by Bill Frist
The man was forty-three years old, just about my age at the time. He had a family about the size of mine, and his kids were roughly the same ages as Harrison and Jonathan. And, after a lot of thought, he said, “ I won’t do it.” That day he made a conscious decision not to go after the transplant. He chose to die rather than leave his family penniless.
It’s not right, I thought. And this scenario was playing out every day in some shape or fashion in every community all over the country. Not just for transplants, but even for basic forms of care like prenatal counseling or treatment for hypertension. I remember thinking specifically that if we only had some system of health insurance coverage for every American, he would have lived a full and productive life watching his kids grow up and get married and have their own families. We are the richest and most generous country in the world, we have the know-how to save lives, yet we still can’t offer every man, woman, and child the security of a basic level of care. You can’t change that by operating on one person at a time. Can you through policy?
Thus, I had a direct personal interest in the national debate that had been mounting in recent years over health care. In the off-year Senate election two years before, a little-known professor in Pennsylvania, Harris Wofford, had soundly defeated the high-profile U.S. attorney general, Richard Thornburgh, for the seat vacated by Senator John Heinz, who had died in a plane crash, solely by championing health-care reform. A little-known political strategist named James Carville (whom sixteen years later I would join in a Coca-Cola commercial during the Super Bowl promoting bipartisanship) had sensed the unease among the American people on the issue and made it the central defining issue of the Wofford campaign. By the summer of 1992, health-care reform was rising to the top of the national agenda as well.
Anne Somers at Princeton had always told me if there was ever a field that you felt passionately about, that you wanted to really learn about, write a book about it. Writing will force a discipline, she told me, that makes you a lot smarter on the topic, and your passion will then have a way to spill over to others. It’s the best way, she said, to translate your passions into action. So I decided to write a book about health-care reform, one that would describe the problems of the health-care system from the inside out in a clear, easily understandable fashion, and that would outline the various approaches to reform being bandied about and weigh their strengths and weaknesses. A number of those already involved in the health-care debate told me that such a book would be helpful, since it might give some realistic shape to the amorphous reform effort being talked about in Washington.
I put Topper Doehring, an inquisitive and industrious Vanderbilt medical student working for me that summer, on the project and partnered with my friend Charlie Phillips, who’d assisted me with Transplant, to help Topper and me with the research, interviewing, fact-checking, and outlining of the issues. Together we dove into the public policy of health care. In fact, exploring health-care reform took up most of my time that summer outside my day job as a heart surgeon. What talking I did to politicians and political advisors about my own political plans was often done in conjunction with these research trips, jammed into lunches or dinners or afternoon appointments between interviews for the book.
We interviewed doctors, patients, hospital administrators, government officials, and policy mavens, and we gathered fact sheets, bulletins, insurance brochures, medical plans, agency documents, newspaper articles, magazine pieces, proposed legislation, research studies, opinion polls, policy pamphlets, histories of medicine, think-tank tracts—anybody we could get to and anything we could put our hands on. I was falling back on the foundation I had laid with my independent study of health policy during my senior year at Princeton.
We got to know the health-care lobby rather well. We visited the headquarters of an organization formed by primary physicians who favored a single-payer universal health-care system like the one in Canada. Tucked away in a rundown building uptown with locks on the shared bathrooms in the hallway, the outfit’s small offices were empty except for a secretary and their spokesman, a young policy wonk with disheveled hair, a rumpled sports jacket, a photocopied agenda, and a David-versus-Goliath sense of determination.
We made the rounds of the K Street crowd interviewing the major private insurance and health-care industry lobbyists. They wore designer dresses and custom-made suits and confidently welcomed us to their plush offices, where they plied us with coffee and four-color brochures that outlined their easy-to-read positions with clever graphics and studies. We even visited the major doctors’ organization, the American Medical Association, although we had to travel to Chicago to do it and make our way past the guards and the security checks to reach the upper floors, where we were passed from one legislative specialist to another, in a series of carefully scheduled meetings.
We also managed to observe those directly involved in policy making, which interested me beyond our investigation of health-care reform. In fact, these visits provided me with my first real glimpses of Congress at work, as it were, day to day. There were myriad position papers, draft legislation, and proposed bills on health-care reform floating about Capitol Hill that summer, but the best, I thought, had come out of the office of Tennessee’s own Representative Jim Cooper, a conservative, pro-business Democratic congressman. I knew Jim casually at the time (since then we have become colleagues and close friends and are both teaching today at Vanderbilt) because his chief of staff was an old high school buddy of mine. Over lunch he kindly hosted us at an outdoor café in D.C. I enjoyed talking to him and to his staff about health-care reform, but what fascinated me as much as the policy he had come up with was how he had come up with it: how he—a junior congressman—had recognized the health issue long before other legislators were paying much attention, then deployed his staff to intensely cover the issue; how he then had shaped their work and his own thinking about the subject into a specific piece of proposed legislation; and, finally, having produced the draft bill, how he went about gathering support for his proposal both on the Hill and around the country. This may all sound pretty boring to some, but I thought, Here is exactly what I do every day, yet in an entirely different world. This fellow really knows how to take a problem, study it, and then fix it.
