It’s an early Thursday morning in mid-March, and 11 floors below Ron Preston’s Ashburton Place office a group of Latino and black teenagers holding signs that read marriage = 1 man + 1 woman are already posted in front of the State House. Nearby are satellite trucks that will broadcast the day’s culture-war battle all over the world.

To Ron Preston, slaying the health care dragon
is just one more thing on his endless to-do list.

There is no camera crew looking over Preston’s shoulder as he meets with his young staff of four women and two men, but the topics discussed here in the Executive Office of Health and Human Services are at least as weighty as gay marriage. If the view of the Charles River from Secretary Preston’s office is breathtaking, so is the agenda of this typical weekly meeting. First up: a new psychiatric hospital. It’s been 50 years since the state has built one; in the past decade, the number of state mental hospitals has gone from 11 to four, and Preston is angling to close two more, in Worcester and Westborough. Some replacement capacity is clearly needed. But should the state construct a new building or renovate one of two dilapidated facilities now available? The sentiment leans toward building anew—something modern and up-to-date, if smaller than what some mental health advocates are hoping for. But what will it cost?

Next: the Department of Youth Services. The female population has exploded in a system that is designed to manage male adolescents. (A week later, there would be this headline in the Boston Herald: POLS CALL ON ROMNEY TO TACKLE DYS’ DEADLY CRISIS. It’s the capper to a series on suicides in juvenile-justice facilities. In the story, Gov. Mitt Romney vows to do something about the situation. Who’s he gonna call?) Then there’s the turf battle between private ambulance companies and local fire departments.

The subject moves to health care, the public policy Godzilla that dominates Preston’s wide-ranging secretariat. Romney calls Medicaid, the state’s health program for the poor and disabled, a “financial beast” that is “eating the rest of state government.” But that didn’t stop the governor from giving Preston, in his first month in office, an even more challenging health care assignment: developing a plan to provide basic coverage for the state’s half-million uninsured. No other state has yet been able to accomplish such a feat; all attempts have been stymied by cost and opposition from entrenched interests.

To Preston, who sometimes seems like an absent-minded-professor and is given to heavy sighs and gloomy pronouncements, slaying the health care dragon is just one more thing on his endless to-do list. “As is often the case in government,” he says, half to his staff, half to a visitor, “we’ll come up with something that everyone is a little unhappy with.”

“Everyone’s holding onto his part of the elephant.”

Welcome to Ron Preston’s world, located in a high-growth region of state government somewhere between the proverbial rock and hard place. It is one crowded piece of real estate, with a population of about a million of the state’s neediest people, from foster kids to the elderly. Among Preston’s charges are juvenile detainees, the disabled, the blind, the mentally retarded, the mentally ill, the uninsured, and the working poor. Then there are the two dozen or so nonprofit groups that advocate for the needy and the scores of public and private institutions and contractors that care for them. Preston’s world is organized, if you can call it that, around 17 separate agencies—sometimes referred to as “fiefdoms”—that employ 24,000 people, and until recently, operated largely on their own, with only the barest coordination from Health and Human Services.

Preston’s is a world where the mental health system has a waiting list so long that advocates claim the state has stopped keeping track, and where Medicaid costs are rising 10 percent per year but some community hospitals are so starved for funds that they’re on life support themselves. And though Health and Human Services has a budget bigger than the GNP of some Third World nations—totaling nearly half the state’s total spending—there’s never enough. Eleven billion dollars looks like big money only until it’s time to pay the bills. And no matter how you spend that money, you can’t win.

“Most of the time in this job, you’re never any better than your worst mistake,” says Charles Baker Jr., who held the secretary’s job in the Cellucci and Weld administrations and is now CEO of Harvard Pilgrim Health Care. “It’s a relatively high-visibility job, and you don’t get much credit for what goes right. You have to get used to it.”

