April Foolery

I left the office Friday evening having been given instructions on what to do and not do in the event of a government shutdown. No work after 6:00 pm until Monday morning, meaning no use of Blackberry or laptop. And no, I didn't get the DT's. Went to dinner with the news still looking pretty bleak, but by the time we were headIng home it appeared that a deal had been reached (as it was, with an hour and a half to spare). all just a prelude to the battles still to come.

No point recounting here how insane this all is, how little it has to do with the problems we face. For those of us just trying to do our jobs and to manage staff members trying to do theirs, all of this is feels like an unnecessary distraction. And it continues to be dispiriting that the public debate was all about who to blame for what seemed like an inevitable shutdown, with much heat but precious little light shed on how any of this is in the country's interest.

The deal apparently does mean that DC will not be able to use locally-raised tax revenue (ie, not from a Congressional appropriation) to provide abortions for poor women. It's strange enough living in a place without representation in Congress; now these folks who don't allow us any say in what our government does are telling us what we can spend our own money on.

March Madness

No, I don't mean the NCAA kind. We went home for Kate's spring break and headed up to Tahoe for a few day's skiing. What we found was more snow than I can remember seeing in the 30+ years we've been going up there. We had a couple of days of great powder skiing, light and fluffy, no Sierra cement--and then had to wait a day to go home until I-80 reopened.

We got back to a cold and rainy DC, but the cherry blossoms are an unmistakeable sign that Spring has arrived. Glorious symbols of the beauty and fragility of life, especially poignant this year after the earthquake and tsunami.

The madness that has been going on here shows no signs of letting up now that April is here. They're playing "chicken" over shutting down the government again--I never stop being amazed by how freely people claim to speak for "the American People" when what they really mean is "that portion of the American people who agree with me." I think it pays to remember that there are lots of folks out there who don't agree with one's own views on every issue--and they are Americans, too.

Meanwhile, the best example of March Madness that I came across is the member of Congress who, during an oversight hearing, compared the Affordable Care Act to Das Kapital.

Snowed in!

Home to Oakland for Kate's spring break, we made plans to head up to Tahoe for a couple of days of skiing, my first of the season, the fewest ski days I've had since--I was five, maybe? Little did we know that we were going to be in the middle of an epic series of stormed that have brought more than 10' of snow over the past 10 days. Great powder skiing at Sugar Bowl and Squaw, including first tracks down 75 Chute (for those of you who know the mountain). Plus yesterday was an historic day (in addition to being the one-year anniversary of the passage of the Affordable Care Act): Kate decided to try skiing again after 11 years on a snowboard, and had a good time. We may have reclaimed one.

Now we're snowed in, I-80 is closed due to blizzard conditions. We'll have to stay another night and hope to get back tomorrow. Cowabunga!

Spring at last

On the Mall, late afternoon, 75 degrees, sitting next to Rodin's Burghers of Calais, looking at cherry blossoms in full bloom. In Japan, the cherry blossom is a symbol of evanescent beauty, of life and death; they are glorious and then blow away. I imagine they will be especially poignant this year, as we learn, yet again, that no matter how advanced we are, no matter how well we think we are prepared for the worst case scenario, we actually can't even imagine the worst case scenario and won't ever be prepared when it comes.

Here in DC Spring is, of course, expected and indeed inevitable. Which doesn't prevent it from being a wonderful surprise when it finally comes. We didn't have a particularly harsh winter, nothing like the "Snowpocalypse" that greeted me when I arrived in Washington last February, and other parts of the country have certainly endured much worse than we did. Still, people don't seem to quite believe the weather has turned: I saw both sandals and UGGS today, along with quite a few unnecessary overcoats. Looking forward to three months of wonderousness before the dreaded summer.

Meanwhile, I fly home tomorrow to see my beloveds, haven't seen them since New Year's so very excited. And of course it's supposed to rain every day during the week we'll be back. Which won't be so bad as long as it stays just cold enough to be snow, as we'll be in Tahoe for a few days. This will be the fewest ski days I've had in at least 30 years, and it is hard to take. One more reason why despite what people here like to say, we will be going back . . . .

