February 27, 2010
By DR. QUENTIN YOUNG

Having watched the entirety of President Obama's televised health summit Thursday, I was struck by several things.

The president's Republican opponents once again revealed their deep-seated, single-minded commitment to enhancing the profit margins of the insurance and drug monopolies. There were no surprises - and next to no useful additions to the debate - from the GOP's stalwarts, only a repetition of their shopworn proposals for tort reform, the ability to sell health insurance across state lines (read as: eliminating state consumer protections) and the like.

The president's proposal, an 11-page document released last Monday, along with the summit itself, was clearly aimed at creating a reform posture that would grease the wheels for getting the 51 Senate votes he needs to pass his party's deeply flawed bill through the reconciliation process.

President Obama sought to create an impression of willingness to deal with his Republican opponents from a straight-up gamesmanship point of view. In this regard he prevailed, in my opinion. His skills of debate are quite formidable, as even his most bitter opponents have to admit.

But the really important question is this: What are the American people being offered in the way of real health reform by the Democrats?

A good starting point is to look at what they are not being offered. They are not being offered a universal plan. They are not being offered comprehensive coverage. They are not being offered affordable care.

In some ways, what they are not being offered is the saddest part of all, because the president, who was elected by a large majority with high expectations - along with solid Democratic majorities in both houses of Congress - has not fulfilled his mandate. Having struck a series of deals with the for-profit health industry, he has been unable to move any genuine health reform legislation forward.

The American people obviously are hurting. The health care crisis has done nothing but worsen in the months succeeding his election. The adverse economic events make certain that there will only be huge increases in the number of uninsured. The last official figure was over 46 million, and it's hard to believe there will be less than 50 million who lack insurance when this year's tally takes place.

The meeting took place with dark economic clouds hanging over it. And the horror stories related at the summit - of people being dropped by the insurers when they got sick, of people being unable to bear the burden of monstrous costs when illness struck - were a recurring and sobering theme.

During the summit I was struck by Sen. Harry Reid's citation of two recent studies from Harvard University - one showing that 45,000 deaths annually can be linked to lack of health insurance (15 times the number of people who perished in the 9/11 tragedy), another showing that 62 percent of personal bankruptcies are linked to medical debt - to make the case for acting quickly to implement a reform of our broken system.

The irony is that those two studies, which played an outsized role in the health reform debate, just happen to have been conducted by research teams led mainly by Dr. Steffie Woolhandler and Dr. David Himmelstein, two of our nation's most prominent advocates for single-payer Medicare for All and co-founders of Physicians for a National Health Program.

The stubborn fact remains that the only way that you can achieve truly universal coverage - that is, give access to health care for every person in our nation - is through a single-payer system. That's also the only way to attain real cost control.

Our present arrangements, dominated as they are by the for-profit insurers, result in about $400 billion annually being wasted on useless paperwork and bureaucracy. Those excess administrative costs are weighing down on the medical profession, the public and the economy. By replacing the private insurers with a streamlined, nonprofit single-payer financing mechanism, we would reap sufficient savings to cover all the uninsured. The same savings would allow us to end co-pays, deductibles and caps, thereby upgrading everyone's coverage. And patients could go to the doctor and hospital of their choice.

We could also reap savings from bulk purchasing, negotiated fees and rational capital improvement planning. From the standpoint of health economics, it's a no brainer.

The tragedy is that President Obama, as recently as when he was an Illinois state senator, acknowledged that single-payer financing of health care was the logical and the best way to go. But now that he's made fatal concessions to the insurers and Big Pharma, crystallized as they are in the odious Senate bill, his stated goal of fundamental reform has unfortunately been foiled.

What does this mean for the single-payer movement? It's worth noting that although that we are obviously not in a decisive, victorious mode, the single-payer position has never been stronger. Whatever the outcome of this round of congressional maneuvering, the need for real reform will remain.

That was the message of the "Sidewalk Summit for Medicare for All" that took place outside the official proceedings at Blair House (and in several cities around the nation) on Thursday. Dr. Margaret Flowers, PNHP's congressional fellow, was joined by other physicians, health professionals, unionists and other health care advocates, in bearing witness to our eminently rational and humane solution. And they are just the tip of the iceberg.

The single-payer issue should loom large in the 2010 elections and single-payer supporters, whose ranks are steadily increasing, are in this battle for the long haul.

Amir's Analysis
$400B in annual waste, given as a subsidy to private insurance, is not sustainable indefinitely. Eventually, it has to go. Thank goodness and the sooner the better!

February 6, 2010
By ROBERT PEAR and DAVID M. HERSZENHORN

WASHINGTON — For a moment, President Obama’s pledge to keep fighting for major health care legislation got personal on Thursday night as he told supporters at a fund-raiser about a former campaign worker in St. Louis without health insurance who had died of breast cancer.

“She insisted she is going to be buried in an Obama T-shirt,” he said, drawing nervous laughter from the otherwise hushed crowd. “How can I say to her, ‘You know what, we’re giving up’? How can I say to her family, ‘This is too hard’? How can Democrats on the Hill say, ‘This is politically too risky’? How can Republicans on the Hill say, ‘We’re better off just blocking anything from happening?’ ”

Despite recent political setbacks, Mr. Obama vowed to win approval of the legislation, and his enthusiastic audience roared: “Yes, we can! Yes, we can!”

But the president’s remarks, at the fund-raiser for the Democratic National Committee, seemed altogether detached from the legislative realities on Capitol Hill, where dejected Democrats have been casting about for a way to salvage the health care bill. The legislation was thrown into limbo by the Republicans’ upset victory in a special Senate election in Massachusetts on Jan. 19.

Mr. Obama suggested that Democrats and Republicans publicly debate the merits of their competing health care proposals, then hold a final vote. Some Senate Democrats dryly noted that they had already gone through such an exercise, debating the legislation for 25 straight days before they approved it, with no Republican support, on Christmas Eve.

Differences between House and Senate Democrats are profound. Republicans, emboldened by their victory in Massachusetts, are more resolute in opposition to Mr. Obama’s health care agenda. And the political tension of a midterm election year pervades all their deliberations.

Senator Mary L. Landrieu, Democrat of Louisiana, said the legislation “is on life support, unfortunately, but it still has a pulse.”

While some Democrats said they welcomed more involvement by the president, as a way to help revive the party’s dispirited base, others said they worried that he was inviting further debate that would prolong an already tortuous process, while doing nothing to win over Republicans and perhaps further imperiling centrists Democrats up for re-election.

In his rallying cry to a crowd of cheering supporters on Thursday, Mr. Obama described, in the clearest terms yet, his vision of how to enact comprehensive health legislation: House and Senate Democrats would resolve their differences and decide on a “final bill.” They would then invite “our Republican friends to present their ideas.” The president would convene a meeting of Democrats, Republicans and health care experts to debate the proposals, in plain-spoken terms, for the benefit of the American people.

Then, Mr. Obama said, “we have got to move forward on a vote.”

The president did not say how he would resolve the knotty questions of policy, procedure and politics facing Congress.

A senior Democrat aide who has worked intensely on the legislation described party leaders as circling a traffic rotary, over and over, looking for a road forward but unable so far to pick a path.

“We’re still going around the circle,” said this aide, who asked not to be identified while discussing the Democrats’ internal debate. “You run out of gas at some point.”

Hours before the fund-raiser, Mr. Obama met at the White House with senior Democratic Congressional leaders to discuss their strategy on health care. The House speaker, Nancy Pelosi, rejected continued pressure from the administration simply to pass the Senate bill and send it to Mr. Obama for his signature.

Ms. Pelosi has repeatedly told the White House, and has said publicly, that it is impossible to pass the Senate bill, in its current form, in the House. For weeks, Democratic House members have complained that the Senate bill is riddled with special deals, carve-outs and exemptions for favored states and constituencies.

House Democratic leaders said they had concluded that the only way to overhaul health care, in a comprehensive way, was by pursuing a complex two-bill strategy.

First, in negotiations with the Senate and the White House, they would agree on changes to the Senate bill. These changes would be incorporated in a separate “budget reconciliation” bill. The House and then the Senate would pass the budget bill. The House would pass the Senate health bill. The two measures would be presented to the president at about the same time.

Mr. Obama would sign the health bill and then the budget bill, which would trump any inconsistent provisions of the health care legislation.

One reason for this elaborate procedure is to avoid the need for another Senate vote on the huge health bill. Senate Republicans could block that bill by filibuster, now that they have 41 votes.

Success of this strategy is far from assured.

Even if Democrats could reach agreement among themselves, Republicans have vowed to use every parliamentary weapon to block the legislation. By using budget reconciliation procedures, Senate Democrats could limit debate, but not necessarily the number of amendments, and Republicans are prepared to offer dozens.

Centrist Democratic senators are also reluctant to use the procedure, knowing Republicans would attack it as an effort to jam the bill through the Senate.

Under Senate rules, Republicans could challenge provisions of the budget bill that did not affect federal spending or revenues. For this reason, lawmakers said, the bill could probably not be used as a vehicle for a compromise on the explosive issue of insurance coverage for abortion.

Representative Jim McDermott, Democrat of Washington, said the bill was so important that Democrats must be willing to take political risks to pass it.

“Look at Winston Churchill,” Mr. McDermott said. “He wins the Second World War, and they throw his government out at the next election. If you believe in a democratic Parliament or Congress, you have to accept that doing the right thing might get you ejected.”



Amir's Analysis
This bill needs to go to the graveyard, immediately.

January 7, 2010
By PAM BELLUCK

Hundreds of thousands of patients each year suffer from infections after surgery, and experts say more than half of those infections stem from bacteria the patients themselves are carrying in their nose or on their skin. Otherwise harmless bacteria can enter the body through surgical incisions and cause infections that can require expensive treatment, slow recovery or even cause death.

But two new studies suggest relatively simple ways hospitals can prevent many infections by killing the bacteria on the patient before surgery, with methods of screening, scrubbing or pretreating the patient that many hospitals do not typically use.

“This is going to be a huge help to the infection-control crowd,” said Marcia Patrick, a nurse and board member of the Association for Professionals in Infection Control and Epidemiology, who was not involved with either study. “How can we not do this? It would truly be penny-wise and pound-foolish. And it’s the right thing to do for patients.”

The studies, published Thursday in The New England Journal of Medicine, examined infections that develop at the site of surgery, often around the incision, and afflict more than 300,000 patients a year in the United States.

While experts are increasingly trying to stop hospital-acquired infections by approaches including stepped-up hand-washing by doctors and nurses, the new studies looked at the bacteria patients may be carrying before entering the hospital, especially a common bacteria, staphylococcus aureus.

“About one-third of people at any one time carry this bacterium in their nose or on their skin,” said a co-author of one study, Dr. Henri Verbrugh, a professor of medical microbiology at Erasmus University Medical Center in the Netherlands. “It does not give them any problem, but if they go to a hospital and the skin is somehow breached, they are really prone to invasion or infection by their own bacteria.”

Dr. Verbrugh and colleagues tested patients for the bacteria using nasal swabs. They treated about 500 who carried the bacteria for five days with an antibiotic ointment on their noses and showers with soap treated with chlorhexidine, an antiseptic. After surgery, which sometimes occurred during the five-day treatment, those patients were 60 percent less likely to develop infections than patients receiving a placebo of ointment and soap.

The study included only patients whose operations were extensive enough to require at least five days of hospitalization. Dr. Richard P. Wenzel, an infectious disease specialist at Virginia Commonwealth University, who wrote an editorial about the studies, said he would recommend the approach primarily for serious operations like heart surgery or joint replacements, or patients with immune system problems.

But Dr. Wenzel said the method used in the second study should be adopted across the board. That study, conducted at six United States hospitals, compared the skin disinfectant hospitals use 75 percent of the time before surgery with another one. The researchers found that patients receiving the standard disinfectant, povidone-iodine, were significantly more likely to develop infections. Those cleaned with the alternative, chlorhexidine-alcohol, got 40 percent fewer total infections, and half as many staphylococcus aureus infections.

A study author, Dr. Rabih O. Darouiche, a professor of medicine at the Michael E. DeBakey Veterans Affairs Medical Center in Houston, said chlorhexidine-alcohol was recommended a decade ago by the Centers for Disease Control and Prevention for cleaning when catheters were inserted, but had not been extensively studied for surgical preparation.

Ms. Patrick said most hospitals still used the iodine solution largely because “we’ve always done it this way.”

Cost is a factor with both studies’ methods. Dr. Darouiche said chlorhexidine-alcohol costs about $12 per patient compared with $3.50 for povidone-iodine. His study was financed by CareFusion, which makes both products. It had no access to the data.

Dr. Verbrugh, whose study was financed by several companies, said the most expensive part of his approach was the rapid-screening test for bacteria, about $20. He said some United States cardiac departments had begun using the nasal ointment for all heart surgery patients, without screening them for bacteria.

Experts not involved in the studies said the added costs of the methods were dwarfed by the money saved preventing infections, which can run to tens of thousands of dollars per patient.

“Everybody wins on this,” Dr. Wenzel said. “Patients obviously have less morbidity, and hospitals and medical centers and insurers save a lot of money.”

Amir's Analysis
Another example of simple solutions to public health that we can't execute due to poor protocol and a lack of centralized, national leadership on health policy and public health. Ugh.

