On Diana Dooley’s office wall in downtown Sacramento is a framed publicity photo of singer Linda Ronstadt, the famous former girlfriend of Gov.-elect Jerry Brown (D) back in the days when Brown was governor of California in the late ’70s. Ronstadt signed the photo with the inscription, “To the Chief.”
It’s an unusual memento to see in the office of the new secretary of Health and Human Services. But it points to the close ties Dooley has with Brown, which she hopes will serve her and her new department well.
“I know the people who know the language of this business and I know Jerry,” Dooley said this week. “It’s an extraordinary confluence of my work in health care and my 35 years with Jerry. Several times throughout my career, it has felt like the right place, the right time. And this is one of those times.”
It turns out to be a time of great change. Dooley, appointed HHS secretary last week, will oversee state efforts to implement federal health care reform, establish a health benefits exchange, revamp a health information technology system and expand health care coverage to millions of Californians. It will be a tidal shift in the way health care is structured in California.
At the same time, California is grappling with budget deficits of staggering size and massive cuts to human service programs in the state — both cuts that have already been made and ones that are likely to come in the first 60 days of the new year.
Dooley’s charge is to oversee the restructuring of California’s health care system comes at the same time the state is under pressure to run current services with less money.
“It is a really big job,” Dooley said with a smile. “I have no illusions that it’ll be easy, but I hope I can help.
“You’ve got to believe you can make a difference,” she said, “or you wouldn’t step up. And I do believe I can make a difference.”
Healthy Background
Dooley has most recently been the president and CEO of the California Children’s Hospital Association, an advocacy not-for-profit that represents eight children’s hospitals in California.
She started her career as an analyst for the California Personnel Board, then began working for Brown in 1975 as a legislative secretary and assistant to the governor. After politics, she opened a public relations agency and served for a time as president of the Visalia Chamber of Commerce. Dooley got her law degree in 1995 and became general counsel for Children’s Hospital Central California in Madera before moving on to CCHA.
“I think of myself as an analyst and a communicator,” Dooley said. “As an analyst, I always want to understand the science: What are the facts? What are the goals? And I think you usually find a path forward from there.”
And as a communicator, she said, “I want to understand who needs to participate, what their language is, what their needs are, and what I can do to translate for them, to turn that into action.”
The first step, Dooley said, is to gather information — particularly the details about the programs most at-risk of possible budget cuts, she said. “We need to make sure we don’t impact essential services,” she said.
“I’m not there yet. I need to do a top-to-bottom evaluation, and from there you can see where are the seeds to grow.”
That doesn’t mean redoing everything, she said. “I respect the path that others have followed; they’ve worked hard and well. I’m not asking for everyone’s resignation on Jan. 3. We need to do what we can to stabilize everything, and move on from there.”
It has been a circuitous path to becoming the head of the state’s Health and Human Services department — a long walk from the small Central Valley town of Hanford, where Dooley (née Diana Stone) grew up.
“I’ve stayed pretty close to everyone there,” she said. That’s one reason she moved back to the Central Valley after leaving Sacramento, she said.
“It’s funny,” Dooley said. “Back home, someone just said to me ⦒Don’t forget the little people.’ And I said, ‘Are you kidding me? I am a little people!'”
Issues on the Horizon
Health care presents some interesting challenges, in part because of the system’s structure, Dooley said.
“We have this triangle between the payor, the consumer and the provider,” she said, “and you don’t really have a direct relationship between them.” That is, the patient doesn’t directly pay the provider, but instead pays insurance, and the insurer is managing risk rather than directly buying health care.
“I call it a false market,” Dooley said. “The laws of supply and demand don’t work in the same way.”
The insurer system is intricate and always shifting balance back and forth, she said. “The big criticism of national health care reform is that it’s massively complicated,” she said. “But I feel the system itself is overly complex.”
That could change, she said, as the machinery of health care shifts over the next few years. With the introduction of the California exchange and the reworking of information technology and other systems, it may be possible to get a handle on how people get their health care, and how that’s financed.
Health care reform could help change management models, from bundled payments to accountable care organizations, Dooley said.
“The ACO is like a unicorn,” she said. “Everyone imagines what it looks like, but no one’s actually seen one yet.”
The Next Four Years
Overall, Dooley said, changes are in the offing, but they will be incremental changes.
“I don’t see it all radically redesigned,” Dooley said. “I see the gradual changes. There is less hospitalization than there was, for instance, and that will continue. There are more people in ambulatory, outpatient care, and that will continue.”
The work of the previous administration has been strong, she said, and that helps frame the work coming up.
“I can’t see the analytical construct for a big change,” Dooley said.
The physician shortage, and the expected rise in demand for primary care providers, will be an important challenge, she said. “We’ll have to look at practice expansion, and letting people work to [the maximum extent of] their license.” She also talked about the increased pressure on the long-term care system. The wave of aging baby boomers, she said, “is like a locust swarm. Just like it hit the economy, and jobs, it’s about to hit long-term care.”
Those and other challenges are not new, Dooley said, adding that her job is to work as hard as she can to keep everything moving forward.
“The trends that are well-established will continue,” she said. “Health care reform will certainly drive that incremental movement faster. But I am nothing if not a pragmatist. I have a passion for moderation.”
And that means starting with gathering as much information and stakeholder input as possible, she said. “In my whole career, it’s always about getting the questions right. And once you get the questions, you can find the answers.”
Then the trick is to get consensus — which, she said, does not mean listening to the far right and far left and settling for something in between.
“It means starting with the things that people can agree on, not starting with the things they disagree on,” Dooley said. “My feeling is,” she said, “the hardest work is done in the middle.”