After the Failure of Reform


The stalemate in the bi-partisan health care summit was cast the moment it was announced. Republicans demanded that the reform process start anew, and Mr. Obama insisted on the Senate bill as the framework going forward. The President may now offer a more modest reform bill that can demonstrate some progress on the health care crisis, but that remains to be seen.

We hoped the White House would seize the opportunity presented by Massachusetts’ election of Scott Brown to begin again, huddling away from the lobbyists to develop a new set of provisions that would include reasonable Republican elements, like medical liability reform, as well as other meaningful cost reduction provisions excluded from the first round of bills: pricing/quality transparency, a move away from fee-for-service reimbursement, and the re-empowerment of primary care.

They took a different path. As Ezra Klein speculated in the Washington Post, Mr. Obama and his advisors may believe that, with the 2010 elections bearing down on Congress, there is too little time to begin again.

But this is a questionable political calculation. The reform process soured the American people and American business on the health care bills. A January 27 Towers Watson/National Business Group on Health (NBGH) survey found that 71% of employers believe the bills “will increase the overall cost of health care services in the United States.” A February 11 Rasmussen survey found that 61% of voters think the bills should have been scrapped and the process started over.

And no wonder. Over the past year, the legalized bribery that is special interest lobbying was fully on display, with members of both parties (but led by the Democrats) taking contributors’ money with a gusto unprecedented since the Republican feeding frenzy set off by Newt Gingrich’s K-Street Project. A new report from the Center for Public Integrity shows that “more than 1,750 companies and organizations hired about 4,525 lobbyists — eight for each member of Congress — to influence health reform bills in 2009.” Together, they spent $1.2 billion on health care, more than one-third of the $3.47 billion spent by special interests in 2009 to buy influence over policy.
And then there was the brazen political deal making. Mary Landrieu brought $300 million in federal aid home to Louisiana for voting with the Democratic Leadership, which the GOP promptly dubbed “the Louisiana Purchase.” Ben Nelson got the Feds to pay for most of Nebraska’s Medicaid expansion…in perpetuity. And, on the eve of the Massachusetts Senatorial election, the White House cut a deal that exempted unions from the tax on “Cadillac health plans” until 2018.

The resulting reform provisions – a cynical combination of expert advice, uncompromising ideology and donor quid pro quos – would have extended entitlements while rescuing the industry at the top of a financial bubble, exacerbating the cost growth problem during a recession by replacing dwindling private funding with public dollars. At the same time, the bills specifically avoided committing to approaches that could wring excessive cost from the system.

In truth, either passing or blocking such poor bills would have had little impact on the increasingly threatening crisis. Short of starting over, American health care will continue to face some very harsh realities. More individual and corporate purchasers, particularly small employers, will be priced out of coverage as health care costs explode. This erosion in mainstream coverage is translating to a reduction in total health plan premium – the engine of the health care economy – and to escalating uncompensated care cost loads throughout the system. A plummeting number of insured patients will find it harder and harder to pay for a rapidly growing number of uninsureds and under-insureds.

These are recipes for instability and disaster. And as health care – the nation’s largest economic sector, representing one dollar in six and one job in eleven – becomes increasingly unstable, so does the larger US economy.

Americans are increasingly aware that a government in which both parties are compromised by political ideologies and special interests will likely leave them to their own devices in dealing with health care. American business had, to a great extent, put health care benefits decisions on hold until reform was complete. Now it is resigned to continuing to cope with that burden, but with a renewed commitment to innovation. A February 22nd Towers Watson/NBGH survey found that “83% of companies have already revamped or expect to revamp their health care strategy within the next two years, up from 59% in 2009,” a clear sign that businesses now think they need to act on their own behalves. (Of course, most individual Americans don’t have that latitude.)

One thing is clear. Without reform as it was constituted and the subsidies it promised, the industry faces an onslaught of actions from the marketplace that will focus on its excesses, drive down reimbursement, and hold it more accountable. A long list of innovations – re-empowered primary care; data collaboratives that identify and then create incentives for making the best choices; new technologies like minimally invasive surgeries, point-of-care testing, and clinical decision support tools; medical tourism; clinical groupware; check lists; Health 2.0 business-to-business ventures that streamline health care processes – are now proving they can improve the quality of care while reducing cost.

