For me, the past year as a Winston Fellow has been nothing short of remarkable. Not only has it been an amazing learning opportunity, but it has exposed me to the diverse (and at times, quite contentious) viewpoints within health policy, challenged my own political beliefs, and afforded me the chance to witness the historic reform of our health care system.
The landscape in which I began the Fellowship was undoubtedly a momentous one: the heavily debated and controversial health reform bill had passed in March 2010 and the country was preparing for major changes to its health care system. Not since the 1960s had so large a change been made. My fellow Fellow, Erin, and I were embarking on this Fellowship amidst a changing health care landscape, and an exciting one at that.
Informational Interviews
The diversity of health policy stakeholders that Erin and I met with is what makes the Fellowship such a unique experience. From policy experts in the Administration and legislative gurus on the Hill (on both sides of the aisle) to advocates fighting for certain issues and trade associations representing specific groups, the access alone to the foremost health policy experts is incredible. Woven together, these individuals make up the fabric of health policy in DC and throughout the country. In the 1st three months of the Fellowship, we discussed anything and everything related to health policy (and health reform) and tapped into the expertise of over 150 health policy experts. These interviews were a critical element of the Fellowship, as they bestowed so much knowledge upon us, challenged our preconceived notions about the health care industry (and the many players within it) and helped us establish a network as newbies to the DC health policy arena.
Placement: U.S. Department of Health & Human Services Office of Health Reform
At the start of the Fellowship, I was intent on landing a position on the Hill. But, given the recent passage of the Affordable Care Act, the onus of implementation was largely in the hands of the Administration, namely the U.S. Department of Health and Human Services (HHS). Given that the bill was about 2000 pages and in some ways, completely transformed elements of the U.S. health care system, this would be no small task. I could not turn down the opportunity that was before me to work at the HHS Office of Health Reform (OHR) and was excited about seeing first-hand how this landmark legislation was implemented piece by piece.
There are five overarching goals of the Affordable Care Act: 1) to expand coverage, 2) offer new consumer protections and choice, 3) make health care more affordable, 4) improve quality of care and 5) improve prevention and public health. To help ensure these goals are met, the Office of Health Reform serves as a coordinating body between several entities (i.e. Congress, the White House, federal Departments, external stakeholders, etc.) and ensures that the Affordable Care Act is implemented in a timely and accurate fashion. Working in OHR has given me a broad, 30,000-foot view of the first four goals, but it has also afforded me a very “in the weeds” perspective on the final goal of improved prevention and public health. Within this goal, I have also assisted with issues surrounding workforce, health disparities, environmental justice and Indian health.
A very contentious item in the law has been the Prevention and Public Health Fund. Although it aims to steer the country towards a more upstream approach, the Fund has come under a great deal of criticism. Despite its critiques, millions of dollars have already been distributed. Earlier this year, I was responsible for pulling together the FY 2010 Prevention and Public Health Fund dollar amounts that had been distributed from the various federal agencies to each State and the District of Columbia. I developed them into fact sheets and they are now posted online so people can see just how the Fund has impacted their State. (You can find them at: http://www.healthcare.gov/news/factsheets/prevention02092011a.html)
I have also served as the main point person from our office on the National Prevention and Health Promotion Strategy (National Prevention Strategy). The President signed an Executive Order creating the National Prevention, Health Promotion, and Public Health Council. The National Prevention Council, chaired by the Surgeon General, is charged with developing a National Prevention Strategy. The Council members span the Federal government and include the heads of the Department of Agriculture, Housing and Urban Development, Justice, Defense, Education as well as the Federal Trade Commission, among others. The National Prevention Strategy is unique in that it takes a comprehensive, cross-sector approach to prevention. Thus, it acknowledges that health comes not just from a doctor’s visit or with an insurance card, but it also stems from the foods we eat, the streets we walk on, the houses we live in, and the places we work, just to name a few. As the Strategy evolves, I have helped develop its framework and its messaging, worked on planning its release, conducted briefings on it for the Surgeon General and engaged external stakeholders on how to get involved.
In addition to the above activities, I have also served as the point person from OHR for the HHS Environmental Justice Strategy. HHS is tasked with creating this strategy and I have helped ensure that we are tying in the Affordable Care Act and specifically, the National Prevention Strategy, where appropriate.
The OHR is a very “all hands on deck” type of office in which everyone has their portfolios but we all chip in as needed. Given that, when necessary, I have helped with the clearance of documents and have fielded press and media inquiries. I have also been privileged enough to sit in on senior-level meetings with the Secretary, Assistant Secretaries and the agency heads where major policies are discussed and decisions are made.
Lastly, one of my favorite aspects of my time in OHR is the outreach component. Our office often meets with external stakeholders ranging from small community organizations to major trade associations. We listen to their concerns and inquiries regarding the Affordable Care Act and try to educate them on aspects of the law, funding opportunities that may be coming down the pike, and/or ways they can get involved. This is a critical element of our office because it not only grounds us, but it helps us understand how the policy decisions we are making each day affect those at the ground level. In fact, it is this reason why I was so drawn to the Fellowship in the first place and why I am so drawn to health policy at the Federal level. Having worked at a community-based organization, I saw how policies had an impact on individuals, their families and communities. I wanted to take this knowledge with me as I moved to DC and utilize it to inform my work in policy. I realize, though, that when working at such a high level, it is critical to keep myself grounded and listen to those at the local level. They are, after all, those who reap the benefits or bear the burdens of the policies we implement.
Concluding Remarks
Without a doubt, this Fellowship has been a life-changing experience. I know that the skills and knowledge I’ve acquired, the people I’ve met and the networks I’ve built will stay with me throughout my career. It has been stated by countless Fellows over the years so, at the risk of sounding redundant, I would like to extend a tremendous amount of gratitude to the Winston Board, who truly make this Fellowship one of a kind and whose support and mentorship is unparalleled.I’d also like to thank AUPHA for their assistance throughout this past year, my fellow Fellow, Erin, and my fantastic colleagues and mentors in the HHS Office of Health Reform. Thank you for the opportunity to work and learn beside you. Finally, I’d like to thank each of the Winston Fellow alumni. I am always amazed at how wonderful each Winston Fellow is, and I am proud to be a part of that family. For the majority of my Fellowship, I was privileged to work with a former Winston Fellow, Mayra Alvarez, whose passion, grace and wisdom provided an amazing platform from which to learn. Thanks to each of you for helping make this year such a great one.
Erin Richardson, JD, MA, 2010-2011 Winston Fellow
As I sit down to write this, my final report, I cannot believe how quickly the Fellowship flew by! It seems like only yesterday that it was the fall of 2009, and I, a third-year law student seemed destined to work in the health care practice group of a large D.C. law firm – extremely interested in health care policy and politics, but ultimately on the outside looking in.Thanks to a chance trip to the Columbia Business School and my eyes catching a sign advertising the David A. Winston Health Policy Fellowship, my reality has changed in ways I couldn’t have imaged.
Informational Interview Phase
Catherine and I began the Fellowship exactly three months after President Obama signed the Affordable Care Act and, needles to say, the health reform law dominated almost all of our interviews.We asked trade associations about their strategies during reform – what did they lobby for; what did they get; what didn’t they get; what concerns did they have going forward.When meeting with think tanks, we asked their opinions on the most promising and troubling aspects of the law – will it bend the cost curve; are medical homes and accountable care organizations truly panaceas or simply overly-hyped; is the individual mandate strong enough or too strong.We asked Congressional staffers about the legislative process and the final law – what was the process like in the House versus the Senate; how did you approach reconciliation; were there times you thought it wouldn’t happen; what are the strengths and weaknesses of the law; what should have been in there but didn’t make it.Every conversation was fascinating, and together, they provided us with a 360-degree view of the health policy community.The interviewees were incredibly gracious with their time and honesty, answering tough questions, admitting mistakes and regrets, and offering to be resources for us going forward.
While a number of interviews were scheduled for us before we even arrived in D.C., I appreciated the flexibility to pursue additional interviews on topics of interest to us.For example, Catherine and I felt that there was a great deal of confusion among the public during the health reform debate, with much of that confusion due to the fact that the media tended to focus on politics, not policy.The ubiquitous references to “death panels” induced fear and disquiet in people across the country, but very few journalists seemed willing to write about the policy behind the politics.We were able to arrange meetings (with some help from the Board!) with health care journalists and public affairs professionals to explore how the public gets its information and what they look for when writing a story or pushing message.
Placement Phase
I entered the Fellowship thinking I would end up doing my placement in the administration.With the passage of the law, attention shifted to HHS to begin the massive implementation process, and I wanted to be in the center of the action.My mindset began to shift, however, as the summer wore on, and I realized that I was being drawn to the Hill.After some debate, I decided to do my placement with the Ways & Means Health Subcommittee and began a few shorts weeks before the election that put Republicans in control of the House.
Past Fellows often discussed their work on a specific piece of legislation, but I knew going into my placement that there would be very little health care legislation that could actually make it through both the House and the Senate.While I am somewhat sad that I did not experience legislative drafting up close, I was able to see a different side of the legislative process – messaging and defense.The Affordable Care Act is both enormous and complicated and, because many of its components are implemented over a number of years, it is difficult for the public to comprehend.Disseminating information about the benefits of the law has proven to be a significant challenge for Democrats and the administration, but an incredibly valuable learning experience for me.Entering the health policy world after the passage of reform meant learning what the landscape looked like before the ACA and what it will look going forward – a very steep learning curve indeed.Thankfully, my Ways & Means colleagues are exceptionally well-versed in both of these areas and always willing to share their knowledge.
In addition to messaging the law and defending against attempts to repeal it, I was able to really get into the weeds on certain aspects of implementation, specifically delivery system reforms such as bundling, value-based purchasing, and Accountable Care Organizations (ACOs).I’ve spent the last few weeks attending various presentations on ACOs, conducting stakeholder meetings, and drafting comments on the regulation.It has been a formative experience for me to understand how the various stakeholders – providers, private payers, consumer advocacy groups, legislators, and CMS – view the potential impact of the proposed regulation and ACOs in general.It has also been frustrating to see just how difficult it is to exact change in our health care system.Although one small piece of the puzzle, for me, ACOs are a microcosm of the much larger health policy challenge.
Acknowledgements
I learned more in the past year than I did in four years of graduate school and for that I am forever indebted to the Fellowship Board, the Fellow alums, and the intrepid staff of the Ways & Means Subcommittee on Health.To the Board, your dedication to training the next generation of health policy – dare I say – geeks is evident in every interaction.Thank you for your advice and support.To the Fellow alums, you are welcoming, warm, and brilliant, and I am proud to be joining your ranks.To the Ways & Means staff, I’m at a loss for words, so I will simply offer you my sincerest “thank you.”I’m afraid nothing else I could say would do it justice.
I would not have passed the bar exam last summer without the support of my co-Fellow, Catherine, and my husband, Josh. Catherine took care of a lot of the scheduling and email so that I could focus on my studies, while Josh kept me sane.I owe you both.
John Barkett, MBA, 2009-2010 Winston Fellow
My year as a Winston Fellow has been formative to say the least.What a year it was.From conducting interviews with just about every stakeholder contributing to health reform to getting to work on the bill itself in a small but meaningful way, I could not have made a better decision than accepting the Winston Fellowship.Below are a summary of the year and some reflections on what went on.
I arrived in Washington on June 16th.A week before, the Senate HELP committee had dropped their bill while the Senate Finance Committee was attempting to craft a bill that would gain bipartisan support.A month later, the House Ways and Means, Energy and Commerce, and Education and Labor Committees (Tri-Comm) would pass HR 3200, which would become the blueprint for the final House-passed health reform bill. With this as our backdrop, Devon and I conducted our first of over 100 interviews that summer.We met with former Winston Fellows, some of whom were on the Hill, some of whom had moved on to jobs in the Administration or private sector.They prepared us for what was to come, walking us through Washington (literally!) and the policy-making process.We also sat down with members of the Board - principals, advocates, and thought-leaders in their own right, spread across the political spectrum - who provided us with a welcomed perspective we embarked on the year.In July we met Administration officials, think-tank researchers, party strategists, policy consultants, and stakeholder representatives.They explained their policy positions, providing a panoply of perspectives that portrayed each participant like an electron orbiting the health reform atom.
The August recess brought us to the nucleus of the atom, Capitol Hill.We met with staff members from each of the committees of jurisdiction, exhausted from having worked non-stop since passing the Stimulus bill, happy to have a temporary break, and looking forward to finishing the bill in the fall.As it went, a spot for a fellow had opened up on the Ways and Means Health Subcommittee, and although I had come into the summer with my mind set on helping implement the HITECH provisions of ARRA within the Administration, I could not pass up the chance to work on the passage of reform.
Starting at the Ways and Means Committee in September of '09 meant I had affixed my experience to that of reform.The first two and a half months would culminate in the passage of HR 3962, the Affordable Health Care for America Act.The bill was 2000 pages, and two of those pages - namely, Section 262 on repealing the antitrust exemption afforded to insurers in the McCarran-Ferguson Act - were my responsibility. To think about our work as the sum of a bunch of individual parts is to not appreciate what it took to move a bill like that across the finish line.Staff constantly supported one another on each other's issues, providing research or a sounding wall when needed.This happened in an unprecedented manner across committees as well; out of solidarity we even made our own Tri-comm bags!
