Who's in charge here? As the new administration of President Bush takes shape, observers in Washington are trying to understand who makes the decisions.
Though many expected HHS and HCFA to have authority on healthcare issues, many of the early healthcare directives have been coming from the White House, not HHS Secretary Tommy Thompson, observers say.
That was most apparent last month, when Thompson predicted a delay in medical-records privacy regulations opposed by providers just days before the White House decided to move ahead with them (April 16, p. 4). Many have pointed to that action as a political one designed to reverse negative perceptions that arose from Bush's reversal of other regulations, such as those governing environmental pollution and workplace safety, which were drafted by President Clinton's administration.
What's more, as Bush tries to work out a compromise patients' bill of rights law, it's not HHS but his healthcare aide Anne Phelps who is said to be negotiating with Congress.
And unlike in the Clinton administration-which celebrated the presence of younger, more junior staffers such as former White House healthcare adviser Christopher Jennings-White House aides and Thompson's assistants in HHS are the lower part of a hierarchy that reports to Bush through senior political adviser Karl Rove.
"Most of the major calls are being made out of more senior slots in the White House," says Daniel Mendelson, founder of Health Strategies Consultancy and Clinton's former associate director of health and personnel at the White House Office of Management and Budget. "Right now, it feels like there's a big disconnect between the policy side and where the decisions are being made."
Slowly filling the positions
If there is a disconnect, then it may be because it's very early on in the Bush administration. Bush is barely past the 100-day mark that some use as an early barometer of a new administration's success, without many key positions filled. Thompson himself has complained publicly of the sluggishness with which the White House sends nominations to Capitol Hill and Congress confirms appointees.
Bush's selection for HCFA administrator, Thomas Scully, president of the Federation of American Hospitals, awaits confirmation, along with several other senior HHS officials. Only one top assistant, Scott Whitaker, assistant secretary for legislation, has been confirmed so far.
"What a loss to have a department like HHS that wants to do so much and can't get anything done," Thompson said at a recent speech at the National Press Club. "I know General Motors would not stand for that."
"You can't do that job by yourself, and the career people begin to feel uncomfortable without leadership," says Nancy-Ann Min DeParle, a former HCFA administrator and budget office associate director for health under Clinton.
In addition, however, the key players in the new administration also are trying to determine what their roles will be and how they will relate to some of the other players.
At the top level, Thompson is well-known in Washington after 14 years as Wisconsin's governor, where he took a prominent role on such issues as welfare reform and as Amtrak chairman. Yet his continuing shtick as he makes speeches in Washington is the story of the small-town lawyer coming to the big city, and he's not afraid to talk about his lack of seasoning in Washington's folkways.
The odd couple in Washington
His chief healthcare subordinate, meanwhile, is likely to be Scully, who gives the impression of a consummate Washington insider. Scully's resume boasts stints both at the budget office under Bush's father and at one of the most powerful law firms in Washington, Patton, Boggs & Blow, not to mention his time at the federation.
Those differences might raise questions of whether the country mouse and city mouse can work together. What's more, Scully's frenzied manner may not always agree with Thompson's more laid-back style.
"We all know Tom Scully. He'll drive the secretary nuts," says veteran healthcare lobbyist Stephen Cooper of the firm R. Duffy Wall & Associates. "Tom has very strong opinions about what he believes is right and wrong."
"Tom and I started to get along very well after about three or six months at HCFA after we accepted how each other works," says Gail Wilensky, a HCFA administrator under Bush's father who dealt with Scully at the budget office. "There were times when Tom would drive me crazy-but I would tell him."
But those who know both Scully and Thompson say their personal styles will mesh. Both are straight talkers-sometimes to the point of saying things that anger allies and enemies alike-and neither stands on ceremony. HHS and HCFA under a Scully-Thompson leadership are likely to feature meetings of top officials with loosened ties and rolled-up shirtsleeves.
"Tom (Scully) is a very open person, so I assume who he is and how he operates is well-known," Wilensky says. "I obviously don't know their relationship, but Thompson selected him so that suggests (Thompson) has some confidence (in Scully)."
