VOL. 37 | NO. 38 | Friday, September 20, 2013
Health care’s ‘lost opportunity’
By Jeannie Naujeck
More than two years after leaving state office, Phil Bredesen, the popular former governor and mayor of Nashville, is still on the go. While enjoying a post-political life in Nashville that includes gardening and grand parenting with wife Andrea Conte, Bredesen remains active in promoting bipartisan solutions to issues such as the national debt as a speaker and as a member of the Governors’ Council of the Bipartisan Policy Center, a Washington, D.C.- based think tank.
He also is chairing the 26-member National Commission on College and University Board Governance, which will this fall begin to review current governance practices in higher education and make recommendations to the Association of Governing Boards of Universities and Colleges.
In 2010, Bredesen authored “Fresh Medicine: How to Fix Reform and Build a Sustainable Health Care System,’’ in which he criticized the newly-passed Patient Protection and Affordable Care Act as a lost opportunity to effect real change in the health care system.
The Nashville Ledger recently caught up with Bredesen to get his latest thoughts on health care reform, economic development, education, whether he’ll return to politics and where to get the best beer in Nashville.
Q: You called the ACA a lost opportunity. On the eve of the state’s health insurance exchange launch, do you still feel that way?
A: “My concern was, I really do believe that there’s a level of health care that we treat functionally as a right of citizenship in this country. And I thought the Affordable Care Act, while it expands coverage, it didn’t do much about the cost side of the equation and fell short of recognizing that, even when it’s implemented, there will remain large numbers of uninsured people in this country.
“The time to do some of the difficult things that we’re going to have to do at some point with health care, in terms of controlling the cost of the services that are provided, or even controlling the volume of some of the services that the medical community provides, what better time to ask people to do those difficult things than when you’re expanding coverage? And the Affordable Care Act was primarily about expanding coverage, not about these other kinds of things. So I just thought it was a unique point in time when the president was first elected.
“People were ready for something, and it was a chance to do something really forward-looking and effective in terms of health care. And we just expanded coverage and double down on the old unworkable system, and that’s why I think it was a lost opportunity.’’
Q: Was the ACA the best thing Obama could push through at the time, politically?
A: “It’s better in the sense that there are more people who are going to have coverage that did not have it before. But it just kicked the can down the road in terms of changes in the cost of health care. I’ve been very concerned as a citizen, and I’m active with things like the fix the debt campaign. This country is on a completely unsustainable course in terms of the deficits that it’s running. Those are largely driven by the cost of its entitlement programs, specifically Medicare and Medicaid. And those are the pieces that are growing faster than the economy and the tax base, with no end in sight.
“And I just think that anything you do with health care has to contain a serious component of trying to begin to manage those costs or to fund them adequately. We didn’t do those things and that’s my concern. I think other things could have been done politically. I think it’s too easy to say that’s the best you could get.
“I was involved as a governor with the National Governors Association. We had a group that came out of the executive committee there with us trying to work on the Affordable Care Act. It was a bipartisan group, and I was the Democratic co-chair of it.
“And I think there were a lot of things that could’ve been done in a bipartisan fashion in health care because certainly the Democrat and Republican governors have lots of things that they can agree upon with that.
“So when you have a bill like that (the ACA), which is written basically by the Democratic staffers in the Senate Finance Committee, and the total outreach to Republicans was trying to find one or two to sign on, I don’t think that’s a bipartisan effort. And that downside to that is you may get it done, which they did. But you ensure that it will be in political play forever, which is going on right now.
“In this country, when we passed Social Security and Medicare, they were both very contentious and in the end they were both modified in ways that got not only Democratic votes, but basically half of the Republicans in Congress in both cases voted for those programs.
“Once it happens, once it’s done, it’s over. When half of one party and most all of another votes for something, it sort of takes it out of political play. Today, you can’t run for office as a Republican, let alone run for president, without promising to abolish Obamacare.
“When I was governor, I tried so hard to get things done in a way that they didn’t just get done, that they had some legs, that they had broad enough support in the state that their implementation wasn’t dependent on my being in office, or a Democrat being in office or anything else. They just were the state’s issues, like the education reforms we put in place, for example.’’
Q: Do you see any viable alternatives to the ACA coming from the GOP?
A: “I haven’t seen it. But that’s sort of the poverty of public discourse today. Most of what I’m seeing is just railing about Obamacare without, really, a sensible alternative.
“I think the stuff Paul Ryan put on the table about turning some of these programs into essentially a premium support program had some interesting aspects about it, but I think it was incomplete and left an awful lot of questions unanswered. But so far I’ve not seen a replacement; I’m just seeing a lot of yelling about it.’’
Q: Should Bill Haslam just hold his nose and take the federal Medicaid expansion money, despite the possible political fallout?
