Health Economist's memo to U.S. Treasury Secretary - "Urgent Need for Changes in Health Reform Implementation"

Memo reviewed by Oriol Solé Borràs, HSPH Masters candidate, 2021

Healthcare reform

David Cutler, a Harvard health economist and an advisor to President Obama’s 2008 campaign sent in May 2010 a memo to Larry Summers, the Treasury Secretary at that time, arguing that the White House had the wrong team in charge of health reform, and they needed to overhaul their implementation strategy.

        The first paragraph of the memo is a clear “bottom-up upfront” - it not only works as a problem statement but addresses the consequences of not following the recommendations of the memo as well (“health reform will be unsuccessful as a result”). To reiterate the point, Cutler also concludes the introductory section with a paraphrase of the problem statement this time using bold typography. Also in the first paragraph, we can appreciate the introduction of the author’s voice, the use of the “I”, as part of the policy conversation. The role of the two following paragraphs is to legitimize this voice and build credibility to be more persuasive. Several strategies are used to pursue this aim: a) presenting himself as a
supporter of the reform; b) showcasing his professional experience in the field; c) revealing that his views are supported by others with authority (the President and senior staff); and d) expressing that the ideas in the memo are shared by others—specifically mentioning who support the content of this memo.

        In the analysis section, the author keeps a low level of abstraction and provides simple and concrete examples. He underlines who represents a problem and why: “Don Berwick has never run a provider organization […] there is no way he can carry it out”. This, coupled with expressions that reiterate the voice of the author and directly appeal to the recipient through the use of “I” and “you”, contribute to the creation of a slightly accusatory tone: “you were dealt a bad hand here”, “I have very little confidence that the Administration will make the right decisions”. This tone is accentuated in the recommendations section, where the use of “need” is extensive: “you need to follow this model”, “you need to start with a strong
team”. Cutler provides “practical solutions” for a “practical problem” but there is a mismatch between the level of abstraction in the analysis section and that of the recommendations part (the level of abstraction in the latter being slightly higher). This, together with the lack of alternatives and an objective and explicit criterion that goes beyond the author’s opinion reduces the compellingness of the recommendations.

        The inclusion of a diagram (something quite unusual in memos) adds more concreteness to the recommendations. However, the placement of the image at the end of the document takes away some of the power of the call to action in the last paragraph, that reads as a hasty and ineffective conclusion.