October 28, 2009
By REED ABELSON

Andrew M. Cuomo, the New York attorney general, on Tuesday announced the details of a new national database that would help determine how much insurance companies should reimburse patients who go out of network to see a doctor.

Consumers would also be able to check a new Web site to see what an insurer was likely to pay before they went to an out-of-network doctor.

The announcement is part of a settlement reached over the last year with more than a dozen insurance companies concerning one of the industry’s most controversial practices: the payment of out-of-network claims.

Using a database run by the UnitedHealth Group, the insurance giant, the industry was accused of systematically understating the doctors’ fees for more than a decade and shortchanging consumers by hundreds of millions of dollars.

Consumers’ reimbursements “will actually go up now because the reimbursements were artificially deflated,” said Mr. Cuomo, whose office conducted an investigation into these practices.

Under the new plan, a nonprofit company, FAIR Health, will be set up and will work with Syracuse University and a group of other state universities to operate the new database and consumer Web site. The system will go into operation within a year, Mr. Cuomo said.

As Congress tries to overhaul the health care system, some policy makers in Washington applauded Mr. Cuomo’s attempt to provide patients with better information about the cost of medical care.

“This is an important step forward for consumers, who too often are unable to penetrate the secrecy and bureaucracy of insurance companies,” Nancy-Ann DeParle, director of the White House Office of Health Reform, said.

At issue is a reimbursement system that potentially affects about 70 percent of the nation’s insured families — ones enrolled in health plans that let them see doctors who are not part of the plan’s network. When patients go out of network, insurers typically reimburse patients for only a portion of the medical bill, based on what is called the “reasonable and customary” cost of the services in that city or region.

A patient might receive a doctor’s bill for $100, for example, but the “reasonable and customary” cost as calculated by the database might determine the bill should have been only $72, based on local rates. If the out-of-network agreement calls for the insurer to pay only 70 percent of the doctor’s fee, the patient would be reimbursed $50 of that $72 doctor’s bill.

Mr. Cuomo’s investigation found that the industry database’s determination of $72 as “reasonable and customary” might have been an unfairly low assessment of the actual prevailing local doctors’ fees.

The database, used by the entire insurance industry, has been operated by a unit of UnitedHealth called Ingenix.

As part of the settlement Mr. Cuomo reached with UnitedHealth last January, the insurer agreed to stop operating the database as soon as a new one could be used. UnitedHealth did not acknowledge any wrongdoing as part of the settlement.

Mr. Cuomo also reached related settlements with other insurers with operations in New York, including Aetna, Cigna and WellPoint. The industry also agreed to provide about $100 million in financing to help start the new nonprofit company, whose name FAIR Health is derived from Fair and Independent Research.

“We stand ready to work with FAIR Health, Syracuse University and the research consortium on an expeditious transition of the database,” UnitedHealth said in a statement.

Mr. Cuomo also noted the value in the information that would be available to consumers about how much their own doctors were charging for services, compared with other local doctors.

Currently, when consumers are told they will be reimbursed for only part of a doctor’s bill, they have no way of judging whether the insurer is stingy or their doctor is overpriced.

The industry says that the information will help patients recognize how much their doctors may be overcharging them.

“We hope this database will help shed light on the exorbitant fees that some out-of-network providers are charging patients for health care services,” said Robert Zirkelbach, a spokesman for the trade association, American’s Health Insurance Plans.

Syracuse will lead a research network composed of SUNY at Buffalo, Cornell University, University of Rochester and SUNY Upstate Medical University.

Amir's Analysis
This is VERY interesting and exciting...one of the more exciting developments I have heard of in a long, long time. Comparative effectiveness roots anyone?

October 28, 2009
By Sheryl Gay Stolberg

WASHINGTON — One is a smooth-talking former congressman from Louisiana — “the Swamp Fox,” constituents called him — who relishes his image as a rascal, a charmer and a Cajun raconteur. The other is a fireman’s daughter from working-class Rhode Island, strait-laced and studious, who mastered the arcane world of health policy as an analyst for the A.F.L.-C.I.O.

As perhaps the two most powerful health industry lobbyists in Washington, the two of them, Billy Tauzin and Karen Ignagni, are the odd couple of the capital’s health care debate. Their paths are as opposite as their personalities.

Mr. Tauzin, a Democrat turned Republican, is the chief lobbyist for drug makers. After cutting an $80 billion, 10-year deal for his industry — blessed by the White House — to help pay for a health care overhaul, he is now working quietly to keep his pact from unraveling on Capitol Hill.

Ms. Ignagni, a Democrat who represents insurers, stood up at the White House in March and told President Obama he had her “commitment to play, to contribute and to help pass health care reform this year.”

Now, a day after losing a critical battle to keep a new government insurance plan out of the Senate health bill, she is fighting to persuade official Washington she meant what she said, as Mr. Obama, a man she says she voted for, accuses her industry of waging a “smoke and mirrors” campaign to undermine reform.

The story of these two lobbyists — a Republican who found favor with a Democratic White House and a Democrat on the outs — illustrates the complexities Mr. Obama faces in the health care endgame. The president had some early success in bringing industry on board. But as the experiences of Mr. Tauzin and Ms. Ignagni suggest, keeping it there will be easier said than done.

“There are very different industry dynamics here,” said Representative Jim Cooper, Democrat of Tennessee, who teaches health policy at Vanderbilt University. “The basic deal for these two industries, and others, is that they promised to behave if they get 40 million new customers. But now they are seeing they might not get as many new customers, and they are wondering if they still have to behave.”

Ms. Ignagni worked her way up the trade association ladder, becoming head of America’s Health Insurance Plans in 2003 after two smaller groups merged. Mr. Tauzin was hired to run the Pharmaceutical Research and Manufacturers of America five years ago, after helping pass an industry-friendly Medicare prescription drug bill. Even by the eye-popping standards of K Street, they are well paid; in 2007, the most recent year for which figures are available, Mr. Tauzin earned more than $2 million; Ms. Ignagni, $1.6 million.

With insurers blaming drug makers for high prices and drug makers blaming insurers for scanty coverage, the two association chiefs have a kind of kind of trust-but-verify relationship.

“Clearly, they have a healthy respect for each other,” said Ken Johnson, Mr. Tauzin’s longtime spokesman. (Mr. Tauzin would not be interviewed.) Ms. Ignagni calls her drug industry counterpart “a wonderfully affable man.”

Washington is full of stories about Mr. Tauzin’s affability. Some people talk about his youthful side career as an actor (“He put the ‘ham’ in Hamlet,” one associate said jokingly.) Others recall him regaling Ronald Reagan with Cajun jokes. Then there was his near-fatal bout with stomach cancer in 2004, an experience that turned Mr. Tauzin into a walking salesman for the pharmaceutical industry.

“I visited him in the hospital and told him I was going to pray for him,” John Breaux, the former Louisiana senator, recalled. “He said: ‘No, no, don’t do that. I want somebody with better connections.’ ”

More than being affable, however, Mr. Tauzin is also wily — “as wily as any alligator in the swamp,” Mr. Cooper said. One story that has people in Washington talking is about how he positioned his industry so masterfully once he got inside the White House door, a door that, Ms. Ignagni helped open.

With her union roots and Democratic pedigree (she once worked as an aide to Senator Claiborne Pell of Rhode Island), Ms. Ignagni faces suspicion from liberals who accuse her of jumping to “the dark side.” She sees nothing unnatural about it. She worked with insurers to preserve union health benefits, she said, and is still working to do that today.

Some critics call her a phony. “She puts on this veneer of caring,” said Richard Kirsch, who runs Health Care for America Now, an advocacy group. But another advocate, Ron Pollack of Families USA, senses conflict between Ms. Ignagni and the companies she represents.

“I think Karen personally wants very much to get to yes,” Mr. Pollack said.

Ms. Ignagni has a policy wonk’s passion for statistics and a chess player’s eye for looking around corners. As early as 2006, she told her member companies that universal coverage — the initiative they helped kill when Bill Clinton was president — was headed back to the national agenda, and that it was time for them to get on board.

“One of her great strengths is that she tends to look where the puck is going to be,” said James Roosevelt Jr., the chief executive of Tufts Health Plan.

This spring, Ms. Ignagni tried to initiate talks with Nancy-Ann DeParle, head of the White House Office of Health Reform, working through a union leader, Dennis Rivera. Ms. DeParle was skeptical, said a senior White House official who insisted on anonymity to discuss internal conversations. She insisted that hospitals, doctors and drug makers be included in any talks.

“Karen said, ‘We’ll never be able to get Billy Tauzin to come,’ ” the official recalled.

But Mr. Tauzin, this official said, was “very aggressive in wanting to be at the table.” One result was the $80 billion deal with the Senate Finance Committee, and the White House’s assent. For the industry, health reform is a chance for millions of new customers.

Now Mr. Tauzin’s task is to keep that deal intact, as Democrats like Representative Henry A. Waxman of California, an architect of health legislation in the House, seek to reopen it. “He’s certainly getting a good deal for his industry,” Mr. Waxman said, “but I don’t think it’s a good deal for the American people.”

Ms. Ignagni offered her own package of concessions, including covering people with pre-existing conditions, ending lifetime coverage caps and simplifying record-keeping, all the while fighting the “public option,” as a government plan is known. She insists her companies are still committed to passing a health care overhaul this year.

But earlier this month, she issued a controversial — and, critics say, flawed — critique of the Senate Finance Committee bill, which insurers say leaves too many people uncovered. Mr. Obama struck back, using his weekly address to accuse insurers of producing “phony studies.”

Shown the text of the address, the lobbyist bristled. “You don’t have to show me,” Ms. Ignagni said. “I suspect I’ll forever remember the words.”

Amir's Analysis
Terrifying...entrenching protection of the special interests certainly will not get us where we want to go.

October 27, 2009
By DAVID M. HERSZENHORN and ROBERT PEAR

WASHINGTON — Senate Democrats voiced deep disagreements on Tuesday over the idea of a government-run health insurance plan, suggesting that the decision by the majority leader, Harry Reid of Nevada, to include a public plan in major health care legislation had failed, at least initially, to unite his caucus.

Simply to get the Senate to take up the legislation, Mr. Reid has said he needs 60 votes — effectively all 58 Democrats and the two independents who caucus with them. Senator Olympia J. Snowe, Republican of Maine, who had been open to supporting the bill, said Tuesday that she would oppose Mr. Reid’s version because of the public plan.

But while some who oppose a public plan said they were willing to let Mr. Reid bring the legislation to the floor, the continuing apprehension of others indicated substantial uncertainty.

Senator Max Baucus, Democrat of Montana, who supports a public plan but shepherded a health bill through the Finance Committee without it because he thought it could never win 60 votes, said he could not predict how senators might line up.

“I don’t know. I don’t know. I don’t know,” Mr. Baucus said when asked if he had changed his view of the public plan’s chances. “I just really don’t know.”

With or without a public plan, Democrats expressed growing confidence that a version of the health care bill would be adopted.

“The alternative of just packing our bags and moving on to another issue is not there,” said Senator Christopher J. Dodd, Democrat of Connecticut.

House Democratic leaders on Tuesday said they, too, were moving closer to passage of a health care bill, and could take up the bill as early as next week. They are still working out some major provisions, including their version of a public plan.

In the Senate, Mr. Reid announced on Monday that he would include a government-run plan in the legislation but would allow states to opt out of the program. On Tuesday, he expressed confidence in his decision.

“Our public option isn’t a left proposal or a right proposal,” he said at a news conference. “This is a consensus, a compromise that represents months of hard work and debate and will benefit all Americans.”

But even as Mr. Reid spoke, some members of his caucus were expressing doubts.

Among the Senate Democrats who have not committed to supporting the bill are Evan Bayh of Indiana, Mary L. Landrieu of Louisiana, Blanche Lincoln and Mark Pryor, both of Arkansas, and Ben Nelson of Nebraska.

The Senate Republican leader, Mitch McConnell of Kentucky, said that in his view a vote to debate the legislation would be tantamount to supporting it, which he said would raise taxes and increase health care costs.

Such a vote, Mr. McConnell said, “will be treated as a vote on the merits of the bill.”

Several undecided Democrats said that they had concerns beyond the public plan, particularly how much the bill would cost, whether it would make insurance affordable for people who stand to gain coverage, and how it would affect health costs for those who already have benefits.

Ms. Snowe, the only Republican to support the health care legislation in committee, said she would vote against opening debate on Mr. Reid’s version.

“It is obviously a fundamental line, the question of putting the public option at the forefront of this initiative,” Ms. Snowe said.

Ms. Snowe said she would work with Democrats and try to alter the measure so she could ultimately support it, but was uncertain how much could be accomplished with Democrats potentially controlling 60 votes.

Senator Joseph I. Lieberman of Connecticut, an independent who caucuses with the Democrats, said he would vote to start debate and then join Republicans to fight the public option, which he said would become “another entitlement program that will end up increasing the national debt.”

Mr. Nelson said he could not make a commitment, even to support taking up the bill, because he did not know what was in it. He said Mr. Reid provided no details at a caucus meeting on Tuesday.

Mr. Bayh, a leader of centrist Democrats, said he welcomed Mr. Reid’s proposal for an opt-out mechanism, but wanted to see a cost analysis of the bill.

