personal physicians.

Framing end-of-life counseling as some form of forced euthanasia robs America’s seniors of the dignity that comes with making these difficult decisions in their waning years. It is a disservice to humane hospice and in-home care, and it insults the intelligence of responsible Americans seeking candid medical advice on extremely sensitive treatment options. This debate is more “sound and fury,” another sidetracked discussion where political rhetoric displaced policy debate.

To get the health care dialogue with the American people back on track, President Obama needs to step up and address these issues directly, along with making the case for comprehensive health care reform – not just health insurance reform – starting with a national focus on wellness and prevention.

Sound and Fury: The Health Care Town Halls

The American healthcare debate has taken a turn for the fanatical. An overzealous constituency, bolstered by a media more interested in the next big controversy than the next big policy breakthrough, has snatched the microphone from the nation’s political leaders and temporary drowned out any semblance of a coherent, meaningful debate.

I cherish the First Amendment. I believe that elected officials need town hall forums to effectively represent their constituents. And I am happy to see the public taking an active role in the discussion.

However, as much as it is someone’s right to speak, it is another’s to be heard. And as much as members of Congress need to listen to their constituents, their constituents need to do some listening of their own.

Reforming healthcare to achieve a cost-reducing and long-lasting system is far more complex than many rally-criers would suggest. Crafting a viable reform bill is an intricate process which brings many potentially competing interests – lawmakers, insurers, lawyers, doctors, pharmaceuticals, interest groups, employers – to the table. Boiling viewpoints down to polar opposites and then boiling over in public rage simply distracts from the true goal: affecting a cost-reducing and integrative reform.

The media, particularly partisan talking heads, shoulder every bit as much of the burden for the confusion, mistrust, and misplaced rage streaking the landscape. The nation needs news anchors to play a role in moderating a complicated discussion. Instead, they are juicing ratings with a turbo charged focus on controversy. News coverage has stoked partisan flames, distracting from the issue.

All things considered, I’m left to ask myself: what are the policy implications of all this? What does it mean for democracy when our politicians cannot have a discussion without being shouted down?

As far as the future health of American democracy and civil discourse, this recent rash of extreme activism has the possibility of discouraging politicians from engaging face-to-face with their constituents on hot-button issues. What rational person runs for office hoping for wrathful constituents to berate her?

At heart, I believe the media pundits and town-hall attendees mean well. Though lacking tact, they have reflect viewpoints that are (in theory) based on what they believe to truly be in America’s interest. But they are going about it all wrong. Debate is only possible when other side will pause and listen. An argument without a counter-argument is just a lot of yelling.

The 2009 Health-Care Reform Debacle

Obama has surrendered policy to politics. Here’s a workable proposal to get health-care reform back on track.

Courtesy of

Health-care reform—version 2009—is heading for a train wreck. The debate in Congress is generating more heat than light. While senators and congressmen are on August recess, they are getting an earful from worried constituents, who sense the flaws in proposed plans. The Obama Administration would be well advised to take its own recess to develop a sound, workable policy proposal that can be reintroduced in the fall.

By focusing on politics instead of policy, the Obama Administration has erred in letting Congress create an unworkable reform. The final health-care legislation is being severely compromised by myriad lobbyists and special interests who advocate to protect their turf but rarely contribute to sound long-term policy. Already numerous side deals have been cut with industry groups that make a noncompetitive market even less competitive. The bills under consideration will only make a broken system worse, resulting in unintended consequences.

Health care already accounts for one-sixth of U.S. gross domestic product, and this legislation pushes it toward one-fifth. The system is extremely complex with many interlinked parts. Of the four major elements of health-care— access, cost, quality, and consumer focus on wellness and prevention—current reform efforts address only access to insurance. By tinkering with just one aspect without looking at the whole picture, the President and Congress risk destabilizing the system further.

Granting access to health insurance to all Americans is a worthwhile goal. However, we cannot do so without addressing problems of ongoing cost escalation, major quality issues, and unhealthy lifestyles. The risk in ignoring these other three areas is runaway costs that could bankrupt Medicare while producing convoluted legislation that satisfies no one.


What’s needed is an approach that enables all Americans to gain access to health insurance while incentivizing them to adopt healthy lifestyle practices and rewards their providers for reductions in spending. Here is an integrated proposal for achieving all these goals on a fiscally sound basis:

1. The greatest risk to individuals is facing catastrophic events without insurance. Instead of providing full insurance coverage, the government should sponsor self-funded low-premium, high-deductible catastrophic coverage plans. Catastrophic coverage would kick in after the individual absorbed the deductible. To reduce deductibles, consumers could pay higher monthly premiums.

2. To administer these plans, the government should set up insurance cooperatives that require mandatory portability for workers changing jobs and no limitations for pre-existing conditions, so that no one would fear loss of health-care coverage. These cooperatives would be self-funded and run independently under rules set by the government. All billing would be handled electronically to eliminate paperwork.

3. To address lifestyle issues contributing to the high cost of chronic disease, the federal government should launch a national wellness and prevention campaign—much like the smoking cessation campaign—focusing on sound nutrition, physical fitness, stress management, and reduction of obesity.

4. The federal government should partner with state and local governments to expand community clinics that provide basic services for modest fees and teach people how to improve their health. These clinics would also help consumers access the massive amount of health-care information available on the Internet. This approach puts responsibility for healthy lifestyles where it belongs—on individuals, with support from their caregivers.

5. To promote quality outcomes for chronic disease, the government would shift from reimbursing procedures to paying for keeping people healthy. Physicians and hospitals would be paid for keeping people well, not doing more procedures and tests. Physicians and caregivers would develop integrated approaches to patient care, rather than automatically opting for high-tech, high-cost approaches.

Comparative effectiveness studies would help patients and physicians choose the most cost-effective, proven procedures for treating chronic illness, including accelerated approval of generic drugs after patents expire.

6. Changes in tort laws should be enacted to protect physicians and hospitals that follow these procedures from punitive damage claims, thereby reducing the malpractice claims and class action suits that dramatically drive up costs.

7. To address high end-of-life costs, patients would shift to hospice facilities or their homes where they would receive palliative care.

By focusing on wellness and prevention, consumer empowerment for healthy lifestyles, improved quality in chronic disease management, and reducing overuse of health care, excessive paperwork, and end-of-life costs, this integrated plan ensures affordable access to all Americans while addressing the major elements of health-care costs.

The only costs of this program would be for a national health and wellness campaign and funding community clinics. These costs, a fraction of the $1 trillion price tag being considered by Congress, would more than pay for themselves as citizens choose healthier lifestyles.

This is the only way that we can ultimately ensure health coverage for all American citizens and high-quality, cost-effective care that strengthens our economy and builds a healthy population.