With passage came two months of waiting for the Senate to pass HR 3590.During that time I was fortunate enough to serve as the scribe for Tri-comm staff who had begun to walk through the Senate Coverage language, while also picking up a grab bag of other Medicare Part A and B issues that served as my introduction to the advocacy surrounding reimbursement of different provider types.It quickly became apparent that not all lobbyists were created equal, but before we could get too far on any one issue January had arrived and the merge between the Senate and House bills had begun.
The January 19th Massachusetts special election and February 25th White House health reform summit served to pause and then un-pause the merger negotiations.By March I had picked up the Fraud, Waste and Abuse (FWA) portfolio, and as it happened one of the key elements of the President's post-summit proposal was to add several FWA provisions to the final bill.We worked late nights with both Energy and Commerce and Senate Finance Committee staff to ready those provisions for HR 4872, the reconciliation bill, that, along with HR 3590, would make up the whole of health reform.
Right now I am preparing to staff my first hearing – an FWA hearing focusing on the past present and future of Medicare fraud.I never thought I’d become an expert on Medicare fraud (my co-workers call me "Miami Vice" thanks to my South Florida roots), but then I never knew what to expect throughout this rollercoaster of a year.Which of course was the best part.
Many of our interviewees last summer told us going to the Hill was the best way to spend our placement.When prompted to explain, they would often say, "The Hill – it's one of a kind."That answer was never satisfactory to me.Throughout the year I often reflected on why it was so important to understand the policy-making process from the inside.I think the answer lies in the constant refrain of House Leadership that they would invoke when addressing the Democratic Caucus, particularly in times of crisis:"the psychology of consensus."Over time I came to appreciate this expression as their way of intellectualizing the constant give-and-take required in the health reform negotiations.By doing so they were able to keep the caucus together through the best and worst times.To see them do it up close - to watch them LEAD - really was a one of a kind experience.
Three groups of people have stood out during my fellowship:The Winston Fellow alums; the Winston Board; and the Ways and Means committee staff.I am always struck by how lucky one must get to find good mentors and in this case I have been statistically significantly lucky.The year would not have been the same without my co-fellow Devon, with whom I work together on anything.Finally, the AUPHA staff members are wonderful, decent people, who when not running their association find time to care about our experience as fellows.I am grateful to all of you for making this year so special.Thank you.
Devon Trolley, MHA, 2009-2010 Winston Fellow
Looking back over the past year, I know there is no way that, at this point, I could have the same experience, knowledge, and network that I have now without the opportunities presented by the fellowship. For this I feel overwhelming gratitude for everyone associated with the Winston Fellowship, particularly the Fellowship Board, for initially creating it and growing it into the unique opportunity it is today. From the first time I learned about the Winston Fellowship, I knew it was exactly the opportunity I was looking for to start on a clear path towards a career in health policy. I had very high hopes for the fellowship, and while high hopes can often lead to disappointment, the fellowship has lived up to and exceeded all of them. Informational Interviews The orientation phase allowed John and me to meet with over 120 health policy experts in the DC area. While this would be an extraordinary learning experience in any year, the summer of 2009 was particularly exciting as momentum was building to pass comprehensive health care reform. The meetings allowed us to dive into the many viewpoints from the perspective of the House and the Senate, Democrats and Republicans, and every stakeholder in between and beyond. We were able to pick the brains of experts who offered seemingly endless knowledge and insights about the vast number health reform issues being grappled with in Congress. I was surprised by the areas of agreement on issues I thought would be controversial, and the heated criticism of policies I thought were not. From the policy to the politics, there was never a conversation lacking of thought-provoking substance or insider knowledge.
The informational interviews were an ideal transition from graduate school into the world of health policy. We not only were forced to quickly learn our way around DC, but by the end of the summer, we had a mental map of the health policy community as well. The first few months helped establish a network that allowed us to be only one or two contacts away from resources in almost any area of health policy. The information and network gained from the informational interviews was also valuable in finding a placement that fit well, and throughout the placement phase itself.
Placement Phase I chose my placement with Senator Rockefeller because of his position as Chairman of the Subcommittee on Health of the Senate Finance Committee, his career-long dedication to improving the health care system for patients and consumers, and his experienced health staff. Once again, the timing seemed improbably perfect. My first day in Senator Rockefeller’s office was the day before the Senate Finance Committee started the mark-up of its health care reform proposal. I spent the first two weeks during the mark-up weeding through and analyzing over 500 amendments. As I drove home at 3 am after the Committee took its final vote to move the legislation to the full Senate, I was struck with appreciation for the fellowship and the opportunity it created for me to see the health care reform debate from such a close vantage point.
From the bill that was passed in the Senate Finance Committee to the various iterations that followed, I worked mainly on the provisions that reformed the health insurance industry to make the market more friendly and fair to consumers. I conducted in-depth research on oversight of the self-insured market, examined the advantages and disadvantages of the market, developed legislative recommendations on how to address the shortcomings, and drafted amendments for the recommendations, some of which were included in the final version of health reform. I also closely followed, researched, and presented alternatives regarding the rate review and medical loss ratio provisions.
The December health reform debate in the US Senate was one of the more formative experiences of the fellowship. I not only learned about the complex procedures used to move legislation through the Senate, but I also experienced the seemingly unpredictable ways of politics. The close proximity to the final negotiations in the Senate was particularly useful in understanding a debate that was publicly confusing due to misinformation. I wrote talking points and rebuttals, worked on floor speeches, and wrote background memos on issues that came up during final negotiations. Finally, I watched as the Senate ended its debate of health care reform, which was complete with its constantly-changing political maneuvering and high-stakes compromises, with a final vote to pass the bill at 7 am on Christmas Eve.
After December and the ensuing special election, the path forward for health care reform was unclear. During this time, I focused on health care issues specific to West Virginia, including the barriers to access typical of rural and geographically isolated areas and other related problems raised by constituents. I also worked to address concerns of West Virginia hospitals regarding the technical definitions of different hospital classifications of Medicare, such as critical access hospitals, sole community hospitals and wage index categories.
At the end of March, I compiled updates and summaries of the reconciliation bill that made small changes to the bill passed in December, tracked the amendments during that debate, and watched the passage of the last component of health care reform from the Senate gallery. After the final passage, much of what I have worked on has been communicating to West Virginians how health care reform will benefit them. I have also been following the regulations as the new law is being implemented, particularly regarding health insurance reforms. Last Thoughts All of the knowledge, skills, and contacts I have made over the past year would not have been possible for me to gain as quickly as I did without the opportunities presented by the fellowship. The value of a comprehensive viewpoint, wide-spread network and hands-on experience cannot be measured. The health policy community, in general, has proven to be one welcoming to honest discussions and forthcoming with helpful advice, for which I am extremely appreciative. Looking forward, I know that I will continue to draw on what I learned during the fellowship in the coming months and years, and will forever be grateful for the generous support that so many people give to the fellowship to make it such an incredible experience. Andrew Roszak, JD, MPA, 2008-09 Winston Fellow
Dear Winston Fellowship Board,
When I first arrived in D.C. for the David Winston Fellowship I was eager and excited at the prospects of what i may learn. However, nothing in my wildest of dreams could have prepared me for the adventure I was about to embark on. The last year has undoubtedly been the most rewarding and life changing experience thus far. My sincere appreciation and gratitude goes out to all of the board members for providing me with this truly unique opportunity.
When I first arrived in D.C. I certainly had a full plate.From learning my way around a new city, to adjusting to life without a car, to studying for a little test called the bar exam.The orientation phase provided an excellent opportunity to discover the District and become familiar with the plethora of public transportation options.
Most importantly, the orientation phase also provided an unparalleled opportunity to meet with the most influential individuals currently working in the health policy arena.To this day, I am still amazed at the access and varying opportunities we had to engage with high level policy experts.This provided a chance to not only expand my understanding of health policy, but to also forge a series of professional relationships that have paid enormous dividends.
After exploring several options, I decided to work for Congress.I figured that DC is the only place in the country where the option exists and, thanks to the fellowship, the door was certainly open.The search was on to find the office that could offer me the best possible experience.After ruling out the House, I began to focus on the Senate.I eventually settled on the office of Senator Judd Gregg (R-NH).Senator Gregg was a power player in the Senate.He had seniority, was well respected, and sat on the HELP, Budget and Appropriations committees.Since Senator Gregg did not have health legislative affairs staff in his personal office, I began working for Senator Gregg on his Budget Committee staff.
My experience on the Senate Budget Committee was very insightful and interesting.Senator Gregg had historically employed around 3-5 health legislative assistants.However, at this time his health staff consisted of just one full time staffer.As you can imagine, there was plenty of work to do.
During this time, health reform became a very important issue.A Bi-partisan coalition of Senators was established, fortunately Senator Gregg was part of this coalition.Additionally, Republican Senators began holding weekly health reform meetings – where they would discuss concepts and strategies.I was very fortunate to be able to attend these meetings and have a hand in some of the behind the scenes preparation for them.
In February of 2009, Senator Gregg was asked by President Obama to become Commerce Secretary.Initially, Senator Gregg accepted the offer.As you can imagine, things in my office became rather complicated at that point.Taking the advice of my colleagues, I began exploring other locations for finishing the duration of my fellowship.
I was put in touch with Michael Handrigan, the acting director of the newly created Emergency Care Coordination Center at the Department of Health and Human Services.I was very excited about the opportunity to help ‘stand up’ a new entity within HHS and to get a chance to be part of the ECCC during its infancy.This new office was especially appealing to me, given my firefighter / paramedic background.
The mission of the ECCC was very ambitions, it is charged with promoting and funding research in emergency medicine and trauma health care; promoting regional partnerships and more effective emergency medical systems in order to enhance appropriate triage, distribution, and care of routine community patients; promoting local, regional, and State emergency medical systems’ preparedness for and response to public health events.
The transition to the ECCC could not have been smoother.The staff is wonderful and they welcomed me with open arms.Further, due to the small staff size, I have been able to become intimately involved in a number of key issues and initiatives.For example, during the spring 2009 outbreak of novel H1N1, I was given the lead in establishing a partnership with the American College of Emergency Physicians to develop, coordinate, and disseminate information and guidelines related to novel H1N1.
I have also had the opportunity to attend numerous conferences on emergency care ranging from Joint Commission conferences to the Institute of Medicine workshops to Homeland Security Briefings at the White House.Additionally, since I am the only paramedic on staff, I was recently appointed as the ECCC liaison to the Federal Interagency Committee on Emergency Medical Services (FICEMS).FICEMS is the federal entity that serves as the coordinating body for more than seven various Federal agencies that are involved in EMS, including HHS, Homeland Security, and the National Highway Transportation Safety Administration.
The fellowship has also given the opportunity to hone my public speaking and presentation skills.This past year I have presented at the following venues:The Legalities of Automated External Defibrillators – American Public Health Association’s Annual Conference, San Diego, CA, EMS and Disaster Law – Illinois, Health Reform and Emergency Care – Council on Emergency Medical Care, Washington DC, HHS – The Office of Preparedness and Emergency Operations Response to H1N1, The Assistant Secretary for Preparedness and Response – OPEO All Hands Meeting, Washington DC, and at the Fellows Roundtable, AUPHA Annual Conference, Chicago.
As I reflect back on the year, it is hard to put into writing all of the wonderful things that I have done, learned and experienced.This has truly been one of the most rewarding and transformation periods in my life to date.Again, I express my tremendous appreciation to the board for their kindness, support, and candid advice.I also wish to thank everyone that, through gracious gift of their time, made this year possible.
Respectfully,
Andrew Roszak
Kelly Whitener, MPH, 2008-09 Winston Fellow
When I first saw an advertisement for the David A. Winston Health Policy Fellowship, I knew I had to learn more.Later that night, I went to the website and I realized it was exactly what I was looking for – an opportunity to use the skills gained in graduate school and see health policy in action.I started my application almost immediately, and I was ecstatic when I was selected as one of the 2008-2009 fellows. I am happy to report that this year has surpassed all of my expectations.I never expected to learn as much as I have and to have as much fun doing it.Some of the highlights of the past year are described below, but I think it is most important to express my deepest gratitude to David A. Winston, the Winston Fellowship Board, and the Senate Finance Committee.I cannot imagine a better introduction to health policy, to politics, and to Washington.
ORIENTATION
During the orientation phase, I met with about 150 health policy leaders in and around Washington, D.C.Each meeting added to my understanding of how health policy works in Washington and simultaneously led to more questions.I was surprised to find that everyone was so forthcoming and honest, willing to teach me the basics and share their personal insight. One of the most valuable lessons I learned was the importance of positive relationships between people, regardless of their role or political affiliation.The world of health policy is small, and it operates through mutual respect and honesty.I learned to think carefully before speaking and to listen attentively to opposing viewpoints, knowing that I would probably learn something worthwhile and would almost certainly end up working with like-minded people in the future.
