Pay now or pay much more later

WASHINGTON – No secretary of health and human services ever feels the job is finished when his or her time is up. Tommy Thompson, the latest in the generally distinguished line of leaders of the Cabinet department closest to the everyday needs of millions of Americans, is no different from his predecessors.

When I dropped in on Thompson a few days before he vacated the office for his friend and successor, Mike Leavitt, moving over from the Environmental Protection Agency, he was surrounded by packing boxes and – as always – full of candid observations.

Thompson, who helped launch the welfare reform movement as governor of Wisconsin, said he took pride in the number of former recipients of government checks who have moved into the work force. He noted that the rolls have continued to decline – albeit more slowly – during the past four years, despite the marked slowdown in the U.S. economy.

But, he said, the remaining cases – chiefly women who are “chronically unemployed because they lack the skill sets or the health” to find jobs, present a stubborn challenge. They will continue to flounder until the states and Washington provide the counseling and job training needed to make them employable.

It frustrates Thompson that since welfare is no longer a hot political issue, the politicians have lost interest in finishing the job. A scheduled extension and overhaul of the federal welfare law was stymied last year – something that can be resolved, he said, by satisfying Democratic demands for more child care dollars. He declined to predict whether that money will be found in the next Bush budget.

On health care, his other main responsibility, Thompson is blunt, calling it “the nation’s No. 1 problem, aside from terrorism.”

He recommends a multi-pronged approach. The first step is to put far more emphasis on preventive medicine – on developing personal habits and screening techniques that would, for example, keep the 41 million people with prediabetic conditions from joining the 18 million diabetics. Thompson has nagged his associates and his audiences about the risks of smoking and of obesity, and he has lobbied medical and hospital groups to invest in the available technology that might simultaneously reduce both costs and medical errors.

But health care inflation will not be controlled, he said, until a real dent is made in the number of uninsured. He supports the president’s proposal for tax credits to offset some of the cost of medical insurance premiums, but says government has to do more than that.

Thompson’s own plan would empower states to organize and subsidize purchasing pools among the uninsured, with the federal government guaranteeing reimbursement for any individual case where medical costs would total more than, say, $75,000 a year. “It would be expensive,” he says, “but no more than having millions of uninsured delaying treatment or filling the emergency rooms.”

Expanding government health care to that extent is heresy to some conservatives – the same people who criticized Thompson in Wisconsin for insisting that financing a broad range of support services to help women leave welfare was a good investment of tax dollars. But he argued that those front-end costs would be justified by the reduction in the welfare rolls, and the same argument, he says, applies to health insurance. Screening people for incipient medical problems is far less costly – and more humane – than treating them when the conditions have become acute.

Thompson leaves the Cabinet with one newly acquired passion – a belief in what he calls “medical diplomacy.” “I have traveled to 37 countries,” he told me, “helping deliver medicine for AIDS, malaria and other diseases. I dedicated a hospital for women and children in Kabul, Afghanistan. The gratitude of people for what America, with its wealth of medical talent, can bring, is overpowering. We’re seeing it again with the tsunami relief. We should be doing this on the scale of the Marshall Plan,” the economic aid program that rescued Western Europe after World War II.

“It can be hugely successful, and much less expensive, as a means of fighting terrorism,” Thompson said. “I use the example of the Comanche helicopter, canceled after an expenditure of $8 billion. That money, used to build hospitals and clinics in Iraq and Afghanistan or Africa, would generate huge, huge benefits for America.”

As he moves to the private sector, you can expect to hear more from Tommy Thompson on that subject. Outside government, he will continue to do what he has done well for 20 years in public office: fight the status quo.