Insuring Influence

During confirmation hearings in 2005 after he was nominated by then-President George W. Bush to become the next chief justice of the United States, John Roberts described a judge's role as that of an “umpire.”

Well, the editors of Modern Healthcare called it as they saw it and named Roberts the most influential person in healthcare for 2012. Although his name did not appear on Modern Healthcare's ballot for this year's 100 Most Influential People in Healthcare annual ranking, there should be little question about Roberts' influence.

Roberts cast the deciding vote and wrote the majority opinion in the U.S. Supreme Court's ruling to uphold the constitutionality of the Patient Protection and Affordable Care Act's individual mandate. It's a move that will undoubtedly have long-lasting impact even after the November election.

It is Roberts' first appearance on the list. This is also true of the second- and third-place finishers: Mark Bertolini, chairman, president and CEO of Hartford, Conn.-based insurance giant Aetna, and Dr. John Kitzhaber, governor of Oregon. The other first-timer in the top 10 is Marilyn Tavenner, acting CMS administrator, No. 8.

Besides Roberts and Tavenner, the other Washington officeholders in the top 10 are President Barack Obama, No. 4, and HHS Secretary Kathleen Sebelius, No. 5.

The others in the top 10 are Bertolini's insurance industry peers: George Halvorson, chairman and CEO, Kaiser Permanente, Oakland, Calif. (No. 6); Stephen Hemsley, president and CEO, UnitedHealth Group, Minnetonka, Minn. (No. 7); Angela Braly, chair, president and CEO, WellPoint, Indianapolis (No. 9); and Michael McCallister, chairman and CEO, Humana, Louisville, Ky. (No. 10).

Health insurance, and whether Congress could compel people to buy it, was the main issue before Roberts and the other justices. While courts have recognized the power of Congress to regulate commerce, the individual mandate was uncharted territory.

“Legislative novelty is not necessarily fatal; there is a first time for everything,” Roberts wrote in the ruling handed down in late June, but he then cited a 2010 court decision that stated sometimes “the most telling indication of (a) severe constitutional problem … is the lack of historical precedent.” He later added that, if the mandate were within its power, then Congress could “use its commerce power to compel citizens to act as the government would have them act” in other matters as well.

Congress already “enjoys vast power to regulate much of what we do,” but it should not be allowed to take this further and regulate what citizens do not do, Roberts wrote, concluding, “that is not the country the Framers of our Constitution envisioned.”

What Congress can do, Roberts argued, “is make going without insurance just another thing the government taxes,” such as purchases and income.

“The question is not whether that is the most natural interpretation of the mandate, but only whether it is a 'fairly possible' one,” Roberts wrote, adding that the Affordable Care Act should not be struck down because Congress did not specifically refer to the penalty for not buying insurance as a tax as dissenting justices argued.

“In effect, they contend that even if the Constitution permits Congress to do exactly what we interpret this statute to do, the law must be struck down because Congress used the wrong labels,” Roberts wrote. “The Affordable Care Act's requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”

In his decision, Roberts would later repeat that he was ruling on the law's constitutionality, not its merits.

While some hailed the decision as well as Roberts' reasoning, others such as Rep. Jack Kingston (R-Ga.) felt betrayed. After the ruling, Kingston tweeted “With #Obamacare ruling, I feel like I just lost two great friends: America and Justice Roberts.”

Still others saw more positive effects of the ruling. “The Supreme Court decision was very important in terms of preserving the linkage between participation and market reforms,” says Karen Ignagni, president and CEO of America's Health Insurance Plans, the top insurance industry trade group, who finished at No. 72 on this year's ranking.

Meanwhile, Dr. Pedro Jose “Joe” Greer Jr., assistant dean for academic affairs at the Herbert Wertheim College of Medicine at Florida International University in Miami, says of Roberts' decision: “Among my peers, it's been a very positive reaction.” (Greer is not on this year's ranking of the 100 Most Influential.)

Although the high court's decision also limited the federal government's ability to force states to expand their Medicaid coverage, Greer says the Medicaid provisions of the Affordable Care Act are needed. “It expands Medicaid—but it also allows physicians to be reimbursed properly,” says Greer, who received the Presidential Medal of Freedom from Obama in 2009. “I'm trying to find the fault with that.”

