New role, new tactics for Kathleen Sebelius
In December 1999, Kansas Insurance Commissioner Kathleen Sebelius expressed concern that new privacy rules imposed by the federal department of Health and Human Services would undercut state jurisdiction over health information. Federal bureaucracy, she argued, could not handle enforcement as nimbly as the states. A decade later, Sebelius will have the opportunity to prove herself wrong, as she takes the helm as Secretary of Health and Human Services under President Obama.
Over the past six years, Sebelius has served one-and-a-half terms as the Democratic governor of heavily-Republican Kansas. Supporters often cite her record of negotiation and compromise with Kansas’s Republican legislature as an indication that she will be able to forge the necessary bipartisan partnerships to get major healthcare reform passed. Yet a closer examination of her relationship with the Kansas state legislature reveals significant differences between that situation and the congressional dynamics that Sebelius will face as Secretary. The fact that she will need to build coalitions within her own party, rather than across the aisle, to succeed in healthcare reform means that Sebelius’s past performance is of little help in predicting her future success; she will have to employ new tactics to succeed in her new role.
Bipartisanship in Kansas?
In his March 2 announcement of her appointment, President Obama praised Governor Sebelius for having “time and again … bridged the partisan divide and worked with a Republican legislature to get things done for the people of Kansas.” Christian Morgan, Executive Director of the Kansas Republican Party, describes it differently; “I would say she knows how to work in the same state as Republicans. I would challenge the assertion that she actually works with Republicans,” he told the HPR. “She doesn’t hold a lot of meetings for negotiations, brainstorming, all the things a true bipartisan would do.”
State Senator Jim Barnett, who opposed Sebelius in her successful 2006 reelection bid, credited her success to internal rifts in the party in an interview with the HPR. As he came to know through chairing both the Senate Public Health and Welfare committee and the Joint Committee on Health Policy Oversight, “Governor Sebelius has been a very savvy politician, taking advantage of the Republican split between conservatives and moderates to obtain coalition votes to pass or block legislation.” Indeed, a disagreement over social issues had split Kansas Republicans into two parallel organizations, the conservative Kansas Republican Assembly and the moderate Kansas Traditional Republican Majority. That divide allowed Sebelius to use her veto to great effect, particularly against anti-abortion bills, as her opponents rarely mustered the votes to override a veto.
Nonetheless, State Senator Laura Kelly, Democratic Minority Whip and a member of the Senate Public Health and Welfare committee, disputes the Republican assertion that Governor Sebelius has only succeeded through division. “Certainly,” she told the HPR, “if the Republican Party in the state of Kansas marched in lockstep, no Democrat could get anything done.” But Sebelius, she insists, is “a very good consensus-builder, regardless of party. She figures out how to draw people to the table.” Perhaps most importantly, Kelly argues, “She lets ideas be someone else’s. Getting credit is not highest on her priority list, whomever she’s working with.” As an example of this strategy, Kelly cites the Kansas Health Policy Authority, an institution established during Sebelius’s tenure to consolidate the management of various state health programs and act as a sort of Public Health policy house. According to Kelly, “[Governor Sebelius] originally suggested creating it by Executive Order, but then the Republicans co-opted the idea and put it in the form of a free-standing agency and authority. She was willing to go along with the Republicans to make it happen.”
Barnett and Morgan agree that the establishment of the Health Policy Authority is one of the most significant health-related accomplishments of the Governor’s tenure, but they are dismissive of Sebelius’s role in its creation. “Her idea of a government entity to run state health policy in the state was more big-brother-like,” Morgan insists, “while the Republican version is like a government-run think-tank. The Governor will take credit, but when it comes to the actual work on the HPA it wasn’t her at all.” Barnett sees this pattern elsewhere, holding up ‘safety-net clinics’ for the uninsured and underinsured as another legislative initiative which Sebelius claims as a Democratic victory but which in fact already enjoyed broad support in the legislature. In Kelly’s view, of course, “Republicans taking credit for ‘safety-net clinics’ is a little disingenuous. It was actually my idea; while I worked with a Republican on it, they were only going to put in half [the funding].”