PLACEMENT
I started my work with Chairman Baucus’ Finance Committee health team in October of 2008, just as he was working on his white paper, “A Call to Action.”Given my background and interest in programs that benefit low-income populations and children, I have worked primarily on Medicaid and the Children’s Health Insurance Program (CHIP) in my time with the Finance Committee.Working on the white paper was a great introduction to the Committee.I learned Chairman Baucus’ position on nearly every issue and grew accustomed to working with a team on tight deadlines.After releasing the white paper, we started preparing for the busy year ahead by developing a plan to reauthorize CHIP and an economic recovery package that would promote jobs and stimulate the economy. If working on the white paper was my introduction to the Finance Committee, working on the reauthorization of CHIP was my introduction to the Senate.At first, the four members who had worked to reauthorize CHIP in 2007 – Senators Baucus, Grassley, Rockefeller, and Hatch – sat down together to work on the bill.But, disagreements about policy and priorities for reauthorization caused the members to split along party lines.With a partisan Chairman’s Mark, we knew the Markup and floor debate would be long and fiery.But, after a full day in Committee and almost a week on the floor, the Children’s Health Insurance Program Reauthorization Act of 2009 passed the Senate with a vote of 66 to 32.On February 4, 2009, CHIPRA was signed into law by President Obama in the East Room of the White House, and thanks to the generosity of White House staff and the Finance Committee Staff Director, I was able to be there.After only four months in the Senate, I was able to work on a bill, help with the Committee Markup and floor debate, and see it signed into law.For those that had been working on reauthorizing CHIP since 2007, the victory was a long time coming, but for a fellow like me, it all happened so fast.I learned more in the course of about three weeks than I ever thought possible.
Before we were done working on CHIP, we started working on the economic recovery package.During CHIP, I had a chance to see nearly every part of the legislative process, but because the House took up the Senate-passed version, I did not get to see how a conference works.While working on the American Recovery and Reinvestment Act of 2009 (ARRA), I had that chance.It was a fascinating process that involved a lot of late nights in the Capitol.I worked primarily on fiscal relief to states and negotiating changes to such complex provisions was difficult.The conversations were heated at times, but in the end we reached agreement.As soon as ARRA passed, we began work on health reform.The Committee started preparing for health reform in the beginning of 2008, and by March of 2009, Chairman Baucus was ready to put a bill together.
During health reform, I have worked on provisions related to coverage of low-income individuals through Medicaid and CHIP, along with provisions related to combating fraud, waste, and abuse in federal health care programs.By the end of May, the Committee had considered policy options for each area, and Senators Baucus and Grassley began more detailed negotiations of each provision based on member feedback. Since that time, Senators Baucus and Grassley have been joined by Senators Conrad, Bingaman, Snowe, and Enzi in the negotiations.The “Gang of Six” as they are called in the press is continuing to work on a bipartisan, fully paid-for bill that will bring down the costs of health care and provide coverage to all Americans.In some areas, there is substantial agreement about how to proceed.In others, disagreement persists.
The Committee’s progress has been slower than originally anticipated, and thanks to the flexibility of the Winston Board, I will be able to continue to work with Finance for a little while longer.Unlike CHIP and ARRA, the process for health reform has been very bipartisan.Senator Baucus has worked hard to include the entire Committee in as much of the decision-making as possible.I admire his dedication to bipartisanship and have benefited greatly from the experience.It has been especially instructive to work closely with Senator Grassley’s staff and to witness the negotiation process among the members.I am continually impressed by the knowledgeable staff and the perseverance of members as they navigate such a complex proposal, and I am hopeful that all their hard work will come to fruition this year.
CLOSING REMARKS
In the past 14 months, I have learned more than I ever thought possible.I feel so fortunate to have been selected as a Winston Fellow and to have been able to work with the Senate Finance Committee.I am confident that I will continually draw upon this experience over the course of my career, forever reflecting on the lessons learned.I would like to thank the Winston Board for giving me this opportunity and for their continued support and guidance.I would also like to thank Chairman Baucus and the Finance Committee staff for allowing me to join the team.Working with the Committee has made my fellowship year truly incredible.This year has been formative in so many ways, and I am grateful for the opportunity to learn from the best. Elizabeth Lee, 2007-08 Winston Fellow
As I look back over the last year, I can say that my Winston Fellowship experience has been a truly remarkable one. It began with three months of a whirlwind orientation into the world of health policy both in Washington, D.C. and across the country, took me into the heart of the politics of Senate health policy, and opened my eyes to the chaos of a presidential campaign. I have learned a tremendous amount about the nation’s capitol, the landscape for health reform, and my personal policy interests. We have met inspiring individuals and spent time with the most influential interest groups. On the whole, I am full of gratitude for my experience and honored to have been a part of such an extraordinary program.
Orientation Phase
Tanchica and I both appreciate the broad range of factors that contribute to the health of our nation and the policies that address it. As a result, we cut a very wide swath with our informational interviews, visiting a number of federal agencies, non-profit organizations, and Capitol Hill offices. Because we had such a wide variety of meetings, I would like to highlight two that I particularly enjoyed and have referenced throughout my time as a Winston Fellow. Gail Wilensky, who is a Senior Fellow at Project HOPE, offered us advice in general terms, but supported it with specific experiences from her own life. She advised us to stake our reputations on the quality of our work, rather than the passion of our positions. As someone deeply committed to the improvement of health care in America, she dedicated herself to excellence of work product early in her career, earning her advanced degree through the analysis of data, without taking specific policy positions or lobbying Capitol Hill. As a result, she earned her place as a trusted voice in health policy, often the source of unbiased analysis of health services, utilization and expenditures. Later in her career, as she delved more into the policy development aspect, she was able to work with a wide variety of stakeholders to garner support and consensus.
Susan Reinhard, Director of the AARP Public Policy Institute, proved a critical contact for me over my year in the Fellowship. During my first meeting with Susan, I discovered the value in building one’s career on the state and local level, providing unique insight into federal health policy making. Having worked as a nurse, Dr. Reinhard grew into a more influential policy making role, developing widely used tools for the improvement of long term care and home health. After working on the state level, she joined the Rutgers Center for State Health Policy; after gaining expertise in various state health approaches to aging and long term care, she has brought her leadership to AARP. She was a tremendous resource as I navigated my way through the complicated world of long term care. These two inspirational women have served as role models to me throughout this experience, and reminded me of the value of integrity, but also personal passion for the outcome of your work.
Placement Phase
In October of 2007, I began my placement with Senator Hillary Rodham Clinton. Senator Clinton’s office maintains two slots for Fellows, and I was accepted to fill one of those spots. I serve as the point person for military health care, mental health, disability, aging and long term care policy. In this role, I am responsible for speeches, press releases, letters, and background memos for these issues. This year, I wrote letters to HHS regarding the Medicaid regulations issued by the Bush administration. One regulation in particular threatened a dangerous impact on vulnerable populations in New York State – the revision to the targeted case management program, which focuses on the chronically ill, disabled, and foster youth. In addition, I authored letters to the Department of the Army regarding suicide rates among active duty troops.
Throughout the year, I have also conducted hundreds of meetings with constituents concerned about these issues, addressing the effects of Congressional legislation and policy on the children and families of the State of New York. As a fellow, I often serve as a last resort for these meetings, and have learned a significant amount about orphan diseases, obscure aspects of competitive bidding, and other intricacies of health policy making. Over the past seven months, I have been involved with various legislative initiatives at varying levels of responsibility. At the most removed level, I have been Senator Clinton’s point person to track the developments on the HELP Committee with respect to mental health parity, legislation which has been in development for over a decade. While we are not involved directly with negotiations, I am responsible for ensuring that Senator Clinton’s interests are protected and no key provisions are removed that are high priorities for New York State. In terms of advancing some of my own ideas, I spent the first few months of my placement working on long term care legislative ideas, which were used primarily on the campaign side, and never turned into full-scale legislation. I focused primarily on workforce development and long-term care quality, two critical issues which will need to be addressed as the Baby Boomers age.
In the months that followed, I focused more on military health care. Senator Clinton has a legacy of leadership on Traumatic Brain Injury and Post Traumatic Stress Disorder, which have proven to be the signature wounds of the Iraq War. Working closely with veteran service organizations, I authored and introduced, on behalf of Senator Clinton, the Caring for Wounded Warriors Act, which supports family caregivers of wounded veterans and servicemen and women. There are two key provisions to the bill; one trains family members of wounded service members to become home health aides, making them eligible for compensation from the Department of Veterans Affairs. The second establishes partnerships between the Department of Veterans Affairs and universities, training students to provide short-term respite care to severely wounded service members and veterans. It was introduced with Senator Dole as a co-sponsor, and was considered through a Legislative Hearing by the Veteran’s Affairs Committee. It will hopefully be included in the National Defense Authorization Act or a larger Veterans’ Affairs package. We are also working with a variety of stakeholders to craft other amendments to the National Defense Authorization Act to help support wounded warriors.
I received a crash course in the federal budget process when the Senate voted on the budget resolution earlier this year. Senator Clinton’s health team offered a number of amendments; I was responsible for an amendment in support of her Lifespan Respite Care Act. The Act provides grants to states to offer respite care programs for family caregivers, and was signed into law in 2006, but has not received appropriations. My amendment authorized $53 million. Through the conference report, that number was reduced to $26 million, but will hopefully remain in the final budget that goes to a vote later during this work period. More recently, I have been working on legislation to replicate an innovative medical home model serving medically fragile children. It is based on a program out of the Medical University of South Carolina, and is a special Medicaid managed program that provides comprehensive care to chronically ill and disabled children. I hope to complete the bill and introduce it before my fellowship is completed.
Overall, I learned a tremendous amount about the reality of health policy development through my placement. Some of these lessons were disheartening and frustrating, including the highly partisan nature of Congress, but others were hopeful, including the remarkable way in which Senator Clinton prioritizes, listens to and responds to her constituents. After five years of implementing federal policies at the local level, the chance to witness some of the development was truly fascinating, and has inspired me to remain in D.C. and continue my work on the federal level. Acknowledgements
Thank you to the entire Board of the Fellowship for making themselves available to us throughout the year, and responding to our requests for counsel. Thank you to the previous Fellows, who were tremendously welcoming and eager to provide us with any assistance that we needed. Thanks to the staff of AUPHA office for their efforts in coordinating our schedules, budgets and sanity. My biggest and most heartfelt gratitude, however, goes to Tanchica Terry, for her humor, grace, wisdom and passion – quite simply, you made this year possible for me. Thank you.
Tanchica Terry, 2007-08 Winston Fellow
INTRODUCTION
This report provides an overview of my experience with the David A. Winston Health Policy Fellowship for program period July 2007-2008. Part one summarizes the introduction of the Fellowship via the orientation phase. Second I discuss the incredible placement assignment with the Senate Health, Education, Labor and Pensions Committee. Next, I highlight recommendations and extend my gratitude to the Board of Trustees, AUPHA, HELP Committee, past fellows, Elizabeth Lee my friend and counterpart in this meaningful endeavor and, of course, my family. WINSTON FELLOWSHIP
Orientation
In previous reports I gave great detail about the orientation phase of the Fellowship; however, I would be remiss if I went without describing again its value to our initial learning of the health care policy arena. The orientation informational sessions with key health care policy professionals particularly brought substance and context to our academic learning. As a post-graduate experience, meeting excellent and diverse health management and policy leaders like Dr. Georges Benjamin, Karen Ignagni, Dan Hawkins, and Karen Davis has been most valuable to my growth. It is also a unique component of this program. I cannot completely capture here how much I gained as a fellow from their discussion and our participation as Fellows in this respect. Yet, I am able to reassure you of its value and thank you for including this in the program module. Legislative Placement
My legislative placement, as you are aware, is with Chairman Edward M. Kennedy’s Senate Health, Education, Labor and Pensions (HELP) Committee. The entire staff is exceptional in its experience and knowledge of health care policy which became essential to my decision making and joining their team as a legislative fellow. In this capacity, I am responsible for many aspects of the public health portfolio, including prevention efforts, health insurance access, health disparities among disadvantaged populations and global health. I develop legislative proposals, plan hearings, and bipartisan educational forums to further Senator Kennedy’s agenda. I advise and prepare materials for Senator Kennedy in advance of hearings, executive sessions, floor debates, and vote recommendations. I give leadership and mentoring to interns on issues in my portfolio and develop assignments to enhance their experience and level of activity with the office. Major Activity
This experience is truly gratifying as I have worked diligently to help ensure floor movement of the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act of 2008 alongside Senate Foreign Relations staff. This bill authorizes $50 billion for HIV/AIDS, tuberculosis, and malaria, allowing for scale-up of these programs over the course of fiscal years 2009-2013. The bill sets out targets highlighted in the table below:
Summary of S. 2731, the Global HIV/AIDS, Tuberculosis, and Malaria Reauthorization Bill
·Prevention of 12 million new HIV infections;
·Support for treatment of at least 3 million people with HIV/AIDS as well as additional treatment through multilateral efforts, with a timetable to help ensure annual progress toward this target;
·Support care for 12 million people with HIV/AIDS, including support for 5 million orphans and children affected by or vulnerable to HIV/AIDS;
·Helping countries in their effort to achieve 80 percent access to counseling, testing and treatment to prevent the transmission of HIV from mother to child;
·Helping countries to achieve access for care for children with HIV in proportion to their numbers among those who are infected with HIV; and
·Helping countries to expand their health workforce with the goal of training and retaining at least 140,000 new health care workers and professionals and with the objective of helping them achieve staffing levels recommended by the World Health Organization.
