5 min read

Does the appointment of Tom Daschle as health secretary points to a NICER USA? Health Policy Today, 25th November 2008

Barack Obama’s cabinet is taking shape, with many predicting that Hilary Clinton will be appointed as Secretary of State this week.  The health appointment was made on Friday when Tom Daschle  was officially confirmed as Health and Human Services Secretary.  Rare amongst health secretaries, Daschle has written a book on health care reform, published earlier this year.  Among his ideas is the creation of a body which would effectively be a national institute for clinical excellence, and rationing (NICER), inspired by the English model.  Daschle’s appointment confirms healthcare as a very important political priority and shows that reform will be fought for by the White House.


Tom Daschle is 61 years old with 30 years in the Senate.  Earlier this year  he was named first author on a book on health care reform .  He has been working with former Senate leaders on recommendations to improve the system.  According to one US daily, "His new leadership position confirms that the incoming Obama administration has made health care reform a top and early priority for action in 2009."

His appointment has been universally popular amongst the health policy experts and advocates of universal healthcare. The American Prospect's Ezra Klein called Daschle's appointment "huge news, and the clearest evidence yet that  Obama means to pursue comprehensive health reform."

The Wall Street Journal says his book argues reform must be comprehensive, stating that we can no longer afford incrementalism or inaction.

“The most important proposal in "Critical" is the creation of a "Federal Health Board,"explicitly modeled on the Federal Reserve Board. Its duties would include "recommending coverage of those drugs and procedures backed by solid evidence. It would exert influence by ranking services and therapies by their health and cost impacts."
During the election campaign, Mr Obama pledged to offer a new state-administered health insurance plan to people who are currently uninsured, while assuring people who were satisfied with their existing employer-provided coverage that they would not be forced to give it up.

So what does Daschle say about the uninsured? The Wall Street Journal explains:

‘Mr. Daschle wants to open to all Americans the Federal Employee Health Benefits Plan - a menu of private-insurance options now accessible only to government workers. He would offer, in addition to the current plans, a government-run program, presumably similar to Medicare, although he provides few details. There would also be some form of means-tested premium support (or tax benefits) for Americans who couldn't afford one of the available plans.

“Tom Daschle admits that the board is based on the National Institute for Clinical Excellence in Britain and the Federal Joint Committee in Germany. Both are charged with managing the public's access to higher-cost drugs, medical devices and procedures. But both are growing increasingly unpopular in their home countries -precisely because they've become a triumph of cost-containment over patient access and choice.

“Mr. Daschle proposes a dozen or so “experts” who would be “chosen based on their stature, knowledge, and experience, ensuring that the decisions they make have credibility across the health-care spectrum.”

Not everyone likes the book .  The chief criticism is that a central approach would limit innovation, enforce price control and limit access to care.


As head of the health and human services department, Mr Daschle will oversee Mr Obama's proposed reforms to the US healthcare system.

The BBC's Adam Brookes  says the decision to appoint Mr Daschle  shows that Mr Obama feels he needs a Senate heavyweight to help him persuade Congress to back major reforms .

Mr Daschle was the Democrats' Senate Majority Leader from 2001 until 2003.

This contrasts with Hilary Clinton who when charged with reforming healthcare had no legislative experience.  Obama seems keen to avoid making the same mistake.  It shows health is seen fundamentally as a political problem.

According to one US newspaper, ‘you don't tap the former Senate Majority Leader to run your health care bureaucracy. That's not his skill set. You tap him to get your health care plan through Congress. You tap him because he understands the parliamentary tricks and has a deep knowledge of the ideologies and incentives of the relevant players. You tap him because you understand that health care reform runs through the Senate. And he accepts because he has been assured that you mean to attempt health care reform.’

The details of his reform package could change, however, as Mr Obama attempts to push legislation through Congress.  It will be Daschle that negotiates the road to reform.


It is not just Republicans that will expose healthcare reform to close scrutiny.  This week’s Time magazine carries a feature on the  ’team of rivals’  that Obama’s appointment of Hilary Clinton would create.

Although political commentators say she is likely to take the job, not everyone thinks it is a good idea.  Hilary’s friend and congresswoman, Louise Slaughter are counseling her not to take the job and instead concentrate ‘on the health-care reform cause that is her passion’.

Time magazine reports that just after the election (i.e. just a few weeks ago) Clinton approached the Congress Health Committee chair, Edward Kennedy, to ask him to create a health-reform subcommittee for her to chair, and was turned down.

There are several big-hitting politicians with very strong interests and views in healthcare reform. Daschle, Clinton and Barack Obama himself have each put forward quite different approaches to reforming the healthcare system. Daschle may be rare as an expert on healthcare in the cabinet, but rarer still, in Obama’s administration he will not be the only one.

The bumpiness of the political road ahead is illustrated by the arguments in the Senate over the Democrats' stimulus plan.

As in England, the Democrats plan to put money into the economy so as to counter the shrinking tendencies within the corporate sector.  Individual states face particular pressures.  The Economist this week says they face a $70bn budget gap this year.  To cover this, ‘half have already started cancelling infrastructure projects, cutting health-care benefits or laying off workers’.

To counter this problem, The Economist believes the federal government should move central to money states, ‘for instance by increasing its share of jointly financed spending such as Medicaid, which pays for poor people’s healthcare’.  The Democrats spending plan would have done this – though ‘too timidly’, according to The Economist.  The problem is ‘Republican opposition, based on a misguided aversion to government spending and political sour grapes’.

The Republicans are ideological in their opposition to central spending.  But then so are the Democrats in their annunciation of ‘grand rhetoric of redefining government’s role’ rather ‘than on the practicalities of designing effective stimulus’

An article in Time magazine this week examined the expectations and hope attached to Barack Obama’s election outside of the US.  It made the point that Obama had been elected US President; not Secretary-General of the UN.  It will be American voters who determine whether Barack Obama’s first term has been successful or not.

Obama will be judged on domestic issues, perhaps the most important of which is healthcare.