Get used to taking lumps, he means. Even compliments are often a setup for complaints —against Preston, or his boss. “Ron has done a lot of thinking about these issues and wants to do a very good job, and help people get help on health coverage who don’t have it,” says Phillip Johnston, another one of Preston’s predecessors, who now runs the state Democratic Party. “He cares about abused children and all the people who fall within his secretariat. The problem is, there’s not a lot of money right now, and he’s working for a governor who would refuse to spend it if he had it.”

Preston predecessor Charles Baker Jr.:
“You’re never any better than your worst mistake.”

Preston’s accustomed to this line of attack—and to defending his boss. “The governor understands that this is a generous state, and he’s fine with that,” says Preston. “On the other hand, he also appreciates that [health-and-human-services spending] can’t grow by $1 billion a year, because taxpayers can’t keep up with it. It pushes out roads, it pushes out schools. Basically, what he wants to do is balance it. He made $500 million more available to us this year, but what do you do when programs want to be [up] a billion dollars?”

Preston put the “compassion” in Romney’s fiscal conservatism when he got 36,000 people who had been booted off MassHealth back on the rolls. But as he struggles with Romney’s audacious promise of health care coverage for the state’s estimated half-million uninsured residents without raising taxes, Preston is finding his name mentioned alongside the term “mission impossible” as often as Tom Cruise’s. Only Preston has no special-effects guru, and many observers are betting that the script he comes up with will be rejected as too expensive to be produced. At stake is the well-being of the state’s battered health care system—and Preston’s legacy.

‘Ron’s about to become the point person.’

“Ron’s about to become the point person for what will be potentially the most controversial, bold, reckless—or all of the above—programs,” says John McDonough, who heads Health Care for All, an advocacy group for expanded health-care access.

But if Preston has any reservations about the assignment, or the administration he works for, he doesn’t express them publicly. “If you remember,” he says with a fleeting smile, “in the movie, and in the TV show, they always accomplished the mission.”

Show time

Talk to advocates and providers in health and human services circles, however, and another Tom Cruise movie comes to mind: Jerry Maguire, with its recurring line: “Show me the money!”

These advocates and the people they represent have been demoralized by three consecutive years of deep budget cuts, some of which predate the Romney administration. This is especially true in public health, which has been hard hit in the budget battles. Romney’s fiscal ’05 budget recommends even more reductions: Funding for school-based health centers and school nurses, already reduced by 56 percent over the past three years, would be totally eliminated under his spending plan. Environmental health, immunization, domestic violence, and antismoking programs have all sustained deep cuts.

To this group, Preston is the human face of an administration that is dismantling a public health system once considered among the best in the country. They, along with former Department of Public Health employees who have quit in frustration, warn that the resulting “brain drain” and cuts in public health infrastructure—data collection, immunization, and other programs—will have consequences when and if the state has to contend with a large-scale epidemic, or an act of bioterrorism. Even DPH Commissioner Christine Ferguson, who reports to Preston, testified in a legislative hearing that she was “heartsick” over the shriveling of prevention programs.

Public health advocate Geoff
Wilkinson calls administration
policy “amazingly shortsighted.”

“It’s the most amazingly shortsighted and reckless policy I’ve ever been involved with, and I’ve been doing this for 20 years,” says Geoff Wilkinson, executive director of the Massachusetts Public Health Association, an advocacy group. “We’ve lost over one-third of the Department of Public Health budget for core public health services, not including the hospitals. If you include the hospitals, we’re talking about over $145 million in three years. For FY05, it’s more than $30 million, or more than 8 percent.”

Preston has heard it all before, and though he’s not unsympathetic, he is unmoved. “Is there pain in the provider community? Are we facing a reduction in some of the things we can do? Undoubtedly,” he acknowledges. “Were these things of value? Yes, they are of value. Is it a loss to lose them? Yes, it is. But on the other hand, to mix all my metaphors, everyone’s holding onto his part of the elephant.”

Preston says that the public health system and its advocates need to adjust to the 21st century. In his view, instead of lobbying to prop up a laundry list of tiny DPH prevention programs, each pursuing its own narrow mission from inside its own bureaucratic box, these advocates should be helping him figure out how to integrate the work of public health into primary care, through the vehicle of entitlement programs like Medicaid. Besides, given the funding constraints he’s faced with, he says there are tradeoffs to be made. And Preston is comfortable with his.