Three liberal Democrats — John Kerry of Massachusetts, John D. Rockefeller IV of West Virginia and Debbie Stabenow of Michigan — said they preferred a public plan for all states but would support Mr. Reid. “This is a good compromise,” Ms. Stabenow said.

In the House, liberal Democrats were elated at Mr. Reid’s decision. “Everybody is tickled to death,” said Representative Louise M. Slaughter, Democrat of New York.

Speaker Nancy Pelosi tried to deflect criticism of the proposal. “It’s not really a public option,” she said. “It’s a consumer option.”

Amir's Analysis
This plan will erode American confidence in health reform and destroy our move towards true single-payer universal health in America.

October 6, 2009
By Ceci Connolly

As Congress presses forward with landmark legislation to revamp the nation's health-care system, lawmakers are grappling with a troubling question:

Are Americans dying too soon? The answer is yes. When it comes to "preventable deaths" -- an array of illnesses and injuries that should not kill at an early age -- the United States trails other industrialized nations and has been falling further behind over the past decade.

Although the United States now spends $2.4 trillion a year on medical care -- vastly more per capita than comparable countries -- the nation ranks near the bottom on premature deaths caused by illnesses such as diabetes, epilepsy, stroke, influenza, ulcers and pneumonia, according to research by the nonpartisan Commonwealth Fund published in the journal Health Affairs.

During last week's marathon health-care debate in the Senate Finance Committee, Sen. Kent Conrad (D-N.D.) bemoaned the findings.

"All of these countries have much lower costs than we do," he said, pointing to a giant blue chart showing the United States in last place. "And they have higher quality outcomes than ours."

Some lawmakers theorized that the rate could be related to trauma from guns and automobiles.

Although gun and auto fatality rates are higher here than they are in most wealthy nations, the statistics underscore more complex, fundamental challenges, say physicians, economists and other experts who track health-care systems across the world.

"Chronic illnesses are a much bigger driver of health-care costs" than trauma cases such as vehicle crashes and gunshots, said Robert Shesser, head of emergency medicine at George Washington University. "Because of our wacky system, some people are bankrupted or avoiding care and some are getting too much care -- they're hogging care."

The performance of the U.S. system is a mix, at best, said Mark Pearson, head of the health division at the Organization for Economic Cooperation and Development, which analyzes data from dozens of countries.

"Where it's good, it's very, very good, and where it's bad, it's horrid," he said. The United States, for example, is the international leader in the detection and treatment of most cancers, he said. Americans have earlier access to new medicine and technology, sometimes while the clinical trial is still under way. Europe, by waiting, often has more information on new products.

For people with insurance, "America delivers care in a timely manner," Pearson noted. That stands in contrast to the situation his own family faces in England, where relatives have waited weeks for tests or elective procedures.

But as many as 80 million Americans are uninsured or underinsured, which means they have little access to a regular physician, checkups, preventive services, affordable prescription drugs, dental care or screening tests.

In tracking preventable deaths, researchers count deaths from illnesses or injuries that either need not happen at all or for which there are therapies proven to keep someone alive to a certain age. Young children dying of measles is preventable in developed countries, for instance. Fatal cases of skin cancer, epilepsy, hernia and surgical complications should not occur before age 70 and are thus deemed preventable.

"These are conditions where early care and the right care should be able to prevent an early death," said Cathy Schoen, a senior vice president at the nonpartisan Commonwealth Fund. "We shouldn't see people dying of diabetes before age 50."

In contrast, more complicated cancers, AIDS and most heart disease, while often treatable, are not considered preventable, because even with the best of modern medicine, patients often die before old age.

In 1997-1998, the United States ranked 15th in preventable deaths out of 19 industrialized countries. In 2002-2003, the nation fell to 19th, even as costs continued to rise. Up to 100,000 lives could be saved if the country's health-care system performed as well those in nations such as France, Japan and Australia, according to the Commonwealth Fund study, which was based on World Health Organization statistics.

Measuring preventable deaths can illuminate strengths and weaknesses in a health-care system, Schoen said. Nations that dramatically lowered their preventable-death rates focused on challenges such as controlling diabetes and reducing hospital-acquired infections, she said.

Looking at the results, Pearson concluded: "The U.S. doesn't take primary care very seriously."

In terms of spending, the United States devotes about 16 percent of the total economy to health care, more than seven percentage points higher than the average of OECD countries. The average American consumed $7,290 worth of medical services in 2007, compared with an average of just under $3,000 in the remaining nations when adjusted for price differences, Pearson said.

More money went to higher physician salaries, larger administrative fees and higher prices for most medical services. Americans also have higher utilization rates of prescription medicines, sophisticated technology such as imaging and surgical procedures such as cataract surgery, knee replacements and Caesarean sections, according to the OECD analysis.

For Conrad, one of the key Senate health-care negotiators, the international comparisons suggest following the lead of nations such as Germany, France and Japan that achieve universal coverage through a blend of private employer-based insurance and nonprofit cooperatives, with a significant governmental role.

"What models most efficiently expand coverage, control costs and provide high-quality care," Conrad said. "You look around the world, and it just jumps out at you."

Amir's Analysis

A very sad trend. For more on this, one can look at the work of John Billings at New York University.

October 5, 2009
By Roger Cohen

NEW YORK — Back from another trip to Europe, this time Germany, where the same dismay as in France prevails over the U.S. health care debate. Europeans don’t get why Americans don’t agree that universal health coverage is a fundamental contract to which the citizens of any developed society have a right.

I don’t get it either. Or rather I do, but I don’t think the debate is about health. There can be no doubt that U.S. health care is expensive and wasteful. Tens of millions of people are uninsured by a system that devours a far bigger slice of national output — and that’s the sum of all Americans’ collective energies — than in any other wealthy society.

People die of worry, too. Emergency rooms were not created to be primary care providers.

Whatever may be right, something is rotten in American medicine. It should be fixed. But fixing it requires the acknowledgment that, when it comes to health, we’re all in this together. Pooling the risk between everybody is the most efficient way to forge a healthier society.

Europeans have no problem with this moral commitment. But Americans hear “pooled risk” and think, “Hey, somebody’s freeloading on my hard work.”

A reader, John Dowd, sent me this comment: “In Europe generally the populace in the various countries feels enough sense of social connectedness to enforce a social contract that benefits all, albeit at a fairly high cost. In America it is not like that. There is endless worry that one’s neighbor may be getting more than his or her “fair” share.”

Post-heroic European societies, having paid in blood for violent political movements born of inequality and class struggle, see greater risk in unfettered individualism than in social solidarity. Americans, born in revolt against Europe and so ever defining themselves against the old Continent’s models, mythologize their rugged (always rugged) individualism as the bulwark against initiative-sapping entitlements. We’re not talking about health here. We’re talking about national narratives and mythologies — as well as money. These are things not much susceptible to logic. But in matters of life and death, mythology must cede to reality, profit to wellbeing.

I can see the conservative argument that welfare undermines the work ethic and dampens moral fiber. Provide sufficient unemployment benefits and people will opt to chill rather than labor. But it’s preposterous to extend this argument to health care. Guaranteeing health coverage doesn’t incentivize anybody to get meningitis.

Yet that’s what Republicans’ cry of “socialized medicine” — American politics at its most debased — is all about. It implies that government-provided health care somehow saps Americans’ freedom-loving initiative. Some Democrats — prodded by drug and insurance companies with the cash to win favors — buy that argument, too.

I’m grateful to the wise Andrew Sullivan of The Atlantic for pointing out that Friedrich Hayek, whose suspicion of the state was visceral, had this to say in “The Road to Serfdom:”

“Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance — where, in short, we deal with genuinely insurable risks — the case for the state’s helping to organize a comprehensive system of social insurance is very strong.”

That’s why, when it comes to health, every developed society but the United States has such a “comprehensive system,” almost always with state involvement. However, pooled risk does not necessarily imply a public option. It can be achieved through mandated private-insurer coverage coupled with subsidies. That, for example, is the Swiss way — and where Congress seems headed.

But it’s nonprofit insurers who provide the coverage in Switzerland because health insurance is viewed as social insurance — as it is throughout Europe — rather than a means to make money. One fundamental reason a public option — yes, “option,” not single-payer monopoly — is needed in the United States is to jump-start the idea that basic health care is a moral obligation rather than a financial opportunity.

Another is to provide competition to private insurers and so force waste, excess and cozy arrangements out of the American system. Behind all the socialized medicine babble lurks a hard-headed calculation about money — all the profits skimmed from that waste and the big doctors’ salaries that go with it.

It’s not over yet for the public option. President Barack Obama should still push it with a clear moral stand.

He’s been too deferential. The best bit of his speech to Congress on health care was the last — and even there he left the most powerful words to the late Edward Kennedy: “What we face is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”

Obama then said he’d been pondering American character “quite a bit” and did some “self-reliance” versus government intervention musing.

He should have been clearer and punchier. A public commitment to universal coverage is not character-sapping but character-affirming. Medicare did not make America less American. Individualism is more “rugged” when housed in a healthy body.

Amir's Analysis

Great. I agree with everything 150%.

September 30, 2009
By DAVID M. HERSZENHORN

WASHINGTON — After a half-day of animated debate, the Senate Finance Committee on Tuesday rejected efforts by liberal Democrats to add a government-run health insurance plan to major health care legislation, dealing the first official setback to an idea that many Democrats, including President Obama, say they support.

All of the other versions of the health care legislation advancing in Congress — a bill approved by the Senate health committee and a trio of bills in the House — include some version of the government-run plan, or public option.

But the Finance Committee chairman, Senator Max Baucus, Democrat of Montana, long ago removed it from his proposal because of stiff opposition from Republicans who call the public plan a step toward “socialized medicine.”

The committee on Tuesday afternoon voted, 15 to 8, to reject an amendment proposed by Senator John D. Rockefeller IV, Democrat of West Virginia, to add a public option called the Community Choice Health Plan, an outcome that underscored the lack of support for a government plan among many Democrats.

Mr. Baucus voted no, as did Senators Thomas R. Carper of Delaware, Kent Conrad of North Dakota, Blanche Lincoln of Arkansas, , and Bill Nelson of Florida, joining all 10 Republicans in opposition.

A second amendment by Senator Charles E. Schumer, Democrat of New York, to create a different version of a public plan was also defeated, though by a closer margin, 13 to 10, with the added support of Mr. Carper and Mr. Nelson.

Mr. Schumer who voted in favor of both proposals, said supporters of the public option would keep on fighting.

“We are going to keep at this and at this and at this until we succeed, because we believe in it so strongly,” he said.

Advocates of a public plan say it would provide crucial competition for private insurers and that the larger goals of the legislation, to extend coverage to more than 30 million uninsured Americans and to slow the steep rise in health care costs, cannot be achieved without it.

The debate came as the Finance Committee resumed debate over the health care bill after a three-day weekend because of Yom Kippur, the Jewish Day of Atonement.

In the emotionally charged debate, Mr. Rockefeller railed against the practices of private insurers, who he suggested were largely preying on a defenseless American public. “They’re getting away with terrible things,” he said.

But Senator Charles E. Grassley of Iowa, the senior Republican on the Finance Committee, stepped in to voice his party’s fierce opposition to the idea of government-run insurance.

“A government run plan will ultimately force private insurers out of business,” Mr. Grassley said, adding that supporters of the public option were trying to open a back door toward a fully government-run, or single-payer, health system like those in Canada or England.

“Public option is a step toward a completely government run plan that they are hoping for,” Mr. Grassley said.

And he rejected assertions by Democrats, including Mr. Rockefeller, that the public plan would compete fairly because it would have to follow the same rules as private insurers.

“The federal government will not only be running the plan, it will also be running the market in which it competes with the private plans and that doesn’t sound like a level playing field to me,” Mr. Grassley said.

Democrats quickly rose up to answer the charges, including Mr. Schumer, who challenged Mr. Grassley to spell out his views on Medicare, the government insurance plan for Americans over age 65 and for the disabled.

“I just want to know what you think of Medicare, which is a much more government-run program,” Mr. Schumer said.

“I think that Medicare is part of the social fabric of America just like Social Security is,” Mr. Grassley said. “To say that I support it is not to say that it’s the best system that it could be.”

“But it is a government-run plan,” Mr. Schumer shot back.

Mr. Grassley, a veteran Senate debater, insisted that Medicare did not pose a threat to the private insurance industry. “It’s not easy to undo a Medicare plan without also hurting a lot of private initiatives that are coupled with it,” he said.

Mr. Schumer pounced. “You are supportive of Medicare,” he said. “I just don’t understand the difference. That’s a government-run plan and the main knock you have made on Senator Rockefeller’s amendment, and I am sure on mine, is that it’s government-run.”

The efforts by Mr. Rockefeller and Mr. Schumer to add a public plan to the bill were really just a dress rehearsal for a fuller battle that will play out on the Senate floor in the weeks ahead.

Senate Democratic leaders, however, do not believe there will be sufficient support to add the public option to the bill.

Senate Democratic aides say the majority leader, Senator Harry Reid, Democrat of Nevada, will not include a provision for the public option when he combines the measures coming out of the finance and health committees.

Mr. Rockefeller, Mr. Schumer and other supporters of a government-run plan will bring floor amendments trying once again to add it to the legislation.