The result is inescapable. No system this far out of balance can remain unchanged indefinitely. So long as it was influencing the policy process, the health care industry would never course correct in ways that are in our national interest. But as the environment continues to intensify, the market will be driven to embrace and integrate these solutions. One way or another, the health industry is in for real change over the next few years.

Meanwhile, until America meaningfully addresses cost and access through policy, proper health care will continue to be out of reach to many and will threaten many more with personal financial ruin. It will continue to sap the nation’s economic strength, and compromise our efforts to lead and compete internationally.

Which is why the President should begin again, and make achieving serious health care policy reform a dedicated goal. In the process, he could challenge special interest influence over policy, and work to refocus the political process on the common interest. We believe the American people can see how the current paradigm is corroding our nation, and would rally behind this approach. More to the point, this was the premise of Mr. Obama’s election. The American mainstream is waiting for him to assert his leadership in this way.

Health care reform has stalled and possibly failed for the moment. But the stakes are so great for America that failure cannot be an option.

Brian Klepper and David C. Kibbe write together on health care reform, market dynamics, innovation and technologies.

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27 replies »

  1. I would love to add if you do not currently have an insurance policy or perhaps you do not belong to any group insurance, you might well take advantage of seeking the aid of a health insurance professional. Self-employed or individuals with medical conditions normally seek the help of the health insurance broker. Thanks for your text.

    Thanks for your text. I would also love to say a health insurance brokerage also utilizes the benefit of the actual coordinators of the group insurance policies. The health insurance agent is given an index of benefits needed by an individual or a group coordinator. Such a broker can is find individuals or coordinators which best complement those requirements. Then he shows his suggestions and if each party agree, the actual broker formulates a legal contract between the 2 parties.

    I’d also like to say that most of those who find themselves without having health insurance are usually students, self-employed and those that are laid-off. More than half with the uninsured are under the age of Thirty-five. They do not think they are looking for health insurance simply because they’re young and healthy. Their own income is typically spent on housing, food, as well as entertainment. Many individuals that do represent the working class either full or as a hobby are not made available insurance via their jobs so they proceed without due to the rising cost of health insurance in the usa. Thanks for the thoughts you discuss through this blog.

    Thanks for the tips you write about through this website. In addition, several young women which become pregnant don’t even try to get medical health insurance because they are concerned they might not qualify. Although a few states now require that insurers produce coverage regardless of pre-existing conditions. Prices on all these guaranteed plans are usually higher, but when considering the high cost of medical care it may be a new safer route to take to protect your own financial future.

    I have observed that of all types of insurance, health insurance is the most controversial because of the clash between the insurance coverage company’s duty to remain adrift and the consumer’s need to have insurance cover. Insurance companies’ commissions on wellbeing plans are certainly low, therefore some providers struggle to earn profits. Thanks for the ideas you discuss through this site.

  2. I fully agree, as usual, with Ms. Mahar’s add-on comment here.
    The seminal article by Prof. Arrow – a genius along the lines of Paul Samuelson – from around 1963 laid out all the relevant characteristics of the markets in any healthcare system. Those characteristics have changed a bit perhaps since then. But the analysis provided in that article still holds and it is an analysis well worth reading now.
    In addition there is an excellent book published sometime in the early 1990s that includes essays by knowledgeable scholars who address each of points raised by Prof. Arrow.
    The point is that legislation can and should address areas – in particular facilitating medical tourism, in encouraging specialty hospitals but reducing payments to them for procedures that reflect the gains from learning, in encouraging the development of walk-in clinics, in encouraging implementation of systems for digitizing clinical data (cheaply however through sponsorship of FOSS EMR/PM systems, not by throwing away tax-payer funds)- where a competitive marketplace can work its magic.
    But only by targeting legislation in those places and not of course by fantasizing that the market for medical services overall now or any time soon will behave like a “normal” market for consumer goods and services.