Clearance

clearance, n

1. The action or process of removing or getting rid of something
2. Official authorization for something to proceed or take place.
3. Clear space allowed for a thing to move past or under another.

You probably think of clearance the way i used to, when I was told to turn off my personal device, or when I was installing some bookshelves. Or when a bookstore files for Capter 11.

Clearance has taken on much more importance for me since I joined the executive branch. It's the process for getting approval to release something in writing to the public: it could be a regulation, to be published in the Federal Register, explaining what we think Congress meant and how we're going to implement it, some sub-regulatory guidance explaining what we meant by the regulation, or it could be just a letter.

Clearance involves some list of people being given some amount of time to make comments on whatever I and my team have written. Some of the people on the list are up the chain of command, so that makes perfect sense. And the lawyers in the General Counsel's Office. And if it's a regulation, the Office of Management and Budget, part of the White House, that must approve all regulations.

Some of these reviewers are other people in the agency, some may be in other agencies. Many of them I've never heard of, and they've never heard of me; some likely know little to anything about the subject the're reviewing.

It's easy to chalk this up just to bureaucracy, and it's also easy to chafe at the delay it causes. But I have come to appreciate the fact that something I do might have an unexpected impact on something that others in the Federal government are doing, and that of course I know nothing about. So we understand why the process is needed. And when we can, we plan our work with a timeline that takes account of the additional time that will be needed. And the system works pretty well. Which doesn't mean we can't grumble a bit now and then.

Traveling south

With apologies to Tony Hurwitz and Sarah Vowell . . .

We went down to Fredericksburg on Saturday. There's some colonial history, George Washington's mother was born there, and his boyhood home, Ferry Farm, is nearby. And beautiful homes, some ante, most postbellum. Apart from some cute shops, for tourists its' mostly The War Between the States.

We had Zorro with us, and folks down there sure love dogs, so we got lots of smiles and he was much admired and petted. One gentleman came over and ended up with Zorro licking his whole face (as he will do, if you let him), after he left Liz said that at first she thought he was speaking another language, but no, it was just the combination of a drawl and maybe a few less than a full complement of teeth. Nice fella.

So we walked around the town, did some window shopping and spent just enough time retracing the battles of Fredericksburg (December 1862, Confederate victory, due mainly to bureaucratic hangups that delayed the arrival of pontoon bridges needed to cross the Rappahannock--I guess the federal government hasn't changed all that much) and Chancellorsville (May 1863, Confederate victory, due mainly to "Fighting Joe" Hooker's failure to live up to his nickname; known best as the battle in which Stonewall Jackson fell to friendly fire). We left the battles of the Wilderness and Spotsylvania Courthouse (Grant v. Lee in 1864, bloody but inconclusive) for another day. The National Park Service does a good job of helping you to imagine what it must have been like to fight over that ground, where so many gave their last true measure of devotion or were maimed for live. There's a genuine Confederate uniform with the leg cut off due to the amputation the man who wore it endured.

All very interesting and noble, but I can't help but wonder why one of the main roads is called the Jefferson Davis Highway, and why the Park Service memorializes Lee and Jackson, both of whom went to West Point, wore the uniform of the United States and fought for their country before raising arms against it. The guy who leaked information to Wikileaks is called a traitor, some are calling for him to be executed, and he will undoubtedly spend some years in prison. Somehow I don't think they'll be naming state highways after him. So why do we have statues honoring Confederate generals? Why wasn't Lee taken out and shot as a traitor?

Liz says that this reconciliation is part of what preserved the Union and is a testament to America's strength. But didn't it also help preserve a Jim Crow way of life that persisted into the 1960s? Maybe a little more shock and awe after the Civil War was over would have been a good thing. Of course I know my history, Lincoln was assassinated, Andrew Johnson became President and radical reconstruction came to an end. But that still doesn't explain why we continue to glorify a society that was built on the idea that one person can own another. I'm not sure why my tax dollars are going to honor those who fought to continue that barbarism and cruelty.

My wife Liz has the most wonderful laugh. When something strikes her as really funny -- and you never can be quite sure why or when that will be -- she loses control completely. Her eyes close, she whoops, she screams, she roars. One of my favorite things is to render her helpless in that way.

