Wednesday, December 24, 2008


It is an interesting time to be in Washington D.C., particularly working on issues of health and health care. I look forward to seeing how things play out with so much talk of health reform going around. I recently picked up a few books and reread some old ones that I think help create a good foundation of knowledge about the challenges and possibilities for health reforms in the coming years. I wanted to highlight four that I think are great reads:

The first and probably most approachable book is Critical: What We Can Do About the Health-Care Crisis by Senator Tom Daschle (with Greenberger and Lambrew). This book is a good primer for the upcoming health care debate, and is extremely timely (making it somewhat hard to find at a bookstore...) given that Daschle will likely be the next head of the Department of Health and Human Services. Daschle, an experienced former Senator, brings a unique perspective to the discussion and highlights the plight of real Americans using poignant and illuminating examples from people he has interacted with during his long career of public service. The book does a good job providing a clear overview of what must be taken into account and what reforms should be made. It is written in a very engaging manner and would be a great read for anyone even vaguely interested in one of the possibly largest overhauls to the U.S. government in history.

The second book is Health Care at Risk: A Critique of the Consumer-Driven Movement by Timothy Jost. Jost is a law professor but the book reads more like a thriller (well, maybe not for most people...). He paints a clear picture of the rise of the consumer-driven health movement and highlights its intellectual as well as political origins. While it would seem that consumer-driven health would be the focus of the book, in fact, that is only one part of the overall story. Jost constructs the most clear and concise narrative I have found about the rise of the current U.S. health care system and how truly exceptional (not in a good way, by most accounts) the American system is. He does a good job identifying the common conceptions that people have about health care and the possible solutions. His analysis questions many of these assumptions and forces us to think critically about the goals of health care and what those goals would mean for reforms.

The third book is Governing Health: The Politics of Health Policy by Weissert and Weissert. The book is the best source I have seen that lays out the different actors and interests that play a role in the health care debate. Each of the key players (Congress, the President, interest groups, etc.) is explored at length, including their often contradictory and nuanced stances and perceived interests. Written by two political scientists, the book provides an excellent overview of the factors that are likely to come into play during any health care debate, particularly one that would entail wide-ranging reforms to the system. The actual policy process is also highlighted, something that is often discounted when people talk about what should be done when it comes to health. Taking into account the feasibility of particular reforms will be key for the new administration and any advocates of reform.

The final book is Why Are Some People Health and Others Not? The Determinants of Health of Populations, edited by Evans, Barer, and Marmor. This classic book is a personal favorite. It expands the notions of health away from just health care by examining the importance of how society is structured and its implications for health. The book highlights growing congruence among a number of fields that identify health issues that cannot be explained simply by differences in care or sanitation or wealth. It highlights the importance of factors like hierarchy, genetics, and structural issues that play an important role in determining not just health outcomes but also opportunities for care and even understandings of what it is to be sick. Many of the ideas underlying this book played a key role in my graduate work.

If there are any books that you have found helpful to understand health or health care, please let me know as I am always looking for new sources on the subject.

Another Day in D.C.

It is strange having a career. In most ways it is unlike anything else I have ever done before. There aren't a set number of years I will be here and there is no final product that will complete it. I am really enjoying everything about the job so far and am optimistic about it continuing that way. I am consistently amazed by how happy people are in their different positions at GAO. One recent announcement was of the retirement of a person that had been with the GAO for forty-one years. It is amazing to think that if I were to work there that long I would be sixty-seven at retiring. It just seems so far away. Similar stories of long tenures at the GAO are not uncommon. One of the other analysts was saying that, statistically, if you stay at GAO past three years you will be there for your whole career. I am beginning to really understand how that is possible. The GAO prides itself on being a model federal agency and is constantly trying to improve itself. Despite the high expectations that are placed upon workers there is an atmosphere of calm and relaxation at all levels. Each worker is treated with respect and expected to carry out there work with little supervision. Understanding what its like to be treated as a professional is not something that comes easy after working at places where you had to document how your time was spent.

Another thing I have really come to appreciate about GAO is truly how flat the organization is hierarchically. When I heard this comment in my interview I was intrigued but skeptical. Over the past month it has become clear how true this really is. The people at the top of the organization are all approachable and engaged, which must be a hard thing to juggle considering the GAO overall has around 3,000 employees and the Health Care team has over 200. I had a really great meeting with the Managing Director of the team, in which it was made clear that everyone was accountable to each other, especially those at the top. Another interesting thing there are surveys of both the analysts and the management that foster discussion about what each can do better to make continual improvements. Both the analysts and the directors seem to really think that these measures have really helped keep people engaged and aware of what needs to be improved as well as what is going quite well.