And even when the debate over the public option is taken up on the Senate floor, most likely it will not be finished.

There is wider support for a government-run insurance plan in the House, where the Democratic caucus is more liberal. And if the House bill includes a public option, as Speaker Nancy Pelosi has indicated, the issue will ultimately be decided in a conference proceedings to reconcile the Senate and House bills.

As an alternative, Mr. Baucus included in his bill a proposal to create private, nonprofit health insurance cooperatives to compete with private insurers.

The Congressional Budget Office has questioned whether the cooperatives would really have much effect. And there are Democrats and Republicans on the Finance Committee who have proposed amendments that would strip the cooperative provisions.

The main architect of that proposal, Mr. Conrad said during the committee debate that it would provide “strong not for profit competition to the private insurers.” But he warned that hospitals in his home state would be devastated by Mr. Rockefeller’s proposal, which would initially tie the public plan’s payment rates to the rates paid by Medicare.

Many hospitals, doctors and other health care providers say Medicare rates are too low.

Mr. Conrad urged his colleagues to consider his alternative,. “We have gotten locked in a very sterile debate ,” he said.

Amir's Analysis

Well, it's dead. I hope all the private solution people are pleased because they got what they wanted.

September 17, 2009
By Paul Krugman

So Senator Max Baucus, the chairman of the Senate Finance Committee, has released his “mark” on proposed legislation — which would normally be the basis for the bill that eventually emerges from his committee. And serious supporters of health care reform will soon face their long-dreaded moment of truth.

You see, it has been clear for months that whatever health-care bill finally emerges will fall far short of reformers’ hopes. Yet even a bad bill could be much better than nothing. The question is where to draw the line. How bad does a bill have to be to make it too bad to vote for?

Now, the moment of truth isn’t here quite yet: There’s enough wrong with the Baucus proposal as it stands to make it unworkable and unacceptable. But that said, Senator Baucus’s mark is better than many of us expected. If it serves as a basis for negotiation, and the result of those negotiations is a plan that’s stronger, not weaker, reformers are going to have to make some hard choices about the degree of disappointment they’re willing to live with.

Of course, those who insist that we must have a single-payer system — Medicare for all — won’t accept any plan that tries, instead, to cajole and coerce private health insurers into covering everyone. But while many reformers, myself included, would prefer a single-payer system if we were starting from scratch, international experience shows that it’s not the only way to go. Several European countries, including Switzerland and the Netherlands, have managed to achieve universal coverage with a mainly private insurance system.

And right here in America, we have the example of the Massachusetts health reform, many of whose features are echoed in the Baucus plan. The Massachusetts system, introduced three years ago, has many problems. But as a new report from the Urban Institute puts it, it “has accomplished much of what it set out to do: Nearly all adults in the state have health insurance.” If we could accomplish the same thing for the nation as a whole, even with a less than ideal plan, it would be a vast improvement over what we have now.

So something along the general lines of the Baucus plan might be acceptable. But details matter. And the bad news is that the plan, as it stands, is inadequate or badly conceived in three major ways.

First, it bungles the so-called “employer mandate.” Most reform plans include a provision requiring that large employers either provide their workers with health coverage or pay into a fund that would help workers who don’t get insurance through their job buy coverage on their own. Mr. Baucus, however, gets too clever, trying to tie each employer’s fees to the subsidies its own employees end up getting.

That’s a terrible idea. As the Center on Budget and Policy Priorities points out, it would make companies reluctant to hire workers from lower-income families — and it would also create a bureaucratic nightmare. This provision has to go and be replaced with a simple pay-or-play rule.

Second, the plan is too stingy when it comes to financial aid. Lower-middle-class families, in particular, would end up paying much more in premiums than they do under the Massachusetts plan, suggesting that for many people insurance would not, in fact, be affordable. Fixing this means spending more than Mr. Baucus proposes.

Third, the plan doesn’t create real competition in the insurance market. The right way to create competition is to offer a public option, a government-run insurance plan individuals can buy into as an alternative to private insurance. The Baucus plan instead proposes a fake alternative, nonprofit insurance cooperatives — and it places so many restrictions on these cooperatives that, according to the Congressional Budget Office, they “seem unlikely to establish a significant market presence in many areas of the country.”

The insurance industry, of course, loves the Baucus plan. Need we say more?

So this plan has to change. What matters now is the direction in which it changes.

It would be disastrous if health care goes the way of the economic stimulus plan, earlier this year. As you may recall, that plan — which was clearly too weak even as originally proposed — was made even weaker to win the support of three Republican senators. If the same thing happens to health reform, progressives should and will walk away.

But maybe things will go the other way, and Mr. Baucus (and the White House) will, for once, actually listen to progressive concerns, making the bill stronger.

Even if the Baucus plan gets better, rather than worse, what emerges won’t be legislation reformers can love. Will it nonetheless be legislation that passes the threshold of acceptability, legislation they can vote for? We’ll see.

Amir's Analysis

Mr. Krugman, with all that I admire you, I have to disagree on some accounts. Your three points of problems within the plan are great, but I just can't let you go on single-payer. One simple reason is that two of your observed flaws, lack of financial aid and weak purchasing cooperatives, disappear under single-payer, universal coverage.

Incremental progress is fine, but incremental progress in the wrong direction that further entrenches private interest is not good. The plans discussed in Congress will create a marginal increase of coverage, through second-class citizen plans, sitting at or below Medicaid level of benefits. Hospitals and physician practices will do anything they can to offer limited coverage to such citizens. Furthermore, the obligation only to create some non-profit options will, likely, result in a high-deductible plan, a low-benefits plan, or both.

I just can't buy this and sit comfortable with it. Your Switzerland and Netherlands examples do not bear fruit with me because there are smaller countries with concentrated wealth that can bear private, incremental coverage for a small number of citizens. We have already seen that even in Massachusetts, private-based expansion to attempted universality can't work without single-payer and that, if it does work, radically balloons costs.

September 3, 2009
Lexington Blog

Americans fear health reform because they fear the Reaper

The first patient Dr Sherwin Nuland ever treated died horribly in front of him. James McCarty, a 52-year-old construction boss, had eaten too much red meat, smoked too many Camels and suffered a heart attack. Dr Nuland, then but a student, was asked to keep an eye on him while he recuperated. Suddenly, McCarty threw his head back, bellowed out a wordless roar and hit his own chest with balled fists. His face turned purple, his eyes bulged out of his head, he took “an immensely long gurgling breath”—and he died. Since this was half a century ago, Dr Nuland did what the textbooks then recommended. He cut open his patient’s chest and tried, unsuccessfully, to massage his heart back to life with his bare hands. It felt like “a wet, jellylike bag of hyperactive worms”. And it did no good. The “dead McCarty… threw back his head once more [and gave] a dreadful rasping whoop that sounded like the hounds of hell were barking.”

That story is one of several that make up “How We Die”, a book Dr Nuland wrote in 1993, after a lifetime of watching the effects of terminal illness. Because modern life is so clean and orderly, he argued, people expect to die with dignity. But this may be wishful thinking: death can be dirty, ugly and often involves the “disintegration of the dying person’s humanity”. Despite its gloominess, “How We Die” was a huge success, because it addressed with excruciating honesty mankind’s greatest fear.

The current debate about health-care reform is in part a debate about death, which is why it evokes such fear. Some of this fear is absurd. Outside a town-hall meeting in Reston, Virginia, last week, a few buffoons likened Barack Obama to Hitler. But most of the protesters are sane. Mr Obama plans to cover millions of uninsured people, says Brittany Tomaino, a young would-be oncologist. He will have to find the money somewhere. That means cuts to Medicare, the government health plan for the elderly, which covers her 95-year-old grandfather, she reckons. “If he needs care, they’re going to give it to someone younger,” she predicts.

A slim majority of Americans support Obamacare. But that majority is declining, and the passion is mostly on the other side. Pro-lifers, for example, worry that reform will mean taxpayer-funded abortions. Half of all Americans believe this will happen. Democrats point out that the bills in question do not mention abortion. Pro-lifers respond that the language is vague enough to allow bureaucrats to add abortion funding after the bill is passed. They also fret, like Ms Tomaino, that Mr Obama will deny life-saving treatment to Grandpa to save money. This possibility alarms Grandpa, too. Americans over 65 currently receive, through Medicare, fantastically generous health insurance for which they pay only a small fraction of the cost. Only 23% of them think Obamacare will make them better off, while a growing plurality think it will hurt them.

Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean? Should doctors seek to save the largest number of lives, or the largest number of years of life? Even in America, resources are finite. No one doubts that $1,000 to save the life of a child is money well spent. But what about $1m to prolong a terminally ill patient’s painful life by a week? Also, who should pay?

There are no easy answers. Unfortunately for Mr Obama, some of his academic chums have pondered seriously and publicly about the questions. Cass Sunstein, an adviser, has written extensively about which life-saving rules are most cost-effective. Ezekiel Emanuel, a doctor whose brother is Mr Obama’s chief of staff, wrote a paper for the Lancet, a medical journal, in which he proposed a system for determining who should be first in line for such things as liver transplants or vaccines during an epidemic. Among other factors, he suggested taking age into account, with adolescents and young adults getting priority, because they have fully developed personalities and many years of life ahead. This may be philosophically defensible, but it is political poison—Dr Emanuel even included a graph showing voters above and below the ideal age how much less their lives are worth. Conservative talk radio predictably dubbed him “Dr Death”. Republicans vowed last week to outlaw the rationing of care by age.


Blithe and distrustful

Mr Obama’s supporters say that objections to his reforms are largely based on misunderstanding, fuelled by Republican scaremongering. They have a point. But the Democrats’ bigger problem is that most Americans have pretty good health insurance and no idea how much it costs. Taxpayers foot the bill for the old. Most workers with employer-provided health insurance imagine that their employer is paying for it, when in fact it comes out of their wages. Soaring medical inflation depresses Americans’ standard of living and threatens to bust the budget. The system is riddled with waste. Yet most Americans feel little urge to make it more efficient. When asked if insurance firms should be obliged to pay for expensive treatments that have not been proved more effective than a cheaper alternative, 56% say yes.

Few Americans have a clear idea how Obamacare will affect them—unsurprisingly, since even quite basic details are undecided. The uninsured have the most to gain, but they are only 15% of the population. Everyone else has something to lose. Many Americans do not trust the government to do anything much, let alone make decisions about life and death. Small wonder Mr Obama finds the headwind against health reform so blustery.

Amir's Analysis

Americans need to accept that rationing is not a four letter word and that conservation of spending, at some level, is vital to the survival of any sustainable health program, universal or not.

August 27, 2009
By NICHOLAS D. KRISTOF

Opponents suggest that a “government takeover” of health care will be a milestone on the road to “socialized medicine,” and when he hears those terms, Wendell Potter cringes. He’s embarrassed that opponents are using a playbook that he helped devise.

“Over the years I helped craft this messaging and deliver it,” he noted.

Mr. Potter was an executive in the health insurance industry for nearly 20 years before his conscience got the better of him. He served as head of corporate communications for Humana and then for Cigna.

He flew in corporate jets to industry meetings to plan how to block health reform, he says. He rode in limousines to confabs to concoct messaging to scare the public about reform. But in his heart, he began to have doubts as the business model for insurance evolved in recent years from spreading risk to dumping the risky.

Then in 2007 Mr. Potter attended a premiere of “Sicko,” Michael Moore’s excoriating film about the American health care system. Mr. Potter was taking notes so that he could prepare a propaganda counterblast — but he found himself agreeing with a great deal of the film.

A month later, Mr. Potter was back home in Tennessee, visiting his parents, and dropped in on a three-day charity program at a county fairgrounds to provide medical care for patients who could not afford doctors. Long lines of people were waiting in the rain, and patients were being examined and treated in public in stalls intended for livestock.

“It was a life-changing event to witness that,” he remembered. Increasingly, he found himself despising himself for helping block health reforms. “It sounds hokey, but I would look in the mirror and think, how did I get into this?”

Mr. Potter loved his office, his executive salary, his bonus, his stock options. “How can I walk away from a job that pays me so well?” he wondered. But at the age of 56, he announced his retirement and left Cigna last year.

This year, he went public with his concerns, testifying before a Senate committee investigating the insurance industry.

“I knew that once I did that my life would be different,” he said. “I wouldn’t be getting any more calls from recruiters for the health industry. It was the scariest thing I have done in my life. But it was the right thing to do.”

Mr. Potter says he liked his colleagues and bosses in the insurance industry, and respected them. They are not evil. But he adds that they are removed from the consequences of their decisions, as he was, and are obsessed with sustaining the company’s stock price — which means paying fewer medical bills.

One way to do that is to deny requests for expensive procedures. A second is “rescission” — seizing upon a technicality to cancel the policy of someone who has been paying premiums and finally gets cancer or some other expensive disease. A Congressional investigation into rescission found that three insurers, including Blue Cross of California, used this technique to cancel more than 20,000 policies over five years, saving the companies $300 million in claims.

As The Los Angeles Times has reported, insurers encourage this approach through performance evaluations. One Blue Cross employee earned a perfect evaluation score after dropping thousands of policyholders who faced nearly $10 million in medical expenses.

Mr. Potter notes that a third tactic is for insurers to raise premiums for a small business astronomically after an employee is found to have an illness that will be very expensive to treat. That forces the business to drop coverage for all its employees or go elsewhere.