A: “I think, all things being equal – and there are others on the other side of the aisle who would agree with me; Bill Frist and I have talked about it and I believe he has basically the same position – but where we are today, I would favor us going ahead and using the Medicaid expansion funds to provide some insurance to those people.
“I think you can negotiate some things related to that with the federal government; they’re anxious enough to have that happen.
“But it’s the same problem I faced several times as governor, which is, whether or not you think this is the best approach, the fact is that Tennesseans and their taxes and the debt they’re assuming are paying for this stuff.
“It’s a little hard to say, ‘Oh by the way, you’re paying for it but you shouldn’t have the advantage of it.’ So I would argue that we accept the Medicaid expansion.
“My point was always, in talking about that and the exchange issue, you’ve got to just separate that from your feelings about the Affordable Care Act. It is the law of the land, we’ve got to make some decisions going forward about what we do, and if you have an opportunity to put a substantial number of your citizens on health care insurance at really no cost to the state, I think it’s something you’ve got to consider.
“I’d be in favor of doing it. I think a lot of Republicans would, too.’’
Q: Hospital owners have lobbied hard for Medicaid expansion because they’re the ones who have to absorb the cost of caring for the uninsured. That’s a tough group for a Republican governor say no to.
A: “I certainly understand the hospitals’ or any providers’ standpoint. It’s important economically. If I were running a hospital I’d feel very strongly about it. Someone is paying for care for a lot of these people and, in the absence of Medicaid, it’s basically the hospitals and the other people in the state who are insured.
Q: How do you feel about the exchanges for subsidized health insurance?
A: “I don’t think the exchanges are inherently a bad thing at all. What they are, really, is just a way of connecting people with suitable insurance. I understand why some insurers are sitting it out.
“I think it’s very unclear how a lot of this stuff proceeds. But I don’t think they’re a bad idea at all. In fact, I argued at the time that we ought to do it ourselves and not turn it over to the federal government.
“Even if you are very conservative politically, it seems to me if you have something which has the potential to affect a lot of what goes on with health care in your state, you’ve got to answer the question as to whether you’re going to let the state handle it or the federal government handle it for you, and I would think a conservative would say the state ought to handle it.
“I think, unfortunately, it just gets tainted with this reflexive flight from the Affordable Care Act, and so I think people just sort of viscerally oppose it. I’ve told anyone who’s asked me about it that you have got to separate those two and just look at the Affordable Care Act as a fact of life. Do we want to run those exchanges or should the federal government run them for us? I think the former is the right answer.’’
Q: Do you think we’ll ever have universal health care or, as some say, Medicare for all?
A: “I think we’re eventually going to get to something like that. I don’t think that the kind of comprehensive health care that covers a vast number of kind of optional things for all is on the horizon anytime soon, but I do think that some basic kinds of things, essential health services … we already treat that functionally as a right in this country today.
“We require hospitals to take people in who can’t pay, emergency rooms and the like. And so we ought to just step up and properly figure out how we’re going to organize and fund that ability. So I hope it’ll go down the road.
“As long ago as Harry Truman, he worked to try to put together a basic health care system that everybody in the country participated in – kind of the health care version of Social Security. And he failed at that, but that still is a worthy goal.
“As I watched the whole thing with the Affordable Care Act unfold, I think it’s unfortunate that so much of it happened in the Congress. Without being critical of Congress as an institution or the individuals in it, it’s just not the right kind of institution to design something that solves a complex problem and has some strategy behind it.
“I described it to somebody as trying to write a coherent novel with 535 authors working on it, or maybe 50 authors, but the point is it’s really hard. I very much hope that when we tackle it again – which we’re going to have to – that it has more of a focus of being someone’s idea, which can then be debated in Congress and so on, as opposed to, throw it into the arena and let a body like Congress try to assemble something out of the pieces.
“We’ve kicked the can down the road a little bit and there’s no taste today, I think, to open up those issues again, but they’re going to have to at some point. We have a very difficult deficit problem and something’s going to happen someday which is going to cause us to face the issue of these entitlements and so on. And I’d like us to be prepared to handle it intelligently when that time comes.
Q: Many Tennesseans would like to see you back in office, possibly in the U.S. Senate. Would you consider running?
A: “During the time I was governor there were a couple of Senate seats that were available, which I think I could’ve won, that I think I would’ve been a legitimate contender for … I mean, who knows? At the time, I thought about it and I said, ‘I really don’t have any interest in that.’ I don’t think I’d like being in the Senate. I don’t think my skills are particularly well matched for what it takes to be successful in that arena. And I don’t think they’d like me (laughs).
“I really prefer the executive side of government, and I really enjoyed being mayor and I really enjoyed being governor. I’m quite happy watching from the sidelines, thank you.’’