“Having billboards on buses to get people to stop smoking is nice,” says Preston. “But if there’s someone in a wheelchair who needs a personal care assistant, I want to have the assistant.”

Made for the job?

If you were casting the part of secretary of health and human services, you could hardly do better than Ron Preston. Raised in West Newbury, Preston graduated from Phillips Academy at Andover in 1969, and then from Columbia University. He holds a master’s degree in sociology and a Ph.D. in medical sociology from Yale. He lives with his wife, Karen, who is a nurse, and his daughter just over the border, in South Hampton, NH. His résumé includes 13 years in the US Department of Health and Human Services, where he worked in health care administration, most recently as New England’s regional administrator for Medicare and Medicaid Services. Preston began his career as a policy fellow for a North Carolina legislative committee on aging. He later moved to Washington, where he worked on the staff of Republican US Sen. Orrin Hatch of Utah.

The man knows health care, Beacon Hill, and Capitol Hill. Most people with his background would be in consulting by now, as Preston is the first to point out, and making the big money. But he’s hooked on the public sector.

“It’s hard to talk about it without sounding corny,” says Preston. “I like the idea of working for the citizens. I like the idea of being involved in efforts to serve needy people, and if you asked any of the senior-level people here—a lot of them could be doing any number of things, some of them were actually out in the private sector for a time, but they’ve come back because they feel it’s worthwhile work to do.”

Even friends say he’s a ‘character.’

That Preston is well qualified and committed, no one disputes. And it’s clear that, in the world Romney’s put him in charge of, Preston is king. “Preston’s predecessors were basically powerless figureheads,” says McDonough, a former lawmaker. “Ron Preston is the most powerful health and human services secretary in the state’s history, bar none. Other secretaries just idly at 2 in the morning would dream of the kind of power that he now has.”

But Preston can also be sharp-tongued and impolitic. Critics say his management style can be imperious, his behavior at times downright flaky. Even friends acknowledge that he’s a “character.” Others are less charitable.

“He sees himself as a big-picture guy,” says one observer. “But he seems to be unable to control his mouth. And he goes off in all kinds of directions. He loses people as he traipses along.”

Preston relishes the role of truth-teller. “Let’s look at the quandary of the hospitals,” he says. “They need more and more money every year. But that’s their responsibility, too. It’s not my responsibility just to come up with themoney for whatever they happen to think they need to charge us. At the end of the day, this money comes from the taxpayers. I don’t have a printing press in the basement.”

Indeed, Preston is known to take the opportunity of advocates and vendors coming to his office to acquaint them with uncomfortable realities. As a result, visitors sometimes leave with the feeling they’ve been “lectured to,” if not shouted at, according to one person who suffered through such an encounter.

The lecturing isn’t always in private. Speaking at a Commonwealth Forum last year, Preston declared that some nonprofit human service providers “don’t keep their books very well” and “need to start getting responsible in terms of business.” That comment prompted a letter to CommonWealth (Correspondence, Winter ’03) from Michael Weekes, president and CEO of the Massachusetts Council of Human Service Providers, charging that “the state system for purchasing human services uses its monopoly powers to make it very difficult for providers to operate as businesses.” Weekes concluded, “Reducing complex issues to glib remarks creates stereotypes and unfortunate prejudices.”

That dustup seems to have blown over. Preston got off to a “rocky start” with providers, Weekes acknowledges, “but to his credit, he’s worked hard at improving the relationships and engaging the provider community in a reform discussion, in which we both have an interest in seeing [service providers] become more effective and provide better quality.”

Then there are the stories, which circulate widely within an advocacy community that Preston sometimes pleases but more often disappoints, if not infuriates. Some roll their eyes over an e-mail he sent to agency heads last fall in an attempt to buck up morale: “Years ago, my uncle was marketing director for a major beer company. At a family gathering, he lamented how he would fare when he stood before Saint Peter. What would he say he did for his fellow man? Sold a lot of beer? Not one of us will have this problem. Our vocations are honorable and difficult, far more difficult than those who get far more credit.”