All this is monstrous, and it negates the entire point of insurance, which is to spread risk.

The insurers are open to one kind of reform — universal coverage through mandates and subsidies, so as to give them more customers and more profits. But they don’t want the reforms that will most help patients, such as a public insurance option, enforced competition and tighter regulation.

Mr. Potter argues that much tougher regulation is essential. He also believes that a robust public option is an essential part of any health reform, to compete with for-profit insurers and keep them honest.

As a nation, we’re at a turning point. Universal health coverage has been proposed for nearly a century in the United States. It was in an early draft of Social Security.

Yet each time, it has been defeated in part by fear-mongering industry lobbyists. That may happen this time as well — unless the Obama administration and Congress defeat these manipulative special interests. What’s un-American isn’t a greater government role in health care but an existing system in which Americans without insurance get health care, if at all, in livestock pens.

Amir's Analysis

Agreed. Private insurance in America is disgusting.

August 21, 2009
By WILLIAM H. DOW, ARINDRAJIT DUBE and CARRIE HOVERMAN COLLA

TWO burning questions are at the center of America’s health care debate. First, should employers be required to pay for their employees’ health insurance? And second, should there be a “public option” that competes with private insurance?

Answers might be found in San Francisco, where ambitious health care legislation went into effect early last year. San Francisco and Massachusetts now offer the only near-universal health care programs in the United States.

The early results are in. Today, almost all residents in the city have affordable access to a comprehensive health care delivery system through the Healthy San Francisco program. Covered services include the use of a so-called “medical home” that coordinates care at approved clinics and hospitals within San Francisco, with both public and private facilities. Although not formally insurance, the program is tantamount to a public option of comprehensive health insurance, with the caveat that services are covered only in the city of San Francisco. Enrollees with incomes under 300 percent of the federal poverty level have heavily subsidized access, and those with higher incomes may buy into the public program at rates substantially lower than what they would pay for an individual policy in the private-insurance market.

To pay for this, San Francisco put into effect an employer-health-spending requirement, akin to the “pay or play” employer insurance mandates being considered in Congress. Businesses with 100 or more employees must spend $1.85 an hour toward health care for each employee. Businesses with 20 to 99 employees pay $1.23 an hour, and businesses with 19 or fewer employees are exempt. These are much higher spending levels than mandated in Massachusetts, and more stringent than any of the plans currently under consideration in Congress. Businesses can meet the requirement by paying for private insurance, by paying into medical-reimbursement accounts or by paying into the city’s Healthy San Francisco public option.

There has been great demand for this plan. Thus far, around 45,000 adults have enrolled, compared to an estimated 60,000 who were previously uninsured. Among covered businesses, roughly 20 percent have chosen to use the city’s public option for at least some of their employees. But interestingly, in a recent survey of the city’s businesses, very few (less than 5 percent) of the employers who chose the public option are thinking about dropping existing (private market) insurance coverage. The public option has been used largely to cover previously uninsured workers and to supplement private-coverage options.

Through our experience working on health-care-reform efforts in California and Washington (one of us worked for President George W. Bush’s Council of Economic Advisers), we have seen how concern over employer costs can be a sticking point in the health care debate, even in the absence of persuasive evidence that increased costs would seriously harm businesses. San Francisco’s example should put some of those fears to rest. Many businesses there had to raise their health spending substantially to meet the new requirements, but so far the plan has not hurt jobs.

As of December 2008, there was no indication that San Francisco’s employment grew more slowly after the enactment of the employer-spending requirement than did employment in surrounding areas in San Mateo and Alameda counties. If anything, employment trends were slightly better in San Francisco. This is true whether you consider overall employment or employment in sectors most affected by the employer mandate, like retail businesses and restaurants.

So how have employers adjusted to the higher costs, if not by cutting jobs? More than 25 percent of restaurants, for example, have instituted a “surcharge” — about 4 percent of the bill for most establishments — to pay for the additional costs. Local service businesses can add this surcharge (or raise prices) without risking their competitive position, since their competitors will be required to take similar measures. Furthermore, some of the costs may be passed on to employees in the form of smaller pay raises, which could help ward off the possibility of job losses. Over the longer term, if more widespread coverage allows people to choose jobs based on their skills and not out of fear of losing health insurance from one specific employer, increased productivity will help pay for some of the costs of the mandate.

The San Francisco experiment has demonstrated that requiring a shared-responsibility model — in which employers pay to help achieve universal coverage — has not led to the kind of job losses many fear. The public option has also passed the market test, while not crowding out private options. The positive changes in San Francisco provide a glimpse of what the future might look like if Washington passes substantial health reform this year.

William H. Dow, who was a senior economist for President George W. Bush’s Council of Economic Advisers, is a professor of health economics at the University of California, Berkeley, where Arindrajit Dube is an economist at the Institute for Research on Labor and Employment and Carrie Hoverman Colla is a doctoral student in health economics.

Amir's Analysis

When people talk about incremental reform to complete public-option, single-payer, federally-organized, THIS is what incremental reform looks like to me. Kudos to San Francisco. While I don't agree with this or the Massachusetts plan completely, these are intermediate steps towards true reform that deserve applause.

August 18, 2009
By BOB HERBERT

It’s never a contest when the interests of big business are pitted against the public interest. So if we manage to get health care “reform” this time around it will be the kind of reform that benefits the very people who have given us a failed system, and thus made reform so necessary.

Forget about a crackdown on price-gouging drug companies and predatory insurance firms. That’s not happening. With the public pretty well confused about what is going on, we’re headed — at best — toward changes that will result in a lot more people getting covered, but that will not control exploding health care costs and will leave industry leaders feeling like they’ve hit the jackpot.

The hope of a government-run insurance option is all but gone. So there will be no effective alternative for consumers in the market for health coverage, which means no competitive pressure for private insurers to rein in premiums and other charges. (Forget about the nonprofit cooperatives. That’s like sending peewee footballers up against the Super Bowl champs.)

Insurance companies are delighted with the way “reform” is unfolding. Think of it: The government is planning to require most uninsured Americans to buy health coverage. Millions of young and healthy individuals will be herded into the industry’s welcoming arms. This is the population the insurers drool over.

This additional business — a gold mine — will more than offset the cost of important new regulations that, among other things, will prevent insurers from denying coverage to applicants with pre-existing conditions or imposing lifetime limits on benefits. Poor people will either be funneled into Medicaid, which will have its eligibility ceiling raised, or will receive a government subsidy to help with the purchase of private insurance.

If the oldest and sickest are on Medicare, and the poorest are on Medicaid, and the young and the healthy are required to purchase private insurance without the option of a competing government-run plan — well, that’s reform the insurance companies can believe in.

And then there are the drug companies. A couple of months ago the Obama administration made a secret and extremely troubling deal with the drug industry’s lobbying arm, the Pharmaceutical Research and Manufacturers of America. The lobby agreed to contribute $80 billion in savings over 10 years and to sponsor a multimillion-dollar ad campaign in support of health care reform.

The White House, for its part, agreed not to seek additional savings from the drug companies over those 10 years. This resulted in big grins and high fives at the drug lobby. The White House was rolled. The deal meant that the government’s ability to use its enormous purchasing power to negotiate lower drug prices was off the table.

The $80 billion in savings (in the form of discounts) would apply only to a certain category of Medicare recipients — those who fall into a gap in their drug coverage known as the doughnut hole — and only to brand-name drugs. (Drug industry lobbyists probably chuckled, knowing that some patients would switch from generic drugs to the more expensive brand names in order to get the industry-sponsored discounts.)

To get a sense of how sweet a deal this is for the drug industry, compare its offer of $8 billion in savings a year over 10 years with its annual profits of $300 billion a year. Robert Reich, who served as labor secretary in the Clinton administration, wrote that the deal struck by the Obama White House was very similar to the “deal George W. Bush struck in getting the Medicare drug benefit, and it’s proven a bonanza for the drug industry.”

The bonanza to come would be even larger, he said, “given all the Boomers who will be enrolling in Medicare over the next decade.”

While it is undoubtedly important to bring as many people as possible under the umbrella of health coverage, the way it is being done now does not address what President Obama and so many other advocates have said is a crucial component of reform — bringing the ever-spiraling costs of health care under control. Those costs, we’re told, are hamstringing the U.S. economy, making us less competitive globally and driving up the budget deficit.

Giving consumers the choice of an efficient, nonprofit, government-run insurance plan would have moved us toward real cost control, but that option has gone a-glimmering. The public deserves better. The drug companies, the insurance industry and the rest of the corporate high-rollers have their tentacles all over this so-called reform effort, squeezing it for all it’s worth.

Meanwhile, the public — struggling with the worst economic downturn since the 1930s — is looking on with great anxiety and confusion. If the drug companies and the insurance industry are smiling, it can only mean that the public interest is being left behind.

Amir's Analysis

I ONE-HUNDRED PERCENT AGREE.
This is sad and pathetic. Pathetic! Government, you are pathetic! Giving in to special interests again at the expense of the public. Again! Pathetic day for our country and its future. Pathetic.

August 17, 2009

By ELIZABETH WILLIAMSON and AUGUST COLE

The Obama administration gave its strongest signal yet that it would be willing to compromise on plans to expand the government's direct role in health-insurance coverage as it fights a growing crescendo of opposition to its effort to overhaul health care.

Health and Human Services Secretary Kathleen Sebelius said Sunday that a new, government-run health-insurance program wasn't the "essential element" of any overhaul plan.

Robert Gibbs, the president's press secretary, said President Barack Obama wants "choice and competition" in the insurance market. Mr. Obama "has, thus far, sided with the notion that can best be done through a public option," or government-run plan, Mr. Gibbs said Sunday on CBS's "Face the Nation." However, he said the bottom line is simply that "what we have to have is choice and competition in the insurance market."

A day earlier, President Obama defended the public option at a town-hall meeting in Grand Junction, Colo., while leaving the door open to alternative approaches that expand coverage and reduce costs, but don't increase the federal deficit.

The public option, "whether we have it or we don't have it, is not the entirety of health-care reform," Mr. Obama said. "This is just one sliver of it, one aspect of it."

The comments come after a bruising two weeks in which the president's call for a public plan to "keep insurance companies honest" has been interpreted by Republican opponents and some members of the public as a push to drive private insurers out of the marketplace.

Insurance companies have fought a public plan, objecting specifically to one that would use the government's buying power to negotiate rates. The worry is that hospitals and doctors would charge private companies more to make up for being underpaid by the government. Concerns have also been raised that insurers would be unable to compete with such a plan, and that the public option would be a precursor to national health care.

The implications for consumers of nonprofit health-insurance cooperatives, one alternative way to help individuals and small businesses get coverage, are unclear. Much will depend on how and how quickly the co-ops can organize -- a daunting task that could involve setting up the equivalent of new insurers on a state or regional basis. The savings wrung from this extra competition could help cash-strapped patients, though it is unlikely that the co-ops would bring prices down as significantly as the government could.

Obama administration officials have indicated before that they could support a health-care overhaul without a government-run insurance option. "Nothing has changed. The president has always said that what is essential is that health-insurance reform must lower costs, ensure that there are affordable options for all Americans and it must increase choice and competition in the health-insurance market. He believes the public option is the best way to achieve those goals," Linda Douglass, communications director for the White House's health-reform office, said Sunday.

But as the debate over Mr. Obama's ideas for a health-system overhaul grows more shrill, proponents have indicated willingness to drop some controversial elements in order to get a plan passed.

Aides to Senate Minority Leader Mitch McConnell (R., Ky.), an opponent of the public option, labeled Ms. Sebelius's comments a "shift" on the issue in an email pointing out various occasions on which President Obama had said a health plan should include a public option.

Some liberal advocates interpreted the administration's position as a shift in emphasis, but not away from the public option. Mr. Obama wants to "broaden the conversation so people understand that health-care insurance reform is bigger than just one element," said Jacki Schechner, spokeswoman for Health Care for America Now, a grass-roots campaign for health-care reform.

Ms. Sebelius's comments come as some senior Democrats in the Senate are urging the administration to give up on the idea of a public plan run directly by the government. The House has already passed a bill with a robust public option. But House Democrats might be reluctant to vote for a final bill that includes a government-funded plan -- exposing themselves to attacks from the right -- if the White House appears willing to bargain that away too quickly.

The insurers set to breathe the biggest sigh of relief if the public plan is dropped are Wellpoint Inc., which operates Blue Cross and Blue Shield plans in 14 states, and the dozens of other not-for-profit Blue plans across the country. They are currently the biggest sellers of individual health policies, the kind that would compete with new public or co-op plans. Companies such as Aetna Inc. and Cigna Corp. have less to lose from a public plan as they market mostly to employers.

Robert Laszewski, a consultant at Health Policy & Strategy Associates, said nonprofit co-ops aren't necessarily an easy victory for insurers, though. If they don't work down the road, and the government has to bail them out, they might be a precursor to a stronger government role in health care, he said.

He pointed out that the barriers to entry for new insurers are high: They need to set up information-technology infrastructure, build networks of providers and raise significant capital to hedge against catastrophic claims. A co-op that doesn't navigate those challenges smoothly runs the risk of being shunned by potential customers.