In a similar way, I found myself being drawn to the work of Tom Scully, another young man about my age in President George H. W. Bush’s budget office, who had been charged with handling current health-care costs. Not surprisingly, he had a good handle on the current system, its inconsistencies and its wastefulness. I interviewed Tom at length about such matters. In doing so, I became interested in the mechanisms of the Office of Management and Budget, in how the process worked, how Tom and others balanced the views of the Bush administration with the demands of the various groups, the parties, and the public, in short, in the way civil servants, appointed to office, wielded administrative power. It was Tom who, twelve years later, then in President George W. Bush’s administration, worked with me and congressional leaders to pass the legislation that made prescription drugs more affordable for seniors, the Medicare Modernization Act of 2003.
What we learned that summer could indeed have filled a book. As it turned out, the book we planned never got written, because events themselves overtook us. The health-care system touched almost every aspect of American life and, for that reason alone, reform efforts were destined to get caught up in a swamp of conflicting interests. The more we looked into the issue, the more it seemed to me that many of the reformers wanted to behave like overly aggressive “surgeons,” all too ready to operate before the specialists could even agree on the exact nature of the disease. Let’s make the diagnosis, get that right…and only then do the operation. More than that, I thought, maybe I should personally get a little more involved as an active participant, not just a passive observer.
The book was not to be, but during the 1992 presidential campaign, I used the information we had gathered over the summer to draft a series of a
rticles for The Tennessean, Nashville’s most widely read newspaper. In the articles, I described the current state of American medicine, reviewed the history of health-care reform, and spelled out the different positions of the two candidates and how those positions related to more detailed proposals already before the public. I was still a full-time, very busy academic and clinical surgeon, but I was now equipped with information and understanding of a national problem that was growing worse and that, in fact, was inconsistent with the greatness of America. And I had seen it all from the inside, where few other politicians had.
When Bill Clinton won the presidential election that fall, he announced plans to launch a major health-care initiative immediately. James Carville, now an adviser to the president, had noticed the power of the issue in the Pennsylvania Senate race. The day after the election, on November 9, I received a telephone call from Tennessee’s governor, Ned McWherter, a Democrat. He had read my articles, and he remembered a conversation we’d had about my general interest in public affairs. He was putting together a bipartisan task force to study the sustainability of the Medicaid program serving the poor in Tennessee. The major goal of the task force would be to answer the question of whether major state reform was necessary. He wanted to know if I would be interested in chairing this committee.
Governor McWherter’s offer meant that the world of politics and the world of medicine—the two worlds in which I was most interested—had suddenly come together for me in a way I could not have anticipated almost two decades before, when I was shuttling back and forth at Princeton between the chemistry building and the Woodrow Wilson School. I accepted the governor’s invitation.
My experience chairing the Medicaid commission accelerated my interest in public service and my belief in its potential. I saw how policy could promote health, hope, and healing. The problems were staggering: the number of patients without government coverage or private insurance who slipped through the cracks and suffered from it, the rising chunk of a family’s resources that had to be devoted to health care that meant less money for food, education, and housing, and the stark differences in health outcomes by race and socioeconomic status, all this complicated by where in the state one lived.
The governor’s commission was set up to address these issues and more, and in particular to answer the question: Can the Tennessee Medicaid program address the health-care needs of Tennessee in a way that is both adequate and sustainable? Our job was not to make a specific recommendation for the future, but rather to predict, based on the best information we could find, what would happen if the then-current structure of Medicaid were to continue without being reformed.
We spent a year studying the problem, held hearings once a month, and interviewed policy experts from across the country. I’d do my surgery four and a half days a week, then spend a half day chairing hearings down at Legislative Plaza. I’d literally strip off my scrubs and jump into a suit, run to the Capitol, and pick up the chairman’s gavel. Our conclusion: Medicaid, as then configured in the state, could not financially be sustained. Its rapid growth would so radically consume the state budget that basic responsibilities like police protection and education would have to be cut in half. Though it was not a part of our commission’s mandate to make specific recommendations, it was clear from our conclusion that our state government had overpromised on what it could deliver and that substantial reform would be required to improve availability of basic health care and lower growth in health spending to within reason and affordability.
What happened over the next six months was what really blew me away. Although our committee was dissolved and not involved in the planning, the governor and his staff designed a bold, revolutionary program built on the model of “managed competition,” the same concept in health-care policy that was also being touted by the policy team of First Lady Hillary Clinton at the national level. For Tennessee, the governor’s goal was to markedly increase the number of people insured in the state by placing those traditionally covered by Medicaid (mostly people with very low incomes), others who were “uninsurable” because of pre-existing illnesses, and still others who were uninsured because they couldn’t find an affordable policy into managed-care plans across the state.