Additional Activities
I am currently working on the Minority Health Improvement and Health Disparity Elimination Act bipartisan meetings that will hopefully advance to a Senate mark up before the end of this year’s Congress. This involves addressing issues with Republican HELP Committee staff, our counterpart bicameral offices, supporters of H.R. 3014, and working with the legislative office of the Department of Health and Human Services to plan briefings from the Administration. What is most important about this work is the firsthand experience and understanding of the complexity of the issues which gives me a deeper respect to the charge of Congressional members and staff. On the other hand, I am bewildered by approaches to health care that are less than scientific and flawed with legalize, politics, and ideology. ACKNOWLEDGEMENTS Board of Trustees
I am filled with gratitude for having been selected as a Winston Fellow 2007-2008. This experience continues to challenge me in ways that are both expected and unexpected. I have grown as an individual and professional, but most importantly, because of this Fellowship I am a better person. Now more than ever because of your wisdom and guidance it is my aspiration to inspire others to think imaginatively and broadly about health and its application across multiple sectors. Thank you very much for your leadership; you are sincerely appreciated. Past Fellows Many thanks to past fellows for their outreach to Elizabeth and I throughout the Fellowship. Your actions and words continue to ease the learning curve and lessen the anxieties of uncertainty. Deb Mizeur, Rachel Nuzum, John Rigg, Martin Sobel and Meghan Taira I owe a special thank you. Senate Kennedy’s Office
The staff and fellows are tremendous in Senator Kennedy’s office. They are extremely collegial and grossly astute in healthcare policy. I am respectful and enlightened by their efforts and all that they will continue to do. I also leave Senator Kennedy and his office confident and assure of my learning. Family and Friends
Thank you for being patient and relentless in your encouragement in this year’s transition. I am because you are. Ms. Elizabeth Lee words cannot express fully my gratitude; however, your truth illuminates and anchors – please sustain your character.
John Rigg, MHA, 2006-07 Winston Fellow ACKNOWLEDGEMENTS I feel that it’s only appropriate to begin this final report to the Board of the David A. Winston Health Policy Fellowship with a note of sincere gratitude. As my comments below reflect, I’m extremely grateful for the Board’s contributions through the Fellowship to the field of health policy and to those of us who are beginning our careers in this exciting field. Your advice and mentorship have been key ingredients to a successful fellowship year, and I thank you for your time and commitment. The Winston Health Policy Fellowship is a real gift to those of us who have been chosen to receive it, and it has altered my life in countless positive ways, many of which I’m just beginning to fully appreciate. I’d also like to thank the staff at AUPHA for their advice and competent administration. Knowing that we had a “home base” with such supportive and knowledgeable resource people was invaluable. I’d particularly like to acknowledge Dennis Morgan for his assistance and advice, which kept us on-track, on-schedule, and helped us to develop a good working knowledge of the area in aspects both great and small.
Finally, it’s extremely important to thank my good friend and co-fellow Martin Sobel for his friendship and companionship throughout this process, and my wife and partner Jennifer for sticking with me through an exciting, dynamic, and occasionally disruptive year.
INTRODUCTIONS AND ORIENTATION MEETINGS The orientation phase of the fellowship began with a week at the AUPHA office, getting accustomed to our technologies, meeting staff, and getting prepared for the interviews. Importantly, Martin and I had the chance to get to know each other during this time, and it very quickly became apparent to me how compatible we were. In the course of several conversations in this early phase, Martin and I got acquainted with each other’s policy focuses and work styles, which proved to be quite beneficial in developing our strategies around our orientation meetings and in formulating our schedule.
Also in this initial week, it quickly became apparent how important and valuable Dennis Morgan was to be to us in the fellowship. Dennis’ knowledge of the area, the Board, and many of the organizations and people with whom we were to meet was an extremely important resource from the time that we arrived. In addition to helping us keep our schedules, he was able to suggest places for lunch and coffee, museums and events, and places to live. To a newly-arrived Washingtonian, this was incredibly helpful.
Once the orientation meetings began in week two, the benefit of the laptops and blackberries became apparent. Because our meetings were with a wide and varied array of extremely busy people, having the ability to know about schedule changes with a keystroke saved us from many wasted trips. Additionally, having access to a laptop allowed us to work remotely when away from the office, thereby maximizing our downtime between meetings, and largely saving us from previous fellows’ late-night runs to the office to print off thank-you notes.
Though the placement phase has comprised the bulk of my fellowship year, the orientation meetings themselves may have been the highlight of the fellowship. Because Martin and I were unaffiliated with any organization other than the Winston Fellowship during these meetings, I believe that the people with whom we met responded to us with much greater candor and openness than they would have had we been already attached to a specific organization (such as the Ways and Means Health Subcommittee, for example). Through these meetings, we had a number of extremely good conversations, and only the very occasional “bad” meeting; we developed a rolodex of contacts, and a file drawer full of organizational literature that would prove helpful during the placement phase. In our preliminary interviews, we focused primarily on the “process” of policymaking, and the interviewee’s role in it; because of the diversity of organizations, this line of questioning gave us a better overview of the types of players in national health policy. As grew more familiar with the types of organizations that inform health policy, our questions became gradually more topical. Eventually, through a great number of interviews with staff from think tanks and research organizations, consulting firms, lobbying firms, and professional associations, I felt like I could begin to draw distinctions in terms of size, scope, mission and, importantly, target market or demographic between the diverse organizations. Moreover, through the orientation meetings I developed a better sense of how organizations collaborate, coalesce and compete, and how their interests converge, diverge, and collide. The best parts of the orientation meetings - the highlights of the highlights, if you will – were our meetings with other Winston fellows and the Board. These meetings allowed us to get to know our predecessors and our “bosses,” and establish important relationships that would yield dividends of friendships and mentorships as the fellowship progressed.
PLACEMENT PHASE: WAYS AND MEANS HEALTH SUBCOMMITTEE I began the placement phase with excitement and a bit of trepidation. Though I had committed to the Ways and Means Health Subcommittee before the “flip” in congress, experiencing the change in congress and the Committee’s status from minority to majority was exhilarating and striking. Literally overnight, the number of people who were requesting meetings with our staff went through the roof, and the manner in which we were treated by outside stakeholders and the (new) minority improved almost instantly. Due to the flip, and because the Committee was initially somewhat understaffed for a variety of reasons, I had the opportunity to get in over my head, and engage on a lot of different issues.
Though due to the Committee’s understaffing and its high workload my tasks were initially somewhat inchoate, as the Committee staffed up, I was able to work on a more defined portfolio of issues. These included emergency care, hospital acquired infections, transplant policy, imaging, clinical labs, ambulance reimbursement, private fee-for-service MA plans, and a number of smaller issues. This allowed me to write and manage a number of bills, and analyze payment policy around several aspects of Medicare policy; for example, I’ve been working on physician payment reform, payment to imaging providers, and clinical lab providers, and developed a coalition around a transplant bill. Perhaps the most exciting portion of my job with the Committee has been writing a couple of emergency care bills from scratch, both of which are being introduced in the next couple of weeks. Though it’s unlikely that they’ll become law as freestanding bills I hope that portions of them will be extracted and added to larger legislation.
An important lesson that I’ve learned during the Fellowship, but especially during the placement phase is the importance of interpersonal relationships, which some argue are the currency of Washington; because power waxes and wanes, the ability to develop relationships of trust and, ideally, respect with others in your policy sphere seems extraordinarily important. Though policy people may wind up on opposite sides of some issues, it is the relationships between people that comprise the glue that holds coalitions, associations and caucuses together, and that form the basis of compromise between competing parties. Though the technical knowledge about the Medicare program and the experience of working with committee staff are certainly valuable, I believe that it is the relationships that I’ve been able to develop during the placement phase that will prove to be the most lasting benefit of the placement phase.
FINAL REFLECTIONS Now that my year as a David Winston Health Policy Fellow is quickly winding down, I’ve found myself reflecting on the experiences of the past year, and the ways in which this unique and valuable opportunity have allowed me to grow and develop, both personally and professionally. Through the “orientation” phase of the Fellowship, I learned the lay of the health policy land, and developed an appreciation for the diversity of perspectives and abilities that various stakeholders bring to the policy process. Through these orientation interviews, I examined a constellation of emerging policy issues from a variety of perspectives, which in turn drew the differences between interested parties into sharper relief. The orientation phase also provided me with an instant network, many of whom I would later call upon to help develop policy during my time in congress.
The Fellowship has enhanced my knowledge of current and emerging health policy and delivery issues considerably. Though the orientation phase provided a good overview, my placement with the Ways and Means Health Subcommittee helped me to develop a fairly in-depth knowledge of many aspects of the Medicare program. Because of its unique size and influence, working on Medicare policy has given me the opportunity to influence regulation and payment in a wide array of settings big and small; from hospitals, to health plans, to oxygen equipment, and ambulances. This technical knowledge about the Medicare program, combined with the cross-sector exposure that I gained through examining the various aspects of payment policy is invaluable, and will prove to be an important foundation for my emerging career in health policy. Finally, I’m just beginning to appreciate the ways in which my life has changed personally. Though the policy expertise that the Fellowship has helped me to develop is extraordinarily important, the alteration of my life’s path will likely prove to be the most profound and lasting effect. In the past year, Jennifer and I have uprooted our lives in Seattle, moved to Maryland, been blessed with a beautiful baby boy, and are in the process of buying a house, and starting new jobs. Everything about my career has changed; though I maintain my licensure as a Paramedic (and still volunteer as a Paramedic-Firefighter one day a week), I’m now thoroughly immersed in the world of health policy, which is a whole other face of health care than the provider world in which I worked previously. Moreover, the knowledge and experience that the fellowship has enabled me to obtain, and, it must be said, the reputation of the fellowship itself, have helped me to land a job that I would’ve had no chance of obtaining one year post-graduate school otherwise. Thank you again for the opportunity to be a Winston Health Policy Fellow. I sincerely hope that I will represent the Fellowship well going forward, and I’m eager to provide whatever I can to contribute to the Fellowship’s continued success.
Martin Sobel, MPA, 2006-07 Winston Fellow
I begin with a thank you and an apology.
I thank each of you for providing me with an unbelievable experience. This past year was everything I wanted it to be. I can't say my expectations were exceeded because I got exactly what I was promised – unparalleled access to and immersion in Washington DC health policy.
As for the apology, today's final report was given short shrift because the new responsibilities recently bestowed upon me have monopolized my time. Though, those tasks are completely a reflection of the high regard for the Winston fellowship and the opportunity it has afforded me. I am a big proponent of the fellowship and at your request will be happy to expand upon this final report and further expand upon how different parts of the fellowship formed my experience.
The reason for the lack of time to conduct a full report is that I have recently begun my post-fellowship career as the health legislative assistant for Senator John Cornyn. Currently, one of his top priorities, if not the top priority, is the Family Smoking Prevention and Tobacco Control Act, of which he is an original cosponsor with Senator Kennedy. Well, almost immediately following today’s farewell lunch I will be staffing Senator Cornyn in a meeting with FDA Commissioner Dr. Andrew von Eschenbach. The FDA has numerous regulatory authorities in the bill, so, understandably my last week has been dedicated to learning the intricacies of this legislation in preparation for this meeting. Aside from the Commissioner’s visit there have also been other meetings and activities surrounding the bill.
Senator Cornyn hired me because of my experiences during a placement with the Senate Finance Committee. As you may recall I was working with Senator Grassley's heath team. The seven months or so I spent there were substantively important, but not as valuable as the lessons of legislating effectively, with integrity, in a bipartisan manner, and in the interest of good public policy and public service.
My mentors there were many, but I asked two of them who had the most influence on me to join me here today. As of press time I am unsure if one of them will be able to join because he has been off doing his duty to negotiate a comprehensive and effective SCHIP reauthorization bill. Nonetheless, I thank them for their willingness to involve me at the highest levels of the policy process, especially during the development and passage of the Tax Relief and Health Care Act of 2006 and the Medicare Part D government negotiation debate. TRCHA is where I cut my teeth. It was my first opportunity to see the sausage grinder of federal policymaking. Their were senate negotiations, bicameral negotiations with multiple committees, staff negotiation breakdowns, secret meetings, member level meetings, leadership meetings, member negotiation breakdowns, reconciliations, all-nighters, backroom deals, and floor debate preparations, which went for naught as the "jet fumes" were strong in the senate chamber resulting in quick passage. The most important lessons that come to mind were realized while watching and participating in the thousands of relationships and data points that occurred throughout the process. And why these interplays are part of the policy process. For sure the goal is to spread this process out over more than a few days, but the steps and entities and lessons are the same. Aside from learning, this was also my first opportunity to contribute to the health team and I think my performance proved to them they could rely on me to effect the policy process.
The Part D debate was a completely different animal. In that instance we were charged with helping Senator Grassley protect a clause from the Medicare Modernization Act of 2003, which created the Part D program. Senator Grassley and the designers of the bill included the restriction on government interference as a method to ensure private competition would be the dominant force in providing a low-cost, high-quality benefit to Medicare beneficiaries. Putting yours or my politics or personal feelings aside, I am glad to say we we're successful. In fact, we received a nice tip of the cap from Robert Pear, a well-respected healthcare writer for the New York Times. He said, “The vote also reflected ineffectual advocacy by Democrats, who were slow in responding to the vehement arguments of knowledgeable and well-prepared Republican senators like Charles E. Grassley of Iowa.” Getting there required a different skill set than the one learned during the TRCHA affair. In this case it required us to think critically and strategically about what arguments are best and which are expected to be used by out opponents. We conducted enough extensive research, collected endless data, drafted and redrafted hundreds of times talking points and speeches, and educated other members and staff. At the end of the day we were a well-oiled machine with evidentiary support and expert opinions to refute nearly any opposition argument that tried to convince members or the public why the non-interference clause should be removed from the legislation. Another valuable lesson is how quickly the winds change around here. One day it is the only thing people can talk about and the next people forgot what they were even talking about. I gained the confidence to actively contribute to both these endeavors because of the first phase of the fellowship. By meeting with key policy players from a diverse background I had a crash course in the issues that matter and how they intertwine with one another. In my past reports I had indicated how some of these people or organizations impacted my thinking. Moreover, the willingness of the members of this board, and those I was sent out to meet, to teach and share their tips for success was invaluable. I hope I have conducted myself in a manner that makes you and all those I have encountered proud to have dedicated your time and effort.
