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REMARKS BY: DONNA E. SHALALA, SECRETARY OF HEALTH AND HUMAN SERVICES PLACE: Pat Hays Lecture, California Health Forum, Sacramento, California DATE: April 27, 2000
Let me say right up front: I come in peace and have no intention of getting in the middle of California's big political fight, I like the Lakers when I'm in Los Angeles - and the Kings when I'm in Sacramento.
As most of you know, this is my last year as Secretary of Health and Human Services - and although I've traveled every year since becoming Secretary, this year my forays out of Washington feel different. This year I feel a little like Don Quixote on his great quest to make a better world. I don't say this because I look like Don Quixote.
Frankly, I look a lot more like his short sidekick - Sancho Panza.
I don't say this because I spend my time battling windmills. I have enough headaches with Congress running around in circles. And I certainly don't say this because I'm ready for Don Quixote's epitaph, which reads: "For if he like a madman lived, at least he like a wise one died."
But Don Quixote did go on a journey. He did maintain his humanity. And he did learn a thing or two along the way. Over the last seven years - I have too. Cervantes wrote Don Quixote almost four hundred years ago. He took a mere 900 pages to say what was on his mind.
This shows his true potential to work in government.
In my line of work, ideas only come in three sizes: Ten-page memo, twenty-page memo and file cabinet. Of course the big advantage of being Secretary is that other people have to write these memos. The big disadvantage is that I have to read them. So yesterday I decided to try something a little different. Instead of sitting at my desk, glasses on and eyes glazed over, reading one more memo, I decided to write my own. I'm not calling this Donna Shalala's bureaucratic revenge. Like any memo writer working tirelessly from deep inside twelve layers of government - I'm just trying to be helpful.
My memo is not an epic novel. And, believe me, it's not 900 pages. I don't even have the name of the addressee. My plan is simply to leave the memo on my chair as I head out the HHS door for the last time. With a little luck - my successor will read it. But remember: Like all Washington "trial balloons," if you like my memo - I wrote it. If you don't - it was all somebody else's idea.
To: The Honorable Next Secretary of Health and Human Services
From: Donna E. Shalala
Re: Which Way is Up? Health Care in the 21st Century.
Date: January 20, 2001
Section I: Drop the Chalupa - You Won't Have Time to Eat it Anyway.
Although we haven't met, my guess is you've come to Washington from someplace else. That, as Martha Stewart likes to say, is a good thing. The fact is, most of what you'll need to succeed as Secretary of Health and Human Services is in pretty short supply around this town. I'm talking about patience, humility - and most of all, a good sense of humor. Also, in spite of what you may have been promised by your new employer, life as a Cabinet Secretary isn't always a bed of roses.
Every hour of your life will be scheduled by people so young they're still having sleepovers. Every decision you make will win you no new friends - and cost you plenty of old ones. Every word you never intended to speak will end up in the press - right next to the worst picture ever taken of you. And every good idea for improving the health of the American people will become a reality only after budget battles, bureaucratic battles, public relations battles - and, on occasion, battles with your own conscience. But the important point is never give up. From your first day on the job to your last - never ever give up. Section II: To Dream the Possible Dream
No Administration achieves everything it wants. But every Administration should set the highest possible goals for itself. That has always been my great quest: To follow President Kennedy's advice and do not what is easy, but what is hard. Today I can say that with a lot of hard work, we've seen dramatic improvements in public health over the last eight years.
Childhood immunization rates for the most commonly recommended vaccines have reached a record high 80 percent.
Head Start has undergone the largest expansion in its 35 year history - and is on track to meet our goal of 1 million children enrolled by 2002.
Teen pregnancy rates have fallen for seven straight years - and overall teen drug use has leveled off or declined.
Deaths from HIV/AIDS have fallen by more than 70 percent since 1995 - and AIDS, once the 8th leading cause of death - in no longer even in the top 15.
Overall cancer deaths - while still too high - are starting to fall.
More Americans than ever are receiving preventive health screenings - many paid for by Medicare or Medicaid.
In the last two years, the budget for the National Institutes of Health has grown by over 30 percent.
So one year into a new century, we are living longer, healthier and better lives. We know more and we're doing more. But more is never enough. Our nation still faces serious public health challenges. Some are old. Some are new. None is easy. And all will confront - but I hope not confound - the next Secretary of Health and Human Services.
Section III: What's up Doc?