  3. David–
    First, thank you for the kind words.
    I certainly didn’t mean to suggest that you should stick to Health IT. And I was referring to the fact that you are, in fact focusing on making Health IT simpler and more affordable.
    As you know, I’ve written about that work, and greatly respect what you’re doing in that area.
    I disagree, of course, about market solutions. Both my first book “Bull: A History of the Boom, 1982 to 2004” and my second book “Money-Driven Medicine” argue agains the market fundamentalism which suggests that markets are efficient and rational. Markets are only as rational as we are–not very.
    And as I argue in Money-Driven Medicine, the health care market is unlike any other market. In the health care market the “consumer” (i.e. the patient) is not in a position to lower prices and lift quality. Nor have other buyers (i.e. employers) been able to do that for a variety of reasons that health care economists have explained (beginning with Kenneth Arrow, the father of health care economics.)
    Every other developed country in the world uses strict government regulation to protect the patient. We are the only country that has chosen to turn healthcare into a largely unregulated for-profit enterprise. This is why we have the most expensive healthcare in the world–with no better outcomes in most areas,often worse outcomes.
    So here, we differ philosophically.
    Also, Brian’s solutions tend to focus on healthcare for employees. I would put much more emphasis on the poor, the unemployed, the uninsured, and people who are too sick to work.
    In the U.S. poor people die 7 years sooner than the wealthy. We should be giving much more attention to that problem, by investing in public health–this means putting money into k-12 education, safe parks, housing, healthy lunches and breakfasts in inner city schools, gyms and gym teachers in those schools, govt-funded community clinics (the Obama plan is doing this). . . . See Steven Schroeder’s wonderful Shattuck lecture in the 2007 NEJM.
    And we need to remember that, in this economy, many in the middle-class are joining the ranks of the jobless and the poor.
    By the way, I agree with you DCK, CONTRARIAN’s comment would make a wonderful political cartoon. It reminds me of Swift (Gulliver’s Travels). The blocked heart, turning education into job-training . .
    I’m delighted that the president has suggested lifting fees for Medicaid providers; they should be paid at least as much as those who treat the elderly under Medicare. The only reason they are paid, on average, 30% less is a legacy of racism: Southern Congressmen refused to vote for the Medicare/Medicaid bill unless doctors and hospitals that treated the poor (often black) were paid significantly less than those who treated the elderly (mainly white– few Southern blacks lived past the age of 65 back in 1965.)
    Finally, with regard to your post, it seems to me misleading to say that “healthcare reform has failed.”
    Under the present pro posal 30 million uninsured with have access to care. Those who are sick will no longer be denied coverage. Can you imagine what this means if you have a child suffering from cancer? This is not failure. It is a first step that cannot be ignored.
    As for whether the current plan saves money: All of the Medicare initiatives in the legislation pave the way for serious savings. As Timothy Jost puts it: “Anyone who says that the legislation doesn’t control costs hasn’t read the legislation.”
    Also, it seems to be somewhat unfair to talk about “brazen deal-making” and list examples–without informing your readers that those deals have been undone.
    In addition, Ezra did not suggest that the President’s decision to move forward was a political calculation. Ezra has been very clear in saying that the “policy-makers” (the people in the administraton who understand health care policy–Zeke Emmanuel and Peter Orszag– won out over the “political strategists” (i.e. Rahm Emmanuel and others.). Rahm didn’t want to try for comprehensive reform.
    As Ezra wrote today: “On health care and torture, [Rahm] Emanuel was wrong, and he lost.”
    And the president is not “slimming down” his bill.
    Finally, to quote Ezra from today: “I’ve said many times before that health care passes in a vote or dies in silence. If Democrats didn’t think they had the numbers, they wouldn’t bring the bill to the floor. Instead, they’d swear their fealty to the project but turn their attention to other priorities and schedule their speeches on other subjects. But that’s not happening. Democrats are setting up their process, giving speeches and interviews, adding Republican ideas, and setting new deadlines. They’re bringing this to a vote. And that means they’re confident that they’ll win the vote. ”
    As I wrote yesterday on http://www.healthbeatblog.org, the reformers are going to win. Yesterday, I reported that Pelosi was just one vote short of winning.
    Ezra suggests that she now has the votes.
    Reform is neither dead nor stalled. The proposal represents a first step, and we have four years to make it better.

  4. “the current trajectory demands a “real” fresh start”
    Fruitless expectation at this stage, but there is potential for necessary improvement once a current weak, but still positive, reconciled bill is enacted.
    Personally I believe that once the bill is enacted, the impetus for all Republicans to lie and deceive for whatever political reason more or less disappears.
    I am still convinced that there is at least one Republican legislator in Congress with enough courage, brains and knowledge to try to enlist business support for a single payer/insurer scheme. That scheme, as I always note, is completely in the interest of business as a whole.
    Once the political nonsense subsides that Republican among others may feel free to start proposing necessary changes such that and others.