As for where I am now, my preference would have been to stay with the Senate Finance Committee, but there was not the opportunity. Though Senator Cornyn is currently not on either the Senate Finance Committee or the HELP Committee healthcare is an area where he wants to be more knowledgeable and involved. But, his leadership position gives him access to the high levels of decision-making, thus allowing him a forum to build his reputation as a member of relevance when it comes to healthcare issues. Senator Cornyn hired me because he is confident that my experiences as a fellow and beforehand will help him achieve his goal.
In the Senate Finance Committee they like to say “job well done, now go back to your desk, have a bowl of soup and move on to the next challenge.” So, I am glad to be here today sharing more than a bowl of soup and having a respite from work, but my next challenge is here and I am deep in it. Thank you again.
Jay Khosla, MHSA, JD, 2005-06 Winston Fellow
As I enter the final months of this Fellowship only one word comes to my mind that can accurately describe the whole experience: life-changing. The Fellowship experience so far has been nothing short of amazing. After nearly three full months of meetings and interviews at the beginning of the Fellowship followed by a very productive placement, I can sincerely state that this has been one of the most educational and mind expanding experiences of my life. The Fellowship has allowed me access to some of the most accomplished individuals in the health care industry and given me the right tools to build a network that will prove invaluable in my growth as a health policy professional.
The Orientation Scheduling meetings with the Board Members towards the beginning of the Fellowship was an excellent suggestion since it allowed me to get a comprehensive overview of the prevailing atmosphere in the health policy arena. Most of the meetings in August were on the Hill due to the recess. This in turn allowed me to focus my questions much more effectively during the meetings. The diverse mix of entities really opened my eyes to the unimaginable complexities of the health policy arena. Meeting with individuals like Linda Fishman and Mark Miller to organizations like NCSL and NBGH really allowed me to develop a true appreciation for the diversity of stakeholders in the policy process. The meetings on the Hill were especially exciting since they offered an overarching perspective of all the diverse viewpoints. The past fellows, especially Deb Mizuer, Rachel Nuzum and Diana Birkett, along with Chip Kahn and Dean Rosen were instrumental in setting up most of our Hill meetings (personal, leadership and committee) on both sides of the aisle. The interview process really crystallized my interests while opening my eyes to a myriad of other policy areas.
The Placement
My decision to work on the Hill was primarily driven by my desire to understand the policy process from the top-down. After spending my graduate and law school years working at the state level, I really wanted to experience it on a national scale. Moreover, the prevailing legislative environment offered huge learning opportunities in my areas of interest, which would serve me well in the long run. The placement decision was extremely difficult because the work of the prior fellows and the prestige of the Fellowship led to some great offers. My mentors on the Board, Dean, David and Chip, along with Dr. Rubin were very helpful in helping me navigate to the right decision. In the end, I decided to do my placement with the Office of the Majority Leader Bill Frist (MLO) based on the immense learning opportunities and potential for responsibility.
As a member of the Leader’s health team, I was assigned the following responsibilities:
§Manage health insurance and health information technology issues for the Majority Leader, including leading coalition efforts to promote legislation and monitoring issues in committees of jurisdiction. §Develop medical liability reform proposals and federal tax reforms related to employer sponsored health insurance, individual tax credits and health savings accounts. §Compose research memoranda and committee markup material analyzing small business health plans, individual market reform, reinsurance and regulatory harmonization. My first major project was to represent the MLO in the development of S. 1955 (Health Insurance Marketplace Modernization Act of 2005) or the Small Business Health Plan legislation. Since the Senate had failed to pass any form of association health plan legislation in more than a decade, there was a lot of excitement around this new compromised approach which discarded the controversial “self-insurance” component of the original AHP bills in favor of a fully-insured environment that allowed independent pooling for small businesses. Moreover, the bill also contained sweeping reforms for the entire insurance market itself with the goal of creating a more efficient and competitive marketplace through regulatory harmonization.
As a novice to the incredibly complex world of the insurance market, I spent hundreds of hours with industry experts, CRS personnel and experienced hill staffers learning the current labyrinth of mandate and rating structures across the nation. I also became intimately involved in the development of the legislation itself and spent countless hours with the HELP Committee staff meeting with the stakeholders. I also spent a lot of time meeting with multiple trade associations promoting and explaining the legislation.
All the hard work paid off, when the bill passed the HELP committee in February. It was the first official Senate action on the issue in more than a decade. After the markup, things really heated up and I suddenly found myself among a select group of Hill staffers working behind the scenes to get the legislation ready for the floor. While working on S. 1955, I was also busy developing and drafting the Medical Care Access Protection Act of 2006 (MCAP), which the Leader co-sponsored with Senator Ensign. I was very excited about this opportunity because I was given direct responsibility to meet with the stakeholders and develop a new model to address the crisis. We finally decided to base MCAP on the highly successful Texas “stacked-cap” model. Drafting this bill was an amazing learning experience because Liz Hall, the health policy director for the MLO, not only allowed me direct member access but also let me lead staff meetings on the issue. Things only became more interesting, when both my bills became the center pieces of the Senate “Health Week.” I suddenly found myself directly staffing not only the Leader along with Liz but also other members due to my intimate involvement with both bills. It was incredibly gratifying to be on the floor and see the political and procedural aspects of “policy-making” after spending months on the substantive aspects. It was at this moment that I truly appreciated my placement decision because as a member of the MLO I had the opportunity to be involved in every step of the bill’s evolution.
Although “Health Week” ended in a disappointing manner, the highlight of the entire placement came on the last day when both Ben Nelson (D-Nebraska) and Mike Enzi (R-Wyoming) thanked me for my efforts on the floor. I knew at that moment that I had taken my first significant step towards building a career focused on developing strong policy ideas in a bipartisan manner.
The Road Ahead One of the most gratifying aspects of the Fellowship for me was the opportunity to develop personal relationships. Everyone from the Board Members to the former fellows to the AUPHA staff and my colleagues on the Hill played an integral role in my learning process.
As I progress to the next step of becoming a Winston Fellowship alumnus, it is extremely comforting to know that there is such a strong network supporting me. I sincerely hope that all my hard work is a testament to my gratitude for being selected as a Winston Fellow. Katie Baker Starkey, MS, 2004-05 Winston Fellow It has been one of the greatest honors and experiences of my life to be a David A. Winston Health Policy Fellow. Throughout the past year, I have often felt like a kid in a candy store. So many incredible opportunities and choices I did not even know existed were placed into the palm of my hands. In my wildest imagination, I never thought that I would have the opportunity to both meet and work with individuals whose positions and achievements I have dreamed of reaching. Not only did the fellowship give me the ability to work with inspiring individuals, I was also able to work in an area I love. Most people are never given the chance to pursue their passion, let alone call it work.
I remember arriving in Washington last July, thinking about the incredible adventure I was about to embark upon – boy was that an understatement! There are no words that can accurately describe the year of a Winston Fellow. I truly believe that only those who have completed this fellowship can understand what it means to be a David A. Winston Health Policy Fellow. It is amazing to be invited into the elite health policy circle in Washington. Throughout the year, I have connected with many people who are genuinely interested in my fellowship experience and who are excited to welcome me into this network.
Orientation I arrived in Washington the day before the fellowship officially began with both a lot of anticipation and a fair amount of intimidation. I was intimidated by the prestige of the fellowship as well as the success of the previous fellows. Thankfully, with the help and support of everyone involved with the fellowship, I quickly became more at ease. After I learned more about the previous fellows, in particular their unique interests and goals, I was able to realize that they were successful because they utilized the inherent flexibility in the fellowship to make this experience their own. No two fellows are comparable, and only the fellow can determine if they met their own expectations.
After having made our introduction to Washington, Rachel and I had to get to the business of designing our approach to the year. The network of former fellows and the experience of the AUPHA staff helped us to approach the orientation in a more strategic manner, breaking the components into manageable chunks. With their help, we had a better sense of whom we should meet and why. Rachel and I also made it a point to discuss our individual goals and interests, as well as our preferences for how to approach the meetings.
The other person who helped me to design the orientation phase was David Winston. Through the stories I heard about him, I learned more about his approach to health policy. I was informed that David Winston never sat back and waited for people to come to him with their agendas, but rather he sought out the stakeholders. He learned about the various stakeholders’ greatest concerns, most inspiring ideas, and top priorities. His approach allowed him to be a step ahead of everyone. The fellowship is modeled after his approach, putting us a step ahead. During the orientation phase, Rachel and I attended conferences, briefings, and met with over 150 people. This first part of the fellowship was eye opening for me. I learned information that cannot be taught through books and seminars. I learned how things get accomplished in Washington, who and what can catalyze or hinder an agenda. I also obtained a greater knowledge about the intersection between stakeholders’ interests and areas of jurisdiction, as well as the history of many organizations and individuals. One of the things that became extremely apparent during the orientation phase is that the Washington network of health policy experts is small.The fellowship is an incredible invitation to this health policy party. The fellowship also taught me that there is no specific way to launch a career in health policy. Individuals follow many different paths in this field, the key is to gain some expertise and skills and through hard work apply them. Hard work cannot be replaced by anything! Given that this was an election year, Rachel and I determined we would have to find an appropriate time to begin the placement phase of the fellowship. As our calendars filled up through October with meetings, I decided that no matter where I chose to work, a slightly extended orientation phase would not be a disservice to me and would accommodate the circumstances of the year. Therefore, I began my work with both the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Medicare and Medicaid Services (CMS) in November, 2004.
Placement
Choosing a placement was one of the most difficult choices I have ever had to make. Each option would have been a new, exciting experience and would have offered me the opportunity to increase my knowledge of the healthcare industry. Ultimately, I decided working to align AHRQ and CMS on a common quality agenda was the best platform from which I could reach my goals and meet my expectations. This placement gave me the chance to integrate myself into a project that was just starting to take shape; Dr. Nancy Wilson had only begun working to align the agencies on a common quality agenda in September, 2004. This placement was also a good fit for me because of its uniqueness; it gave me the chance to work in two federal agencies trying to ultimately achieve complimentary goals in healthcare quality with very different tools. While both of these were factors in my decision, probably the most critical factor was that I would be working in the quality improvement arena – the area where my passion lies. As I arrived at AHRQ and CMS in November, 2004, I found myself at the bottom of an extremely steep hill. I realized that I knew relatively little about each agency and that in order to be a contributing member of this team I would have to get up to speed very quickly. I had to learn the organizational structures, priorities and needs of each agency. Understanding the relationships between these agencies and each other, OMB, Congress, and other stakeholders was also crucial to success. It seemed like a daunting task, but I rolled up my sleeves and dug in. I spent a great deal of time reading documents, being briefed by Dr. Wilson, and attending meetings in order to obtain the essential knowledge.
In the early stages of my placement, as well as throughout, I attended the strategic planning meetings of AHRQ and the CMS Quality Council meetings. These meetings gave me an insight into the inner workings of the agencies and the directions in which the administrators were guiding their respective agency. I found that the information I obtained from these meetings was essential to aligning the agencies on a common quality agenda. A phrase often heard at AHRQ is “connecting the dots.” This phrase is a good explanation for the task of aligning the agencies. Part of our work has been to determine the point where both agencies are operating, the points where they want to be, and then develop a strategy to get the desired destinations to overlap.
Not only have I been able to attend these meetings, but I have also been able to participate. One of Dr. Wilson’s deliverables was to create and present a strategic framework for AHRQ. It was incredible to me that within my first few weeks of the placement, I was helping to shape a strategic framework for a government agency. This project challenged my analytic skills; tying a vision and mission to available tools and levers within the statutory framework and OMB rules of engagement. I thoroughly enjoyed this project; it challenged my skills and gave me a deeper understanding of government.
Some of the other projects in which I have been involved include developing a framework for measure development; working with Section 1013 of the MMA, creating options to improve healthcare quality; developing a strategy for CMS to address the IOM Quality Chasm aim of patient-centeredness; and participating in designing pay for performance initiatives. Being involved with a variety of projects has helped me to achieve my goals and expectations for this year. Each project gave me a different viewpoint of the agency or agencies including the leverage points at their disposal. The projects also helped me to expand my understanding of the term quality and how to improve it.
Another highlight from my placement worth mentioning is the Ambulatory Care Alliance. This Alliance has brought together a vast array of stakeholders to create agreement and alignment on ambulatory quality measures, data aggregation, and reporting. Sitting at the table of these meetings are AHRQ, CMS, private insurers, physician groups, certification boards, employer coalitions, and consumer advocates. Attending these meetings has been a highlight for me because it truly embodies the beliefs of David Winston – the partnership between the public and private sectors. It is incredible to be in a meeting where all of the stakeholders honestly state their objectives, priorities, and timeframes. I never thought that I would witness a meeting quite like this. Participating in this Alliance has helped me to think about the roles of numerous stakeholders, drawing connections between these dots to create transformational change.
