Donna E. Shalala: ‘Democracy at its best was very messy, and it proceeded to confuse people as we went from one bill to the other.'

Although she described the current attempt at health system reform as "very messy," Donna E. Shalala explained Sunday why it is necessary to have overall legislative reform and why it should be so contentious.

"One of great criticisms of the Clinton health care reform effort was that it was done in secret," said Shalala, the secretary of Health and Human Services under President Bill Clinton. "Mrs. Clinton convened a group of experts who wrote it pretty much in secrecy and delivered it to Congress, and they expected Congress to draft the legislation based on a very big proposal to transform the American health care system."

After that effort failed, political experts recommended that any future health system reform be transparent, which is how President Barack Obama's reform effort developed, said Shalala, the guest speaker at the Sunday Plenary.

"(The Obama administration) sent it to Congress, which is incapable of doing anything in secret," said Shalala, who is currently the president of the University of Miami and lectures frequently on health reform issues. "As a result, democracy at its best was very messy, and it proceeded to confuse people as we went from one bill to the other, from a bipartisan effort in the Senate to a very partisan effort in the House.

"But you can't have it both ways. You can't say ‘don't do it in secret' and then when you do it in public, expect it to be anything else but a very open, very messy process, which proceeds to confuse large numbers of people as they go through and listen to the debate."

Different drafts of different proposals, though, allowed those who opposed small pieces of different proposals to gang up — exactly as they did with the Clinton plan, Shalala said.

"They identified pieces of the bill they did not like and got together with other people who didn't like other pieces to create what we in political science call a ‘negative coalition,'" she said. "They used that negative coalition to try to beat down the bill and confuse people, and then point to the confusion as the reason you shouldn't go forward."

Others argue that reform should be taken in incremental steps, but that is not only difficult to do, but it can block some important overall goals of reform.

"You cannot eliminate pre-exisiting conditions and you cannot eliminate lifetime limits unless you have everyone covered. You can't have people who are well coming in and out of the system depending on when they need health care," Shalala said. "You need everyone covered to do those things or you basically put a lot of people out of business because they won't be able to maintain any pools of coverage of people who are sick."

Another roadblock in health system reform is that there is an alternative in the private sector. Previous attempts at major social change —Social Security, Medicare and Medicaid — had strong overall support.

"We are faced with a shared history of giant steps that have been taken only when there wasn't a private sector that was prepared to participate," Shalala said. "In this case, we have a private sector, and so we are going to end up with a system that is essentially administered by the private sector with some kind of a federal framework, particularly for those who cannot afford health insurance of their own.

"We started with the elderly, we went to the disabled and now we are going to, essentially, the working poor. I think that is a very important point."

Shalala concluded by addressing the physician payment system, which she said everyone supports. The only problem is that there are not resources available to implement a payment system now.

"Should you be nervous? Absolutely. It's healthy to be nervous when you are making this many changes at the same time," she said, adding that the costs now seem intimidating. "The history of this country is not to have the government step in such a dramatic way. This is one of those times in which the government is going to have to provide the framework."