Q: You’ve made some specific criticisms of Medicare; for example, about the lack of competitive bidding, which drives up drug prices. What about, say, heading up the Centers for Medicare and Medicaid Services?
A: “Well, that’s a hypothetical question. If somebody called me up some day with anything they wanted me to do for the good of my country, I’d think about it and decide. But I’m certainly not seeking anything like that or posting my availability or anything like that. I spent 16 years as mayor and as governor, and I really enjoyed it. I think we got some good things done. And I think, realistically, probably that phase of my life is behind me.’’
Q: You’re chair of Silicon Ranch, a solar company run by your former administration officials Matt Kisber and Reagan Farr, which flipped the switch earlier this year on a solar plant to power the Volkswagen factory in Chattanooga. What other projects does Silicon Ranch have going?
A: “Most of its business is outside Tennessee now. The biggest project we have is in Georgia, which is a 38 megawatt project that is three times the size of all the rest of the stuff here in Tennessee. I’m not an officer of it or engaged in running it day to day or anything like that, but I think they’re going to continue to grow, they’ve got a lot of good opportunities and a lot of good ideas and I think like any developing space, it’s going to require some, to use a football analogy, broken field running – looking for opportunities and the like. But Matt and Reagan are working hard at it and I think it’s an interesting area and so far they’ve been very successful.’’
Q: What industry might you get into next? Is there any field that’s ripe for disruption that you are interested in?
A: “I think there’s hardly anything as exciting as health care right now, because I think that we are on the verge of so many changes in the organization and delivery of care. So that certainly is one that I’d be interested in.
“Obviously I’ve had an interest in these various green technologies, and from the time I was governor, I was not justifying it or signing on to the notion that it was all because of climate change or anything else.
“I was just saying, ‘Look, for whatever reason, a lot of people have an interest in being more green, and Tennessee’s got an opportunity to build a lot of jobs and a lot of activity satisfying that desire so that was the reason for the interest for things like the solar businesses and the silicon manufacturing facilities like the one up in Clarksville and the one over in East Tennessee and the like.
“My point being, when it comes to green technology I don’t think we need to argue about climate change or anything else. I think we’ve just got to say, ‘Look, whatever you think about it, lots of people are going to be buying green so let’s have Tennessee be the place that sells it to them.”
Q: Are you involved with any of the Haslam administration’s economic development efforts?
A: “He’s talked to me a number of times about opportunities they have. I’ve gone to a couple of meetings and I’ve got a couple more scheduled this fall with prospects that they’re bringing into the state, in part to show that the process of recruiting business is not a partisan issue in this state. A former Democratic governor and the current Republican governor can stand arm-in-arm and explain why you should come to the state.
Q: One of your big “gets” as governor, the Hemlock Semiconductor plant in Clarksville, is essentially idled at the moment.
A: “One of the good things that we did with that was to structure the incentives and so on so that they were dependent upon the success of plant. So with the slowdown that happened in that industry and the slowdown of the plant, we’re not way out on the limb in terms of what we put into it. I actually think, in the case of Hemlock, it really is just a delay.
“There’s going to be a large demand for their products In the future. They’ve spent well over $1 billion and paid sales taxes on it and they do have some people on the payroll up there. It’s taking a little stutter-step right now, but I think it will be just fine up there and we’ll go back in 10 years and find a growing, expanding high-employment facility. All they’re making at the plant is refined silicon and that’s something that is dependent upon technology and power costs and some things we have here – and less so on cheap labor. So I think they can be very competitive in that field.
“Remember we had the Wacker Chemie group from Germany over in East Tennessee doing the same kind of thing, feeling that Tennessee was a good place to produce this material. I think they all got hit by the slowdown when Europe removed these very attractive feed-in tariffs, combined with what happened to the economy in 2007 and 2008 and that sort of slowed the industry down. But the answer is, it’s a stutter-step and so they’re just going to take a deep breath. They put a lot of money in those plants and I think they’ll be producing polysilicon in a relatively few years.’’
Q: How would you score the current governor’s follow-up on your education reforms?
A: “I think Bill Haslam has done everything I ever possibly could have asked in terms of following through on the funding formula changes we put in place both in K-12 and in higher education, that kind of stuff. And part of the reason is that we all worked to make sure that was a bipartisan Tennessee plan, and not Bredesen’s plan, or the Democrats’ plan, or anything like that. So the stuff that was done contains stuff that the Republicans wanted, it contains stuff that the Democrats wanted, it contains stuff that I wanted, and so on.
“And so it’s got good legs, and I have no complaint about the way that Bill Haslam has continued down the path. And I think that’s really important, because to make the kind of changes in big institutions like K-12 and higher education it’s not a one or two or three-year thing. It’s the sort of thing that two or three or four governors are going to have to work on over a period of time, and a generation from now it can all be very, very different.