She has recently taken laughter to another level, as a certified laughter yoga leader. Check out laughteryoga.org, it's good for you.

New Title, New Duties, redux

I posted here a week ago about my new position as Acting Director, Oversight, in the Center for Consumer Information and Insurance Oversight (CCIIO) within the Center for Medicare and Medicaid Servics (CMS). I took the post down because I heard some mindless chatter that some folks out there--you know who you are, I don't--thought I'd jumped the gun because they hadnt seen a press release from CMS announcing my appointment. As if. For the record, there has been and there will be no press release about this--I am not all that (yet, anyway). And of course I had approval from the right people to share the news, as it was official and all the people who needed to know had been informed. 'Nuff said.

I've been in the job just short of two weeks and things are going just great. There's a lt going on and quite a few plates to keep spinning on those long sticks, but I wouldn't have it any other way. This is what I came to Washington to do; I'm happy and grateful that I'm having the chance to do it.

If you go to our new website, cciio.cms.gov/cciio, you can see lots of info about what we do. One day we may have an organization chart on there, but for now I can tell you that there are four Offices below the level of Center Director. The website describes our duties this way:

The Office of Oversight
This office will implement, monitor compliance with, and enforce the new rules governing the insurance market and the new rules regarding medical loss ratios. It will also be responsible for rate review at the federal level, and for providing rate review grants to states.

So that's what we're going to do.

More reorganization

My boss Steve Larsen, head of the Office of Oversight in OCIIO, announced this week that we are combining two divisions to create a Division of Compliance and Enforcement. You may already be wondering why in the world you should care about this piece of Tricia, and there is no particular reason other than the fact that I am the head of the Division, and now have about half of the staff in the Office of Oversight reporting up to me. So to the extent one measures success in a bureaucratic organization by an increase in span of control, this would be an indication of success.

There will be lots of changes in the days to come, which I will try to keep my faithful readers up to date on, to the extent I can speak publicly.

Beginning of a New Year of Change

I can make no comment on the accuracy of the story I have provided a link to on the right, although I will say that it is odd to assert that Secretary of Health and Human Services Kathleen Sebelius has relinquished control over the office responsible for implementing health care reform by moving it into the Center for Medicare and Medicaid Services (CMS), since CMS is part of the Department of Health and Human Services.

I will also say that I can now state without any fear of contradiction that I am a federal bureaucrat.

End of a year of change

This has been a year of change, in many unexpected ways. For me, it meant a move to DC, first to work for Congressman Garamendi as his Chief of Staff, and then in the Office of Oversight in OCIIO at HHS. By now you know that Dave has decided to keep Adam on as GC. I hadn't wanted to say anything until he made the announcement.  I'm disappointed, but I've also got plenty more to do at my job in DC.  

All the best for a happy and healthy New Year.  That job has brought some unexpected changes as well; I never imagined that I would be managing the teams responsible for drafting two sets of regulations implementing major parts of health care reform; one on how the requirement that health plans spend 80 or 85% of premium dollars on clinical care or activities that improve health care quality, the other establishing a process for review of "unreasonable" increases in health care premiums.

The process was long and exhausting, including working late into the night. I think that any reasonably objective view would be that we did an excellent job of staying true to the language of the statute (sometimes rather opaque), giving deference to the States as much as possible, while providing a federal "floor" that will protect consumers.

Next year will bring it's challenges, as the political environmental will be, shall we say, less friendly to our efforts. We will persevere.

Happy New Year to you all, I hope that 2011 brings you all the happiness that life can offer.

At Last

I was filled with so many emotions last night My Dad grew up in NY a Giants fan.  By the time I was old enough for him to take me to games, the Yankees were the only team in town. My Dad took me to see Mantle,  Maris, Tresh, Richardson, Howard, Ford.  When he moved to LA, he became an SF Giants fan, which caused some good-natured conflict with my Stepmom, who rooted for the hated Dodgers.  Who were much more successful, of course.  

We went to some great games together, we saw Barry hit his 71st homer, we were at the tragic Game 6 in Anaheim, when we were six outs away.  But no championship.

