Sebelius' health care plate is full

Forty-five years ago, U.S. Rep. John J. Gilligan cast one of the 307 House votes that created Medicare and Medicaid.

That piece of "Great Society" legislation changed the delivery of health care in America.

Now Gilligan's daughter, Kathleen Sebelius, the Health and Human Services secretary, is the general in charge of another sweeping change in the health care system.

Implementing the health care bill passed earlier this year makes her one of the most powerful bureaucrats in the country with one of the toughest jobs.

How important is her role?

Forbes magazine last year ranked her the 57th most-powerful woman in the world.

Gilligan, now retired after a public service career in Ohio, admits he's "a little prejudiced," but says "he can't imagine anyone doing a better job. She's steady. She's not a volatile person. And everything she's ever done has contributed to her ability to handle the stress and strain."

Less-partial observers agree that Sebelius is handling the job with aplomb, even as it puts her on the hot seat for critics of "Obamacare."

"You have to deal with what comes at you," Sebelius shrugged with characteristic understatement in a recent radio interview. "You use the resources you have and figure it out... You don't get time to say let's stop for a month or two."

Massive challenges

Here's what the former legislator, insurance commissioner and governor of Kansas is facing:

The massive health care bill says "the secretary shall" make roughly 1,300 decisions on provisions in the bill, everything from the smallest detail to defining what constitutes "essential" health care.

She's charged with leading teams of government regulators who will add an expected 30,000 to 50,000 pages of regulations to the 2,800-page law.

And "she's writing those regulations under such a cloud of uncertainty. Everything she does will become a political football," said Patrick Tuohey, who managed the successful Yes on Prop C campaign in Missouri.

Tuohey is one of the health care law's most successful opponents. On Tuesday, primary voters in the state resoundingly rejected a key element of the law, the requirement that individuals purchase health insurance by 2014.

But whatever he thinks of the policies, he's charitable toward Sebelius herself: "I don't envy her."

Indeed, few would.

"Implementation is incredibly difficult, and unlike with Social Security or Medicare, the secretary does not have much help from the other side of the aisle," said Kansas City, Mo., Democrat Rep. Emanuel Cleaver.

"A person not hardened and shaped by Midwestern roots would, frankly, not have been up to the task," Cleaver said. "She is a successful Democrat from Kansas, and that's no small feat."

Private, personal side

A Roman Catholic who's been under fire from the church and anti-abortion advocates since her days as governor when she vetoed anti-abortion legislation, Sebelius' appointment to Obama's Cabinet was called "radical" by Troy Newman, president of Operation Rescue.

Patrick Mahoney, executive director of the Christian Defense Coalition, tried to create a social-conservative bloc to oppose her nomination.

But, reflecting some of the bipartisan support she's always been able to summon (Bob Dole backed her at her confirmation hearings), the Senate confirmed Sebelius' HHS appointment on a 65-31 vote.

Yet after confirmation, she immediately was hit with criticism from reform opponents. Last month a group of Senate Republicans accused her of misusing public funds to promote health reform in an ad using 84-year-old Andy Griffith.

But it's nearly impossible to hear someone criticize Sebelius personally. In public, she chooses words carefully and quickly deflects most personal queries to concentrate on public policy.

It helps that she has a dry sense of humor, say those who know her. For example, she enjoys telling about when the president sent a plane to rush her to Washington to deal with the H1N1 issue — while her confirmation hearings still were in progress: "I said to the guys on the plane, if they vote no, do I get a ride home?"

Home continues to be — at least once a month or so — in Topeka, where her husband, K. Gary Sebelius, is a federal magistrate judge.

"There are lots of demands on her time, but I don't think we've ever missed a night talking to each other," said Gary Sebelius, himself the son of a politician. "And we try to get together at a bare minimum at least every two weeks. ... She made some meals here last weekend when she was here and had some friends over. It's a way to exhale and get outside the pressure for a few moments."

The couple has two adult sons. Ned, born in 1982, is a lawyer in Boston and married Lisa Rockefeller last year. John, born in 1985, is doing graduate work in art and design at the University of Kansas.

Sebelius' personal side is rarely revealed in public. If she departs in interviews from public policy statements it's typically to praise "lots of very talented, very passionate people who are working hard to make sure Americans will see the benefits of this bill" rather than expand on herself.

Experience and determination

She does acknowledge that a lifetime of experience — a former executive director of the Kansas Trial Lawyers Association, eight years in the Kansas Legislature, eight years as the state insurance commissioner, one and a half terms as governor — was good preparation for dealing with partisanship and budgets.

Those who know Sebelius well say they can't imagine a person better suited to the challenges of her job — even in a climate lacking the bipartisan support that her father's Congress gave Medicare in 1965.

"I sympathize with the problems she confronts in Congress," her father said. "But there's nothing new about that. She and I both know how that works."

That family support is important.

"Having grown up in a political family, she's so savvy about the reality of politics," said Marcia Nielsen, vice chancellor-public policy at the University of Kansas Medical Center.

Nielsen was appointed by Sebelius to serve as chairwoman of the Kansas Health Policy Authority in 2005 and later served as the authority's executive director, working closely with Sebelius on public health issues.

"On a very basic level, she gets the political challenges. Plus, with both a policy and political background, it helps her wade through a really sticky and uncomfortable situation," Nielsen said.

Cleaver pointed out another asset: Sebelius' reputation for "dogged determination on the job."

