Policy high points: Medicare and Medicaid in the new millennium.

T he three years that i s pent at hcfa / cms were the most rewarding of my career. I had worked with the Health Care Financing Administration (HCFA) as a Senate staffer, in the White House (George H.W. Bush), and as an outside lawyer and president of a hospital association. I thought I understood HCFA. I really did not. The issues are endless, as is the complexity. It is a fairly small agency (4,500 staff) but an enormous amount of spending ($600 billion plus, including Medicaid). There is simply no way to deal with it all effectively. There is a friendly bipartisan mafia of former HCFA administrators—from Leonard Schaeffer to Bill Roper and Nancy-Ann DeParle. They all warned me about the job—and still I underestimated the task. The staff of the Centers for Medicare and Medicaid Services (CMS) was terrific. There is a core of dedicated career people—such as Michael McMullan, Tom Gustafson, Charlene Brown, and Gary Bailey—who work incredibly hard and keep the programs running no matter the political leadership. Although few are Republican or conservative, I always thought that the career staff were supporting me, even if they did not like all of my “market-oriented” ideas. They can run the agency without the political appointees. I saw my job as generating new ideas and needed change in both policy and operations, stirring the pot to make them think differently. There were many policy high points—mostly notably the Medicare reform and the drug benefit. In a decade, the program will be far more competitive and efficient and will provide far better coverage, especially for poor seniors. But I will leave that judgment to time. The drug discount card did exactly what it was designed to do: act as a short-term benefit to get immediate help to the poorest beneficiaries as the full prescription drug benefit was being developed. Possibly our C M S R e f l e c t i o n s