  5. Maggie: Great to have your comment here. First, we’re going to have to agree to disagree about the best course of events with respect to the current bills, Pres. Obama’s leadership, and whether or not change can occur without structural reforms. I respect your opinion, and I do hope it works out for the best.
    Secondly, I think your comment about K2 focusing on how to “make health IT simpler and more affordable” is both poorly informed, and insulting. Anyone who knows my work knows that I am already doing a considerable amount to make health IT simpler and more affordable for physicians and staff in small and medium size medical practices. That’s my cause and raison d’etre. If I’m lacking in success in that endeavor, it’s not for lack of effort and trying! However, you seem to imply that Brian and I should stay out of commenting on less “focused” areas, e.g. health reform and political leadership pertinent to health reform. You seem to be saying “go stay in your corner” and don’t meddle in other stuff. That is a really weird thing to say.
    But I’m glad you commented! Thanks, DCK

  6. This post seems oddly out-dated.
    Two weeks ago, it would have been more persuasive.
    Today, it seems clear that passage of health care reform is much more likely than it seemed a few weeks ago.
    It seems that Pelosi is very, very clsoe to having the votes she needs. (See http://www.healthbeatblog.org and Joanne Kenen on The New American Foundation’s blog today–she reported this first.) Obama has finally begun to make his determination clear. The letter to the Congressinal leadership today should make it easier for moderate Democrats to vote for reform.
    During the Summit last Thursday, I think the Republicans did the Democrats an enormous favor: the Republicans made it clear that they are not interested in covering 30 million uninsured Americans. They would insure 3 million uinsured Americans.
    While many Americans are ambivalent about reform, a relatively small minority would say that it’s okay to leave 27 million Americans uninsured.
    I very much wish that Kibbe and Kleeper would take their considerable skills, knowledge of healthcare and intelligence, and apply them to figure how to help make the current healthcare legislation work.
    Focusing on how to make health IT simpler and more affordable for hospitals and doctors would be a huge help.

  7. “One, conducting undercover investigations of Medicare and Medicaid providers to search for waste, fraud and abuse”
    Isn’t the FBI already doing this?
    “Two, experimenting with specialized health courts as an alternative to jury trials in medical malpractice cases to cut down on defensive medicine.”
    If you’ve been reading doctor responses here on THCB they don’t want to be forced to show up in court – any court, any time. Their idea of malpractice reform is not being held accountable to anyone.
    “Three, Obama also will agree that health savings accounts might be offered in new markets his plan sets up for individuals and small business to purchase coverage.”
    Got an idea of the income group this will cover? Would that also include HDHPs with the HSAs? What income group would a HDHP cover successfully? What if you get a major sickness before you build up savings? If you loose your job will you be able to withdraw from the account for emergency needs?
    “Four , Obama will aoso suggest increasing reimbursements to Medicaid providers,”
    I think Medicare providers would also want in on this. Would you reimburse Medicaid providers at private insurance rates? If not why not? How would doing this affect the deficit and more importantly the states burden of Medicaid?
    “These ideas will not win GOP support…”
    Of course they won’t, will anything?

  8. medinnovation;
    You appear to be quoting from a press release, since one almost identical just appeared in the Washington Post. What gives; did you write it or something?

  9. Brian;
    Your comment does a good job of explaining why you think starting over is better and would achieve a better bill. However, since I know your cynicism about Congress exceeds even my own, I am surprised that you still think it is politically achievable.
    First, he can’t start over “independent of opposition demands.” The minute he does start over, that same opposition will declare victory and redouble its efforts to kill any bill.
    Second, although he is CAPABLE of communicating as well as you say, the fact that he has not done so indicates to me that he is a rookie and/or out of his depth, and may well strike out the 2nd time at bat as he did at the first – and that strikeout will end the healthcare game. Besides, the pitcher and defense now know his weaknesses – among others, listening to his own party telling him when to swing.
    Like you, I think that this debacle indicates a vacuum in leadership and unfortunately, the President has nowhere to lay the blame but at his own doorstep. This is an ominous sign. Unless he learns how to become a leader very fast, this will not be the first game lost – to the detriment of us all.