“The changes we made in my last year in order to use test scores as a part of teacher evaluations, that I’m totally on board with. You can take it too far and make it into this automated thing with pay and licensing. The issue is in the execution and just how you use that material.
“[Regarding Republican teacher pay and tenure reforms] I thought it was unfortunate the way the Legislature … I think it was just Republican payback for the teachers union’s support of Democrats all these years.
“Given the fact that the union was not any particular sort of a problem in Tennessee and had actually supported these kinds of reforms that were talking about, I thought that was relatively punitive. I think a lot of it depends just on how it’s done. But my basic feeling has been always been that a good education system is about the teachers in the classroom, it’s not about testing or computers or any of that other kind of stuff. You’ve got to have good teachers; you’ve got to have good classrooms. I tried to put some tools in place so that the next administration could manage them intelligently and well.’’
Q: As a former mayor of Nashville and a current resident, it must be rewarding to see the city rise to its current prominence.
A: “I really enjoyed my time as mayor, and it was my first political office and my first political experience. But I think it was really a fortuitous combination of a person and a time in the city.
“Obviously, I was cut from different cloth than a long succession of previous political leaders in Nashville. I wasn’t from East Nashville; I wasn’t from the political culture in the city. I was a businessman from the west side of the river.
“But in 1991, Nashville was just ready for something else. Bill Boner had been the mayor for four years … and all the issues that he had. So the city was ready for a different direction and you had a different person with a different approach to things in the mayor’s office, and we got a lot of things done.
“I really believed in downtown development, and I thought the way you had to do it was to put some anchors down there, so we started out with the arena, and later on the library system, the stadium across the river and a lot of the ancillary stuff, the Country Music Hall of Fame and other things down here.
“I think that part of it was important, for a city to pay attention to what people want to have in their city, those kinds of amenities. You do those things and then people are going to take over and make the city into the kind of place that people want to live.
“I don’t think you just sit around and let things come to a halt because of corrosive politics. I just think you just pick some things and do them. If more than half of them are right then things will move forward.
“I learned, particularly when I was in the recruiting business as governor, that while anybody in power likes to take credit for recruiting a company or something like that, really, nine out of 10 things happen not because of some effort on the part of government but really on the conditions you create.
“I think a lot of the growth in Nashville is not because myself or any of the other mayors have actively done something; it’s because we’ve all worked at creating the ability to have the sports teams, the library, those kinds of things that make it an attractive place for people to be and to live.
“People today are so mobile. They can build businesses and run companies and so on from anywhere. They can live wherever they want. When Andrea and I moved to Nashville late in ’75, I can’t say I thought I’d spend the rest of my life here. But we really liked it and our son was born here and we just find it’s been a wonderful place to live. I’m very happy right here.’’
Q: And now we finally have the big new convention center that was argued about for so long.
A: “Now we have it, and just like any of these things, I’m sure there will be this stumble or that stumble. I remember with the arena, it seemed like every five years there was some little crisis there, but they’re all minor and you get over them just fine. But you’ve got one more piece of civic furniture that it takes to really be an attractive fine, city.
“What I’m trying to emphasize is just this notion that, rather than recruiting business or doing specific things, just laboring to create the background and the framework in the city that makes it an attractive place to live, I think, is ultimately much more important.’’
Q: Your son Ben has a brewery (Fat Bottom Brewing Co.) in East Nashville that has been very successful. What’s your favorite Fat Bottom offering?
A: “Oh I like the Ruby Red, the red beer. That’s my favorite. I’m really, really proud of him. That’s just something he wanted to be in forever, to do it himself. And he’s done a great job. It’s rolling; it gets good marks from everybody I talk with. So I’m real pleased for him.
“The real trick in that is not the brewpub – the place – but in getting out and getting it in restaurants. And he’s making a lot of progress on that, so I’m real proud of him.
“When he started out it was not, “Oh, let me get 50 restaurants for customers in Nashville and I’ll have a nice living for the rest of my life.” He has every intention of being the next Sam Adams or something. So good luck to him, and I hope I can look at it 10 years from now and it’s a great big regional operation and very successful.’’
Q: What is (former First Lady) Andrea Conte working on?
A: “She’s continuing to work on (the nonprofit group) You Have the Power that she’s been associated with for a long time. During the time she was First Lady she didn’t get a chance to spend a lot of time over there, so she’s spent some more time on that, kind of straightening out some issues over there.
“And Ben has a daughter, and Andrea has helped take care of her during the week so that her mother can go back to work. And I love being a grandfather! So Andrea is really enjoying this time too. She’s got a big, big garden and we get lots of food out of that. And we’ve got the granddaughter, so life is good.’’