My Life At HCFA: A True Parable

Abstract

T he be st four and a half years of my professional life—as administrator of the Health Care Financing Administration (HCFA)—involved many tense congressional hearings, White House meetings, late-night phone conversations with the health and human services (HHS) secretary’s office or the Office of Management and Budget (OMB), and other stuff of high drama. Those years also contained a constant flow of formidable intellectual challenges: how to improve the hospital wage index; how to reduce beneficiaries’ copayments for outpatient services without busting the budget; how to permit states flexibility to expand Medicaid without violating federal law; and so on. But perhaps my fondest memory concerns something more mundane. Alone in my office one evening, I picked up the phone. On the other end was a young constituent service staffer from Rep. Louis Stokes’s office in Cleveland. Her call had obviously been misdirected, and she was flustered and embarrassed to find herself talking to me. She offered to call back in the morning, but I told her I would be happy to try to help her, and she told me the following story. Her constituent was a man in his fifties who had lost an arm in an industrial accident, as a result of which he qualified for Social Security Disability Insurance (SSDI) and, thereafter, Medicare, which was his only health insurance. With the income SSDI provided, and good health, he had managed for years to support himself quite adequately in the community, having no family and living alone. Then he developed carpal tunnel syndrome in his remaining hand. A sympathetic physician tried every form of medical and mechanical treatment for this painful and debilitating ailment, without avail. At that point, the surgical procedure of carpal tunnel release was the obvious and only treatment choice. It is routine and generally successful, with only one major problem: For six weeks after surgery, the patient has no effective use of the hand that has been operated on. For most patients, that’s a major inconvenience; for a one-armed man living alone, it C M S R e f l e c t i o n s