After we moved to SF in '85, i took up the team.   That meant freezing at Candlestick with crowds around 5,000, that first year they lost 100 games.  I was in the stands when they beat St Louis in '87 to go up 3-2, only to lose the last two.  I was in the stands when the Thrill beat the Cubs in '89, only to be beaten by the A's and Loma Prieta.  Then there was '93, Dusty's first year, when they won 103 games and didn't make the playlets.

David and Kate were raised Giants fans and I loved the fact they they enjoyed going to the ballpark with me.  By 2000  they won the division, only to lose to the Meta.  Kate and I were there for one of the most exciting moments in sports I've ever seen, JT's 3 run shot in the bottom of the 9th to tie game 3, which they lost in the 10th.

Finally in 2002, we were there to see Kenny Lofton put us in the Series, the year we should have won it all.

And now, at last, we have.  Here I am, 3,000 miles and three time zones away.  How can it be that this team was able to do what all those other teams with all those stars couldn't do?   Better pitching, I guess.   It's a funny game.


Gary

Long time, no post

I see that it's been just over month since I last posted here, the reason being the same--there is really very little I can say about the work I'm doing, most of which involves drafting regulations and recommendations to policymakers, none of which is public. I did meet Secretary Sebelius last week, she was very gracious in her appreciation of the work we've been doing and remembered that John Garamendi had spoken to her about me.

The other big thing that has been going on for the past few weeks has been the GIANTS !!!! I've been glued to the TV throughout the playoffs, and have been thrilled by their wins, especially in the first Series game last night. It's hard being so far away while all this is going on . . . .

Here in DC, we've been enjoying a lovely fall, the city looks beautiful, the weather has been great, we've done a lot of walking, sitting on the roof of our building at dusk, etc. I know that winter is coming, but for now it feels like an ideal climate.

We're looking forward to being home for Thanksgivivg, seeing David and Kate, being back in California. We miss them, and it, a lot.

September 23, 2010--The beginning of a new day in health care in America

As I'm sure you know, yesterday was the first day that a number of the new health care insurance market provisions of the Affordable Care Act went into effect. I'm sure you've heard the drill: no more excluding children under 19 with pre-existing conditions, no more deductibles or co-pays for preventive care, no more cancelling your policy when you get sick unless the insurance company can prove that you intentionally withheld important information when you applied, no more lifetime limits on how much your insurance company has to pay for your medical care, and a minimum of $750,000 in annual limits, phasing out to no annual limits in 2014.

On a personal note, these are some of the provisions that it is my job to enforce, along with the Departments of Insurance in the states.

The post to the right, by John Garamendi on Huffington Post, tells some stories about real people who have already been helped by this law. If you make it through almost to the bottom, you'll see some extraordinarily gracious remarks John made about me. It's possible that someone outside my immediate family has said such nice things about me before, but I can't remember when.

Is this law perfect, or is it the end of the need for reform to our health care system? Unquestionably not. Is it a enormous step forward, and will it help millions of Americans get affordable, quality health care? Unquestionably yes.

It's been a while

It's been quite a while since I posted here last. The main reason is that there's very little that I can say about what I'm doing at work--we are busy drafting regulations, developing options for how we are going to enforce the Affordable Care Act, and none of it is public just yet. And I don't want to become one of those people you read about in the paper who had to resign because of impolitic comments in a blog.

I can say that the work environment is wonderful--everyone is smart, dedicated, motivated, excited to be doing this work, pleasant to work with, a team player, etc. etc. There is something about our mission and the fact that we are creating something new that so far has enabled us to keep our spirits high despite impossible deadlines, not enough people, many and conflicting demands on our time. The staff that I've put together for the Division of Enforcement has already been recognized for its superb work and work ethic. I am proud to be doing this job with them.