Bugs Bunny has never seen my one-handed reverse dunk, so of course he'd rather have Michael Jordan on his Space Jam team than me. But eight years as Secretary of Health and Human Services puts me in an all- star position to answer the W'ascally Wabbit's famous question.
Here's what I believe is up for docs - and other health professionals - in the 21st century.
Section III, subpart A: The Greening of America is Now the Graying of America
There is probably no greater public health challenge facing our nation than the demographic time bomb now ticking away. The number of Americans over 65 is expected to double in the next thirty years, and seniors over 85 are the fastest growing segment of our population. At the same time, we have the first budget surplus in three decades. So this is a window of opportunity. But the window will not stay open for long.
The time has come to modernize Medicare so that it neither bankrupts our children - nor is unavailable to our grandchildren. We've already strengthened Medicare through a vigorous campaign against waste, fraud and abuse. In fact, we fundamentally changed the behavior of the entire health care industry. We also strengthened Medicare by investing in prevention services, learning from the private sector, and implementing reforms in the bipartisan Balanced Budget Act.
All this bought us valuable time.
The hospital trust fund is now solvent until 2025 - a big turn around from our first days in office when the trust fund was projected to go broke in 1999. Now we must finish the job by setting aside a portion of the surplus for Medicare - and by modernizing Medicare with tried and true private sector strategies, including Preferred Provider Organizations, Centers of Excellence, and a prescription drug benefit.
No sane person designing a Medicare program today would leave out a drug benefit. But not just any prescription benefit will do. A 21st century drug plan must be voluntary, accessible and affordable. It must provide meaningful protection and bargaining power for seniors, offer competitive prices, and be easy to administer through the private sector. And it must maintain Medicare's tradition of social insurance.
Fixing Medicare is not the end of our preparations for the graying of America - which I prefer to think of as the "silvering of America." It is only the beginning. America's growing population of elderly will change the world of health care as we know it.
There will be new needs - and new opportunities.
I'm talking about opportunities to shift from costly, institutional care to home based care, opportunities to change our culture that tends to devalue the contributions - and frankly the wisdom - of older Americans, and opportunities to promote "active aging."
Most people understand active aging to mean encouraging older Americans to keep working if they want to, and participate in social activities as long as they are able. That's true. But it's also true that active aging begins long before old age. In order to stay active when we're old, we must be active when we're young, because that will help stave off diseases like hypertension, stroke and osteoporosis later in life.
As for new needs in the 21st century, we must focus much more attention on long term care - and on serving people where they live, which for the most part will mean in their homes and communities. A commitment to long term care will be a shared responsibility. We need to strengthen Social Security, build more accessible housing, and promote lifelong learning. But there is also a leading role for the Secretary of Health and Human Services - and the health profession. We must make sure that the growing number of seniors in managed care plans receive both high quality - and cost effective - health care. We must learn more about chronic diseases associated with aging like Alzheimer's, Parkinson's and diabetes. And, perhaps most important, we must come up with new ways to lessen the "squeeze" that many Baby Boomers now face. They are raising children - and supporting their older parents at the same time. This is not easy.
Over the last eight years, we worked hard to help working families take care of their elderly loved ones - through tax credits, more respite care and better home health services. But the 21st century demands we do a better job. This is a big challenge - not only for the next administration, but for our entire health care community. Government, doctors, nurses, hospitals and insurance companies all have to work together to make sure that growing old means growing old with dignity - and in the best health possible.
Section III, subpart B: The Uninsured Still Wait
The problems faced by the uninsured have not yet been solved. Today, over 44 million Americans still have no health insurance - including over 11 million children. Our original plan to was insure all Americans at one time. That turned out not to be politically feasible. Experience taught us that the best way to achieve universal coverage is one step at a time. We began by making health insurance portable. Now changing jobs, or having a pre-existing condition, doesn't mean losing coverage.
In 1997, the President proposed and Congress passed the State Children's Health Insurance Program. Today, almost 2 million children from working families have access to insurance through S-CHIP. These families earn too much for Medicaid - but not enough to afford private insurance. We also made it possible for millions of Americans with disabilities to join the workforce without fear of losing their Medicaid or Medicare coverage. Similarly, children who age out of foster care can now keep their Medicaid coverage until they're 21.
Equally important, we've learned to "think outside the box" on this issue. Yes, we can provide more insurance. But we can also provide more health care. More health care means strengthening the safety net of clinics, Federally Qualified Health Centers, and hospitals that traditionally serve the health needs of low income workers without to regard to ability to pay.