A taxing schedule

Starting with a 6 a.m. jog on the Washington mall and finally taking pages of work home with her at 8 or 9 p.m., Sebelius faces a physically, mentally and emotionally taxing schedule.

"She runs about five miles a day most days," her husband noted. "I think that's very helpful to manage the stress."

"She has this Energizer Bunny-ness," Nielsen said. "Plus she's an incredibly quick study."

But more than energy, Gary Sebelius said, his wife has passion for public service and the topics she's assigned to handle.

Whether that's enough to shepherd health reform through a multiyear, multiagency process is yet to be answered.

Her department alone, with its $900 billion annual budget, 11 major agencies and 300 programs, must coordinate implementation with the U.S. Department of Labor, the Internal Revenue Service, as well as with the governors of all 50 states.

The law she's charged with implementing, the Patient Protection and Affordable Care Act, had Republicans united against it, and a day after passage, a bill was submitted to repeal it.

Subsequently, about 20 states and some organizations have mounted legal challenges against the law. And public sentiment, as evidenced in the Missouri vote, is strong. Many citizens don't want the government to tell them they have to buy health insurance, even as they bemoan the ever-higher costs of medical care.

Critics of reform also accuse her of downplaying actuarial estimates that the costs of reform will soar far higher than predicted.

In addition to those challenges, the law she's charged with implementing is under the microscope by many powerful business organizations, such as the U.S. Chamber of Commerce and the National Federation of Independent Business, that want to minimize employers' costs and make reform mandates more palatable.

Forging ahead

Sebelius remains resolute in the mission to extend access to affordable health care to those who don't fall under Medicare or Medicaid umbrellas.

It's time, she wrote in an essay published in the July 26 issue of Modern Healthcare magazine, to focus attention and dollars on preventive rather than catastrophic care and to remove "far too many decisions" from the hands of insurance companies.

Aided by the current Kansas Insurance Commissioner, Sandy Praeger, a Republican, who's helping lead the National Association of Insurance Commissioners in writing the first phase of reform regulations, Sebelius is forging ahead with the rules to put a broad range of reforms in place by 2014.

"With all the references in the law to 'the secretary shall,' she is the one who's going to interpret, create and amass the structure and specificity behind health reform," said Rick Kahle, president of the employee benefits division of the Lockton Cos., an insurance brokerage.

"It's going to be a contact sport for a while," Kahle acknowledged. "Most of our (insurance) clients have concluded that costs will continue to rise and that they'll have to do things differently, that they'll have to create a culture of health and productivity. But behaviors won't change with a light switch."

The first reform taking effect this year — requiring insurance carriers to extend dependent coverage up to age 26 — is being implemented at a "feverish" pace, said Tom Bowser, CEO of Blue Cross and Blue Shield of Greater Kansas City and a national industry leader.

No matter the pushback, "The law has been passed," Bowser said. "Our total focus is on helping the administration implement this" and "to make this massive health care law understandable and beneficial."

It helps having Sebelius in charge of implementation, Bowser said: "She's a known commodity. She knows our industry as insurance commissioner. She knows states' concerns as governor."

States' concerns

Indeed, some of her time recently has been spent with governors, hosting meetings to hear their concerns and guide them in setting up the state-based insurance exchanges mandated under the new law.

Still, many governors, like Americans at large, are skeptical about the high costs of reform. Budget-strapped states, suffering from tax revenue declines because of the recession and long-running, high unemployment, say the road ahead is under-funded and rocky.

But Sebelius as a former governor "understands the process," said Kathleen Stoll, director of health policy at Families USA, a consumer-advocacy group. "She seems to be calm in the face of the storm."

That storm is blowing in faster than some would like. Jay Kirschbaum, practice leader for a national legal and research group, Willis Human Capital Practice, said new compliance rules are being rolled out so fast that employers don't have time to provide input during the drafting process.

"I haven't heard specific reactions to Kathleen Sebelius, but our employer clients do note that HHS hasn't traditionally been charged with regulating employer-provided benefits, so it's a longer learning curve for the people at HHS than for regulators at Labor," Kirschbaum said.

He added that the Treasury Department and the IRS also have had more involvement with employer-provided benefits than HHS.

Fighting misinformation

On NPR's "Talk of the Nation" radio show on Tuesday, Sebelius referred to the strength of the anti-health reform storm and the need to contain or direct it.

On her radar screen is the fact that nearly half of the states are mounting court challenges against the health reform law.

"I'm not a lawyer, but I do get briefed by Justice Department lawyers about the constitutional issue" of the government requiring the purchase of health insurance, Sebelius said.

She said she's confident that the reforms stand on strong constitutional grounds, mainly that the federal government has the right to make the rules on interstate commerce.

Sebelius said she's most concerned about countering "so much misinformation out there" about health reform.

Misinformation was directed particularly at Medicare recipients, she said — a group that now includes her father, "a pleased beneficiary" of the program he helped enact, she said.

Sebelius said seniors have been targeted with anti-reform misinformation "that something would happen to their guaranteed benefits, that Medicare Advantage Plans would cease to exist, and people wouldn't have any options, that there'd be a restriction in coverage, that huge cuts were going to be made that would affect their care.

"Nothing could be further from the truth."

Reality is that "the truth" — the eventual consequences of health reform — is yet to emerge.

In that maelstrom of politics and policy, fans and critics of health reform alike agree that Sebelius has a thankless job.

"She'll not make anybody happy," Tuohey said "I'm sure there'll be some days she wishes she was back in Topeka."