PROVIDENCE – It was the first time, Ira Magaziner said, that he has talked publicly about health care reform since he left Washington, D.C., some 20 years ago.

Magaziner, who had led the Clinton Administration in its failed efforts to enact health care reform, delivered the 2014 Paul Levinger Lecture about health care reform on March 20 at the Warren Alpert Medical School of Brown University. The topic: “Can Health Care Reform Fix Health Care?

Magaziner is a Brown grad (1969) who, with Elliot Maxwell, authored the reform of Brown’s undergraduate new curriculum. Magaziner, who also led the Clinton Health Access Initiative, remains a “Friend of Bill” as well as Hilary Clinton – and a Rhode Island resident.

[Magaziner was also co-author of The Greenhouse Compact, a proposed $250 million plan to revitalize Rhode Island’s economy, that was defeated by Rhode Island voters in a special election held on June 12, 1984. The plan, which called for investments in research, new product development, job creation and a venture capital fund to accelerate startups, ideas that today appear part of the common agenda for state’s economic development, but 30 years ago, were deemed too far ahead of the curve.]

Magaziner began his talk by sharing some stories. When he left the White House after six years, a good friend told him: “Now, for the first time in six years, you’ll be able to say what really think.”

Magaziner said he responded. “For the first time in six years, no one will care what I really think.”

He went on to describe one of the first meetings he had with President Clinton and Hillary Clinton in the White House, in January 1993, soon after the inauguration. “It was freezing, it was January, and no one knew how to turn on the heat,” Magaziner said. After about 45 minutes to an hour, someone found the janitor across the street and got his permission to turn on the heat. “I remember President Clinton saying that was a metaphor for what it’s like to be the most powerful man in the world.”

When the announcement was made that Hillary Clinton would direct the health care reform initiative and Magaziner would direct the day-to-day effort of that work, Magaziner said that he received some advice.

One was from a seasoned political insider, who had gone to Brown with Magaziner, and who warned him: “If you want to commit suicide in Washington, there are easier ways to do it. Tell the President that you’d like to do something else.”

Even among Democrats, there was no consensus on how best to move forward, Magaziner continued, describing a meeting organized by Rep. Dick Gephardt that ended in an actual fist-fight between advocates of seven different strongly held positions.

Another piece of advice was from a member of the Joint Chiefs of Staff, who said that when you are about to enter a battle, military strategists tell you to assess the strength of your forces and those arrayed against you. If you’re realize you’re going to lose, the military commander told him, decide how many of the opposing force you want to take with you when you go. “Son, you’re going to lose,” he told Magaziner.

Magaziner said that Hillary Clinton had been hearing similar things, and when that feedback was shared with President Clinton, his response was: “I feel like we have to try and do this,” based on his campaign pledges.

“Despite what happened, I’m proud of that decision that we all made,” Magaziner said, to applause from the audience.

Critique of the Affordable Care Act
Magaziner began his comments about Obamacare by reading the audience some quotes criticizing the president – accusing him of fostering Bolshevism and attacking the free enterprise system. The quotes had been from the 1930s, and they had been attacks on Social Security and President Franklin D. Roosevelt.

“Sounds familiar, doesn’t it,” Magazine said. He compared the problems of rolling out Obamacare with similar problems with the implementation of Social Security.

In terms of the new health care reform law, he said: “Make no mistake. It’s a significant step in the right direction.”

Magaziner admitted that if one could design, as he put it, “a rational system” for organizing health care, it would not look like Obamacare. “It’s complicated; it’s filled with compromises. But given the political climate of Washington in the 21st century, it’s the best that can be gotten.”

Having been through the wars in Washington, Magazine continued, “While it’s far from perfect, it provides some steps in the right direction.”

Understanding how we got into the mess
Magaziner, addressing the crowd as if he were a college professor and they were his students, gave his explanation of how health care delivery got to be so dysfunctional. The employer-based system, he explained, developed after World War II, when there was a wage and price freeze, and companies, in an effort to recruit workers, offered health insurance as a competitive edge.

Then, the concept of the community pool, that had been the strength of the Blue Cross and Blue Shield insurance model, in which everyone puts in the same amount of money, was then undercut by for-profit health insurers, Magaziner said, by offering companies reduced rates through the use of actuarial analysis. They were able to grab an increasing share of the market with younger, healthier employees, leaving the Blue Cross companies to insure the older and sicker people.

Under President Lyndon Johnson, there was an attempt to take on health care – when there was “an extinct breed of what was then called moderate Republicans” – but the best he could do was to limit it to poor people and old people, without cost controls, Magaziner continued.

Important steps forward
Magaziner touted a number of the reforms with the Affordable Care Act – such as the removing pre-existing conditions, and lifetime limits for care, and addressing the problem of uninsured and underinsured populations.