Looking Ahead As this incredible adventure comes to an end and I begin to transition into the next phase of my career, I have many mixed emotions. I am sad that this year has gone so quickly and that no other experience I will ever have will come anywhere close to comparing. Over the past year, I have learned and grown more than all my years of school combined. At the same time, I am feeling energized and excited because I know that this is only the beginning. I have the tools, network and platform from which to pursue other options because I have been a David A. Winston Health Policy Fellow. This fellowship has enabled me to begin chasing my dream of working in health policy to make our health care system highly reliable, high quality, and person centered – my broadened definition of my passion to improve health care quality.
Rachel Nuzum, MPH, 2004-2005 Winston Fellow It’s truly hard to believe that my year as a Winston fellow has already come and gone. Just over a year ago, I arrived in DC and this amazing journey began. Now I’m getting settled into my new role as the health policy advisor for Senator Cantwell, and adjusting to life as a home owner!
When moving to a new city, everything is a challenge. The AUPHA staff and the former fellows were instrumental in making us feel welcome right from the beginning. Even before we arrived into town we had suggestions on neighborhoods we might enjoy, tips on how to handle the logistics of moving and a welcome cocktail party in our honor scheduled. The AUPHA staff even provided recommendations for local jazz acts for my husband and I to enjoy. I can’t stress enough how helpful it was to have a ready-made network of former fellows that were willing and able to share their time and insights with us. It not only made life as a fellow easier, but I’ve made some lifelong friends as well.
Having Katie Baker as a partner in crime during our year as fellows was invaluable. Her enthusiasm for everything was contagious and she never failed to make me smile or laugh regardless of what was transpiring. I’m honored to have been able to get to know and work with Katie and call her a friend. Diana Birkett and Chad Shearer went out of their way, repeatedly, to help us succeed. I hope I can be half as helpful to the new fellows as Diana and Chad were to Katie and I.
One of the most exciting parts of the fellowship was the opportunity to sit down and brainstorm about who I’d like to meet in the world of health policy. Rare was the occasion that the AUPHA staff couldn’t make our dream meetings happen; our access to the experts still boggles my mind. From mid July to mid October, Katie and I met with over 150 people. We really maximized our time and covered a lot of ground in the three month period. Katie and I learned a lot about each other and ourselves as we tried to meet as many health policy leaders as possible. Our busiest days included 4 meetings or interviews, often in various parts of the District. I have fond memories of running in the August heat for the metro dressed in a suit while typing on my Blackberry – I had become a Washingtonian!
After a month or so, we settled into a nice routine of scheduling, preparing and reviewing for our meetings in a more relaxed manner. In the evenings, I researched the individuals and organizations we were meeting with and developed questions for the meeting.
Many of the meetings inevitably turned to the topic of the upcoming election and possible implications of a second term for Bush or a Kerry administration. We attended debates that featured top officials to the Bush administration and the Kerry campaign and watched as healthcare became an issue that both camps were trying to distinguish themselves on. Also during the meetings, I first heard the famous words “pay for performance” and realized the importance of the cost, quality, and access – the triad of health policy. It also became quite clear that Health Information Technology was going to be a predominant theme of any viable healthcare agenda. Liability reform was also a top issue and the patients’ bill of rights was discussed regularly. Our best meetings were those in which the participants were passionate about their areas of expertise and willing to suggest individuals for additional meetings. For example, Linda Fishman was a wonderful resource having worked both on and off the hill Not only did she have expert advice on what to look for when considering a placement location, she was funny and down to earth, reminding us that this process is fun and that we should be enjoying ourselves. Having two fellows in the meetings was very helpful at the beginning of the process. I really enjoyed being able to prepare with a colleague and debrief after a meeting as well. I think committing to two fellows is a fantastic idea. However, two fellows will typically mean two different sets of interests and maybe even two different political ideologies. For the most part, our different interests enhanced the learning experience and exposed us to issues and ideas we may not have sought out personally. There were however, times that it was hard to strike a balance in some of the meetings and make sure that both of our interests were being pursued. There were also meetings that were very partisan that inevitably appealed to one of us more than the other which provided for occasional mild discomfort. For the most part I think this was due to the election politics that were gripping the nation especially hard at that specific time. My recommendation would be for future fellows to have open conversations on this topic so that both feel that they’re being respected and that they have the opportunities to pursue their interests. This worked very well for Katie and I. We did the majority of our meetings together, separating in late September as we began to narrow down our choices for our placements. One major advantage that enabled us to maximize our time was the acquisition of the Blackberry’s. We were able to schedule meetings, respond to email and confirm directions on the run which was the only way I can imagine being able to keep all of the meeting times, locations and specifics straight. It was also very helpful to have remote access to the AUPHA server, especially with AUPHA located in their new location of Arlington. It was wonderful to have a “home base” at the AUPHA office, especially at the onset. As months wore on however, we were in the office less and less and the technology really helped us to maximize our time.
I had a pretty good idea upfront that I wanted to work for Congress. The way I saw it, this might be my one chance to live and work in DC so why not really do it and do what could only be done in DC? The pressure to decide on a placement location before the election was particularly high. Although the board members were supportive of us waiting to decide on a placement location, we knew that fellows from other programs would be pounding the pavement looking for placement locations, so we chose to decide sooner rather than later. By September however, I realized that there was no way I was going to know for sure what was going to happen in the election or how that would affect the congressional offices before it was time to make my choice. For example, even if a particular member wasn’t “in cycle”; the outcome of the congressional elections could change the ratio of majority and minority members on a committee and could lead to committee changes. Since the committee level is where much of the work is done, I knew that I wanted to work for a member that was on a key authorizing committee for health issues. I finally realized that all I needed to do was remember what I wanted to work on - improving access to healthcare for underserved populations, particularly rural populations – and to focus on finding a placement location that would enable me to do just that.
When I walked into the office of Senator Bingaman from New Mexico, I knew I had found my home for the next year. We met with the Bruce Lesley, the Senior Health Policy Advisor and discussed Senator Bingaman’s work on health issues. I knew that Senator Bingaman had a strong history of advocating for underserved populations, protecting the safety net providers and that he truly understood the challenges of delivering care in a rural setting. In addition, Senator Bingaman is one of the few members that are on the Senate Finance Committee, which has jurisdiction over Medicare and Medicaid, and the Health, Education, Labor and Pension Committee which covers all of the discretionary health programs. Regardless of the outcome of the election, if something was going to happen on healthcare, I knew Senator Bingaman would be intimately involved. My decision was made and I became part of the Bingaman family in November.
One of the first issues I focused on was the FDA, vaccine purchasing policies and the drug approval process. On my second day, I wrote a letter to the FDA asking that New Mexico to be allowed to partner with Illinois to purchase flu vaccine from Europe in response to the shortage. Later that week, I staffed the Senator at the Vioxx hearing where four other drugs were mentioned as being of questionable safety, setting off a flurry of activity focusing on the FDA. On Friday of my first week, I found myself at my desk at 8pm, preparing for the appropriations bill to be released so that I could go through it and decipher implications for New Mexico. Later that night, Senator Frist announced that the bill would not drop until 12:00 or 1:00 am and that the vote would happen by 10am the next day. I wondered briefly how anyone would have time to go through the 1300 page document between 1 am and 10am the next day before realizing that it’s not physically possible and that most people were heading home to get some sleep before the long weekend at work got underway.
Later that month, the legislative team began to meet with Senator Bingaman planning our legislative agenda for the session. I focused my presentation to him on obesity/nutrition education issues and children’s mental health. This is when it hit me – I’m talking to a US Senator. He’s listening to me and asking questions. Later I’ll realize that he’s willing to take my advice. I panic briefly and then smile and realize that this is it! This is what I’ve always wanted to do and I’m doing it.
Much of my time in the office focused on obesity and nutrition issues which are a high priority for the office. With obesity levels rising all over the country but even higher in rural, underserved areas, New Mexico was often on the cutting edge of programs and policies to combat the obesity epidemic. I took the lead on the reintroduction of the Improving Physical Activity and Nutrition Act (IMPACT) with Senator Frist. In addition to modifying the legislation to make it palatable to the new chair of the HELP committee, we also combined language addressing eating disorders from a bill that Senator Clinton and Senator Bingaman partnered on in the 108th. This was a great opportunity to learn the art of compromise, how things get accomplished and the importance of having a “moving vehicle” in Congress. I met with key groups such as the American Cancer Society, American Heart Association, etc. to make sure that all of the interests were represented and that the bill had adequate support for reintroduction. The highest profile issue in our office this year was Senator Bingaman’s work to preserve Medicaid and to stop cuts to the program. Along with Senator Smith, we introduced a bill that created a bipartisan Medicaid Commission that would examine the program and make programmatic policy recommendations in a year. After 30 years, there was no doubt that the Medicaid program could probably use an examination and some updating. However, Senator Bingaman felt strongly that this shouldn’t be done in the context of a budget crisis. Instead, he thought that the Medicaid program should be examined systematically so that informed changes could be made if they were determined to be needed. The bill was eventually offered as an amendment to the budget and it passed, striking the instructions to the Finance committee to find $15 billion of savings from their jurisdiction and instead recommending a bipartisan commission. After much effort and compromise, instructions for the Finance committee to find $10 billion in savings remain. It remains to be seen how the budget conference process will play out or how effective the commission that Secretary Leavitt will appoint will be.
Another bill that I took the lead on was the Children’s Health Crisis Relief Act which seeks to increase the number of trained and licensed child and adolescent psychiatrists. I was able to follow the bill from drafting with Legislative Counsel to soliciting endorsements to writing the floor statement. In February, I had the opportunity to travel to New Mexico to participate in the Student Leadership Institute (SLI). The SLI is an annual event that Senator Bingaman and his legislative staff participate in. High school students from across the state were invited to attend policy sessions on multiple issues, including health care. I led the health policy sessions with my colleague, Nancy Falk. Together we conducted sessions with over 150 students and had them grade the health of their community. After grading their community, we talked about policy solutions to some of the problems they identified and discussed other possible solutions. After two days and many hours in the car, we had covered many miles and had conducted sessions in Santa Fe and Farmington. My final day in New Mexico was spent meeting with groups working on nutrition and obesity issues, the mental health purchasing collaborative and HIV/AIDS groups. This visit to the state was really instrumental in feeling like part of the team and putting the issues that we work on everyday into context.
In early spring, work began on the Ryan White Reauthorization effort. Having worked with this program in two other states before, I was comfortable engaging in discussions about how to improve this program which provides much needed services and treatment for individuals with AIDS. Much time was spent meeting with HIV/AIDS groups both from New Mexico and from national organizations. By the beginning of May, I was starting to wonder where I’d be after the fellowship. It felt like once I had an idea as to what I was supposed to be doing, let alone how to do it, it was time to move on. The idea of leaving and starting the job hunt was a bit daunting. I had the perfect job. Why would I want to leave? What could possibly better than what I’m doing now for Senator Bingaman? Eventually, I realized that although every office is different, they all present an opportunity to grow, learn and contribute. I was certain I wanted to stay on the hill because my time here just went by so fast. I knew that I still had so much to learn and that there was so much that I hadn’t seen yet. Thanks to all of the meetings I attend and the remarkable network that the Winston Fellowship provided me with, I learned of opportunities that I never would have had it not been for the fellowship. The most exciting opportunity was to serve as the Health LA for Senator Cantwell from Washington. My year as a Winston Health Policy Fellow was truly the most transformational of my life and I’ve learned many things. I’ve become rather immune to warnings over the intercom about “suspicious packages”. I’m no longer perplexed by the yellow color and slight odor that Congressional mail has. I learned that no matter how many times you practice an evacuation, when the time comes for the real thing, it’s still going to be chaotic and even Senators don’t always know where to go. I’ve learned that the first floor in the Hart building is the same as the ground floor in Dirksen and that the “cloakroom” is a man in a hallway in a chair, not a room at all. I’ve learned how to type using only my thumbs while crossing a street and talking on the phone. But most of all, I’ve learned that there are passionate, intelligent people here working more hours than one would think physically possible to make our country a better place. It’s been a privilege to be part of such a group and an honor to be able to continue to do so.
I’ve tried to explain how this fellowship has changed my life but there’s more to it than that. Constituents that I’ve met with have taken my hand and told me through their tears that all they really wanted was for someone to listen to their story, to listen to them. I was able to listen but even more importantly, I was able to act. I was able to bring their concerns to the attention of two United States Senators who truly care about the well-being of their constituents and who are willing to take on the tough issues to get their problems solved.
Diana Birkett, MPH, 2003-04 Winston Fellow As my year as a Winston Fellow draws to a close, it is startling to think back on the beginning of the year, to realize how much I have learned and how much has changed. I could never have imagined the opportunities I have had, the things I am doing now, or that I would have the chance to stick around. But this place can get to you – meeting passionate people on an almost daily basis, being given a heady level of responsibility, never quite knowing what the next day will bring, and having the good fortune to call each day’s different learning experience “work.” I’ll admit to a bit of idealism (I don’t plan to lose it entirely just yet) but that isn’t what’s keeping me. I don’t feel done here – there is still far more I can learn, and I am excited to see where the experience leads.