Two years ago, Congress embraced this idea by providing funding for our Community Access Program. Since then, we have continued to help these networks build a seamless system of care for workers with no other place to turn. So we've made incremental - but very important - progress over the last eight years helping the uninsured get health care, through either an insurance card - or a caring heart.
But we still have a long way to go. The next administration doesn't need to reinvent the wheel to expand access. It only needs to build on existing structures - while teaming up with local doctors and other health care professionals - to make sure that no worker falls through the cracks.
Section III, subpart C: 21st Century Health Care in Three Words: Quality, Quality, Quality
In 1997 President Clinton created the Advisory Commission on Consumer Protection and Quality - co- chaired by the Secretary of Labor and me. The Commission issued a landmark report calling for a Patient's Bill of Rights. The President was absolutely firm that he would not sign a bill that was nothing more than an empty promise. There must be strong protections for all Americans - and a meaningful way to enforce those protections.
When you take the reins at HHS, you'll quickly learn that quality health care is more than just a Patient's Bill of Rights. Quality is doing the right thing, for the right person, at the right time and in the right way. You'll also learn that the Agency for Health Care Research and Quality is the lead agency for improving health care quality. AHRQ funded critical research into the frequency and causes of medical errors - research that was later used by the Institute of Medicine in its own report on quality. That report revealed that at least 44,000 deaths occur every year because of preventable medical errors - and perhaps as many as 98,000. Early in 2000, we announced a comprehensive plan to meet our goal of cutting medical errors by 50 percent in five years.
We cannot see this goal through to the end. But you can. We did, however, put our own house in order by requiring over 6,000 hospitals participating in Medicare to have their own error reduction programs. We also support a nationwide system of error reporting - one that will be state-based and phased in over time. We know mandatory reporting has raised concerns among health professionals. But under our plan, disclosure will be limited to the small number of serious, preventable and adverse events that cause lifelong disability or death. This program needs to work hand in hand with clinicians and hospitals to help reduce errors.
This is the right road to take - and I hope you take it.
Section III, subpart D: HIV/AIDS: We Can Beat This Disease
HIV/AIDS was with us eight years ago - and it is still with us. Nevertheless, much has changed. Death rates are down dramatically thanks to powerful new anti-HIV drugs. We established a permanent Office of AIDS Research at the National Institutes of Health - and released the first National AIDS Strategy. Funding for AIDS research is up dramatically - as is funding for Ryan White services.
In the first seven years of our Administration, money to help people living with HIV/AIDS purchase drugs increased almost 1,000 percent, and overall AIDS funding went up 150 percent. Our budget request for AIDS in FY2001 was over 9 billion dollars - which includes money to help us reach President Clinton's landmark goal of finding an AIDS vaccine by 2007.
I'm very proud of this record. I have no doubt that we saved many lives through our focus on research, treatment and prevention - and extended many more. But as good as this record is - I urge you to do even better, because as we move from one Administration to the next, there must be no let up, no pause, no surrender in the fight against this terrible disease.
HIV/AIDS is a bigger problem for most of the rest of the world than it is for the United States.
Which bring me to, Section III, subpart E: Global Public Health Brings Global Prosperity
Treasury Secretary Summers recently noted that delivering vaccines and effective treatments for infectious diseases is one of the most important investments we can make in the economic development of poor countries. He's right. Setting up a strong international public health infrastructure - that includes research, surveillance and treatment - is absolutely in the long term interest of this nation.
Infectious diseases such as TB and West Nile know no borders. In a world of instant communication, global markets, and easy travel - all of which will expand in the next decade - fighting disease anywhere means fighting disease everywhere.
In addition to the humanitarian need for a global campaign against infectious diseases - we also have a strong economic incentive to wage this battle. Countries devastated by disease cannot contribute to global growth. Today, 40 percent of our exports go to developing countries. We need those markets to expand - not shrink. But shrink they will if millions of people in the developing world are cut down in the prime of life by diseases like AIDS. Finally, developing countries winning the fight against disease - and growing more prosperous - are much more likely to be democratic, and much less likely to threaten our security.
Section III, subpart F: Bioterrorism: It's Not Just a Movie Anymore
We don't know the likelihood of a deadly biological attack. But this much seems certain - as terrorists become more sophisticated, the threat will grow. That is why I advise the National Security Council on bioterrorism - and the next Secretary of Health and Human Services should too. We have already requested a major increase in funding to prevent and respond to biological attack - money for surveillance, strengthening local medical teams, stockpiling drugs, and research into new treatments and vaccines.