  10. I agree with the thrust of Brian’s and David’s blog, but no way is Obama going to start over again. He will simply give lip service to the four GOP ideas he finds tolerable. Here is my interpretatioh of what likely to happen.
    Four New Ideas to Jumpstart Reform
    On Wednesday. March 3, President Obama will announce he is open to these four GOP ideas.
    One, conducting undercover investigations of Medicare and Medicaid providers to search for waste, fraud and abuse, an idea put forth by Sen. Tom Coburn, R-Okla., at least week’s summit.
    Two, experimenting with specialized health courts as an alternative to jury trials in medical malpractice cases to cut down on defensive medicine. That idea has been promoted both by Democrats and Republicans, including Coburn and Sen. Mike Enzi, R-Wyo., who attended the summit. The approach calls for an expert judge — not a jury — to hear the evidence and make a final determination in cases where a patient has suffered harm. Trial lawyers are strongly opposed to the concept.
    Three, Obama also will agree that health savings accounts might be offered in new markets his plan sets up for individuals and small business to purchase coverage. Sen. John Barrasso, R-Wyo., brought up the idea at the summit.
    Four , Obama will aoso suggest increasing reimbursements to Medicaid providers, a concern raised by Sen. Charles Grassley, R-Iowa.
    These ideas will not win GOP support for the whole package, which includes covering 31 million more Americans and a mandate requiring all to pay, nor will they necessarily win over 216 votes needed in the House to make health reform a reality. The new Obama proposal is said to “much smaller” than anything previously proposed and may reflect Obama’s desire to get something, anything, passed to preserve his domestic legacy.

  11. Contrarian: Can you find someone to draw and annotate your wonderful image? It’s truly a wonderful exercise of the mind, which could be a great political cartoon.
    Regards, DCK

  12. Talking about America. I am looking at those things not seen or in the conscious lexicon of Americans. Let me give you an analogy.
    Imagine America is a muscular, somewhat younger, Arnold Schwarzenegger. He is decked out in a Giorgio Armani suit, Italian shoes, a Hugo Boss dress shirt, a Charles Tyrwhitt necktie and Brooks Brothers socks. Over his shoulder is a color coordinated leather 63 round ammunition belt. At his waist is a two gun holster holding 45 Magnum long barrel pistols. Cradled in his left arm is a massive anti-personnel machine gun. In his right hand is a fist full of cash. He sports a broad grin and a smoldering soggy. This is the popular image of American strength and defiance.
    Look beyond the veneer. The attire is based on “robbing Peter to pay Paul” with Hedge Funds, CDCs, economic disparity, and neglect of sustaining and enhancing core infra-structures. The muscle culture is the product of steroids. Tax beaks and loop holes for business and the mighty. Beneath the suit is a body with an arterial system choked with plaque. The roads, bridges water systems, sewage systems and dams have far exceeded their life expectancy and are poorly maintained. A deluge of catastrophic failures could occur at any time. The transportation systems of the electric grid and railroads are from the early part of the last century. We have even lost out in the première communication vehicle of this century, broadband. Our national cell phone network is a group of mutually exclusive fiefdoms.
    The legs that carry us have Osteoporosis. Our education systems embraced the objective of “giving business what it wants”. That is not education. It is skills training. It is creating a serdom workforce. Education is teaching people to think, anaylze and question. It is helping people appreciate life. These things are the staple of liberal education. All our effort has been focused on upper body strength, task orientation. Our weak legs will not carry us far in a changing and dynamic world.
    The heart of America has two main arteries blocked and is arythmic. The allocation of wealth has been systematically pumped over decades to the richest 1% of the nation and blocked for populous initiatives. It has not been used for bolstering national things such as heathcare, better public education, nuitrition, and infra-structures.
    The brain elicits a socio-pathic behavior with clinical depression of insipid denial. The government is disfunctional in marshalling the will to allocate resources away from personal wealth of the richest 1% to those things truly in the interest of the nation. The nomination and election system is completely in the control of Wall Street. It can craft the message, it can annoint candidates and it can destroy others at will.
    This is why I say America is “dead man walking”. No political party can change the system of things today. They can only change the perception of reality. We did not get this way over night. In fact we are talking more than 60 years. We are not going to change things overnight, even if we had the will to try. It would take a century of concerted effort.
    I believe second world status is not only inevitable, it is already here. It may be comforting for some, but splashing perfurme on with a different political party will not change things.
    ED – I digress

  13. “Without a new kind of leadership, the same forces that have dominated Congress will continue to dominate,”
    A new kind of leadership will happen when a new kind of legislative reward for doing the right thing is achieved independent of corporate lobby money. But for now even the Supreme Court has given it’s blessing to the status quo.

