by Ron Suskind
Nonetheless, the data was irrefutable, making the “Wennberg Variation” accepted dogma. Now Wennberg shared stages atop the profession with the likes of Dr. Paul Farmer, cofounder of Partners in Health and builder of hospitals and clinics in some of the most forbidding corners of the globe. Wennberg and Farmer had just won the annual Public Health Heroes Award at University of California, Berkeley, and Wennberg is finally being credited with forever changing American medicine.
But Wennberg’s most auspicious contribution may be the man he helped create and was now hugging inside the auditorium of the elementary school, where a fund-raiser for special-needs children was about to start.
Weinstein, twenty years Wennberg’s junior, had a tenured chair in orthopedics at the University of Iowa when he came to Dartmouth to do a fellowship in outcomes-based research in 1994. “As an orthopedic surgeon, I often didn’t feel that my patients were getting the information they needed to make their decisions,” Weinstein said in a recent interview. “They were talking to me, but maybe that wasn’t good enough, because I was a surgeon and surgeons do what surgeons do. Maybe they weren’t getting a fair shake.”
Wennberg soon had another disciple, but one he noticed had a surprising ferocity. Wennberg learned that Weinstein had a daughter, Brianna, then nine, who had been diagnosed with leukemia when she was one. Weinstein had been on the receiving end of what Wennberg called “an uncontrolled experiment in medicine.”
It had been hell. There were complications from chemotherapy that had not been well explained. She was given the wrong drugs. And, most tragically, as a toddler she’d been treated with unnecessary radiation that caused extraordinary pain and ongoing disabilities.
What Weinstein had studied at Dartmouth, in terms of unnecessary procedures, he lived when he returned to Iowa. At one point an oncologist threatened to sue him for not accepting a cancer treatment protocol he was recommending. After two years back in Iowa, the Weinstein family moved to Hanover for good in late 1995. Brianna was eleven then. She died a year and a half later.
After her death, Weinstein said, he and his wife “felt it was our obligation to make it better for others. So I decided to try to change the world of medicine from within.”
That is where Weinstein began to step beyond his mentor, Wennberg. He became the head of orthopedic surgery at Dartmouth and turned the department on its head. Back surgeries are among the most common, and lucrative, major medical procedures. What Weinstein discovered, using the might of Dartmouth Atlas research and data from within his own hospital, was that many back surgeries offer no lasting benefit to patients. The problem at Dartmouth, like that at hospitals across the country, is what happens once the hard truth is uncovered. There was a department full of surgeons who made their living from these operations. Opting for an array of less intrusive, less expensive, and less profitable alternatives—mostly various kinds of physical therapy—was a formula for economic ruin. Weinstein began what he called “a transition program” to bridge his department to a different model of medical practice. Some doctors left. Others managed on lower incomes. But over the years the situation stabilized. “We simply weren’t going to do procedures that had no discernible value—period.” Of course, Weinstein, having battled unnecessary treatments with his daughter, carried a tenor of moral authority in this conversation. He could not be opposed. And that made all the difference. “It’s Jack’s mission and my sadness that came together and gave me direction,” Weinstein said. “She was so courageous. She never complained. She fought through all the pain, and the nonsense, and she taught me everything I’d need to know about living this gift of life to its fullest, and with purpose.”
Soon Weinstein had gone national, as the principal investigator of the Spine Patient Outcomes Research Trial, one of the largest recent studies funded by National Institutes of Health. The multiyear study examined a wide array of spinal surgeries, including the common surgery for lumbar disk herniation, and has found that nonoperative procedures are often a better choice. Slowly, procedures are beginning to change at many of the leading hospitals.
What Weinstein did for aching backs, along the way saving significant Medicare payments, was what enlivened Orszag and intrigued Obama: the possibility of reshaping medical practice in the United States through the power of evidence-based outcomes and data on comparative effectiveness.
It was, however, a long distance still between theory and practice. Though the data was pleasing to technocrats, it remained threatening to the long-established ways of the medical world. Change is hard, as Obama often said, and always driven, in Margaret Mead’s famous quip, by small groups of committed people. In this case, it was two headstrong men and one brave young girl.
As the sun set, those two men were working hard at having a good time. This was the Tenth Annual Brie Fund Concert and Quilt Raffle, a tradition started by the Weinsteins after Brie’s death to celebrate her memory and here—at the elementary school she attended—raise money for children with special needs, physical and cognitive, like those their daughter struggled with after her childhood radiation.
Brianna’s younger sister, Shelsey, a senior at Middlebury College and the first cellist in their orchestra, played an original composition and joined other musicians for six selections, ending with the “Song of the Birds,” by Pablo Casals, dedicated to her sister.
The day’s big money-raiser is always an ample, colorful quilt made by Brianna’s mother, Mimi Weinstein, in honor of her daughter. When Shelsey pulled the winning raffle ticket from the bucket, she looked twice at the name, surpressing disbelief, and then called out, “Jack and Corky Wennberg!” A crowded elementary school auditorium of onlookers gasped, then cheered, as one obstinate middle-aged man passed a quilt, a stitched emblem of his inspiration, to an old stick-in-the-mud, and everyone basked in the certainty of what inspiration, and irrefutable data, can achieve.