America's Health Insurance Plans, the lobbying group that represents the industry, is also cautious about the idea of co-ops, saying it hasn't seen any details on how such a system would operate. Robert Zirkelbach, a spokesman for the group, said that reforms the insurers have proposed -- such as accepting patients with pre-existing conditions -- are enough to fix the health-care system. "If we do those things, a government-run plan -- including a co-op -- is not necessary," he said.

—Avery Johnson and Vanessa Fuhrmans contributed to this article.

Amir's Analysis

At this point I am ready to declare any real reform dead. The non-public Swiss option simply won't work in America for many reasons. These efforts have been watered down repeatedly and I have tried to embrace some gradual change and to find some sense in the Administration's plans, but this is the last straw at giving in to industry and coming out with nothing. Awful. Reform over. Now it's just nonsense.

I encourage all voters to reach out to their Congresspeople and reject this legislation.

August 11, 2009
By Paul Krugman

The Swiss Menace

It was the blooper heard round the world. In an editorial denouncing Democratic health reform plans, Investor’s Business Daily tried to frighten its readers by declaring that in Britain, where the government runs health care, the handicapped physicist Stephen Hawking “wouldn’t have a chance,” because the National Health Service would consider his life “essentially worthless.”

Professor Hawking, who was born in Britain, has lived there all his life, and has been well cared for by the National Health Service, was not amused.

Besides being vile and stupid, however, the editorial was beside the point. Investor’s Business Daily would like you to believe that Obamacare would turn America into Britain — or, rather, a dystopian fantasy version of Britain. The screamers on talk radio and Fox News would have you believe that the plan is to turn America into the Soviet Union. But the truth is that the plans on the table would, roughly speaking, turn America into Switzerland — which may be occupied by lederhosen-wearing holey-cheese eaters, but wasn’t a socialist hellhole the last time I looked.

Let’s talk about health care around the advanced world.

Every wealthy country other than the United States guarantees essential care to all its citizens. There are, however, wide variations in the specifics, with three main approaches taken.

In Britain, the government itself runs the hospitals and employs the doctors. We’ve all heard scare stories about how that works in practice; these stories are false. Like every system, the National Health Service has problems, but over all it appears to provide quite good care while spending only about 40 percent as much per person as we do. By the way, our own Veterans Health Administration, which is run somewhat like the British health service, also manages to combine quality care with low costs.

The second route to universal coverage leaves the actual delivery of health care in private hands, but the government pays most of the bills. That’s how Canada and, in a more complex fashion, France do it. It’s also a system familiar to most Americans, since even those of us not yet on Medicare have parents and relatives who are.

Again, you hear a lot of horror stories about such systems, most of them false. French health care is excellent. Canadians with chronic conditions are more satisfied with their system than their U.S. counterparts. And Medicare is highly popular, as evidenced by the tendency of town-hall protesters to demand that the government keep its hands off the program.

Finally, the third route to universal coverage relies on private insurance companies, using a combination of regulation and subsidies to ensure that everyone is covered. Switzerland offers the clearest example: everyone is required to buy insurance, insurers can’t discriminate based on medical history or pre-existing conditions, and lower-income citizens get government help in paying for their policies.

In this country, the Massachusetts health reform more or less follows the Swiss model; costs are running higher than expected, but the reform has greatly reduced the number of uninsured. And the most common form of health insurance in America, employment-based coverage, actually has some “Swiss” aspects: to avoid making benefits taxable, employers have to follow rules that effectively rule out discrimination based on medical history and subsidize care for lower-wage workers.

So where does Obamacare fit into all this? Basically, it’s a plan to Swissify America, using regulation and subsidies to ensure universal coverage.

If we were starting from scratch we probably wouldn’t have chosen this route. True “socialized medicine” would undoubtedly cost less, and a straightforward extension of Medicare-type coverage to all Americans would probably be cheaper than a Swiss-style system. That’s why I and others believe that a true public option competing with private insurers is extremely important: otherwise, rising costs could all too easily undermine the whole effort.

But a Swiss-style system of universal coverage would be a vast improvement on what we have now. And we already know that such systems work.

So we can do this. At this point, all that stands in the way of universal health care in America are the greed of the medical-industrial complex, the lies of the right-wing propaganda machine, and the gullibility of voters who believe those lies.

•

Correction: In Friday’s column I mistakenly asserted that Senator Johnny Isakson was responsible for a provision in a House bill that would allow Medicare to pay for end-of-life counseling. In fact, he is responsible for a provision in a Senate bill that would allow a different, newly created government program to pay for such counseling.

Amir's Analysis

Great article although I would have appreciated a mention that, for our country, the French/Oslo model is a better fit and the reasons why.

August 11, 2009
By John Mackey

"The problem with socialism is that eventually you run out
of other people's money."

—Margaret Thatcher

With a projected $1.8 trillion deficit for 2009, several trillions more in deficits projected over the next decade, and with both Medicare and Social Security entitlement spending about to ratchet up several notches over the next 15 years as Baby Boomers become eligible for both, we are rapidly running out of other people's money. These deficits are simply not sustainable. They are either going to result in unprecedented new taxes and inflation, or they will bankrupt us.

While we clearly need health-care reform, the last thing our country needs is a massive new health-care entitlement that will create hundreds of billions of dollars of new unfunded deficits and move us much closer to a government takeover of our health-care system. Instead, we should be trying to achieve reforms by moving in the opposite direction—toward less government control and more individual empowerment. Here are eight reforms that would greatly lower the cost of health care for everyone:

• Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems. For example, Whole Foods Market pays 100% of the premiums for all our team members who work 30 hours or more per week (about 89% of all team members) for our high-deductible health-insurance plan. We also provide up to $1,800 per year in additional health-care dollars through deposits into employees' Personal Wellness Accounts to spend as they choose on their own health and wellness.

Money not spent in one year rolls over to the next and grows over time. Our team members therefore spend their own health-care dollars until the annual deductible is covered (about $2,500) and the insurance plan kicks in. This creates incentives to spend the first $2,500 more carefully. Our plan's costs are much lower than typical health insurance, while providing a very high degree of worker satisfaction.

• Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits. Now employer health insurance benefits are fully tax deductible, but individual health insurance is not. This is unfair.

• Repeal all state laws which prevent insurance companies from competing across state lines. We should all have the legal right to purchase health insurance from any insurance company in any state and we should be able use that insurance wherever we live. Health insurance should be portable.

• Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.

• Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.

• Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor's visit and how that total breaks down? What other goods or services do we buy without knowing how much they will cost us?

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

• Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren't covered by Medicare, Medicaid or the State Children's Health Insurance Program.

Many promoters of health-care reform believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?

Health care is a service that we all need, but just like food and shelter it is best provided through voluntary and mutually beneficial market exchanges. A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That's because there isn't any. This "right" has never existed in America

Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.

Although Canada has a population smaller than California, 830,000 Canadians are currently waiting to be admitted to a hospital or to get treatment, according to a report last month in Investor's Business Daily. In England, the waiting list is 1.8 million.

At Whole Foods we allow our team members to vote on what benefits they most want the company to fund. Our Canadian and British employees express their benefit preferences very clearly—they want supplemental health-care dollars that they can control and spend themselves without permission from their governments. Why would they want such additional health-care benefit dollars if they already have an "intrinsic right to health care"? The answer is clear—no such right truly exists in either Canada or the U.K.—or in any other country.

Rather than increase government spending and control, we need to address the root causes of poor health. This begins with the realization that every American adult is responsible for his or her own health.

Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.

Recent scientific and medical evidence shows that a diet consisting of foods that are plant-based, nutrient dense and low-fat will help prevent and often reverse most degenerative diseases that kill us and are expensive to treat. We should be able to live largely disease-free lives until we are well into our 90s and even past 100 years of age.

Health-care reform is very important. Whatever reforms are enacted it is essential that they be financially responsible, and that we have the freedom to choose doctors and the health-care services that best suit our own unique set of lifestyle choices. We are all responsible for our own lives and our own health. We should take that responsibility very seriously and use our freedom to make wise lifestyle choices that will protect our health. Doing so will enrich our lives and will help create a vibrant and sustainable American society.

Mr. Mackey is co-founder and CEO of Whole Foods Market Inc.

Amir's Analysis

While I dramatically disagree with about 80% of what Mackey says in this article, and also question his hubris in commenting on health policy as a supermarket manager, I have posted this piece in respect of opposing viewpoints and the repeated push of many of my conservative colleagues who asked that I feature this article today.

July 30, 2009
By IAN URBINA

The bitter divisions over an overhaul of the health care system have exploded at town-hall-style meetings over the last few days as members of Congress have been shouted down, hanged in effigy and taunted by crowds. In several cities, noisy demonstrations have led to fistfights, arrests and hospitalizations.

Democrats have said the protesters are being organized by conservative lobbying groups like FreedomWorks. Republicans respond that the protests are an organic response to the Obama administration’s health care restructuring proposals.

There is no dispute, however, that most of the shouting and mocking is from opponents of those plans. Many of those opponents have been encouraged to attend by conservative commentators and Web sites.

“Become a part of the mob!” said a banner posted Friday on the Web site of the talk show host Sean Hannity. “Attend an Obama Care Townhall near you!” The exhortations do not advocate violence, but some urge opponents to be disruptive.

“Pack the hall,” said a strategy memo circulated by the Web site Tea Party Patriots that instructed, “Yell out and challenge the Rep’s statements early.”

“Get him off his prepared script and agenda,” the memo continued. “Stand up and shout and sit right back down.”

The memo was obtained by the liberal Web site ThinkProgress. Its author, Robert MacGuffie, a founder of the conservative Web site Right Principles, confirmed to The New York Times that the memo was legitimate.

In response, liberal groups and the White House have also started sending supporters instructions for countering what they say are the organized disruptions.

A volatile mix has resulted. In Mehlville, Mo., St. Louis County police officers arrested six people on Thursday evening, some on assault charges, outside a health care and aging forum organized by Representative Russ Carnahan, a Democrat. Opponents of the proposed changes, organized by the St. Louis Tea Party, apparently clashed with supporters organized by the Service Employees International Union outside a school gym.

That same day in Romulus, Mich., Representative John D. Dingell, a long-serving Democrat, was shouted down at a health care meeting by a rowdy crowd of foes of health care overhaul, many crying, “Shame on you!” A similar scene unfolded in Denver on Thursday when Speaker Nancy Pelosi of California visited a clinic for the homeless there.

In a statement Friday, Mr. Dingell, 83, deplored those trying to “demagogue the discussion,” but said he would not be deterred. “As long as I have a vote, I will not let shouting, intimidation or misinformation deter me from fighting for this cause,” he said.

The tenor of some of the debates has become extreme. Ms. Pelosi has accused people at recent protests of carrying signs associating the Democratic plan with Nazi swastikas and SS symbols, and some photographs showing such signs have been posted on the Web.

On Thursday, the talk show host Rush Limbaugh said the administration’s health care logo was itself similar to a Nazi symbol.

On Friday, the Simon Wiesenthal Center and the Anti-Defamation League released statements criticizing the comparison.

“It is preposterous to try and make a connection between the president’s health care logo and the Nazi Party symbol, the Reichsadler,” said Rabbi Marvin Hier, the founder and dean of the Wiesenthal center.

On Thursday, top White House aides tried to bolster Senate Democrats during a lunch meeting, arming the lawmakers with tips for avoiding disastrous public forums.

“If you get hit, we will punch back twice as hard,” said Jim Messina, the deputy White House chief of staff, according to an official who attended the meeting.

Earlier this week, Robert Gibbs, the White House press secretary, compared the scenes at health care forums to the “Brooks Brothers brigade” in 2000, a reference to the protests that disrupted the vote count in Miami during the presidential election battle between George W. Bush and Al Gore. Portrayed at the time as local protesters, many were actually Republican staff members flown in from Washington.

For Representative Steve Kagen, Democrat of Wisconsin, Mr. Gibbs’s criticism rang true.

After he faced heckling during a heated discussion about health care at a forum on Thursday, Mr. Kagen was confronted by a vocal opponent named Heather Blish, who identified herself as “just a mom from a few blocks away” and “not affiliated with any political party.”

When interviewed by the local NBC affiliate, Ms. Blish insisted she was not a member of the Republican Party. But her page on the networking Web site Linked In said she was the vice chairwoman of the Republican Party of Kewaunee County until last year and worked on the campaign of John Gard, a Republican who ran unsuccessfully against Mr. Kagen last year.

Ms. Blish’s boss, Scott Detweiler, owner of IdealCampaign.com, which develops political candidate and campaign Web sites, confirmed that she had been active in local Republican politics. But Mr. Detweiler said she was sincere when she said she was not involved in any party, because she ended her activities with the Republican Party a year and a half ago.

One of the week’s most raucous encounters occurred Thursday in Tampa, Fla., where roughly 1,500 people attended a forum held by Democratic lawmakers, including Representative Kathy Castor. When the auditorium at the Children’s Board of Hillsborough County reached capacity and organizers had to close the doors, the scene descended into violence.

As Ms. Castor began to speak, scuffles broke out as people tried to push their way in. Parts of her remarks were drowned out by chants of “read the bill, read the bill” and “tyranny,” as a video recording of the meeting showed. Outside the meeting, there were competing chants of “Yes we can” and “Just say no.”