As a result, practically everyone in the state would have health insurance, making Tennessee the first state in the country with universal coverage. The care for each person would be managed by about ten managed-care companies across the state and thus, the state officials reasoned, covered more efficiently and less expensively. The doctors and hospitals would get paid a little less for every patient, but they would no longer have to take care of the uninsured for free, so at least initially they were happy. The plan was called TennCare. Tennessee would implement exactly the same kind of program Hillary Clinton was designing at the same time in Washington, D.C. Tennessee would lead the way for the president’s health-care vision.
These optimistic forecasts proved illusory. The Clinton program failed before it got off the ground, and unfortunately, over a ten-year period, TennCare, the state version of the federal model by the Clintons, ultimately failed as well—not in greatly expanding the availability of care, which it did, from about eight hundred thousand to 1.2 million Tennesseans—but in managing efficient delivery. When the program began, there were essentially no existing managed-care companies in the state. In the years that followed, the newly created managed-care plans went bankrupt, in large part because of mismanagement and lack of experience. Care was not “managed”; instead, doctor reimbursement was drastically cut. Meanwhile, TennCare’s costs exploded. Lawsuits to expand coverage (and thus costs) were successful, so even when prudent management was attempted, it was preempted. In 2007, the program was abandoned. The lessons learned from this bold yet unsuccessful attempt to improve care at the state level are applicable today as we discuss how to expand coverage to the uninsured at the national level: You can’t responsibly expand coverage without addressing the growth in costs.
All this is the policy. But it was the process that had the greatest impact on me. I observed one individual (the governor) take on a major problem (health care) in the state. Because of his vision and the power of his office, he was able to single-handedly pick up $2.8 billion—one-fourth of the Tennessee state budget—and radically reshape the way it was spent to realize his vision. That is the power of policy and politics. I realized that despite the poor public perception of politicians, individual political figures had vast potential to do big things, significant things, to directly and forcefully improve the lives of millions. I saw how a single politician with the right motives could help heal some of the major problems of our society. I saw, for the first time, the potential of politicians as healers.
THE MEDICAID COMMISSION EXPERIENCE LEFT ME MORE READY than ever to take the plunge into full-time public service. But there were still some interesting medical experiences for me to encounter along the way.
In December 1993, Uwe Reinhardt, my college professor from twenty years earlier and now one of America’s leading economic advisors, had come down to Nashville to attend a small Princeton alumni gathering at our home and to speak to a group of health company executives about American health care.
Uwe seemed embarrassed that I was waiting at the airport to give him a ride. “You surgeons are supposed to be a busy bunch,” Uwe quipped. “Besides, I would have been happy to take a taxi.” No doubt, Uwe probably viewed me showing up in my old jeep as, well, real down-home. But, otherwise, I would not have been able to give him the grand tour of my hometown Nashville and spend the morning catching up with him.
After the briefing, where Uwe did his usual iconoclastic and witty job of puncturing our assumptions about the financing of health care in America (with the same style that had made his accounting class fun), I dropped him off at the Loews Vanderbilt Plaza on West End and went back to the hospital on the other side of the Vanderbilt campus to check on my patients before the alumni dinner with about sixteen people
that evening.
The dinner was perfect. Karyn was a wonderful and charming host as always, making everyone feel comfortable. Uwe hit it off with my family as I knew he would, but with the Princeton crowd there, and sitting at opposite ends of our dining-room table, I did not have much chance to talk to him, especially about the decision I had so recently made that was going to radically change my future.
Then the black paging beeper on my belt began to vibrate. Karyn looked knowingly at me. She knew exactly what that meant. I excused myself and went to the kitchen to call the hospital operator.
“Dr. Frist, we’ve got a heart for you,” said the caller from the regional organ-procurement agency. “It looks like a perfect match for Meadows,” she said as I traced down my list. Robert Meadows was the sickest person listed on my index card of potential transplant patients, and had waited the longest. Blood type matched.
By the time I’d come back through the dining-room door, Karyn had already explained that in all likelihood the call meant that I would have to leave immediately and that she would not see me for twenty-four hours. Transplants are unpredictable, she told our guests, and they might occur once a week, or three nights in a row. And they always occur at night. I walked over to Uwe and whispered, “I’m so sorry. I have to leave when you are the featured guest in my home. I’ve gotta go take out a heart that just became available in Chattanooga.”
“I understand,” Uwe said, nodding. “You go on and I will carry the Princeton flag.”
I kissed Karyn good-bye and out the back door I went, rushing to the hospital to quickly see Robert and give him the good news before going to the airport. My brother Tommy and Trisha agreed to give Uwe a ride back to his hotel. But once at the hospital, I decided I really wanted to talk to Uwe before he left town the following morning. There was no guarantee I would even be out of surgery by then, so I called Tommy on his car phone.