Along with touting the ruling, Greer credits the influence of the president for getting the law passed in the first place. “This is a landmark policy and it's his administration that did it,” Greer says, adding that it's up to local communities to make healthcare reform work.

“It's not a blue and red issue, it's about making this a healthier country,” Greer says. “It would be nice if we just talked about making people healthier.”

As controversial as Roberts' decision might have been, Bertolini says that, while Aetna “will continue to fully comply” with Affordable Care Act requirements, the ruling itself is not having a great impact.

“The Supreme Court's decision did not change our business strategy or commitment to system reforms that make quality care more affordable and accessible, and improve simplicity and convenience for consumers,” Bertolini said in an e-mail.

Aetna recently announced its plans to buy Coventry Health Care—which offers Medicare and Medicaid managed-care plans—for $5.7 billion, in part to increase its “presence in the fast-growing government sector.” It also made news this summer by announcing plans to create a new company—Innovation Health Plans—jointly owned with Falls Church, Va.-based Inova Health System, and to collaborate with Aurora Health Care on the Milwaukee-based integrated healthcare system's accountable care organization.

“The agreement between Aetna and Inova to jointly form Innovation Health Plans represents complete alignment between a health plan and a health system,” Bertolini said in his e-mail. “The joint ownership drives a new level of shared accountability across all aspects of healthcare—from underwriting to patient care.”

Bertolini also said that collaboration with Aurora had been discussed “long before the Supreme Court ruling. … We expect that together with Aurora, we will improve the coordination and quality of care in this market and create more competition through our lower-cost plans.”

Bertolini also described how he leads “an organization that impacts the health and wellness of nearly 37 million people,” and said he uses that role as a platform “to create and influence positive changes” to a healthcare system that “is not working for too many people.”

“We are committed to making the system simpler, more focused on wellness and ensuring that chronic patients get the coordinated care that will help them achieve better health,” he said. “I am hoping I am on the list because Aetna sees this effort as a collaborative enterprise, where all healthcare players have the same economic incentives to do what is best for the consumer. We are not waiting for reform to happen, we are leading the change.”

AHIP's Ignagni made the list for the 11th consecutive year. She is one of only eight people who have made the ranking in every year of its existence.

“I think it is a reflection of the importance of our membership to the delivery system and to policymaking,” she says. “I think it's a reflection of the work our members are doing.”

Ignagni describes that work as a collaborative effort “to turn the boat in a new direction that will allow the system to be sustained” and toward “setting up a system to reward high performers.”

“I'm very excited about the changes that are coming to the reimbursement system that will drive higher quality and lower costs,” she says. “I see a real commitment to collaboration, which is crucial to taking the leap we have to take.”

Another perennial winner is Chip Kahn, president and CEO of the Federation of American Hospitals, an advocacy organization for investor-owned hospitals. Kahn, who placed No. 33 this year, says healthcare reform has moved into the second inning of a three-inning game, with the first being the Supreme Court ruling, the second being the November elections and the third being continued implementation if Obama is re-elected or unknown action if the Republicans win the White House.

Kahn says his influence stems from his job and, while he represents only 20% of the nation's hospitals, they are part of the largest systems and tend to have the largest market share in the communities where they're located.

Kahn denies a story that's been widely circulated on the Internet that he used his influence to strip a government-sponsored “public option” health plan from the Affordable Care Act.

“In our discussions with policymakers—in terms of the big-picture issues—there was hardly a mention of the public option,” Kahn says. “It was our feeling that the public option was something that wouldn't make it off the cutting-room floor.”

The highest-placing elected official on the list was Oregon's Gov. Kitzhaber, a Democrat who earlier this year was able to push through a Medicaid reform plan in his state with bipartisan political support as well as with federal financial support.

Kitzhaber, a former emergency medicine physician, on March 2 signed the law creating Medicaid coordinated-care organizations. On May 3, the CMS announced that it would be providing a $1.9 billion grant to be paid over five years to help fund the new program for Oregon's 600,000 Medicaid beneficiaries. If the program works as planned, it's projected to save $11 billion over the next 10 years.

Critics, however, have referred to the plan as a “gamble.”