Some of the protesters told local reporters they had been urged to come by a local activist group promoted by the conservative radio and television host Glenn Beck. Others said they had received e-mail messages from the Hillsborough County Republican Party that urged people to speak out against the plan and offered talking points.

Elsewhere, there was similar discontent. On Sunday in Morrisville, Pa., Representative Patrick J. Murphy, a Democrat, was forced to scrap plans for a one-on-one, meet-the-congressman session when people in the crowd started shouting, so he agreed to discuss the issue with the entire audience.

At an appearance at a grocery store in Austin, Tex., on Aug. 1, Representative Lloyd Doggett, a Democrat, was drowned out as he tried to speak on health care change. One opponent had a mock tombstone with Mr. Doggett’s name on it.

Last week, a protester hanged an effigy of Representative Frank Kratovil Jr., Democrat of Maryland, at a rally opposing health care change. This week, Representative Brad Miller, Democrat of North Carolina, said he had received a death threat about his support.

Contributing reporting were David M. Herszenhorn and Theo Emery in Washington, Brian Stelter in New York, Sean D. Hamill in Pittsburgh, Carmen Gentile in Miami and Malcolm Gay in St. Louis.


Amir's Analysis

Wow...just wow... another American policy debate turns to yelling and irrational emotional arguments versus an actual understanding of facts or analysis. Amazing...

July 30, 2009
By ADAM NAGOURNEY and MEGAN THEE-BRENAN

President Obama’s ability to shape the debate on health care appears to be eroding as opponents aggressively portray his overhaul plan as a government takeover that could limit Americans’ ability to choose their doctors and course of treatment, according to the latest New York Times/CBS News poll.

Americans are concerned that revamping the health care system would reduce the quality of their care, increase their out-of-pocket health costs and tax bills, and limit their options in choosing doctors, treatments and tests, the poll found. The percentage who describe health care costs as a serious threat to the American economy — a central argument made by Mr. Obama — has dropped over the past month.

Mr. Obama continues to benefit from strong support for the basic goal of revamping the health care system, and he is seen as far more likely than Congressional Republicans to have the best ideas to accomplish that. But reflecting a problem that has hindered efforts to bring major changes to health care for decades, Americans expressed considerable unease about what the end result would mean for them individually.

“We need to fix health care,” Mary Bevering, a Democrat from Fort Madison, Iowa, said in a follow-up interview, “but if the government creates the system, I’m afraid the quality of care will go down and costs will go up: We will pay more taxes.”

“It’s going to come down to regulation,” Ms. Bevering said. “What also worries me is whether we will be told what physician we can have.”

The poll was taken at a moment of extreme fluidity, both in terms of the complicated negotiations in the House and the Senate as lawmakers and the administration sort out the substance and politics of competing proposals, and in the efforts by both sides to define the stakes of the health care debate for the public.

With Congress now almost certain to recess until after Labor Day without floor votes on any specific plan, a vigorous advertising and grass-roots effort to shift public opinion is likely in the next month or two. The poll offers hope to both sides.

The changes in the public’s attitude over the past month, even if not huge, suggest one reason Mr. Obama sought so hard to get Congress to vote on some version of an overhaul before heading home.

Opponents of the proposed health care overhaul have already spent $9 million on television advertisements raising concerns about it, said Evan Tracey, the chief operating officer of Campaign Media Analysis Group, which tracks political advertising. The advertisements are financed by the Republican National Committee and aimed at constituents of wavering lawmakers. The committee is also running radio spots.

Officials said the advertising would accelerate as the legislators returned home for the summer. The advertisements present the overhaul as a risky experiment, or a government takeover of health care that would prevent people from choosing their own doctors.

Mr. Obama is making an intense effort to rebut those claims. On Wednesday, he flew to Raleigh, N.C., for a town-hall-style meeting to address the kinds of public concerns reflected in the poll results.

“First of all,” Mr. Obama said, “nobody is talking about some government takeover of health care. I’m tired of hearing that. I have been as clear as I can be. Under the reform I’ve proposed, if you like your doctor, you keep your doctor; if you like your health care plan, you keep your health care plan. These folks need to stop scaring everybody, you know?”

Mr. Obama sought in particular to reassure people who already have health insurance and whom the overhaul plans under consideration in Congress would benefit by preventing insurers from dropping them or diluting their coverage if they become ill, while also bringing rapidly rising costs under control. And he sought to stoke a sense of urgency for getting a bill signed this year.

“If we do nothing, I can almost guarantee you your premiums will double over the next 10 years, because that’s what they did over the last 10 years,” Mr. Obama said. “It will eat into the possibility of you getting a raise on your job because your employer is going to be looking and saying, ‘I can’t afford to give you a raise because my health care costs just went up 10, 20, 30 percent.’ ”

The national poll was conducted by telephone starting on Friday and ending on Tuesday. It involved 1,050 adults, and has a margin of sampling error of plus or minus three percentage points.

Mr. Obama’s job approval rating has dropped 10 points, to 58 percent, from a high point in April.

And despite his efforts — in speeches, news conferences, town-hall-style meetings and other forums — to address public misgivings, 69 percent of respondents in the poll said they were concerned that the quality of their own care would decline if the government created a program that covers everyone.

Still, Mr. Obama remains the dominant figure in the debate, both because he continues to enjoy relatively high levels of public support even after seeing his approval ratings dip, and because there appears to be a strong desire to get something done: 49 percent said they supported fundamental changes, and 33 percent said the health care system needed to be completely rebuilt.

The poll found 66 percent of respondents were concerned that they might eventually lose their insurance if the government did not create a new health care system, and 80 percent said they were concerned that the percentage of Americans without health care would continue to rise if Congress did not act.

By 55 percent to 26 percent, respondents said Mr. Obama had better ideas about how to change health care than Republicans in Congress did.

There is overwhelming support for a bipartisan agreement on health care, and here again, Mr. Obama appears in the stronger position: 59 percent said that he was making an effort to work with Congressional Republicans, while just 33 percent said Republicans were trying to work with him on the issue.

Over all, the poll portrays a nation torn by conflicting impulses and confusion.

In one finding, 75 percent of respondents said they were concerned that the cost of their own health care would eventually go up if the government did not create a system of providing health care for all Americans. But in another finding, 77 percent said they were concerned that the cost of health care would go up if the government did create such a system.

Amir's Analysis

I agree that the Obama plan is not without many flaws, but more disturbing to me is the opposition playing the Harry/Louise HillaryCare tactic to destroy a health reform initiative again without any counter-proposals for real reform. It is not good enough to just say a proposed plan is awful or will bloat costs. If the existing system clearly doesn't work, suggest a meaningful second option without buzzwords that don't mean anything or don't work like "let's let the private sector work it all out". Because, unless a health analyst has been in a cave for the last 15 years, it is obvious that the suggestion of letting the market work out most things in the private sector hasn't quite settled out...especially for big social programs. This truth has been shown again and again and again...and they keep playing the same worn-out doesn't work card and it works. I don't understand...

July 25, 2009
By DAVID M. HERSZENHORN and ROBERT PEAR

WASHINGTON — On the agenda is the revamping of the American health care system, possibly the most complex legislation in modern history. But on the table, in a conference room where the bill is being hashed out by six senators, the snacks are anything but healthy.

Last week, there were chippers — chocolate-covered potato chips — described on a sign as “North Dakota Diet Food.” More often, there are Doritos, pretzels, Oreo cookies and beef jerky: fuel to get through hours of talks on topics like the actuarial values of private insurance plans or the cost-sharing provisions of Medicare.

The fate of the health care overhaul largely rests on the shoulders of six senators who since June 17 have gathered — often twice a day, and for many hours at a stretch — in a conference room with burnt sienna walls, in the office of the Senate Finance Committee chairman, Max Baucus, Democrat of Montana.

President Obama and Congressional leaders agree that if a bipartisan deal can be forged on health care, it will emerge from this conference room, with a huge map of Montana on one wall and photos of Mike Mansfield, the Montanan who was the longest-serving Senate majority leader, on the other.

The battle over health care is all but paralyzed as everyone awaits the outcome of their talks.

Mr. Baucus says his group will produce the bill that best meets Mr. Obama’s top priorities, broadly expanding coverage to the uninsured and curtailing the steep rise in health care spending over the long term, what policy makers call “bending the cost curve.”

Still, if the three Democrats and three Republicans can pull off a grand bargain, it will have to be more conservative than the measures proposed by the House or the left-leaning Senate health committee. And that could force Mr. Obama to choose between backing the bipartisan deal or rank-and-file Democrats who want a bill that more closely reflects their liberal ideals.

Already, the group of six has tossed aside the idea of a government-run insurance plan that would compete with private insurers, which the president supports but Republicans said was a deal-breaker.

Instead, they are proposing a network of private, nonprofit cooperatives.

They have also dismissed the House Democratic plan to pay for the bill’s roughly $1 trillion, 10-year cost partly with an income surtax on high earners.

The three Republicans have insisted that any new taxes come from within the health care arena. As one option, Democrats have proposed taxing high-end insurance plans with values exceeding $25,000.

The Senate group also seems prepared to drop a requirement, included in other versions of the legislation, that employers offer coverage to their workers. “We don’t mandate employer coverage,” Senator Olympia J. Snowe, Republican of Maine and one of the six, said Monday. Employers that do not offer coverage may instead have to pay the cost of any government subsidies for which their workers qualify. In the House, centrist Democrats have temporarily stalled the health care bill, many lawmakers want to see what Mr. Baucus’s group produces before voting on tax increases in the House bill.

Mr. Obama, in his news conference last week, praised the three Republicans in the Senate group — Michael B. Enzi of Wyoming, Charles E. Grassley of Iowa and Ms. Snowe. Mr. Grassley, the senior Republican on the Finance Committee, and Mr. Baucus share a history of deal-making, and group members said they share a sense of trust despite the partisan acrimony that pervades the Capitol.

Mr. Enzi, who sits on both the Finance Committee and the health committee, has a long record on health issues but found Democrats on the health panel unwilling to compromise.

And Ms. Snowe, one of two centrist Republicans, often teams with Democrats as she did on the economic stimulus plan this year.

After the group insisted it needed more time, the majority leader, Senator Harry Reid of Nevada, conceded that a floor vote would have to wait until after the summer recess. “If this is the only bill with bipartisan support,” Ms. Snowe said, “that will really resonate. It could be the linchpin for broad bipartisan agreement.”

In addition to Mr. Baucus, the Democrats are Senators Kent Conrad of North Dakota and Jeff Bingaman of New Mexico.

“I think there’s a heavy sense of responsibility among this group,” Mr. Conrad said in an interview. “Our country needs us to get this right.”

As they near a deal, however, Mr. Baucus is getting resistance from Democrats who think he is giving too much ground.

Mr. Grassley said the group agreed on how to achieve most of the larger policy goals, including barring insurance companies from denying coverage based on pre-existing conditions and better managing treatment of costly chronic diseases like diabetes and asthma. But there have been sharp disagreements, particularly over how to pay for the legislation.

Often a single topic can consume an entire day or more. On Wednesday of last week, it was Medicaid, the federal-state insurance program for low-income people that was likely to be expanded but was also a major factor in the legislation’s high cost.

Another recent topic has been how to create payment incentives for doctors and other providers to work in collaborative teams, as part of so-called accountable care organizations.

“The talks are free-flowing,” Ms. Snowe said. “Max is very inclusive,” she said of Mr. Baucus.

Members of the group methodically work through issues. When they reach a tentative agreement, Mr. Baucus asks, “Can I put down a ‘T’?”

“It’s very businesslike,” Mr. Conrad said. “Everybody participates. One senator might carry a discussion. Others chime in. Senator Baucus, the chairman, is the leader, but he rides with a very light rein.”

Typically, they gather at 10 a.m., break around noon for meetings, lunches and votes, and then resume at 2:30. Each senator now claims the same seat — “just like kids in school,” Ms. Snowe said in an interview.

Then, there are the refreshments. The coffee, brewed in the office, is roasted in Montana, usually the Grizzly or Buffalo blends.

For all the discussions about preventive medicine, and the need to encourage Americans to lead healthier lives, carrots and celery sticks are not typical.

“The food leaves something to be desired,” Ms. Snowe said. But she also noted that no one was in the room to eat.

“There are not many occasions when we have the opportunity to sit down and immerse ourselves in an issue like this, an issue that has profound implications for the country, with historic overtones, to say the least,” Ms. Snowe said. “I feel privileged to participate.”
 
Amir's Analysis

...and the watering down of an already toned-down plan and the elimination of policy reform begins. I wasn't crazy about this proposed legislation to begin with, but I held back because I held out some hope for an incremental reform roadmap. However, I am increasingly very worried that this ending legislation won't include anything resembling real system change. If some tax increases are passed, I would normally feel some solace that our health system might not go bankrupt, but simply pouring more money into a bloated system does not decrease cost problems. To this extent, I feel more taxes on Americans, without also passing a real plan to fundamentally reduce costs, is unfair. All the details in this plan go after small, insignificant beans of costs. If you want to go after meaningful costs tackle single-payer, defensive medicine, the primary/specialty ratio, or healthcare IT. You need to get money out of the pockets of insurers, drug companies, device manufacturers and lawyers, in whose pockets most of our system's cash is now lodged (30-40% in total surplus as a percentage of total health expenditures, by my count). It is not just a cooincidence that our per-capita health expenditures are multiples of spending in other industrialized countries. I will repeat these concepts until I go blue in the face.