Meanwhile, Liz came out at the end of August, just in time for the weather to turn from the miserable heat and humidity we had for three months. We love the neighborhood and all the places we can walk to easily from our apartment. Liz has started blogging as well, you can follow her at liznichdc.blogspot.com

Peaches and Herb

Reunited and it feels so good,
Reunited 'cause we understood,
There's one perfect fit
And sugar, this one is it
We're both excited 'cause we're
Reunited, hey, hey

Eastern Shore

I took my first big excursion out of DC on Sunday, to Ocean City on the Maryland Eastern Shore. A lot of driving, three hours each way, but worth it to get out of the city, to feel the cool breeze, to swim in the ocean, to eat those steamed blue crabs off of a piece of brown paper, so sweet and juicy.

Hot, Hot, Hot

Eighteen days over 90 degrees in June, another eighteen already in July. Today its over 100. Very tough. Sitting by the air conditioner watching movies on Netflix.

Friday I went to a public meeting held by the National Association of Insuramce Commissioners on implementation of health care reform. Good, but a bit strange, to see old friends now that I'm on the other, other side--not the industry, but the Feds.

There is a lot of uncertainty and a fair amount od suspicion about how this law will be interpreted and how it will work in practice. Some of this is understandable, there are lots of provisions that are unclear and the regulations that will provide some clarity (and undoubtedly raise more questions) haven't all been issued. And of course there will be problems, both with the law and because the law doesn't address much of what is wrong with the health care system.

But there also seems to be a underlying lack of trust, or confidence, or maybe it's just fear of change. Even when the way things are going is bad, the devil you know seems better than the unknown one you can't see up ahead.

For those of us at the Office of Consumer Information and Insurance Oversight the feeling is quite different. We are creating something new, we have very little that "has always been done that way" or "isn't the way we do things here." We have an enormous amount to do, and very little time to do it, and much of it has never been done before. But we believe in what we're doing and in our ability to get it done.

Random Thoughts

Went to see my Giants beat the Nationals 6-2 last Sunday. The stadium a disappointment when compared to the standard set by Camden Yards, PacBell park--no architectural elements to reflect the location in Our Nation's Capital, apart from the relentless red, white and blue. They do have mascots with huge George Washington, Abe Lincoln, Teddy Roosevelt heads who do race from center field to a finish line along the first base line. Live version of the animated cable car race. Seat almost too hot to sit on at 1:00 in 95 degree heat, lucky for me I got tickets on the third base side, in the shade by the third inning. Strong performance by the Giants, good pitching, good clutch hitting.

It's been the best of times and the worst of times (well, not really) at HHS. I've decided that if I do end up in Purgatory I'll just say, "Naah, this isn't anything, I've been through the process of getting a security badge at HHS." After numerous visits to the Security Office, filling out lengthy, repetitious forms for a background check which I'm sure no one actually did, the day finally came when I was supposed to get my badge--when I was told that they had run out of badges. "Badges? We don't have no stinkin' badges."

For the best of times, I attended a meeting of the leadership group at HHS that is coordinating implementation of health care reform. Deputy Secretary Corr presides, Secretary Sebelius attended as well. Very impressive group, very impressive process. You're in good hands.

Week deux

When I was practicing law, I used to imagine that my client could be in my office watching me work, and I'd want them to be satisfied that they were getting good value for their money. Ok, ok, there were some clients whom I was happy to bill for every second I spent, say, in the shower, thinking about their case. Anyway, with the enduring debate over whether the amount of government we have is too little, too much, or just right, and all the hostility expressed toward civil servants (for example, in the budget debate and the campaign for governor in California), I wonder sometimes what the public would think if they could watch their tax dollars at work in the agencies and departments that do the people's work.

Of course at times they would see inefficiency and incompetence at times. More than in your average corporation? I don't know. But they would also see people working long hours to get a web portal running to provide information to people about their options for health care coverage. www.healthcare.gov. Check it out. They would be impressed, as I was, by a meeting of brilliant, dedicated people working together to figure out what things that insurance companies spend their money on should count as "improving health care quality." I know we may disagree over whether the government should be influencing how insurance companies spend your money, or whether we should leave that up to them and to "the market." But I think most people would agree that if we are going to have a law that gives the government that job, this was an impressive group of people and an impressive process to be involved in the decision.

So many decisions, so little time. I feel as though I'm drinking from the proverbial fire hose while running after the proverbial train that is leaving the proverbial station.