“I would say the current system is a gamble,” Kitzhaber replies. “We know it is costing huge amounts of money and producing very poor population health statistics. We also know there is excellent evidence that shows that, if you develop an integrated system that seeks to manage chronic conditions in the home and in the community and actually seeks to link up with programs that focus on wellness and prevention, you can save vast amounts of dollars.”

Kitzhaber says the plan could easily serve as a model for other states to use and that, while Oregon's House of Representatives is split evenly between Democrats and Republicans, the Medicaid reform plan passed on a 53-7 vote.

“If there's the political will, certainly any state could move in this direction,” Kitzhaber says. “In a year when healthcare has become a political football, been divisive and partisan, I think we've demonstrated here in the state of Oregon that it doesn't have to be.”

Former Massachusetts Governor and presumptive Republican presidential nominee Mitt Romney, whose state's program for universal coverage is considered to be the model for the Affordable Care Act, returned to the list in the No. 13 spot. He also finished at that same spot in 2006 and was No. 2 in 2007—between Sister Carol Keehan, president and CEO of the Catholic Health Association who was No. 1 that year and then-California Gov. Arnold Schwarzenegger in the No. 3 spot.

Romney's running mate, House Budget Committee Chairman Rep. Paul Ryan (R-Wis), finished first last year and No. 24 this year, though the votes were tallied long before he was chosen as the GOP vice presidential candidate.

Ryan has proposed to transform Medicare into a “premium support” system where senior citizens will receive a certain amount to buy health insurance and could pick the plan of their choice—with those who pick less-expensive plans getting a rebate and those who choose more expensive plans paying the difference out of their own pockets.

“We believe consumer-driven, market-based reforms do more to alter the cost curve of healthcare inflation,” Ryan says in an interview. Ryan's Democratic co-sponsor, Sen. Ron Wyden of Oregon, makes his first appearance on the 100 Most Influential ranking, holding the No. 44 spot.

The other elected officials on this year's list: Obama, who placed No. 4 (he topped the rankings in 2009 and 2010); House Speaker John Boehner (R-Ohio), who finished at No. 19 in his second time on the list (he was No. 21 last year); Senate Finance Committee Chairman Max Baucus (D-Mont.), coming in at No. 35 for his seventh time on the rankings (he finished fourth in 2009 and 2010); House Majority Leader Eric Cantor (R-Va.), making his first appearance at No. 42; Florida Gov. Rick Scott, making his second appearance, climbing to No. 43 after placing at No. 49 last year; Rep. Pete Stark (D-Calif.) making his 10th appearance on the list at No. 49; Sen. Chuck Grassley (R-Iowa), the only elected official to be on the list all 11 years, holds the No. 56 spot (See related story, p. 22); House Ways and Means Committee Chairman Dave Camp (R-Mich.), making his first appearance on the list, at No. 65; and Vermont Gov. Peter Shumlin, No. 86, who finished second on last year's roster.

One person pushing back against the Medicare premium-support plan is Rose Ann DeMoro, executive director of National Nurses United/AFL-CIO, who also has made the most-influential list every year, holding the No. 36 spot this year. DeMoro advocates a “Medicare for all” plan, and her organization is collecting anecdotes of the hardships faced by people without insurance.

“The stories are heartbreaking,” DeMoro says, telling of an instance where a woman having a heart attack was prepared to die rather than call an ambulance because she was afraid that, if she went to the hospital, she would lose her home and her son would have no place to live. DeMoro says the woman's son called an ambulance.

DeMoro contends that the biggest influence in healthcare today is information technology. She says healthcare CEOs have become “captivated” by IT and worries that technology is replacing human judgment and the human touch. “All the hospitals worship it, and they're trying to provide healthcare without human beings,” she says. “Nurses are now monitoring the monitor instead of monitoring the patient.”

Making her third and highest appearance on the list is Judith Faulkner, founder and CEO of Verona, Wis.-based Epic Systems, the nation's leading vendor of electronic health-record systems. At No. 22, Faulkner was the highest IT professional on the list, and she says the biggest influence on her is the feedback her customers provide.

As Faulkner rises in influence, she's finding herself—rather than her company—in the spotlight, which she says is not always pleasant.