Scully acknowledges a difference in temperament, but says it won't be a problem. "He may be more laid-back in his approach, but he's more of a china-breaker in his desire for change," Scully says of Thompson. "Our outward approaches may appear different, but I can't think of an idea he has for HCFA I haven't agreed with, and vice versa."
In the lower echelons, where some positions remain unfilled, those relationships can take longer to sort out, DeParle says.
"People in the beginning are trying to measure each other up and figure out if that person is going to be at the table or they'll be bypassed," DeParle says. "In the beginning, many of us did not know each other in the Clinton administration. It takes awhile to begin to work together effectively and figure out whether you need to have meetings to form policy or (simply) hold phone calls."
Better than the last time
Though the Bush administration may take months to sort through those relationships, it still may move more quickly than Clinton did.
As Clinton was forming his administration, he also had undertaken the giant task of comprehensive healthcare reform. In 1993 he drew together a task force of administration officials and private-sector representatives, led by policy expert Ira Magaziner, to develop healthcare legislation, which Congress eventually defeated. The creation of the task force further complicated the developing relationships between members of the nascent administration.
"We had the overlay of the whole healthcare reform task force," DeParle says. "There was that whole issue of Ira vs. everybody, and (HHS) vs. the White House. Who knows how much of that was real? But it was a distraction."
Furthermore, Clinton-who ran as an insurgent rather than as a Washington insider-brought in many outsiders to staff his healthcare policy agencies. Those included former HHS Secretary Donna Shalala, a university president, and former HCFA Administrator Bruce Vladeck, who came from the United Hospital Fund, a New York healthcare foundation.
That lengthened the relationship-building period, say many observers. "In some ways, (the Bush administration is) more organized than the Clinton administration at this point, in terms of structure," Cooper says. In the early Clinton administration, "nobody knew who was doing what. It was a big mishmash," he says.
And on healthcare appointments, the junior Bush is doing even better than his father. Wilensky wasn't named until August 1989, eight months into the senior Bush's administration, after two earlier picks fell through. She didn't officially start work at HCFA until January 1990.
The junior Bush, meanwhile, named Scully in March, and his confirmation is expected shortly.
The virtue of familiarity
At the more junior levels, Bush may have avoided the Clinton staffing travails by hiring Capitol Hill aides who had worked together extensively in the past.
White House health adviser Phelps, for example, came from the office of Sen. William Frist (R-Tenn.), a surgeon and member of the family that created for-profit hospital giant HCA-The Healthcare Co.
Sally Canfield, a counselor to Thompson, was Bush's healthcare aide during the presidential campaign and worked for Rep. Jim McCrery (R-La.), a member of the House Ways and Means Committee's health subcommittee.
Whitaker, recently confirmed as assistant HHS secretary for legislation, served as healthcare policy adviser to Assistant Senate Majority Leader Don Nickles (R-Okla.).
Jim Capretta, now associate director of human resource programs at the Office of Management and Budget, was a healthcare expert for the Senate Budget Committee, and worked with Scully at the budget office during the Bush administration.
"It's totally different from Clinton," says healthcare lobbyist Frederick Graefe, in the Washington office of Baker & Hostetler. "They all know each other. They respect each other. In many instances they're friends. It makes it much easier when you know the person at the end of the phone line."
Canfield, for one, sees the advantage of her history with some of the other administration aides, especially when working with the White House, which in many cases is required to make the toughest calls when advancing its political agenda.
"When Jim says, `We're going to do this,' or `We're not going to do that,' I can appeal to his lighter side," Canfield says. "I call up Jim and say, `Please?' "
Though the tag of Washington insider may not always play well in Peoria, hiring officials who are experienced in dealing with how government functions can help an administration get started more quickly, Wilensky says.
"We criticize too much being inside the Beltway, but there is somewhat of an advantage," she says. "You can short-circuit some of the learning."
Likewise, Scully says he's looking forward to working with the former Capitol Hill aides. "All these people know each other. I think it's enormously helpful," he says. "They all have pretty good histories with each other. I've never seen a less turf-conscious crowd."