Someone asked me the other day what I would have said if someone told me a year ago that I would be exploring the opportunities I have been for the coming year. I might have brushed them off with a laugh. One stunning thing about health policy – which everyone says but you can’t quite believe until you experience it – is that everyone knows each other. It is a small network, and once you get to know some of the players you begin to see opportunities to play a part yourself. I don’t know that I would have gotten this far without the fellowship, and certainly not so fast – I might be in Seattle working for GAO. The fellowship is like a ticket to a party that you didn’t even know existed, but that may change your life entirely once you do.
“Orientation” The fellowship stretched my thinking and challenged every part of me, beginning on day one. One of my weaknesses coming into the year was a temptation to shy away from things I don’t know how to do, or where there wasn’t a clear model to follow. And I sure didn’t know how to set up a three-month orientation to health policy. A small network of former fellows was a great asset – the more ways to get together with them early on the better. And with the great help of Dennis Morgan and others at AUPHA – who had plenty of work to do on top of helping us - Chad and I were able to identify people with whom we wanted to meet and set up appointments. Chad and I met with over 150 people in and around DC between mid-July and mid-October. It was helpful to approach the first meetings with structure. Each evening I read about the people scheduled for the next day and learned a bit about their organization from what was posted on the web or from articles they had written. Chad and I each developed questions for the interviews. Some questions were specific to a person’s work or to a particular issue they followed. Others were more general, such as:
What brought you to your current job? What skills, education, or experiences have been most important for your work today?
How does your work fit into the patchwork of organizations and individuals that work on health policy?
What do you think will happen in the coming year? What to you think the top health policy issues will be?
On this last question, Chad and I were able to informally poll the field on whether or not a Medicare prescription drug bill might come out of conference and be passed this year, and to get expert opinion on what that bill might look like. And we discovered that no one really knew!At the end of those three months, we had a split decision; perhaps an indication of the contentious negotiation process and quiet legislative year to follow. I particularly enjoyed hearing how people found their way into their current positions, because there was no common route. Too often I expect a clear path, thinking I should set 5- and 10-year goals and then take the steps necessary to get there. In reality, many leaders in health policy got where they are through a combination of interest, hard work, and pure serendipity. Things happen – like this fellowship – that steer you in a direction you wouldn’t have expected. And embracing those changes of course can reveal more wonderful 5-and 10-year outcomes than a structured process might have done.
Chad and I came to this experience with different interests, and were able to structure our interviews accordingly. As guinea pigs in the new 2-fellows set-up, we didn’t have a model from which to work. While not a stipulation of the fellowship, we decided to do most of our interviews together, learning about each others’ areas of interest on top of more general themes discussed at each meeting. As the weeks passed we did more meetings independently, and I think the balance worked well – having different areas of expertise probably broadened our learning. It was productive to have someone to de-brief with after each interview, it was nice to go through the process with a colleague.
We continued with interviews – long enough that each of us was itching to get to work. Starting a placement about three months into the fellowship might be a good goal, but I wouldn’t recommend cutting the interview period too short. There are few times in life where your main purpose is to learn and explore, at your own pace and with your own structure, and by meeting almost anyone you want. I would recommend taking full advantage.
I would also recommend, as others told us, staying in touch. Chad and I wrote thank-you letters to each person with whom we met, touching on unique things about each interview. Often these letters elicited a reply, follow-up meetings, or simply a reminder if we called up later in the year for information on a project. Another set of letters went out about the time we started our placements, letting people know where we would be. It was a time-consuming endeavor, but worth it to begin building a network.
The Placement Throughout August and September, Chad and I met with staff from Congressional offices and at the agencies, trying to find a good “fit” for a placement. A good fit meant matching interests, personalities, and timing. We followed up with offices of interest individually, had more in-depth second interviews, and ultimately chose a place to work.
I have been working with the Senate Finance Committee minority staff, on the health team. This was a good fit for me because they treat me like a staff member – expecting participation at all levels and creative thinking about building a portfolio of issues – and because their jurisdiction filled a hole in my health policy training – teaching me about the payment and structure of government health care programs. At first, the fellowship was a hectic whirlwind, and I wasn’t sure how best to fit in. I started my placement 4 weeks before the Medicare Modernization Act passed. Everyone in the office was stressed – after years of working on a bill they were so close and yet so far. Working for only one of two Democrats participating in conference, they were trying to contribute substantively to drafting sessions and member-level negotiations while working to bridge a divide with many in the Democratic caucus. It was an intense introduction to the mix of policy and politics that makes this place what it is.
With everyone so busy, training a new fellow was understandably not a priority. Which is where my good fortune in working with the people I do began to be apparent – instead of having nothing to do, I was handed the chronic care piece of the bill. Not a make-or-break provision, obviously, but an interesting issue and an area that I already knew something about. On my second day, I found myself in a drafting session talking about adverse selection and risk adjustment and wondering what had happened.
So the first weeks were a whirlwind – I attended one member meeting, a bunch of drafting sessions, briefings, and early-morning open houses Senator Baucus held to talk with Democrats about the bill. I tried to do anything I could that no one else had time for, and followed the rest of the staff around trying to soak in everything I could (seeking an elusive balance of being omnipresent and not annoying!). I watched C-SPAN and ticked off names during the cloture vote, was on the floor when the bill passed, and sat about 10 rows back in Constitution Hall that chilly morning when the President signed the bill. It almost seems like a joke that I am in all the photos from that morning – not your typical fellowship experience, but a part of history that I will not forget witnessing. If I had to name just two things that made my placement experience a personal success, they would be the trust that the finance committee staff extended to me, and my ability to grab a project and run with it. The first I have described; from the start, everyone treated me as a member of the team. This meant there were very few meetings or projects from which I was excluded, but also that with Medicare over I needed to start some projects and contribute substantively to the team. School – even grad school – is structured around a series of assignments; in this world, you take cues from researchers and mentors and others around you, and then you build your own.
So began my work on quality, and the start of writing a bill. Following up on an interest piqued during the interview phase and on some provisions in the MMA, I set about talking with as many people as possible about what we could do on health care quality, and then began developing a policy. That’s another heady thing about the Hill – you can call people up to ask about what they do, and they’ll make time to come in and tell you all about it. The process itself took far longer than I would have thought: balancing stakeholder interests, drafting and re-drafting, vetting ideas, thinking about how to structure a policy in an administratively feasible way and to match changes made in the MMA, and thinking about how to make “good” policy in the political context. This year is quiet – no Medicare legislation addressed for fear of changing or repealing parts of the MMA. Our team is using it as an opportunity to educate Senator Baucus and ourselves about aspects of the health care system, past attempts and current proposals for reform. We are holding a series of internal bi-monthly briefings with outside experts – on cost & value, drug pricing, the Kerry & Bush health plans, tax policy as it relates to health care, and health information technology, and more.I have found my fellowship-built network an asset in helping to arrange these briefings.
Another highlight worth mention is my trip to Montana. In 5 days, another staff member and I logged 1600 miles through eastern Montana, conducted 5 senior center meetings, and met with administrative officials at 20 hospitals, health centers, organizations, and media outlets. If DC ever seems like the center of the universe, I would invite you to head to eastern Montana, North Dakota, or a similar frontier area. Towns are tiny, jobs are scarce, and health care fuels the economy. In addition to getting some perspective, the trip provided me with practice in public speaking, working with the press, and constituent relations. While I value the ability to focus on policy as committee staff, it provided a good balance to get out into the field and talk with the people who have voted for and are represented by my boss. And it didn’t hurt to be visiting state with great outdoor sports, microbrews, buffalo burgers, and an inspiring horizon.
Looking ahead Somewhere along the way I had to acknowledge that the fellowship is a temporary opportunity, and to think about next steps. One former fellow recommended writing a list of 40 places I would like to work and setting out to learn more about those. While I never sat down and actually wrote them out, that idea kept me from feeling overwhelmed. In the end, talking to people on and off the Hill helped clarify how different opportunities might fit my skills and interests, and what doors different positions might open down the road. I decided to try staying on the Hill, ideally to find a spot with a Senator (apologies for my Senate snobbery…) on a committee of jurisdiction, where I would have the chance to work substantively on issues that interest me. Unlike other job search processes, looking for work on the Hill is all about keeping your ears open and being willing to jump when opportunities come up.
Finally, this is an incredible year and it is entirely your own to make. As I mentioned about following everyone around during Medicare, there’s a fine balance of being self-motivated and over-eager. I’m not sure I found it, but I would recommend that you try. In most cases, you have nothing to lose by trying, and interesting experience to gain.
Thank you to everyone who made this possible.
Chad E. Shearer, JD, MHA, 2003-04 Winston Fellow The David A. Winston Health Policy Fellowship has been, by far, the most exciting experience of my life. For as long as I can remember I have wanted to come to Washington, DC and experience how government really works. This fellowship has been the perfect introduction to the field of health policy, and has given me the tools and contacts I need to embark on a successful career of pubic service. I would like to thank everyone involved with the fellowship for giving me this opportunity, especially Dr. Rubin, the entire board and all the wonderful staff at AUPHA. I will never be able to express my full gratitude to those involved in this process, but I hope that everyone involved with this fellowship realizes what a wonderful legacy you have created in honor of David Winston. As I summarize my year here in DC, I hope the board and anyone else reading this realizes how blessed I feel to be part of this amazing fellowship. As someone from a town of 1,500 people in rural Iowa, this year has been more than I ever could have expected out of life. With that background I begin my summary as a sheltered Iowa boy moving to the big city. A little daunting would be an understatement in describing my feelings when I moved from Iowa City, population 65,000 (big by Iowa standards) to the DC metro area. Thankfully support from another fellow, the former fellows, and the staff at AUPHA made me feel right at home in very short order. So this is where it all begins, the first few weeks as a Winston Fellow. Learning a new city, meeting new people and trying to get settled in to an unusual style of urban life were all very scary. I am thankful that the staff at AUPHA had been through this before and knew that Diana and I would be completely lost without their guidance. Having meetings already scheduled with board members, former fellows and friends of the fellowship during the first few weeks were vital to the success of the initiation stage. I believe that all future fellows should follow this same basic outline for the first few weeks, and am happy to meet with them and set up meetings for them with people who will provide the most benefit during the early stages of the fellowship.
From about the first of August through the end of September, Diana and I were very busy, meeting with over 160 different people at over 120 different organizations. I was amazed at the level of access we had to high level health policy makers that I always thought should be doing much more important things than talking to me. The success of this fellowship relies heavily on that level of access, and as an alumnus of the program I hope to do all I can to ensure that access continues. Because of the health policy ball the fellowship has a remarkable following and name notoriety that is invaluable, and as more fellows reach the upper echelon of health policy, I believe someday people may refer to it in the same sentence as the Robert Wood Johnson Fellowship. The Winston Fellowship will generate the next generation of health policy experts, and I will always be proud to say I was a Winston Fellow.
My thoughts on the future of the fellowship (comparison to RWJ) may be a little premature, but I think the fellowship is moving in the right direction with the expansion to two fellows. I admit, I was a little apprehensive when I heard there would be two fellows, but it only took a short while to realize that two fellows is better than one. I don’t think it would be possible to find two better people to attempt be the first dual Winston Fellows. Diana and I, though we come from very divergent backgrounds, really seemed to click from the start. We have different areas of interest that made all our meetings very interesting as I asked about my issues and she asked about hers. I knew everything was working splendidly when I started asking questions about her areas of expertise and she mine. As the fellowship continues to grow, it will not always be possible to find two people who will be friends as well as colleagues, but I feel very lucky to have a new friend and an amazing sounding board in Diana. The great thing about the three month orientation phase of the fellowship, is just when it starts to get a little monotonous, the focus completely changes. Toward the end of September Diana and I both were worried that only a few early meetings provided any real placement opportunities. Dealing with the August recess precluded us from getting meetings on the hill until late September, but once those meetings materialized, it was apparent to me there was no other place to be. The strange thing is, it did not turn out the way I envisioned. Early on I thought it would be great to work for the Senate Finance Committee. The staff is absolutely amazing and I really thought I made a connection with them. The beautiful thing is, they were looking for someone like Diana, and I wasn’t the right fit for them anyway. Somehow with this fellowship it all seems to work out for the best in the end. When I did finally find where I belonged (the House), it was very hard to deal with the fact that both Energy and Commerce and Ways and Means wanted me to work with them. I was an absolute mess for almost a week as I pondered which office would be the right fit for me. Without Diana and Deb Veres I could have easily made the wrong decision, not that either position wouldn’t have been a great experience. Finally, with some great advice from board members, others in the field I had met with over the previous months and former fellows I decided to go to work for Representative Pete Stark and the Ways and Means Subcommittee on Health. For the rest of my life I will remember my interview with Mr. Stark and how welcome he made me feel, and that is how I knew I was in the right place.
With the placement decision out of the way, the remainder of the orientation phase seemed much less pressured than before. I was now able to engage people in policy discussions through the lens of where I was going to be working, which helped me focus my vision, but may also have closed off some of the initial openness that is common during orientation phase interviews. I think the timing of my decision and my start date with Mr. Stark near the end of October was ideal and I would suggest that all future fellows try to follow the same timeline. Coming to the hill in October 2003 was like walking into a raging fire. I’m sure many books will be written about the Medicare Prescription Drug Improvement and Modernization Act of 2003, and I will be able to say I was there for the end of it. Though I had learned much about the bill from orientation interviews, I had no idea how the fight was really playing out on Capitol Hill. My first assignments included writing dear colleague letters about sections of the MMA that I knew nothing about. I knew the learning curve on the hill was steep, but I had no idea just how steep. I spent the first month going to briefing after briefing trying to figure out what the conference committee was going to put in the bill. I learned more in that month than I did in four years of graduate school, and that knowledge will be absolutely invaluable going forward. In the end, the bill passed, against my boss’s objections, but with my own guarded optimism.