“I'm frequently referred to as 'media shy,' so to me, publicity is something I prefer to avoid—not because it's good or bad—but because I prefer to be someone who's not in the public eye,” Faulkner says, adding that inaccurate articles—such as a recent London Daily Mail story—do little to change her mind. “People read it and believe it.”

The Daily Mail story described her as a “Harley-Davidson-riding friend of President Barack Obama.”

“I don't know (Obama),” she says. “And, by that, I don't mean I'm an enemy, but I met him once and that was for a few seconds—and I don't own a Harley.”

Dr. Carolyn Clancy, director of HHS' Agency for Healthcare Research and Quality, holds the No. 32 spot in her 10th appearance on the list. And she says she's excited about the work AHRQ is doing in using technology to advance healthcare quality and patient safety—even if the fiscal 2013 Republican budget calls for eliminating funding for her agency.

“We're very optimistic,” Clancy says, adding that it's because she's hearing a common message across healthcare industry sectors. “They want to dramatically accelerate high-quality care, but they need good information, and that's what AHRQ does.”

Of particular interest is the $475 million AHRQ received from the American Recovery and Reinvestment Act, which was used to develop a health “data infrastructure” that Clancy says created a platform for future studies.

“We recognize that that the Recovery Act was a one-time investment and we would never have the opportunity again,” she says, adding that the investment helped create a scientific foundation for “transitioning from people running around looking for paper charts to getting feedback in real time for doing the right thing.”

One technological innovation that Clancy highlighted was at a California hospital where the patient population speaks 21 languages. In addressing readmission challenges, Clancy says the hospital developed a system where patients are provided a password-protected recording in their own language and can listen to their discharge instructions over and over.

“It's hard not to feel optimism,” Clancy says.

Dr. Eric Topol, chief academic officer for Scripps Health, San Diego, and director of the Scripps Translational Science Institute, feels the same optimism. Topol, making his second appearance on the list, holding the No. 64 spot after landing at No. 69 last year, says genomic medicine is making “remarkable” progress in fighting cancer and Alzheimer's disease. He also notes advances in telephone technology that can diagnose a child's ear infection, help to regulate a patient's high blood pressure medication or calibrate a new prescription for their eyeglasses.

Topol, who this year was named to the No. 1 spot in the Modern Physician and Modern Healthcare 50 Most Influential Physician Executives in Healthcare competition this year, says he contacted some Australian college students who developed StethnoCloud, a telephone attachment that can help remotely diagnose pneumonia. He says that, in their reply, the students told him they were inspired by his book The Creative Destruction of Medicine.

Despite all the attention focused on the Affordable Care Act, Topol says the politics are “in a separate orbit from what we're talking about.”

“The hope is that, through continued, relentless effort, we will be able to get that public demand and get that consumer-driven revolution,” Topol says. “This is highly threatening to the medical community, but highly empowering to the public.”

Kevin Lofton, president and CEO of Catholic Health Initiatives, also sees brighter days ahead, especially in terms of ending healthcare disparities, increasing leadership diversity, and changing the industry's focus from sickness to health—with an eye on planetary health as well.

Lofton has appeared on the most-influential list nine times, holding No. 48 this year and as high as No. 16 on the 2006 ranking. He says the people he finds influential are those who lead other organizations and “are intent on challenging the status quo.” The 2007 chairman of the American Hospital Association, Lofton served as the first chairman of the AHA's Equity of Care Committee, which works to increase diversity in healthcare management and governance.

With hospitals in 19 states, CHI has access to 38 senators and 40-plus representatives, Lofton says. He says he uses that access to advocate for lowering costs by improving quality. It's his goal to have the elected officials come together and “and put something special in place,” which Lofton says would be a “payment structure that would reward providers to do what we all want to do—and that's keep people healthy.”

Lofton says CHI is also working to restore the health of the earth, and is an active participant in organizations such as the Healthier Hospitals Initiative and Health Care Without Harm. CHI has hired a sustainability director, makes environmentally directed choices in its supply chain and does the same for its investment strategies, Lofton says.

“We won't invest in companies that are not good stewards of the earth,” Lofton says. “We've been one of the pioneers in that area. The sustainability of the planet and the impact healthcare has on that area has been a focus of CHI for some time.”

TAKEAWAY: Executives who run big health insurance companies take the reins of influence in the new era of healthcare reform.