Leaving Kansas for the Emerald City
The debate over relative ‘credit’ for various initiatives reflects the typical acrimony of divided state government. Of course, neither the Republican depiction of a governor at the mercy of the legislature, nor Obama’s sweeping assessment of Sebelius as a great uniter, seems especially plausible. More than anything, however, the debate indicates how different Sebelius’s challenges in her new role will be from those of her governorship. Although her experience with coalition building in Kansas is often cited as one of Sebelius’s qualifications for overseeing healthcare reform, the coalition she must help the Obama Administration build in Washington is very unlike the ones she built at home.
Sebelius is adept at concocting strategies that pull policy from the ideological right towards the center. The advantage of this situation is that it masks a politician’s true ideology; activists from the left may assume that they have her sympathies, while independents give her credit for the centrist policies she enacts. Reconciling the full spectrum of positions within the Democratic party, however, promises to be a challenge for both Obama and Sebelius because it will require them to reveal some of their ‘true’ ideology on healthcare, and thereby alienate some portion of the party base.
Sebelius, to be sure, can claim that she is merely negotiating on behalf of Obama, but as a potential future contender for the Presidency she does not have the luxury of fully abdicating responsibility. Obama may have selected her in part to build relationships with moderate Republicans — whose potential support can be used as an excuse for ignoring more extreme liberal proposals — but doing so runs the risk of establishing her national profile as too moderate to ever win Democratic presidential primaries. On the other hand, if Barnett is correct in his expectation that Sebelius will “move very much to the left” in her new position, any future bid for a seat in Kansas’ Senate delegation will be somewhat more difficult.
Furthermore, the extent to which Sebelius and Obama’s healthcare agendas align are unclear. Known as a moderate Democrat, her approach to healthcare has focused on efficiency and has always trumpeted the cause of small businesses, an important constituency in Kansas. Obama employs some of the same rhetoric, to be sure, but the two may diverge somewhat on policy. One early signal of perceived divergence is that Sebelius was not offered the same dual role originally marked for Tom Daschle. As both HHS Secretary and head of the White House Office of Health Reform, a newly created office within the West Wing, Daschle would have been both public face of healthcare reform and the president’s foremost policy advisor on the subject; Sebelius will be forced to contend with the potentially divergent views of Nancy-Ann DeParle, whom Obama chose instead.
Accustomed to leading her state Democratic Party, Sebelius will have to adjust to advocating a policy that may not be her own. Besides DeParle and the president himself, she will need to cultivate a strong relationship with Max Baucus, Chairman of the Senate Finance Committee and the most important congressional voice on the issue besides Ted Kennedy. Thus far, Baucus’s unqualified support for Sebelius’s nomination bodes well on this front. Yet, ultimately, his is not the only support she will need: her relationships with all of the key players on the Democratic side will be critically important in determining the success of Obama’s proposal to provide a public health plan option for citizens to select in place of private insurance.
As former DNC Chairman Howard Dean told the HPR, “healthcare reform without a public option is not worth doing.” But Dean conceded that some conservative Democrats concur with the Republican view that this policy would threaten the free market and lead inevitably to a single-payer system, given government’s ability to operate at a loss and undercut private prices. Uniting Democrats behind a ‘public option,’ distinct from a single-payer system in that the public plan would be offered but not mandated, Dean asserted, “will be an essential aspect of achieving health care reform.” Kelly is certain that “everything [Governor Sebelius] does will be with the ultimate goal of equal access to affordable healthcare,” but the exact nuances of Sebelius’s position on providing a public health plan option are not yet clear. She and the other chief Democratic voices on health care will have to present a consistent view on this issue if they are to unify their caucus and win over at least two Senate Republicans to prevent a filibuster.
Uncertain Path Ahead
In her new role as HHS Secretary, Governor Kathleen Sebelius will confront a host of new challenges. Her experience as an insurance commissioner gives her a very detailed understanding of the healthcare system, her move to combine all of Kansas’s health-related government operations into one Health Policy Authority shows that she believes in efficiency, and her management style as governor indicates that she will be a competent administrator of existing policy and whatever new law may be enacted. But her past experience does not provide her with a clear model of how to succeed in passing national comprehensive healthcare reform, her most significant new responsibility as Secretary of Health and Human Services. To succeed in that task, she will have to adapt her leadership strategy as governor to a different style of forging coalitions. Her success in making this transition could permanently shape the future of American health care policy.