It was this vote in the House that taught me the most important lesson that I may ever learn on the hill. You don’t always have to agree with your boss, but you have to advocate his position with undying devotion. I had never figured out why I went to law school before the Medicare vote, but in only a month it had all become crystal clear. As I sent out the press release at 6 A.M. on a Saturday morning, I couldn’t help but think that after a crazy all-nighter (didn’t think there were supposed to be any of those after grad school) I had witnessed a little bit of history. Unfortunately, my grandkids are going to have to hear about it 50 years from now and for some reason I doubt they are going to feel the same way about it that I do.
After the Medicare bill passed, I spent the next two months trying to figure out what the statute actually said and did. In two months I learned a couple of key provisions, and at the same time learned the second most valuable lesson on the hill. Everyone here has a specific area of expertise, and no one is expected to know the minutia of every single policy. For the Medicare bill, my area of expertise became the drug discount card and its implementation. I continue to pretend that I was given that responsibility because I had some clue about what was going on, but realize that my staff wanted to give me something that would be nearly complete when I left in July. Amazingly enough, I now consider myself to be somewhat expert on the discount card program. I realized this when other staffers started calling me and asking me questions I could actually answer. It felt really good to know that others looked to me for answers, and how lucky I was to be in the right place at the right time to get that opportunity.
It should be no surprise that I have spent 90 percent of my time here dealing with the Medicare bill. I have written constituent letters, dear colleagues, opening statements, floor statements, briefing memos and numerous other staff documents all dealing with MMA. I have, however, also worked on a number of other interesting and surprisingly diverse health policy issues. My major piece of legislation during the fellowship was the Medicare Early Access Act of 2004. This bill would allow certain people between ages 55-64 to buy into the Medicare program with the help of a substantial refundable, advanceable tax credit. The goal of the legislation is to reduce the 3.6 million uninsured people in that age group by giving them an affordable coverage option not currently available in the private market.
I have also become deeply involved in the drug reimportation issue and all its associated offshoots. In particular I have become the office expert on the interaction of international drug pricing and trade negotiations. As the United States Trade Representative negotiated a free trade agreement with Australia I was thrust into the debate over whether the Australian reference-pricing model was an unfair barrier to international trade. Though I viewed this as a public health issue rather than a trade question, I quickly learned that business interests have amazing power to get what they want in trade agreements. This was my unfortunate third lesson on the hill, everybody has a financial stake, and sometimes money is the power to get things done. To make a long story short, I had numerous meetings with PhRMA, USTR and Australian ambassadors, which opened a whole new realm of policy I had never even considered.
As the months flew by, and they did fly, I began to worry about the next step in my career. I thought about what seemed like millions of options – moving home, working in a hospital, being a lawyer, lobbying, staying on the hill, working in an agency – but no matter how hard I looked, I couldn’t seem to find a job that fit me. I put in a few resumes and made some contacts back home, but I was not really excited about my prospects and was beginning to think I would have to go back to Iowa with nothing to show for this year in DC. Luckily, when it rains it pours and for me two great opportunities came knocking at my door in less than 24 hours. I had already decided by late April that I wanted to stay on the hill, if possible. Fortunately for me, hill jobs are about who you know, not what you know, and working for Cybele Bjorklund and Debbie Curtis, I seem to know everybody by association. I knew there was an open job with a blue dog, but I wasn’t all that excited about ending the fellowship early and moving to an office that didn’t really match my political leanings. I did decide to interview with that office, and came to find it would have been a great fit for me. This was a Thursday, I was to meet the Congressman on Monday, and likely would have had the job by Tuesday.
Knowing I would have to leave the office I love, I stuck my neck out and made a proposition to my boss. Though healthcare is my first love, and will always be my main issue, I would be remiss if I pigeonholed myself into one area of expertise. Realizing there was an open position on Rep. Stark’s staff I made a play for the position of Legislative Assistant covering tax, trade, labor and health on his personal staff. By Friday afternoon I had the job and I know that this is right were I am supposed to be. If someone would have told me last year at this time that I would be staffing three Ways and Means issues for the second ranking democrat on the committee I would have laughed. As it is, the Winston Fellowship has put me in a position to do just that, and that is a debt I will never be able to repay.
So with that story finished, I can look back on my year and reflect on the experience knowing where I have come from and where I am headed. My initial reflection is this fellowship is an amazing opportunity for someone my age with no previous Washington experience. The design of the fellowship was ideal for me in that I needed the first few months to really get my bearings before finding the placement that was right for me. I cherished the ability to go out on my own and have meetings with people that interested me, but appreciated the structure of having many of the meetings pre-scheduled when I arrived. The freedom during the initiation stage allowed Diana and I to learn from each other, but also to pursue our own interests without causing each other undue hardship. The placement process is as scary as any other job search, but I always knew there were certain people I could turn to for help and guidance. Though I am independent to a fault at times, I finally broke down and called former fellows and people I had met along the way and asked pointed questions about my placement options. Come to find out, I got great advice from everyone, and that led to the right decision. In hindsight I would have developed a better dialogue with a number of board members during this period of time, but I was always very cautious not to abuse the access I had to board members.
The placement itself is by far the best aspect of the fellowship. To have Diana and I on Finance and Ways & Means says a lot about the fellowship and the quality of experiences open to Winston Fellows because of the successes of former fellows. Though the learning curve is steep on the hill, and there are many other possible placement opportunities in and around DC, I truly believe that most Winston Fellows should pursue opportunities on the hill. There is nowhere else in the world to learn the ins and outs of health policy making like Capitol Hill. I agree that certain individuals may be better suited to other placements, but as a general rule I will advocate a hill placement when I meet with future fellows.
Planning for the long-term during the late stages of the fellowship was a fairly easy process as soon as I decided what I wanted to do and where I wanted to be. It is unbelievable to look back now and see how many contacts I have made, knowing that I have a list of 20-30 people that I can call today and pick their brains about current policy, job opportunities or anything else that may tickle my fancy. With this type of network it would have been nearly impossible for me to not find a great first job in DC after the fellowship. In reality I had people looking for jobs for me before I was even ready to begin the process. Developing and utilizing this network is one of the major keys to being a successful Winston Fellow, and though I don’t have the network Diana does, I do have the key contacts I need to get where I want to be ten years from now.
With that thought in mind, my long-range goals are a little hazy, but I am still thinking about positioning my self for a run at elected office in Iowa in about ten years. My current plan would be to stay in DC for another 5 years, move home, develop a name for myself in the community, and run for the state legislature, or maybe even Congress if the cards fall in the right places. Obviously I have no real idea where I will be ten years from now, but I do know that I have put myself in a position to do whatever I want with the knowledge I have gained and will gain over the next few years here on the Hill.
In closing I would like to express my gratitude to a number of people who have made this year the most amazing year of my life. First and foremost I must thank Diana, whom I would have been lost without. Obviously I have no frame of reference, but I can’t imagine going through this process by myself. I was very lucky to have her as a colleague, but am even more blessed to know that I have gained a life-long friend. The staff at AUPHA, especially Dennis Morgan, was instrumental in making this process run as smoothly as possible. Finally, my thanks go out to the board, especially Dr. Rubin, and everyone who makes this fellowship possible. Your constant support, gracious gifts of time and wisdom and continual openness make this fellowship what it is today. Though I only know about David Winston through stories and anecdotes, I feel blessed to be part of something that bears his name. I can say without hesitation that this fellowship has changed my life, and will be an amazing springboard for all my future endeavors. Again, I would like to thank everyone involved in making this year so special. Jason Ormsby, 1999-2000 Fellow My name is Jason D. Ormsby and I am the 1999-2000 David A. Winston Health Policy Fellow. Before I pursued the fellowship, I had only a small understanding of its parameters. In fact, only now do I realize the true importance of the position and the incredible career-building opportunities it affords. I am writing to supply you with information regarding my experiences, and persuade you to place the Winston Fellowship at the "top" of all your students’ post-graduate pursuits. It is my opinion that little is known of the fellowship "outside the beltway". I can honestly say that within the Washington community, it is highly respected. I am hopeful that when you review the enclosed materials, you will reserve this experience for only your finest scholars.
My Fellowship Activities June (2nd week) - Private (2 hour+) meetings with the Winston Board members. These individuals are some of the most influential leaders within the health care community. Even with their limited time allowance, they are always attentive to the Fellow’s needs and will arrange any meeting that is desired for the entire year.
June (3rd week) - Attended AUPHA’s annual meeting. For students interested in pursuing future graduate work (Ph.D.), this situation allows one to spend time with academic leaders from across the country. June (4th week) to September (2nd week) - Experienced more than 100 meetings with health care leaders from every sector of government, academia, and industry. The term "health care leader" is not used loosely. The meetings are with only the leaders of the organizations, which proves to be extremely exciting as well as informative. I have included most of my sessions in the following list:
Government White House (President’s health advisor) U.S. Congress (Congressmen and Committees) U.S. Senate (Committees) Office of Management and Budget (Director/Health) HCFA (5 different Program Directors) Dept. of Health (Inspector General) FBI (Health Care Fraud) HRSA (4 different Program Directors) AHCPR (Administrator) General Accounting Office (Director+Analysts/Health) Congressional Budget Office (Director+Analysts/Health) National Institutes of Health (Program Directors)
Health Care Organizations (Lobby/Associations) National Committee for Quality Assurance (President) Joint Commission on Accreditation of Healthcare Org (Vice-Pres) American Hospital Association (3 Vice Presidents) American Medical Association (2 Directors) American Association of Health Plans (Director) American Association of American Medical Colleges (Director) Federation of American Health Systems (President/Vice Pres) Association of Schools of Public Health (Executive Director) Voluntary Hospital Association (Vice President/Managers) American College of Healthcare Executives (President/Vice Pres) Healthcare Leadership Council (President) American Association of Dental Schools (Executive Director) National PACE Association (Director) Center for Studying Health System Change (President) National Conference of State Legislatures (Director/Health) Health Insurance Association of America (President) National Association of Community Health Centers (Vice President) Citizens Advocacy Center (President) Healthcare for Special Children Foundation (CEO/President) Catholic Health Association (Director) National Rural Health Association (Director) Healthcare Companies (Lobby/Associations) Humana (Vice President) Pediatrix (Vice President/Director) LEWIN Group (President+Analysts) Health Plans of Greater New York (Vice President)
Pharmaceutical Companies (Lobby/Associations) PHARMA (President) Eli Lilly (5 Directors - site visit to Indianapolis) Pfizer (Vice President) Merck (Director) Bristol-Myers Squibb (Vice President) BioTechnology Companies (Lobby/Associations) Health Industry Manufacturers Association (Vice Pres/Directors) BioTechnology Industry Organization (Director) Genentech, Inc. (Director)
Academic "Think tanks" Institute of Medicine (Executive Officer+Analysts) Brookings Institute (Director) Heritage Foundation (Vice President+Analysts) Alpha Center (President+Managers) American Enterprise Institute for Public Policy Research (Director) Urban Institute (Director) Academy for Educational Development (Vice President+Analysts)
Current Situation At the commencement of my information sessions, I was selected (facilitated through networking channels) to be one of three professional health policy analysts for the Ways and Means Committee - U.S. Congress. My first two weeks at this powerful Committee has been extraordinary. With pending legislation in Balanced Budget Act refinements, fraud and abuse, medicare reform, patient appeals, medical record confidentiality, and physician reimbursement, the learning experience is unparalleled. I am at the apex of the health policy-making process and the magnitude of my responsibilities correspond accordingly. My day includes meeting with lobbying groups, briefing Congressmen on health care issues and legislation, attending policy meetings, planning hearings, and coordinating specific issues for future legislative efforts. I will remain in this position until the end of my fellowship (July 2000). In addition to my work at Ways and Means, a generous Winston travel budget will allow me to attend conferences and seminars. Because of the prestige of the Fellowship, most registration fees are covered by the organizations involved.
The Candidate The Winston Fellowship is obviously a wonderful experience. However, I do not think it should be viewed in this temporary manner. People who choose to pursue it, should be those who want to enter the field of health policy/government relations. In my opinion, these are the individuals that would derive the most benefit from the post-graduate endeavor. Most of the past Fellows (not all) remained within the field of health policy, ... with several in Washington D.C. The past Fellow, Deborah Veres, is now the health care advisor for Senator John D. Rockefeller. Maturity and past work experience is essential for success. It is imperative that the Fellow have an excellent grasp of the health care system, from the clinical foundation to the governmental agencies. Because the meetings are with the "elite" of the policy world (many of them former clinicians), an informed Fellow will promote a mutually-beneficial interaction. Final Analysis This is the perfect opportunity for someone, with an existing interest in health policy, to broaden their horizons. There is not another avenue, to my knowledge, that so dramatically advances a post-graduate in the field. I hope this information has given you a better perspective on the experience and serves as a catalyst in the promotion of the Fellowship.
Thank you for your valuable time and feel free to contact me with any questions.