In the busy world of immediate health care needs, it is easy to overlook preparations for a "what if" problem like bioterrorism. That's a mistake. As the new Secretary of Health and Human Services - working in partnership with law enforcement and public health organizations - you must stand vigilant against any possible attack.
Section III, subpart G: Focus Like a Laser on Prevention
The majority of preventable deaths in our country are rooted in just three behaviors: Tobacco, poor diet and lack of physical activity. That means over the next decade millions of lives can be saved through changes in behavior - and early screening for disease. The Supreme Court - while acknowledging the overwhelming public health threat posed by tobacco - decided that the FDA does not have the authority to regulate tobacco. Congress must be persuaded to give that authority.
Believe me, there'll be lots of resistance. But there is also plenty of bipartisan support for giving the FDA the power it needs to keep tobacco out of the hands of children. Harness that support - and team up with the doctors, nurses and public health leaders - to keep the pressure on.
Eventually, Congress will do what's right.
As for promoting prevention: We just released our Healthy People 2010 prevention agenda for the next ten years. The agenda sets broad national health goals to help us live longer - and with a higher quality of health. As part of Healthy People 2010, we unveiled 10 Leading Health Indicators to help Americans easily assess the overall health of our nation, as well as the health of their communities. Healthy People 2010 follows on the heels of Healthy People 2000 begun by the administration that preceded ours. The baton is now being handed to you. America waits for Healthy People 2020.
Section III, subpart H: Keep Our Science Strong - and Our Ethics Stronger
You are about to inherit the leadership of the most talented scientists - and the greatest research infrastructure - ever assembled. From the human genome to vaccine research to food safety - this century's blockbuster discoveries will come from American scientific genius, but only if they continue to receive support from policymakers and Congress.
We have never wavered in our support. Over the last eight years, funding for every science-based agency in HHS has risen steadily. Frankly, when it comes to science, we believe in throwing good money after good. That's why we not only need to continue investing in public health agencies, we need to protect the treasure of academic health centers - which will train the next generation of researchers, doctors and other health professionals. I'm not talking about walling off academic health centers from the revolution in managed care. But I am talking about preserving the irreplaceable role these institutions play in training, indigent care and clinical research.
As much as I love and support science, I recognize that our revolutions in research and health care raise serious ethical questions. We must not create a 21st century health care system where our genetic map is used to deny jobs or health insurance, where medical breakthroughs widen the gap between the haves and the have-nots, and above all, where our science gets ahead of our ethics - or eclipses our fundamental sense of humanity, fairness and values.
Which brings me to my concluding Section III: subpart I: The Moral Challenge of Health Disparities
A famous African American comedian once said, "Why should I pay taxes? I won't get the money until I'm 65. Meanwhile the average black man in America dies at 54." Behind that joke is a moral challenge. Consider this: If you're an African American woman, you're over 20 times more likely to be diagnosed with AIDS than a white woman. If you're a Native American, your rate of diabetes is 3 times the national average. If you're a Chinese American, you are 4 to 5 times more likely have liver cancer.
So yes, overall life expectancy for Americans is going up. And yes, some gaps in health outcomes between minorities and the majority population are closing. But they're not closed yet. So we haven't finished our work yet. In 1998, President Clinton set a goal of ending health disparities in six major areas: Infant mortality, cancer screening and management, cardiovascular disease, diabetes, HIV/AIDS and childhood immunizations. Since then the Centers for Disease Control and Prevention has awarded millions of dollars to 32 community coalitions to help eliminate these disparities. Our last budget called for spending 4.6 billion to improve health in minority communities - including American Indian and Alaska Natives.
Still, when it comes to closing gaps in health outcomes, our Administration is like Moses standing on the edge of the Promised Land. We will not quite be able to get there under our watch - but you must get there under yours.
Good luck. You're about to start the journey of a lifetime.
That's the end of my memo to my successor. I began this lecture by mentioning Don Quixote. From my point of view, one of the great things about this book is that even though the hero, Don Quixote, dies, Sancho Panza lives.
And I'm going to keep right on living too.
I'm looking forward to a new life. New challenges. And new opportunities to continue our mutual quest for better health for all Americans in the 21st century.
Thank you.