By all accounts this is crunch time for President Obama on health care reform, and things couldn’t be more tenuous. In the past several weeks, we’ve seen unified Republican opposition to his ideas, a revolt against reform from leaders inside his own political party, and the head of the non-partisan Congressional Budget Office testifying that the only direction he is bending the cost curve in is sharply upward.
As a physician who supports the President’s vision to improve the quality, access and lower costs, I’ve been following this debate closely. I’ve also been wondering what the debate about health reform tells us about the President’s leadership style. While I see him continuing to communicate his vision eloquently, there are two key leadership qualities Obama seems to lack that may prevent him from achieving his goals for reform.
The first is the President’s unwillingness to attend to the details of his plan, a pattern we’ve seen before. During the campaign, he often outlined big, inspiring ideas that were short on specifics. This was in sharp contrast with who was then his main rival, Hillary Clinton, who recited volumes of information about policy in the primary debates. With health care, this pattern has become apparent again as he’s outlined similarly broad ideas. Yet, as the myriad of bills moving through Congress shows, he has left the details of how to cover, pay for and deliver reform to America to the other side of the Pennsylvania Avenue.
Obama’s focus on the forest instead of the trees is also the reason why his point person on reform, Secretary of Health and Human Services Kathleen Sebelius, had such a rough outing on Meet the Press last Sunday. When host David Gregory asked her basic questions about whether any of the current proposals met Obama’s goals, and whether the most important goal was cost containment, Sebelius frequently had to turf her answers back to lawmakers. “…this is still a work in progress,” she said, in non-committal fashion.
Yet if Obama’s plan is to work with Congress, recent history shows he still ought to be more assertive. When the stimulus bill went to Capitol Hill, lawmakers put so many provisions into it that to critics, it looks more like a pork-barrel bill than a shovel-ready jobs one. The latest double-digit unemployment numbers don’t contradict that criticism.
On PBS’ The News Hour last Friday, liberal commentator Mark Shields suggested that Obama’s hands-off style may be his way of avoiding what befell the Clintons during the 1990s. Most of us recall the secrecy that Hillary Clinton insisted on, behavior that upset her allies on Capital Hill and fueled her critics with enough fodder to kill reform quickly. On the other hand, Shields also noted that Obama may have “overlearned” that lesson and is giving too much away by outsourcing reform. He ought to own it instead.
Even if one supports the President’s delegating of details, he may lack the kind of powerful of influence over his Congressional colleagues that can help get things done. It’s this characteristic—his lack of influence--that could be his biggest problem in achieving reform.
As we all know, Obama’s tenure as a Senator was a quick 4 years, two of which he spent the better time of campaigning for the Presidency. It’s not likely that this in-and-out drive through the Senate provided him enough time to build a lot of clout.
To better understand this, we need to step back for a moment, and look at one of the most useful and important business books in recent years—Robert Cialdini’s The Psychology of Influence. In it, Cialdini, a professor emeritus at Arizona State University, defined 7 principles that people use to influence others. Among them is the principal of reciprocity—do a favor for someone, work with them, and you will earn the same from those who you helped. Reciprocity, whether or not you find it fair and appropriate, is the underlying principle behind political logrolling, the kind that gets deals made and laws passed.
It’s also, in my view, the reason experience, which Hillary Clinton and John McCain tried to channel to defeat Obama, is so crucial in Washington. Despite the distaste many of us have for Beltway politics, and our romantic ideals about the outsider coming in and fixing business as usual, the experience to get things done effectively is gained by those who are there, build relationships, and make deals that keep the logs rolling. It’s a big reason that Senator Ted Kennedy’s absence due to his illness is most felt now. Kennedy’s life work has been to reform health care, and he has the influence to get deals done.
This view is not without precedent—in his book, Cialdini surmises that Jimmy Carter suffered from the same problem when he was elected President. As the outsider Governor of Georgia, he didn’t owe anybody in Washington anything when he moved into the White House. But nobody owed in Washington owed him anything, either. We all know how that ended.
It certainly doesn’t have to be this way for President Obama—certainly, he has amazing intellectual and rhetorical strengths. He is in every way the foil of the man who preceded him in the Oval Office. And contrast the President’s vision for reform with that of the one of the most powerful Republicans in the country--Senate minority leader Mitch McConnell. McConnell, as he revealed on Meet the Press (he appeared after Sebelius), still myopically believes that “America still has the best health care system in the world” and that “we do not have a quality problem.” His comments made me want to email him a link to Atul Gawande’s New Yorker article and a decade’s worth of health policy pieces proving the exact opposite of what he believes.
Yet, as I said, this is crunch time, and the President needs to take ownership of health reform with more than just his vision. Americans (including many doctors like me) truly believe that the status quo in medicine must change—we believe—and are inspired by-- the words of our President. But in Washington, words don’t herd Congressional cats—details and deals do. So the President best roll up his sleeves to craft some details of his vision—access for all, real quality, modern IT systems—so that they can be turned into law. And though he may not have the “experience” to have earned some reciprocity, in order to bend the health care curve, he is going to have to exchange tough promises with fence-sitters to line up the votes. He may owe those folks something later, but if the President believes what he says about health care being the pivotal issue for us and our economy, he best get a little ornery. Otherwise, I fear, we will have missed the best opportunity in decades to change medicine for the better.