We’ll never know what would have happened if Tom Daschle had kept his books in order and become Health and Human Services secretary. He was widely regarded as a promising choice for the secretary’s job and a role as point man on health reform for the Obama administration. What is clearer is the likelihood that Daschle’s tax peccadilloes will throw a monkey wrench into the timing of the administration’s health reform initiatives.

In a keynote presentation Monday at the AcademyHealth/Health Affairs National Health Policy Conference, Daschle’s lieutenant Jeanne Lambrew, deputy director of the White House Office of Health Reform, outlined health provisions in the pending stimulus package. But Lambrew cautioned that it would be “a few weeks” before further details about the administration’s overall health reform strategy would be announced, due to the urgent priority of working through the first steps of its economic recovery program.

Meanwhile, congressional leaders are not yet on the same page with the timing question. House Majority Leader Steny Hoyer (D-MD) said cagily last week that he is committed to enacting broad health reform legislation during the 111th Congress, but not necessarily this year. But Senate Finance Chairman told the AcademyHealth conference Tuesday morning that fast action is imperative. “We have to get momentum,” he said, and “seize the opportunity.” Baucus reiterated the need for speed after the news of Daschle’s withdrawal. “The committee’s moving full speed ahead.”

There is momentum. Democratic leaders are hoping that long-delayed reauthorization of the State Children’s Health Insurance Program (SCHIP) will come this week. The health provisions in the stimulus package have the wind at their backs, although Republican staffers offered an assortment of criticisms of proposed Medicaid, COBRA, comparative effectiveness, and health information technology (IT) measures at an AcademyHealth panel Tuesday morning. But the administration can hold up its end of the stimulus negotiations without a confirmed HHS secretary on board.

Perfecting the design and political strategy for the next phase of the health agenda, though, will require a full-strength leadership cadre. Office of Management and Budget Director Peter Orszag was quoted by Lambrew and others at the AcademyHealth conference as saying that the cost problem is rooted not in Medicare and Medicaid but in the health system as a whole. The need to change the delivery system, and not just insurance payment, is increasingly recognized as the foundation for cost control. So while Congress will have to address Medicare physician payment again this year, the need for an array of Medicare changes that will foster delivery-system change needs to be thought through in the context of future private-sector coverage expansions. That implies that the Centers for Medicare and Medicaid Services (CMS) should be involved in reform strategy. But a new CMS administrator can’t be appointed until there is an HHS secretary. The same logic applies for other key HHS positions. Democratic staffers also said on Tuesday that congressional leaders will want to hear from the Obama administration before proceeding with details of legislation now on their plates. So in the short term, at least, Daschle’s withdrawal means that the administration will have trouble storming out of the gate with health reform as soon as the stimulus package is launched.

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