Others tell of Preston’s rambling, 30-page analysis of health care, a draft that circulated so widely it could have been listed on In its first five pages, Preston referenced Baum, Carroll, and de Tocqueville as he described a public with great expectations of government (the Great and Powerful Oz), a health care system out of control (the Red Queen, running just to stay in place), and the problem-solving potential of “professional and practice communities” (the voluntary “associations” extolled inDemocracy in America). Buried within are some intriguing ideas about the role of medical professionals in stemming the problems that lead to higher health care costs. But it’s not easy to follow.

In conversation, too, Preston often makes analogies to movies and books, perhaps in an attempt not to seem like such a wonk. But it may also reflect one of his old sidelines, writing book reviews for the Christian Science Monitor. And the habit is not without charm.

“He’d make a fabulous university professor,” says Matt Fishman of Partners HealthCare, who served under HHS secretary Johnston. “He’s the first human services secretary of my acquaintance who quotes de Tocqueville and Alice in Wonderland.”

In terms of what people say about him, Preston doesn’t mind taking the bad with the good, as long as the back and forth stays within bounds. “Part of this is a game,” he says of his occasionally testy relationship with providers and activists. “I expect advocates to advocate. Even when times are good, they say, ‘I need more money.’ That’s what they do. What I don’t like is when our motives are impugned. Challenging our values is not fair game.”

Rearranging the deck chairs

At mid-morning, wearing a heavy coat and one of those Irish tweed hats Daniel Patrick Moynihan used to favor, Preston makes his way across Boston’s City Hall Plaza to a windowless room in the Department of Public Health. A group of programmers and administrators from various agencies have gathered here to view, along with Preston, a demonstration of the “Virtual Gateway,” a new system that will allow clients to fill out a single online application for 10 different services, including WIC, Food Stamps, transitional assistance (otherwise known as welfare), and child care assistance. The system was developed by Louis Gutierrez, one of the top health care information technology experts in the region, and about 40 programmers and designers, who have been working on the project for a year.

Virtual access is a pivotal piece of the re-organization of the Health and Human Services secretariat now underway. Most people who need state help are clients of more than one agency, but until now, they have had to travel to several different offices to apply for services; in the worst-case situation, they’ve gotten social workers from each, but services from none. Under the new automated system, which will be launched at two pilot locations in July, it will be easier for intake personnel at agencies, hospitals, and shelters to match people with the services they are eligible for.

State Sen. Susan Tucker, an Andover Democrat who chairs the Health and Human Services Committee, says her committee has been pushing for the “no wrong door” approach to providing services for years, but she gives Preston credit for getting it done.

“It’s a totally different climate from years ago, when agencies were fighting each other instead of looking for common solutions for the families,” says Tucker. “There’s a different attitude at the top. Whether or not clients have seen that is subject for debate, but if the leadership and vision stays on course, it will make a tremendous difference.”

“What he’s accomplished is extraordinary,” says Romney. “This reorganization has been fought since the early days of the Weld administration. We got it done and Ron is making it work, and opening up options we’d never have otherwise.”

The irony is that it’s not at all clear how many of those services will be available. Ease of application means more clients for an already overloaded system. Meanwhile, Steve Collins, executive director of the Massachusetts Human Services Coalition, says the only visible impact of the reorganization so far is the closing of 36 offices around the state.

Writing a scrip

“Do you remember the movie M*A*S*H?” asks Preston, back at the conference table in his office. “What was the part that the doctors there enjoyed the most?”

The martinis back in the tent at the end of the day?

“The camaraderie!” he replies. “This kind of work is a lot like M*A*S*H. Think about it.”

Camaraderie is important to Preston, and he doesn’t see enough of it in the medical community, let alone government. When he became concerned about the financial and social impact of overprescribing psychotropic drugs such as Ritalin to young children, Preston’s department launched the Targeted Child Psychiatric Service, a pilot project with Dr. Ronald Steingard of the University of Massachusetts Medical School in Worcester, who is one of the few experts on pediatric pharmacology in the state. The program now provides consultation to more than 70 primary care doctors, and Preston is hoping to get financial support from insurers to help keep such medication to a minimum.

