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Dr. Zwelling prescribes: 5 cures for congressional health policy paralysis

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You may want to change how Congress handles Medicare, health care for people under age 65, or long-term care (LTC) finance.

Whatever you want to do to influence the people on Capitol Hill, Dr. Leonard Zwelling has some highly personal unfiltered ideas about how you, as an outsider, may look to the people working on the inside.

See also: House panel considers public catastrophic LTCI proposal

Zwelling, an independent who believes in the need for a single-payer health care system, had been a cancer research and research administrator at MD Anderson Cancer Center in Houston.

The Robert Wood Johnson Foundation fellowship program gave him a chance to spend a sabbatical year jammed into the Republican staff of the Senate Health, Education, Labor and Pensions (HELP) Committee. Starting in late 2008, he got a chance to watch the committee work on some of the proposals that eventually served as the basis for the Patient Protection and Affordable Care Act of 2010 (PPACA).

In a book about the experience, Red Kool-Aid, Blue Kool-Aid, Zwelling tries to analyze the chronic legislative blockage in the bowels of Congress and develop a treatment plan. One reason Congress works so slowly is that the founding fathers meant for it to work slowly, to keep bad bills from ever getting through, Zwelling writes.

But Zwelling says another reason health policy efforts work so slowly is that health policy advocates often have a weak understanding of how Congress really works.

The Robert Wood Johnson Foundation fellows program director taught the incoming fellows that there are four critical P’s in Washington: Policy, Process, Politics and Personality.

Personality is the most important, according to Zwelling.

“Nothing is more critical to getting something done in Washington,” he writes. Elsewhere, he gives a chapter the title, “If you’re right, but you’re rude, you’re wrong.”

See also: Alexander Hamilton: What did he really say about health policy?

The insurance industry often organizes “fly-ins,” to get members involved in a little citizen lobbying in Washington. 

Zwelling talks about what it’s like to be the target of the fly-in. In too many cases, he says, when professional organizations send members to Capitol Hill, “These professional groups target the policy issues and are largely unaware of the process, politics or personalities involved.”

Zwelling recalls the time the head of a major university visited the HELP Committee to “explain” the issues to the committee staff. ”When he was gone,” Zwelling writes, “one of the young staffers who met with the chancellor and me turned and asked, ‘Why do the academics come to the office to tell us what we already know?’”

Meanwhile, Zwelling says, the staffers often had only a vague understanding what life was really like for the visitors from outside Washington.

For a look at some of Zwelling’s ideas for suturing the gap, read on.

U.S. Capitol

1. Decrease the size of congressional staffs.

More than 10 thousand people work on Capitol Hill, either for Congress itself or for the agencies or vendors that support it.

Zwelling says the sheer number of aides on lawmakers’ staffs adds to the legislative paralysis.

In Congress,”535 people get elected,” he writes. “What are the rest of the thousands of staff doing up there?”

See also: FIA Fly-In: More Than 150 Offices Visited

A physician

2. Get real subject matter experts a higher level of importance among the staffers who are still employed in the Capitol.

Zwelling says that, even though members of Congress and their committees employed thousands of aides, the percentage with relevant professional experience often seemed low.

He recalls that, when he went through the fellowship program orientation, the director warned the incoming fellows to avoid the appearance of teaching anyone anything.

But on the HELP Committee staff, for example, Zwelling says he was the only medical doctor. He often found that the people trying to write legislation that would affect patient care had little understanding of medical terms or how modern medicine works.

The staff members who drafted a colon cancer screening provision had no idea how screening for colon cancer is done, he writes.

“I have observed the writing of the follow-on biologics bill by people who may or may not have ever studied what a protein is and, if so, have surely forgotten,” he writes.

See also: House Republicans blast PPACA risk programs

A 2013 roundtable in Lowell, Mass., that was organized by Elizabeth Warren

3. Turn more hearings into roundtable hearings.

Zwelling says a typical HELP hearing had time slots for four witnesses, where the majority party controlled three witness slots and the other party one slot.

Roundtables could include as many as 20 witnesses. Holding roundtables is a way for lawmakers to get multiple perspectives on important, complicated issues, Zwelling says. 

See also: UnitedHealth Says N.Y. PPACA risk-adjustment program could be in trouble

(Photo: A roundtable in Lowell, Mass., organized by Sen. Elizabeth Warren, D-Mass.)

A hand edits a document

4. Require that members of Congress or federal employees draft all bills.

Zwelling says the best lobbyists came in to the HELP offices with the verbatim legislative language they wanted inserted in the final bill.

Zwelling admires those lobbyists’ expertise and hard work, but he objects to the idea of letting lobbyists have so much of a say in drafting legislation.

“Lobbyists shouldn’t suggest legislative language for bills,” Zwelling says.

See also: House Republican caucus drafting ‘Contract With America II’

5. Make members of Congress read bills and amendments before they vote on them.

Zwelling says he was disappointed to find that Sen. Max Baucus D-Mont., who came out with a major health system change proposal in early 2009, had little to say about the proposal. The senator’s aide, Liz Fowler, had written the proposal, according to Zwelling. 

Zwelling also refers to the times that Baucus reportedly said that reading the PPACA bill would be a “waste of his time” and then House Speaker Nancy Pelosi said lawmakers would have to pass the bill to find out what was in it. 

Zwelling says he recognizes that reading every line of a 2,409-page bill might not have been a good use of lawmakers’ time, but he said he wishes lawmakers like Baucus and Pelosi had at least shown that they had an understanding of some of the key details. 

“It appeared they really had no idea what they had voted for,” Zwelling says. “Therefore, the American people can be excused for the skepticism and resentment with which they greeted this legislation, given that the people who wrote it apparently had little idea what was in it and certainly were unaware of the likely consequences of the bill’s provisions.”

See also: 

PPACA: A history

5 Ways to Handle a Falling Sky

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