July 25, 2009
By GARDINER HARRIS

COOPERSTOWN, N.Y. — Visiting the Cleveland Clinic this week, President Obama held up that well-known hospital as a model for the rest of the country. But for most of the nation’s nearly 6,000 hospitals, copying the Cleveland Clinic would be like asking the Durham Bulls, a minor league team, to copy the New York Yankees.

A more accessible example is a hospital that sits a bit more than a home-run blast from the Baseball Hall of Fame here. Called Bassett Healthcare, this modest hospital of 180 beds delivers high-quality care at low costs in the face of federal reimbursement policies that discourage many of its best practices.

Changing those policies is crucial to the success of health care reform, economists say — something Mr. Obama said that he would do. “Our proposals would change incentives so that doctors and nurses finally are free to give patients the best care, not just the most expensive care,” the president said Thursday in Ohio.

But almost nothing in proposed legislation that has so far emerged in Congress would encourage the creation of similar hospitals.

Bassett looks like a small liberal arts college, with ivy-covered fieldstone buildings connected by a warren of passageways. But what really sets it apart is the way the system pays its 260 doctors.

Doctors in the United States are usually paid fees for each service they provide. The more procedures and tests they order, the more money they pocket. There is widespread agreement among health policy analysts that many of these procedures are unnecessary, raising costs in ways that often do nothing to improve patient health.

By contrast, Bassett — like the Cleveland Clinic and a small number of other health systems in this country — pays salaries to all of its doctors. No matter how many tests or procedures are performed, they take home the same amount of money. Medical costs at Bassett are lower than those at 90 percent of the hospitals in New York, while the quality of care ranks among the top 10 percent in the nation, surveys show.

Dr. William F. Streck, the longtime president of Bassett, said the hospital paid salaries that were competitive with the money earned in a fee-for-service setting. Some fee-dependent physicians, though, either by working hard or by providing excessive treatments, can make more, an ability doctors trade associations have long defended.

“Everyone knows that the Bassett model is the right model,” said Senator Charles E. Schumer, a New York Democrat involved in negotiations over health care legislation. “The question is, How do you get from here to there?”

It is a question that has plagued lawmakers and medical experts for nearly a century. As early as 1910, Abraham Flexner wrote a landmark report that argued teaching hospitals should be staffed only with salaried doctors. In 1970, the Carnegie Commission released a report calling for drastic improvements in rural health care, and highlighted Bassett as a model.

Many doctors who work at Bassett believe deeply in its mission. Bassett has opened 13 clinics in schools around the region. The clinics lose money, but Bassett is considering opening 14 more.

“I was in private practice for years in New Mexico,” said Dr. Philip A. Heavner, the chief of pediatrics at Bassett, “and there was no interest in doing anything like this because people thought it would take volume away from their practices.”

Dr. Randall Zuckerman, an attending surgeon at the Hospital of St. Raphael in New Haven, left Bassett a year ago because his wife wanted their four children to grow up closer to family. Since many of his patients see fee-dependent doctors, Dr. Zuckerman said in an interview, their care is more disjointed than was common at Bassett.

“They get a lot of different consultations, some necessary and some not,” he said. “They are always missing parts of their medical records because the information is coming from multiple private offices.”

Michelle Griffiths, 41, of Edmeston found a lump on her breast six years ago. During cancer care at Bassett, Ms. Griffiths’s appointments to see her oncologist and primary care doctor are often scheduled on the same day. One doctor will sometimes accompany her during a procedure performed by another, and each has her complete medical history.

“The communication amongst all of my doctors is impressive,” said Ms. Griffiths, who works as a database administrator for the insurance company New York Central Mutual. “They always call each other or shoot each other e-mails.”

Such coordinated care is a hallmark of integrated health systems with salaried doctors, like Kaiser Permanente, the Mayo Clinic, the Veterans Administration and the Cleveland Clinic. In each system, medical records are electronic, so doctors have quick access to patients’ entire histories, including X-rays and prescriptions. And doctors often treat patients in interdisciplinary teams where coordination is encouraged since no one loses money by passing a patient to a colleague.

But for some, wages are not enough. Dr. J. Turner Stauffer, a gastroenterologist in Thomasville, Ga., left Bassett 10 years ago. He has four children, including two of college age.

“To provide for my family, I felt I needed to be reimbursed on a fee-for-service model,” Dr. Stauffer said. “I make three to four times what I was making there, although I don’t know what my salary at Bassett would be now.”

Dr. Stauffer would not reveal his pay. A recent national survey found that gastroenterologists earned $457,000 on average, with the top 10 percent making $715,600.

For decades, powerful doctors groups like the American Medical Association opposed efforts to change fee-for-service pay systems. And the culture of medicine has been entrepreneurial, with doctors saying they wanted to be their own bosses.

“Medicine is the last cottage industry,” said Dr. Jordan Cohen, president emeritus of the Association of American Medical Colleges.

Even without legislation, much of this is changing. The share of doctors in one- or two-physician practices dropped to 33 percent in 2005, from 41 percent in 1997, according to the Center for Studying Health System Change. Just 10 percent of doctors in their early 40s work in one- or two-doctor practices, compared with 38 percent of those 60 and older.

Whether these trends will encourage the creation of more hospitals like Bassett is uncertain. Legislation pending in the House instructs the government to create pilot programs for “accountable care organizations” like Bassett. But the history of Medicare is full of pilot programs.

Dr. Streck said there was growing recognition that hospitals like Bassett were models. “Does it appear that Congress is going there?” he said. “No.”

Senator Schumer said the Senate Finance Committee was determined to make major changes to the government’s fee-for-service payment system.

“We talk about it all the time,” he said, “but it’s uncharted waters.”

Amir's Analysis

I think this is a very sensible idea and would likely eliminate waste. It would also provide clarity to care providers on levels of income from year to year. Clearly the challenge, as mentioned in the article, is conforming such practices to smaller regional and community hospitals.

There will remain private practice, but especially in hospital in-patient settings, fighting against unnecessary tests and procedures is important. It is well studied that the highest levels of waste and unnecessary patient risk and co-morbidity are created during unnecessary, or even necessary, hospitalization. Outpatient risks are usually much lower. Salarying physicians would have the intended effect in in-patient settings. Big approval from me on this idea.

July 23, 2009
By SHERYL GAY STOLBERG and JEFF ZELENY

WASHINGTON — President Obama tried on Wednesday to rally public support for overhauling the nation’s health care system and said for the first time that he would be willing to help pay for the plan by raising income taxes on families earning more than $1 million a year.

“If I see a proposal that is primarily funded through taxing middle-class families, I’m going to be opposed to that,” Mr. Obama said in a prime-time news conference in the East Room of the White House. A surcharge on the highest-income Americans, under consideration in the House, “meets my principle,” he said.

On a day when the leader of fiscally conservative Democrats said a deal was a long way off and House Speaker Nancy Pelosi insisted that she had the votes to push a bill through, Mr. Obama used the news conference to take his message over the heads of lawmakers and straight to the public. Conceding that “folks are skeptical,” he sought to convince Americans that overhauling the nation’s health care system would benefit them and strengthen the economy.

“If somebody told you that there is a plan out there that is guaranteed to double your health-care costs over the next 10 years,” he said, “that’s guaranteed to result in more Americans losing their health care, and that is by far the biggest contributor to our federal deficit, I think most people would be opposed to that,”

“That’s what we have right now,” he said. “So if we don’t change, we can’t expect a different result.”

While Mr. Obama declared, “it’s my job, I’m the president,” he did not use the appearance at the White House to make any fresh demands on Congress, which is struggling to meet his timetable for both chambers to pass legislation before members break for August recess. Mr. Obama did not repeat that demand Wednesday night.

Instead, he sounded cerebral as he delved into policy specifics for nearly an hour and tried to link them to the concerns of ordinary Americans.

As he sought to reassure the public that a new health care system would be an improvement, he also acknowledged that there would be changes that could be unsettling, a point that is often raised by critics of overhauling the health care system.

“Can I guarantee that there are going to be no changes in the health-care delivery system? No,” Mr. Obama said. “The whole point of this is to try to encourage changes that work for the American people and make them healthier.”

Health legislation is Mr. Obama’s highest legislative priority, and his success or failure could shape the rest of his presidency. But while he is under increasing pressure from leading Democrats to delve more deeply into the negotiations by taking positions on specific policy issues, he largely resisted doing so Wednesday night.

But the president did weigh in how the government might pay for the plan.

In addition to saying he would be open to taxing those households earning more than $1 million — a scaled-back version of an earlier proposal that would have imposed a surcharge on households earning $350,000 or more — he signaled that he was also receptive to another idea under consideration in the Senate: taxing employer-provided health benefits, as long as the tax did not fall on the middle class.

On Capitol Hill, Ms. Pelosi said Democrats remained on track to reach a deal on major health care legislation. But she acknowledged that the process had slowed in response to concerns among conservative Democrats about the cost of the bill, and that some House Democrats were reluctant to embrace the income surtax on high-earners without knowing whether the Senate would go along.

Indeed, even as Ms. Pelosi insisted that Congress was closer than ever to achieving a comprehensive overhaul of the nation’s health care system, leaders of the Blue Dogs, a conservative faction of Democrats, said a deal was still a long way off. Asked if the House Energy and Commerce Committee could resume work on the bill by late Thursday, as House leaders hoped, Representative Charlie Melancon, a Blue Dog from Louisiana, said: “No way.”

A senior Democratic aide on Capitol Hill said party leaders now believed it was essential for Mr. Obama to be more specific about what he wanted in a health care bill — and not just exhort Congress to pass one.

“The president needs to step in more forcefully and start making some decisions,” said the aide, speaking on condition of anonymity because he did not want to be publicly identified as criticizing Mr. Obama. “Everyone appreciates the fact that Obama has devoted so much time to health care. The bully pulpit is powerful. But in view of the deadlines Congress has missed, we would like to hear more from the president about what he wants in this bill.”

While he faces pressures from fellow Democrats, Mr. Obama is also fending off attacks from Republicans who sense an opportunity to knock him off his stride by arguing that the health care bill, estimated as costing more than $1 trillion over the next decade, will not slow or reduce the growth of health spending.

The White House has been in a running debate this week with Senator Jim DeMint, Republican of South Carolina, who predicted that health legislation would prove to be Mr. Obama’s “Waterloo moment” and would break the president. To that, Mr. Obama said: “This isn’t about me. I have great health insurance, and so does every member of Congress.”

In his opening remarks Wednesday night, Mr. Obama said he was aware that many Americans are asking, “What’s in this for me?” But he also tried to appeal to the nation’s conscience, casting the issue as a matter of urgency to families who are losing their life savings trying to pay for medical care and to businesses burdened by trying to provide coverage to their employees.

Asked what the rush was to meet his August deadline for passage of House and Senate bills, Mr. Obama replied: “I’m rushed because I get letters every day from families that are being clobbered by health care costs. They ask me, ‘Can you help?’ ”

In fact, there is another reason Mr. Obama is rushed: he knows time is not on his side. The more Congress delays passage of a health bill, the more time his Republican opponents will have to marshal their opposition and kill it.

“If you don’t set deadlines in this town, things don’t happen,” Mr. Obama said. “The default position is inertia.”

David M. Herszenhorn and Robert Pear contributed reporting.


Amir's Analysis

Some thoughts on the Obama press conference:

1 - I think some expansion of coverage is better than none, so that is good
2 - I was disappointed there wasn't a single mention of medical malpractice and tort reform. It is, as high as, 30% of medical costs according to the CBO
3 - The goal is single payer which eliminates another 10-15% of costs, which this isn't
4 - Nothing mentioned about more primary doctors.

These reforms are often incremental and the thought of more people having something is good. However, I fear, based on my humble estimates and the CBO, that the costs of executing such a plan might be way beyond what the president is estimating without going to single payer first.

If you remember how half-baked social security was when they first started it, or Medicare, they passed barebones bills to try to get something on the record and improve them later. I don’t know…I don’t know…

I feel bad for Obama in a sense because he is caught between a rock and a hardplace. He either passes no reform and sees 40-50 million people suffer for god knows how many years with still no coverage or he passes a somewhat half-baked plan but gets something on the board.

As a health policy person I'm not sure how to feel. I obviously want more coverage but I am very troubled that this plan is not single payer and does not work at medical liability reform. Sigh... but people do need coverage. I would prefer single payer and liability reform and i am still studying whether this is better than doing nothing. I am fairly sure it is but not without risks.

In a sense the public health side of me says pass whatever you can but the policy side says... sigh... I want single payer... it's hard I know!

The worry is the CBO is already putting up estimates of the plan higher than the White House and this is still in pre-planning without even formalized legislation, where costs can often get higher through riders and amendments. I am just worried, and they should be mindful, that coverage is like the water and the dam is like the system of coverage... Read More. If the dam remains multi-payer,no lawsuit caps, 75/25 specialty/primary mix versus single payer, lawsuit caps, 25/75 specialty/primary mix, you don't want to add 50 million people and break the dam before you can repair it and incrementally change those three aspects of the system.

I want incremental reform and support it but proceed with GREAT caution Mr. President!

-Amir