  14. Having the President start over, independent of opposition demands, would be far more than caving to a Republican obstructionist tactic. It would be the President demonstrating that he believes specific elements of health care reform are essential, in ways that he hasn’t until now, by offering a “straw man” set of provisions that are capable of actually addressing the issues that face us. He is quite capable of articulating the problems and how each solution addresses it in ways that are compelling.
    The President punted to the Democratic Congress the first time around, and received initial bills that were largely created by health industry lobbyists. By moving forward with these bills, the President appears to condone the process, its result, and worse, conveys that, when faced by a problem as severe as this one, this is all we’re capable of.
    We have no illusions that the bitter partisanship that now rules Congress will continue, but the President could add a key missing element – the leadership to turn around the processes that are devastating the nation – which was what was promised during the campaign and what got him elected.
    As to market forces that work, I’ll be glad to supply data on the efficacy of all the approaches I listed. There is tremendous uptake of each of these in the market now, though it takes time to for these kinds of mechanisms to bear fruit.
    Those who believe that reform can be achieved incrementally are dreaming. Without a new kind of leadership, the same forces that have dominated Congress will continue to dominate, and so the rules will continue to favor the corporate interests that prey on the system.

  15. I agree with Margalit and others. I know Dr. Kibbe and Brian are not so naive as to believe starting over will produce a better bill (note Margalit’s reasons and agree.) I have come to the conclusion that a bad bill is better than none as, at the very least, it will require action to fix it. No bill at all, which is what I fear would result from starting over, means we are right back at square one for the next 16 years (From Clinton to Obama time frame).
    Besides, these bills are a joke anyway – witness Congress refusing to cut physician Medicare payments incrementally over 10+ years, as provided for in the last “fix”, which now has accumulated to a truly unachievable 21% cut. If they don’t do what the bill says to do, what’s the use of any legislation anyway?
    (Do I sound like a tea partier?? I’m not!!)

  16. First this statement:
    “Short of starting over, American health care will continue to face some very harsh realities. More individual and corporate purchasers, particularly small employers, will be priced out of coverage as health care costs explode. This erosion in mainstream coverage is translating to a reduction in total health plan premium – the engine of the health care economy – and to escalating uncompensated care cost loads throughout the system. A plummeting number of insured patients will find it harder and harder to pay for a rapidly growing number of uninsureds and under-insureds.”
    Then this:
    “A long list of innovations – re-empowered primary care; data collaboratives that identify and then create incentives for making the best choices; new technologies like minimally invasive surgeries, point-of-care testing, and clinical decision support tools; medical tourism; clinical groupware; check lists; Health 2.0 business-to-business ventures that streamline health care processes – are now proving they can improve the quality of care while reducing cost.”
    Then why do anything if the market in your opinion will just work it out? Are you guys for no government action then? Dr. Kibbe, you say that you don’t agree that, “health care reform can happen piecemeal and over time,” with good results, but describe in your piece how that is going to happen. I like Margalit am confused by your own self argument.
    For me abandoning the insurance industry and using medical tourism for the expensive stuff will be my part at “market” solutions to my personal health needs. But I know is not a national solution to the cost/access problems.

  17. I agree with Dr. Kakutani. Perfection is not to be had from a sausage factory, and what we have now going forward – as well-summarized in the article – is worse than the bill. Despite the pork and complexity, the core of the bills is based on years of careful design and salient ideas.

  18. You guys have been suspiciously quiet here of late about the looting and plundering of the insurance Visigoths. Might that have to do with the fact that “insurance for all” is the new mantra of the month?

  19. Government can’t fix anything when it is itself the problem.
    Government can cut Medicare costs now, but won’t because of the political pain. But this is why the Constitution did not provide for direct government benefits and why they whould be abolished; no end in sight once you start.
    The states would not be bankrupt without federal mandates. It was intended for the states to be strong, united by a federal government where they needed to be united. The tail became the dog, but that end does not have the brain.