“So instead of a rulebook, you have the professional community working with evidence-based data,” says Preston. “A doctor wants to talk to another doctor.”

This is the kind of thing Preston loves: neatly wrapped problem-solving that actually makes a difference in people’s lives. Even from a big-picture perspective, it is a thing of beauty: no laws or mandates, not even much money spent, just collaboration and collegiality—and results.

What’s not so clear is whether Preston can attain universal health care coverage the same way. The federal government couldn’t do it a decade ago, and no individual state has done it either. At a hearing before the Legislature’s Health Care Committee in March, Preston admitted as much, telling impatient lawmakers that there was probably not enough money within the health care system to pay for such a plan.

Charles Baker, one of those being consulted in Preston’s policy-development process, says there are “three big questions they’re wrestling with. Are there any mandates associated with this and, if so, what are they? Everyone has to buy auto insurance. Should everyone have to have health insurance? Do you require everyone to have coverage? Next, are there penalties for not being covered? Should employers be assessed for free care, since employers who do provide it are also paying for those who don’t? That’s an equity issue. Then there’s the question of what’s the right level of basic benefits?”

The other big issue is the use of the state’s “uncompensated care pool” to fund the program. The pool, which is funded by hospitals and employers, paid $565 million in health care costs for uninsured patients last year. But nobody likes it. Hospitals that pay into the fund, mostly those in the suburbs, say they end up subsidizing the urban hospitals, specifically Boston Medical Center and Cambridge Hospital, which serve most of the state’s uninsured population. And no one thinks the pool, which already faces a $200 million shortfall, will be enough to fund full coverage of all the uninsured.

Preston doesn’t say so, but another movie title comes to mind: Something’s Gotta Give. Every answer he comes up with is going to make someone unhappy. Moving uninsured patients from the hospital setting to community health centers, which he has mentioned as a priority, could be a cost saver, but not all clinics are capable of providing services, such as mammography, that require specialized, and costly, equipment. And although Romney has promised to double their state funding, from $28 million to $56 million, those who run the centers say they’re already stretched thin by past budget cuts. Meanwhile, many providers complain about the possible disruption of doctor-patient relationships and the lack of choice, along with the feeling that they’ve been cut out of the debate.

“It’s a big shift,” says Matt Fishman, of Partners HealthCare. “It’s very different from everyone having choices. To make that proposal is to say that our values have changed. But I’m not sure we got to have that discussion.”

If providing universal care seems impossible, however, so does maintaining the status quo, says Gov. Romney. “The uninsured are a financial burden to the rest of the state, and they’re receiving insufficient care for themselves,” he says. “We need to solve the problem, not only to express compassion, but to help the state’s finances. It’s an effort that’s difficult, but not impossible.”

Health Care for All’s John McDonough wants to
see “some kind of mandated employer coverage.”

Whatever he comes up with, Preston needs to get on with it. At the March hearing, legislators voiced frustration at the administration’s failure to move health care reform forward faster. The Health Care for Massachusetts Campaign is pushing for a state constitutional amendment to require affordable insurance for everyone. And John McDonough says Health Care for All is working on its own reform agenda, which it expects to file as a bill next year. In a perfect world, McDonough would like to see a single-payer system, he says, but he knows that’s not going to happen. So he and other advocates propose expanding eligibility standards for public health programs like Medicaid.

“We’d also like some kind of mandated employer coverage for everyone who’s working, which would deal with the lion’s share of those who were above 200 percent of the poverty level,” McDonough says. “Then the uninsured population would be so small, it would be quite manageable.”

But employer mandates—and tax increases—are not likely to play well in Ron Preston’s world. So he and his staff will be crunching numbers and working the models until they find something that will.

“I like the line from the movie Gandhi, when Gandhi says, ‘What we can do we will try to do,'” says Ron Preston. “You know, government is the art of the possible. We’re doing the best we can.”