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JULY 23, 2009 1:59PM

Health Reform and Obama's Leadership Style

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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.    

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I will refer you to my latest blog as to why there's hope for health care reform. Thank you for your very thoughtful piece. rated
I still have hope Obama will enact meaningful reform. But I fear that his program will turn to be nothing more than a giant giveaway for the insurance companies. If that's the case, we'd be better off not having a bill passed at all.
Rated and Twittered. I'm just not eloquent enough to add anything to your post, but I think it needs to be heard.
@Patrick Hahn -

That is my concern as well. See my latest post. One of things I write about -- based on what I find in the draft legislation thus far -- is the necessity of yet another bureaucracy via which to assess citizens' eligibility for insurance premium "affordability credits." That simply smacks of welfare means-testing, is contrary to any notion of basic health care as a right (which Obama otherwise declares it to be).
There seems to be a lack of discussion about premises and ends about healthcare with everyone, maybe because it brings up some uncomfortable facts of life, like death and suffering.
I rated this post, and submitted it to digg, reddit, and stumbleupon. Great work, Doc.
Nicely done. I tried to add to the health care discussion here yesterday with my take on Mayo Clinic, but it didn't have the impact that Chinese suicides and Iranian protesters do. Thanks for your thoughtful essay. I join you in hoping this gets done right.
A thoughtful, cautionary post, which is what those supporting true health reform (myself included) need to see right now — again and again. Thanks.

It's highly dubious, though, that Obama got as far as he has as fast as he has without a thoroughgoing gut understanding of reciprocity. And let's remember that Obama, as green as he may appear, had more time in state and local government and Congress than Jimmy Carter had (Carter had no time in Congress). And he had roughly the same level of pre-presidential qualifying experience as JFK and, yes, Lincoln had.

Unlike JFK and Lincoln, Obama also has access to the not insignificant political wisdom of predecessors Clinton and Carter (and Gore) and their worldwide entourages.

Nor is it likely that he's delegating the details because he doesn't want to deal with them. This man has a first-rate mind and, as we saw during the campaign, a wonkish grasp of policy detail that was unequaled among the candidates, Hillary included.

As you surely recognize, it's a common strategy among politicians not to give more details about their plans and strategies than they absolutely must. The more details you give, the more misinterpretations (bona fides or other) you invite, and the more underbelly you expose.

Obama is one man; the media and pseudo-media (FauxNews & Co.) are many. And those whose interests lie in taking him to task could open up many time-consuming fronts with as little substance as the "birthers" now have.

It's a thin line he's walking, to be sure — more of a tightrope. But I'm as certain as you are doubtful that he's proceeding along it conscious of the trade-offs among speed, flourish, and inattention.

He may make mistakes, but in the end he'll own them and, one hopes, recover from them.
If Obama wants to get any kind of reform momentum where health care is concerned, he needs to return to the principle that Americans want health care just like Congress has--or rather health care insurance like all Federal employees have.

This isn't rocket science. The Federal Government has some excellent rules in place for insurers, and can basically tell insurers that they have to offer plans with the same minimums in terms of benefits and cost that the Federal Government has already negotiated. They can make a number of the hideous practices that the health insurers get away with illegal in a stroke of Obama's pen.

It's an elegant solution that could drive costs down simply because the pools of risk are spread out over many more millions of people. It would deal with the underinsured, because ALL insurance would have certain basic features and costs.

It's sure a better stop-gap measure that delivers the best long-term benefits if reform goes no farther than pie-in-the-sky socialisms in the midst of a recession.
I recently posted a detailed series on my blog on reforming our healthcare system, including what we need, why we need it, how to get it done and how to pay for it.

If I can crunch the numbers, determine how much healthcare will cost and where the money will come from to pay for it, why can't the lawmakers? Why can't the Obama administration?

Perhaps Obama needs to seek out the wisdom of those who actually work in healthcare, rather than getting a bunch of nurses to stand behind him while he advocates a plan that has yet to be (fully) written.
Good post, though I suspect you and other commentators are falling for the conventional wisdom that Obama is failing and needs to get dirty with congress to save reform.

There are two overwhelming factors that cut against the conventional wisdom: first, Obama is a patient man. He's got a strategy and he'll stick to it no matter how many commentators scream. Second, all dems, even the so-called blue dogs, know that this reform cannot fail. They remember what happened in 1994 after the last reform stalled in congress and they will act to avoid that disaster.

Rahm Emanuel made it quite clear when he said the only non-negotiable item is success. The dems will pass a bill with significant reforms, yet will also include numerous large give-aways to the corporate health care industry.
As to the immediate issues at hand, a very fair and reasonable summary. The background is a bit of another matter.

Pace Cialdini: Why cherry-pick Carter as the inexperienced Washington outsider? In the post-Nixon era, Reagan, Clinton, and GW Bush all arrived in DC with no experience in federal office of any kind. GHW Bush had two terms in the House and an arm-long list of executive appointments; Ford had 24 years in the House. Putting aside the wisdom and effectiveness of their policies and judging them purely in political terms (i.e., getting what they wanted, including re-election) in recent years the outsiders have been batting a far higher percentage than the insiders.
imagine how much easier this would be, if all obama had to do, was craft a proposal, and put it to the people in a referendum.

or if he would not, a citizens action group could put a citizen initiative before the electorate.

don't you ever wish america was a democracy? are you really satisfied with simulated discussion leading nowhere among the citizenry, while the elite think of new ways to turn taxes into personal wealth?
are you satisfied with your SAILBOAT!?
Personally, I'm not optomistic. Obama doesn't have ownership of this issue because he doesn't have control of it. Congress has both ownership and control. Obama has only rhetoric, which he uses to jawbone a vision. His big, correction, HUGE error was in not creating draft legislation and presenting it to the solons on the hill.

That draft legislation should have been written and ready on the day after his inauguration. To present it, he should have invited Pelosi, Reid and the Dem leaders to the White House to discuss it and explain to them what in the draft legislation was untouchable.
That was when his personal connection with the electorate was at its highest. He could have cowed the blue dogs, especially the freshmen who rode his coattails, but who are now the saboteurs of any bill that has a public option.

Obama is reaping what he sowed (nothing), and it now looks like we can kiss reform goodbye. Sadly, this defeat of reform will rob Obama of political capital and make other parts of his agenda harder to get passed.

We elected a naive greenhorn. We lose.
I hope EVERYONE reads this simply and so well written post. Makes everything so clear. THIS IS IT. Mr President. This is the moment you have to seize! This is where your legacy will be felt. This is the reason we, who supported Hillary felt you were lacking and worried ourselves to death even as we cast our ultimate vote for you.

Today Arianna Huffington in Meet The Press nailed it when she said that without the public option all will have been for naught. Mr President we all are behind you.. there is no other choice. You simply HAVE to get this right. This opportunity , if lost, will start yet another cycle of failures and you will personally have let the ball slip.

Roll up your sleeves sir and roll them up high...cos we are all behind you and support you the whole way...........too much to do and too little time..............
I hope he can change things for the better, but I fear that with so many problems, this will all be too much for him.
Thank you for this.
If the health care bill does not pass congress it is because the business interests through the congressmen and the media have sacred the public away from a better health care system. Why? because the insurance companies stand to lose a lot of money if Obama's bill is passed!!! Follow the MONEY!!!!!!!!!!!!!!!!!!!
Pft, we can attribute Obama's position as president to Oprah and every other loser in Hollywood who thought that charisma would help our country's problems. I'm just going to focus on being healthier by Losing Pregnancy Weight.