Unlike many university presidents, former HHS secretary Donna Shalala makes time to teach, and she offers a course on health reform.  When she assigned a paper on how to fix US health care, one student handed in a one-sentence paper:

"Campaign Finance Reform."

Shalala, now president of the University of Miami, gave him an "A."

As an academic, HHS secretary during Bill Clinton's health reform effort (and its aftermath), the head of a large university (which means a large purchaser of health insurance) and, for a time, a member of a health insurers' board of directors ("I wanted to see it from the other side") Shalala has seen health policy from many perspectives.

Addressing  a workshop for writers who specialize in health and health policy in Miami the other night, Shalala said she is increasingly confident that reform will pass.  "I think we are going to get a bill," she said. "You can see the contours of a deal." 

The center of the Democratic party, she continued, was pretty close to where the center of the country is.  Consensus is in reach -- even if we have "a lot of people moaning and groaning."

Whether there's a public plan, no public plan, or a compromise fallback on the public plan, she does not know. Nor does she think it's the linchpin of reform. The burning issue, and the one Congress will have to resolve, is how to pay for this and does it bring down health care costs over the long haul. Having worked a lot on Medicare over the years and more recently co-directing an inquiry into the care of veterans and injured soldiers, she's also particularly concerned about improving care coordination and care management. In other words she's less concerned about who the payer is, than what they are paying for, and in creating a teamwork approach to medical care instead of our current fragmented fee-for-service system.

I asked her whether, having had first hand experience in trying to get Congress to make some changes in Medicare payments, she favored creating some version of  I-Mac, or Medpac on Steroids (we're rooting for calling it "Big Mac"). The goal is to empower the panel to make recommendations to Congress that have a lot more teeth. MedPAC would make "strategic decisions" about payment and care models in Medicare, (with Congress being able to vote it up or down, along the lines it does with military base closing recommendations), Congress, she said, needs to be protected from itself.

"Someone  has to make the decisions," and once Medicare gets it right, it will drive much of the rest of the health care system. But right now, it's politically very difficult for Congress to do so. If Congress keeps micromanaging, there is always  pressure. "Everything has protection" from some member of Congress.  Which is why that term paper got an "A."