After leaving work today, I took advantage of the warmer temperatures (40s today up from 10s over the weekend). I walked over to a nearby bookstore and picked up a couple new books and spent some time at the cafe. It still feels so funny when walking a couple blocks to pass by Chinatown, the National Portrait Gallery, the Spy Museum, the Ford Theater (where Lincoln was assassinated) among other nationally important sites. It is still hard to wrap my head around all of the things that exist within blocks of where I work and live. It is hard to imagine how long it would take to hit all the things Heather and I have talked about visiting. Looking back, Heather and I took a risk coming out here with only our M.A.s in hand and some idea of what we wanted to do. I could never have imagined it would work out as well as it has.

Saturday, December 13, 2008

Like A Real Adult

This week I received my business cards at work. Honestly, I was pretty excited about it. The ones that I received from the people during my interview looked really cool and I couldn't wait to get my own. There is something special about having a real business card. I think the cards came out quite well. Now I just have to start meeting important people to give them to.

Saturday, December 6, 2008

Hard To Imagine How The NRA Can Spin This

A recent study which was underwritten by more than 300 U.S. mayors has uncovered some extremely damning evidence about the link between lax gun laws and legal guns ending up being used in crimes. The study makes clear that 10 states with lax gun laws are responsible for over 50% of guns used in crimes across the U.S. This number should be staggering and the repercussions swift. This sort of dangerous funneling of weapons to be used in crimes cannot be allowed to continue. While people will continue to argue that it is not the guns that commit the crimes, it is clear that access to guns is providing the ability to carry out many crimes. It is hard to imagine how anyone reading the report could come to the conclusion that gun control does not have a positive effect on reducing the amount of guns in the hands of criminals. Particularly deplorable was the cover-up pushed by the industry to keep this data from seeing the light of day. To know that such data exists and to try to censor it is despicable and calls into question how dedicated to safety those involved really are.

It isn't just purchasing guns intended for use in crimes that is making headlines. In the same days as the above-mentioned report was released, this story came out as well. I cannot imagine how horrible all those involved must be feeling at this moment. It is difficult to imagine such a senseless thing, all because a weapon was being treated as a source of entertainment. Why an eight year-old would be allowed to fire such a deadly weapon is beyond me. I hope people learn to respect the dangers that guns pose and accept that they must be regulated for public safety. Together these two articles highlight what many researchers in a variety of fields (including public health, criminology, sociology, economics, and others) have found, that guns must be regulated and that protections must be in place to keep guns out of the wrong hands. Clearly many states are failing on this issue and must be brought to task.

Finding My Stride

After a week of mostly training and paperwork last week, this week gave me a better idea of what the job will actually be like. I had a really good time conducting background research and identifying relevant legislation for our engagement. It is an interesting topic and I am starting to feel like I have a good handle on many of the background factors that will help to set up our analysis. Also exciting is that we will soon have our meeting with the requesting Congressional office and identify how their interests or needs have changed since the request letter was sent to GAO. On Thursday we met as a team with the director on our project and it went really well. The AIC (analyst-in-charge, GAO love acronyms, it's kind of an obsession) was really pleased with how often I spoke up and the points I raised. Prior to the meeting she emphasized that I didn't need to be nervous. Her saying that was the only thing that made me a little nervous. 

The GAO is heavily involved with the 2009 Congressional and Presidential transition. They will be doing a lot of briefings of the president's staff on important issues and have even created a website that highlights some of the key issues that will play an important role at the beginning of Obama's term. I am really excited about the transition and am reading everything I can about the health care reform plans. It is amazing to think that I will likely have a chance to work closely on these issues, and to see some of that work end up being made into policy. While that may sound overly optimistic, consider the following numbers for 2008 alone for the GAO:

-Over 1,200 requests from Congress in 2008 (this is the main way GAO gets work, comes from a chair or ranking member on a committee)
-160 new mandates written into law (mandates are the second most common way of GAO getting work, things written into legislation that ask GAO to examine something later on, usually examining the effectiveness of a program)
-Provided testimony to Congress over 300 times
-Financial benefits 57.8 Billion dollars
-Other benefits 1398 (defined a variety of ways, can see more info on their website:
-Products (meaning reports and other written work, such as audits) with recommendations 66%
-Recommendations implemented 83%
-Timeliness (based on client feedback) 95%

I was particularly surprised by the recommendations implemented. I knew that GAO played a key role in helping Congress legislate (being the "investigative arm of Congress"), but I wasn't aware that some much of it was directly made into law. It really helps to explain the level of detail and precision that is emphasized in the GAO training. It is exciting to be working in such a powerful but accountable place like the GAO. They take their responsibilities seriously and I look forward to doing so as well. It is nice to have a job that I look forward to going to each day.