He told the story of his own small company’s experience in Providence, when one of the secretaries was stricken with breast cancer, and his health insurer told him that if got rid of her, the health insurance rates would remain the same. If not, they would double. Magaziner gave the health insurer an answer that he chose not to repeat. “Of course, our rates doubled.”

The problem with health care costs, Magaziner continued, is not how much doctors and nurses get paid, but rather, the administrative complexity of health care that takes time away from enabling them to do their job, undermining health care delivery.

“There are a mind-numbing number of cover-your-ass activities that have nothing to do with good health care, and it costs huge amounts of money and takes precious time away from treating patients,” he said.

In addition, the problem is not technology, Magaziner claimed. In the coming years, he predicted, delivery of health care will be transformed by advances in molecular biology and genomics, in neurosciences and robotics.

Magaziner said that he was wary of pay for performance, because it was just as easy to create the wrong incentives for what a group does, rewarding poor behavior at the organizational level as at the individual level.

“We need to empower our front-line workers, the doctors and nurses, get them good evidence about what works and what doesn’t, and trust them to do the right thing,” he said. He also called for better coordination and more investment in primary care providers.

Injustice
In the question and answer period, a well-heeled, middle-aged man pressed Magaziner about whether Obamacare was really a rip-off of young people, getting them to pay for older people.

Magaziner, saying that this was a common criticism of health care reform, turned the question around. “Yes, young people will be paying into the system to pay for care for older people, many of whom are their parents,” he said, saying the arrangement reflected upon the idea of community, not selfishness.

“I believe that access to good health care should be a fundamental human right,” he said. “Not to provide such access because someone is poor is injustice.”

In the audience
The crowd that gathered to hear Ira Magaziner was perhaps as intriguing as the topic. Sitting behind ConvergenceRI were William J. Allen and Jane Nugent, who, in collaboration with Magaziner, had put together a report, “Needs for the Nineties,” published in 1993 by United Way of Rhode Island.

The report was the cornerstone of numerous efforts to change the way that Rhode Island looked at its public sector spending and outcomes. It led to the development of landmark welfare reform legislation, written by a group of citizens, activists, legislators, and community leaders that actually became law in 1995.

Nugent and Allen recalled, with laughter, how a Boston Globe reporter had spent hours on the phone with them in 1993 trying, unsuccessfully, to dig up some dirt about Magaziner, who was then at the center of the maelstrom of health care reform efforts in Washington, D.C.

To the right was Constance Howes, former president and CEO of Women & Infants Hospital, who is now on the board of trustees of the American Hospital Association. In her new role, Howes is part of an initiative called “Redefining the ‘H’” in hospitals, as the world of health care moves from inpatient care to more patient-centric care delivery.

“One of the big initiatives [the AHA] is trying to do this year is to have community conversations to see what the community wants in their health care,” she said. One of the examples Howes cited was a little community hospital in Maine. “I think it was Bar Harbor, Maine, the hospital was slated to close, because on any given day, it might have one or two people [being seen] in the emergency room, and they were employing an emergency room doctor to staff that. It’s just not an affordable type of system.”

According to Howes, the community rose up and said, you can’t close this hospital. “Somehow people have to understand the choices, the trade-offs, they are making, between the comfort zone of having a hospital right there, and what is a reasonable cost,” she told ConvergenceRI.

To the left was David Orenstein, the intrepid communications person behind the Twitter handle, @BrownLifeSci, who had retweeted a story from the most recent issue of ConvergenceRI, “RI medical researcher on verge of promising breakthrough in treating Alzheimer’s.” The story, in turn, he said, had been retweeted to Brown’s entire 50,000 + Twitter list. Talk about the reach of social media. After the event, Orenstein talked about the transformation of the space that would be created for the next day’s big event, Match Day, for Brown medical students.

In front was Lt. Gov. Elizabeth H. Roberts, one of the leading proponents of health care reform in Rhode Island.

Nearby was Lynn P. Blanchette, the nursing program director at Rhode Island College, who is an active proponent of patient-centered primary care, based upon Dr. Michael Fine’s concept of neighborhood health stations.

Also there was Andrew Shearer, co-founder and chief technical officer of Care Thread, a new startup firm that is promoting secure mobile messaging and team-based collaboration solutions to empower hospital providers to deliver “more efficient patient care and improve patient outcomes.”

And, Edward Hawrot, Associate Dean, the Division of Biology and Medicine at Brown, and Dr. Jack A. Elias, Dean of Medicine and Biological Sciences at Brown. Elias is the midst of completing a new strategic plan that will include $1 million in a new fund to underwrite research at Brown, according to sources.

Of course, there was also a large mix of undergraduate Brown students (one, a native of Italy, said he was studying the economics of health care), and Brown medical students (one first-year med student, focused on primary care, was busy taking the leftover food from the reception and putting it into a plastic container, explaining that otherwise, it would be just be thrown away).

The conversation about health care reform continues to reverberate.