A team of senior advisers gathered in the Oval Office in August. Rahm Emanuel had been “begging” for a more modest approach to health care reform, dubbed the “Titanic” plan. It would insure more than ten million Americans by widening previous congressional plans to expand coverage for children, and lift the number of single mothers eligible for Medicaid. It could get bipartisan support. “We’ve always done health insurance in groups: the elderly, the poor,” he said, according to a participant in the meeting. “And we can do it again, with a few large groups, like children. That brings us close to everyone.”
Obama resisted. The whole enterprise had been badly botched; that was indisputable. But he didn’t want to retreat. He was the president, after all. Phil Schiliro, the head congressional liaison, laid out the grim outlines of a Congress in flight. If the swing votes such as Grassley or Enzi, or the Maine twins, Snowe and Collins, had ever been “possibles,” they were now reaches. They had all been to town hall meetings in their states, crammed with new enthusiasts of government opposition—many of them self-defined as Tea Partiers, some not. But whatever they were labeled, these dissenters were having an effect. Everyone in the room agreed that health care reform had become a long shot.
Everyone, that is, except the president.
Obama looked around at grim faces, and reached back to see if he could touch the fire—the lightning strike that, as Axelrod said, had propelled a man just four years out of the Illinois Senate into the White House. Whether or not there’d been a “wisdom” to those crowds, in Iowa and everywhere else, Obama had to believe there was.
“Look, I feel lucky,” Obama said to the dispirited group. “How can any of you not feel lucky? Just look at me. I was elected president of the United States.”
The president had lost control of his White House; he had almost no process to translate his will into policy on the occasions when he could decide on a coherent path. But such decisions were rare. A group of four men, all seasoned Washington hands, had assumed enormous authority in his administration, and the women, who often were more attentive and purposeful in carrying ou
t his wishes, were aggrieved. He was being reviled across much of the country and called a socialist, or worse. His approval ratings, in the 70s in February, had slipped to the signature tipping point of 50 percent, with 43 percent disapproving, in an authoritative Gallup poll of August 24 through August 26.
In a meeting in the Oval Office on September 1, Gibbs quipped about how bad the poll numbers were on health care reform, as others recounted how Obama and his main policy initiative were being framed, far and wide.
“This is about whether we’re going to get big things done,” Obama said. “I wasn’t sent here to do school uniforms.”
That barb was directed at Emanuel, who’d been filling the roles left untended by Obama, because someone had to make some decisions. All right, Emanuel said archly, “So, you still feeling lucky?”
“My name is Barack Hussein Obama and I’m sitting here,” Obama answered evenly. “So, yeah, I’m feeling pretty good.”
What lessons did Obama’s days of greatest good fortune hold? When in trouble, dig deep and conjure a defining moment of oratory. It had always worked. It was who he was. As he had prepared his speech for the 2004 convention, some had asked if he was nervous. He laughed, “I’ve got this. In this, I’m Michael Jordan.” He could still give a speech, damn it, and that was exactly what he wanted to do. Emanuel now said he should wait. He’d get only one chance at a big health care speech. If he went for it, and it wasn’t well received, it’d be a disaster. He would have dropped the last card in his hand. Obama seemed to say, How much worse could it get?
The health care speech, slated as a major address to a joint session on September 9, would have to be written fast, and it would have to be the best of his presidency, Obama told Favreau. This just seemed to fire up both men. It felt like the glory days, and Obama kept everyone at arm’s length. Favreau, who had to fly to California for the wedding of another speechwriter on the staff, Ben Rhodes, worked over the long Labor Day weekend, sending Obama pages from a California hotel. Obama hunkered down. Axelrod dove in, too. They had received from Vicki Kennedy a letter Ted had written in the spring, to be released after his death (he died on August 25), calling health care “the great unfinished business of our society,” something that was above all “a moral issue,” touching “the fundamental principles of social justice and the character of our country.” It would be a signature theme in the speech.
The president was suffused with a take-charge forcefulness that was uncommon—he was going to save this thing—and it went beyond what he would say. There had to be substance, so the speech didn’t simply lift emotions without lasting effect. He wanted the White House to prepare a detailed plan of where it stood, especially on what he considered the all-important program of evidence-based practice of medicine. In June the president had read a New Yorker article by Atul Gawande that essentially applied Dartmouth’s model to look at two counties in Texas with enormous variations in health care costs—one of them, the highest-cost county in the United States for Medicare—but negligible differences in the health of their populations. He ordered the entire senior staff to read it. The matter perplexed Orszag, as the article was just a narrative rendering of what he thought the president understood from their frequent discussions on the matter; Axelrod later said putting the latest findings “in that format was eye-opening for him.” But it fired up Obama, and he pressed to add new powers to the Center for Medicare & Medicaid Innovation—which would allow them to direct vast annual payments for those programs around principles of comparative effectiveness—to the White House health care plan. And he wanted that plan, the fully articulated position of his administration on health care reform, to be released along with the speech. In a way, it was to be a detailed rendering of what Zeke Emanuel would call C: how health care in America will look when reform becomes real.