  20. Dear Margalit: I admit, I’m afraid, it does sound as though we’re agreeing with the Republicans in the Senate and House, but that is not the case. In fact, I think most of them simply want to delay and foil the Obama administration’s plan. They’re not serious about any health plan, as far as I can tell.
    On the other hand, what we’re saying is that the current trajectory demands a “real” fresh start, but with all the experience and learnings from the past several months’ mistakes and miscues in hand, so that progress could occur quickly and we’d have a meaningful bill that actually addresses the core, systemic problems. I disagree with those, including Paul Krugman, that health care reform can happen piecemeal and over time, even if we do very little now. Build a house with bad plumbing, a crumbly foundation, and at the water line….well, the results aren’t going to necessarily improve with time.
    It’s a hard call. But I think it needs to be substantial change, even if it’s just a few first steps. That’s not what I see happening now.
    Kind regards, dCK

  21. It doesn’t matter if you start over, Republicans have no incentive at all to compromise on anything. Their obstructionism is working.
    People don’t support the health reform bills because they don’t know what’s in the legislation. I’ve spoken to people across North Carolina and even supporters of reform are unsure whether or not the current proposals include death panels or not.

  22. We (e.g., the readers of this blog) know too much. We think about this too much. In some regards, we have lost our objectivity.
    Just to offer some perspective, consider the unraveling debate around financial/banking system reforms. All the same forces are at play, most notably mega-lobbyists promoting private interests through their bought-and-paid-for legislators. Pair this with scorched-earth, no compromise political theater and we have an environment where government can’t do too much effectively, let alone really help fix anything.
    Personal interest being what it is, sending this back to the “market” will lead to little macro progress as a result, because individuals and providers don’t generally act “macro-ly.” The Geisingers and Mayos of the world will do innovative things to improve delivery that will help a small universe of people but, at some point, some macro action will be necessary.
    Personally, I keep coming back to a program of massive “innovation” demonstration projects and pledge to bring the learnings from those demonstrations back to the people so we can collectively celebrate a truly American-made solution to our unique situation.
    Unfortunately that would take 2-3 election cycles, so….

  23. “A long list of innovations – re-empowered primary care; data collaboratives that identify and then create incentives for making the best choices; new technologies like minimally invasive surgeries, point-of-care testing, and clinical decision support tools; medical tourism; clinical groupware; check lists; Health 2.0 business-to-business ventures that streamline health care processes – are now proving they can improve the quality of care while reducing cost.”
    I doubt you can provide proof that all of these ‘innovations’ have had major impacts on either the quality or cost of care. If the market was correcting as you state, then why wouldn’t we just let it continue to correct – why interfere? It is a well known contradiction that health care technology tends to increase the cost of care, not decrease it.
    I agree with Margalit – starting over will produce nothing but longer delays. Your underlying assumptions that everyone will suddenly start acting in the best interests of the underinsured is laughable.
    Seeing a crisis coming and acting to prevent it are not core competencies of our political process. We are very good at procrastination, delay and demonization.

  24. Starting over is just a Republican tactic for delay. They have no intention of ever voting for any health care reform. Their strategy is to kill the bill and then point to Obama’s failure.
    Margalit is right. Starting over will lead to the same result. The bill has lots of warts but it can and will be improved.
    Special interests control the process and the outcome. Unfortunately, that’s the current situation. Without serious reform of money in Congress (unlikely), the process and outcome will be the same.

  25. I just have one question about this “start over” chant.
    What makes you think that starting over in the same exact environment will lead to different results?
    Lobbyists are not going to magically retire. Congressmen are not going to become honest over night. The industry, freshly supplied by Supreme Court ruling, will not “do the right thing” and abstain from interference.
    Basically we are going to “shake the “Etch-a-Sketch” and erase the imperfect drawing, in the hopes that we have, overnight, turned into Picasso through mere wishful thinking. You do know what they say about repeating the same actions and expecting different results….
    So what is the real purpose behind the suggestion to “start over”, or some unidentified Plan B? Why not take what’s there and modify it? Should take less time and accomplish the goal, if we are serious about wanting reform and if the goal does not include tilting future elections one way or the other.

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