Now that he's shed the mantle of a federal official, Tommy Thompson is his old acerbic self when it comes to the subject of state and federal relations. It's nice to have him back. During three-and-a-half terms as Wisconsin governor, Thompson said pretty much whatever was on his mind. Then, for four years, as Health and Human Services secretary in the George W. Bush administration, he mostly couldn't. Now he can again.
Last month, at Governing's annual management conference in New York City, the ex-secretary was Thompson-esquely blunt in his assessment of the intergovernmental side of the crisis in health care policy and costs. He said the states were being foolish if they thought they could solve their problems by looking to the feds for help. You're on your own, he told them. Get used to it.
The specifics of the message Thompson delivered were two-fold: One part had to do with the dysfunction in federal-state relations--on Medicaid and on health care costs in general. He warned that the longstanding state-federal compact on this issue was dead, and the result was not going to be beneficial to the states and their budgets. Thompson's other message was a rallying cry to collective action on the part of states to make up for the absence of federal responsibility.
On the dysfunction side, Thompson ran through a routine that described the vetting process for any of the reform ideas he tried to push as secretary. The routine went something like this: Any idea he had went down his immediate chain of command, where it was picked at, pummeled and pilloried. Ideas that survived that process were then sent out to "the 64,000 people who work for HHS"--that is, into a maw of bureaucracy seemingly dedicated to ensuring a slow, painful death for any new policy idea.
If it managed to climb out of that quagmire, it was sent to the White House where "some recent college graduate who has never held a real job" would sniff it over. Assuming the young White House aide deemed the notion worthy, the president would review it and, perhaps, pass it along to Capitol Hill, where, Thompson said, it was pretty much guaranteed to be dead on arrival.
The dead-serious corollary to Thompson's message: States, either individually or collectively, had better start coming up with ways to deal with health care costs themselves. Listing the use of tobacco as a continuing cause of soaring health budgets, he urged state political leaders to consider a $1-per-pack state cigarette tax, with the money flowing into a fund that could be used to prevent smoking and to help smokers quit.
To help address the serious matter of 45 million uninsured Americans, he suggested that states organize purchasing pools for health care insurance and negotiate with insurance companies for competitive premium prices.
If the states are on their own in handling chronic health care, Thompson said, they may be totally isolated when it comes to an acute public health crisis. Indeed, his opening remarks were devoted entirely to the looming threat of avian flu and its potential to mutate into a bug that could be transmitted from human to human, possibly creating a pandemic on the scale of the 1918 influenza outbreak.
In the past few years, the American public has been treated to a tepid federal response to influenza, exemplified by last year's flu vaccine shortages and this year's slow start in ordering flu treatments for the coming winter season. All of this may reflect Washington's deteriorating capacity in the face of acute health threats.
That's what Thompson thinks. His message is that states should not count on some coherent federal response to the threat; they had better begin working individually and together on getting ready, whether or not such work includes partnerships with federal authorities.
Thompson's sarcasm served as a reminder that Washington's hapless approach to innovation and action in the face of clear need can make for good standup comedy. But the consequences of it often prove to be most unfunny.