But in senior staff meetings without the president attending, Rahm Emanuel dissented. He felt it would be smarter to remain less specific, as the White House had been to that point, and just release a two-page paper, with a few bullet points and no details.
Orszag disagreed. So did Dan Pfeiffer, the deputy press secretary. “I can’t believe we’re releasing a two-page thing when the president keeps talking about releasing his full plan in the speech,” Pfeiffer said in one meeting. The White House had a plan pulled together, ready for dissemination.
When Orszag was about to say as much in a meeting with the president, just days before the speech, Emanuel glared at him with what Orszag later recalled as a “do not do that” look. The OMB director put a lid on it.
Meanwhile, the president moved, unaware, thinking his comprehensive proposal was to be released along with the speech, which was turning into a tour de force.
Obama worked furiously on the speech and was still rewriting key passages on Tuesday, the eighth. Emanuel was screaming—they needed to see “at least one final draft before it’s delivered.” They would get it for only a few hours on Wednesday afternoon before it had to be finalized and printed for the press. This was an adolescent rebellion against the naysayers, such as Emanuel, who were constantly assessing the political landscape and saying what could, and mostly what couldn’t, be done. On Wednesday, Obama was adding lines, including a few of the most memorable ones. While the facade of his address to Congress was rooted entirely in pragmatism, its beating heart was something much more profound. The speech confronted a more fundamental question: the identity of government in the modern era.
Unlike at Obama’s previous attempts at rhetorical conceptualizing, his audience had become wary. He had to convince rather than drum up. At first he appeared to be going through the motions, laying out his case for reform. “The time for bickering is over. The time for games is passed. Now is the season for action,” Obama declared, a secure applause line before “Now is the time to deliver on health care!” Midway through, while the president was countering a Republican claim that reform would cover illegal immigrants, a shout came from the audience: “You lie!” It was Joe Wilson, a Republican congressman from South Carolina.
Obama continued undeterred, churning his way slowly toward his dramatic conclusion. The third act of the speech was a show-stopper. Invoking Kennedy, thoughtfulness, and basic decency, Obama made the most compelling case for liberalism that has been made in recent memory. “We did not come to fear the future. We came here to shape it. I still believe we can act even when it’s hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history’s test.”
Still, the speech was light on substance—many proposals were offered, not all of them fitted inside a sweeping, carefully crafted plan. There was no news, about something Obama was strongly for or against, that prompted surprise. But as is the case with leadership, the content of the speech was secondary to the tone. For the first time since Manassas, Obama sounded like a man ready to lead. His words were authoritative and moving, making a case not just for health care, but for the community of states and a powerful ethic of shared purpose.
The next morning, Favreau received a note from the president complimenting him on the job. He was sure he knew what the president was thinking. They were all thinking it. They’d recaptured the magic. “Just like the campaign,” Favreau wrote back.
Barney Frank, trailed by an aide, was standing in front of a church talking to a cop.
“Excuse me, can you tell me where Wall Street is?”
The heavyset cop, gut over his belt, looked this way and that.
“Let me see, I know it’s near here somewhere, but . . .”
Frank stormed off in midsentence.
“All these damn cops are from Staten Island. None of them know where the hell Wall Street is.”
It was September 14, the one-year anniversary of the Lehman Brothers bankruptcy that set off the Great Panic, and the Washingtonians had descended on Wall Street.
Or close to Wall Street.
Barney Frank, the forceful chairman of the House Financial Services Committee and arguably Congress’s most powerful single actor in reforming Wall Street, continued to wander the caverns of Lower Manhattan, talking nonstop.
“This time, we’ve got ’em, we’re gonna get reform, something through, October or November . . . wait a minute, Broad Street? . . . No, Wall Street lost it, they have no clout . . . the only issue is the Consumer Bureau, because that’s the one where I have to fight community banks on, they don’t like it . . . hold on, where the hell are we? . . . But when it comes to derivatives, and all those other issues, they’re done. These people have no clout . . . Okay, I think I’m getting close . . . There’ll be some loopholes they can exploit if the FDIC and the SEC don’t significantly increase capital requirements . . .”
He could tell he’d hit home, because there was an uncommon ruckus on the street even at 10:00 a.m. The president was due to speak in Federal Hall, the gold-domed neocolonial temple at the corner of Wall and Nassau. It was a summit, of sorts, between America’s two great capitals—one of private endeavor, the other of public purpose.
And it was a circus. Barney slipped in the nondescript side entrance of the New York Stock Exchange and soon stepped in front of CNBC’s television cameras to talk about the day’s events.
The mood on the network was ebullient. The market was back. Wall Street was roaring forward. Trading profits were high. JPMorgan and Goldman Sachs were soon to book record profits for the third quarter, ending September 30. The stock market had risen from 6,600 in early March to 9,000.
Frank said he was ready to start hearings next week to deal, piece by piece, with the major elements of financial reform.
“These issues are complicated,” said CNBC’s Erin Burkett. “It’s tough. Very few people in the industry understand derivatives and what went wrong and how to deal with them. And you may be the only person in Washington who really, some people say, is capable of drafting a reform bill.”
