Critical Condition

Who’s Minding the Store at CMS?

Robert Pear of the New York Times asks a good question, which is why the Obama administration has been unable to find an administrator for the Centers for Medicare and Medicaid Services. The position, which oversees the government’s two largest health-care programs, pays for health benefits for 98 million Americans, yet it has not had a Senate-confirmed head since 2006.  The unusual length of this period, which dates back to the last administration, stems largely from the Democratic Congress’s refusal to confirm the eminently qualified and knowledgeable Kerry Weems, who was nominated by President Bush in the Spring of 2007.

The Obama administration, with a friendly Congress eager to confirm the president’s appointees, has no such excuse.  In fact, according to the article, Congress is puzzled by the oversight.  Pear quotes Democratic Senator Jay Rockefeller, chairman of the health subcommittee of the Finance Committee, as follows: “It’s a big problem. I can’t explain it.”

And it’s not just Congress that is puzzled.  According to the Mayo Clinic’s Denis A. Cortese, also quoted in the article, “[t]he vacancy stands out like a sore thumb.”  At a time when the Medicare hospital insurance trust fund is set to run out in 2017, and when the Obama administration is talking about reshaping health care, possibly according to a Medicare-type model, the position really needs to be filled.

So what’s going on?  There’s always the obvious answer, which is that they cannot find anyone qualified for the job.  This happens to be the case more often than you would think in senior government slots, since many qualified people don’t want to make the necessary sacrifices or put up with the complicated government reporting structure, which generally keeps the CMS head away from the Oval Office.  Still, the article cites at least six people that have been considered for the job, which is a plum assignment in the health-care world.

One theory is that they are waiting until after health-care legislation passes to put up a nominee, but with a Democratic Congress, there is little need to wait if confirmation is the concern.  Even if the Blue Dogs object to some of the excesses of the health-reform bills, they are not currently engaged in the kind of revolt that would have them reject the president’s nominees.  In any event, the Blue Dog issue is a bigger one in the House than in the Senate, and it’s the Senate, where the Democrats have a comfortable 20 vote cushion, which confirms nominees.  Still, given that the president called for health-care legislation to pass before the August recess, it’s possible the administration just did not anticipate how long waiting for health care to pass would delay this selection.

The article also names two senior Hill aides — “Elizabeth J. Fowler, chief health counsel for the Senate Finance Committee, or Jack C. Ebeler, a top aide at the House Committee on Energy and Commerce” — as possible nominees, suggesting that they would be unavailable for nomination until after health reform passes.

One interesting theory I have heard is that the White House is looking at Ezekiel Emanuel, Rahm’s brother and currently a health-policy adviser to OMB head Peter Orszag, as CMS administrator, and does not want to nominate him while the health bill is on the table.  Emanuel’s selection could make some unwelcome noise in two ways, because his brother is White House chief of staff and because he is an expert on the question of allocating resources, which is seen, with some justification, as a euphemism for rationing care.  Under this theory, the concern is less about health care legislation harming the nominee so much as the potential for a controversial nominee to make things more difficult for the legislation.

Whatever the actual reason, the Times article makes clear that even the administration’s allies are getting impatient with the delay.  A properly functioning CMS requires an administrator in place to make tough calls and to raise key issues for review at the secretarial or White House level.  Even if no health reform passes, CMS faces significant financial problems in the years ahead.  And if health legislation does pass, in whatever form, a full-time confirmed CMS head will be needed even more to handle a host of knotty implementation issues.