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Could It Be That the System (Gasp) Works?

Picture 101 Heading into the final weekend of Mr. Toad’s Wild Ride, who could have guessed that in a year that brought us Death Panels, Pickup Trucks, “You Lie”, The Cornhusker Compromise, Bart Stupak (boy, that must have been a tough name to grow up with), and the Senate Parliamentarian-as-Rock-Star, we would be on the cusp of passing a perfectly acceptable healthcare reform bill, a once-in-a-generation legislative achievement.

Unmistakably, the mojo has shifted back to the Democrats – it is amazing how a dour and monolithic opposition can cause even Dems to unite for a common cause. Our President has also learned a few lessons, including the importance of symbols, populism, and singing with one’s diaphragm. (We knew we were in trouble a few weeks ago when Rahm started being criticized for not being sufficiently Machiavellian.) With yesterday’s CBO figures showing that the reform plan will save nearly $150 billion, even fence-sitting Democrats now see more political risk in saying No than Yes. That, of course, is the most relevant calculus, and with it more and more of the Blue Dogs are entering the Yes column each day.The politics were fun enough, but the thing that’s most remarkable is this: The legislation that now seems likely to pass ain’t bad. To an impressive degree, the crazy deals, the budget sleights-of-hand, and the extremist positions have been or will be stripped out of the final text. The bill will manage to cover most uninsured Americans. Its new revenue streams are not magical: higher taxes on wealthy Medicare recipients, some take-backs from generously funded Medicare HMOs, and some (watered down to keep the unions in line) new taxes on “Cadillac” health plans. The most heinous aspects of the under-regulated insurance system – particularly the exclusions for preexisting conditions and the possibility of losing insurance after becoming ill – will become memories of a crueler American past, like slavery and McCarthyism.

Not perfect, you say? Sure, the legislation is not perfect. Not everyone is covered. The problems with the malpractice system remain largely unaddressed. Hard decisions about promoting quality, safety and efficiency are kicked down the road. Lots of newly insured people won’t be able to find a primary care doc. Care will remain fragmented and chaotic for the foreseeable future.

But even in these areas, the winds are blowing in the right direction: support for comparative effectiveness research; experiments with bundling, Accountable Care Organizations, and Medical Homes; promotion of improved transitions; malpractice pilot studies; a small dose of steroids for MedPAC.

And maybe, just maybe, a renewed sense that Washington can tackle hard problems.

Even the most infuriating examples of demagoguery may have silver linings. The whole Death Panels thing made me ill (particularly when I learned that Governor Palin supported legislation to promote end-of-life discussions in Alaska precisely one year before she went on her cynical Death Panel tirade), but the topics of rationing and how we approach end-of-life care are crucial and really sticky. When we return to them, as we inevitably will, we’re likely to have less heated, more thoughtful discussions, having gotten some of the craziness out of our system this time around. Just think about the tenor of today’s public debates over legalizing pot, gays in the military, and stem cell research – the topics remain lightning rods, but the discussions are much more civil and thoughtful than those of a decade ago.

All in all, the legislation being considered this weekend is sufficiently reasonable and centrist that it can resist the playground name-calling (“Socialist!” “Government Takeover!). The fact that it has no chance of attracting a single Republican vote speaks volumes about cold political calculation, and relatively little about the nature of the changes the bill will usher in. This is, in fact, a bipartisan bill – one that deftly splits the difference between lefties who want single payer and massive government involvement, and righties who want to “keep Government out of my Medicare!”

Watching the process was nauseating, but if I could have gone into a deep sleep after the Obama election and awakened this weekend to find Congress passing the bill it is now considering, I would have said, “Hey, that’s not too bad.”

Unfortunately, I stayed awake for the whole thing, and I may never eat sausage again. But that doesn’t change the outcome.

Or the fact that the system, to a remarkable degree, worked as the Founding Fathers hoped it would.

Robert Wachter is widely regarded as a leading figure in the modern patient safety movement. Together with Dr. Lee Goldman, he coined the term “hospitalist” in an influential 1996 essay in The New England Journal of Medicine. His most recent book, Understanding Patient Safety, (McGraw-Hill, 2008) examines the factors that have contributed to what is often described as “an epidemic” facing American hospitals. His posts appear semi-regularly on THCB and on his own blog “Wachter’s World.”

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Could It Be That the System (Gasp) Works? | The Health Care Blog

georgieboy
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georgieboy

As a member of the African Diaspora living in the US, I find myself constantly frustrated with the African American (AA) guest speakers that are on the news. Their continuous denial of what is really going on in this country reminds me of how long it took them to actually take a stand against this country’s racism. Think about it; African Americans did not actually stand-up for themselves until the 1950s. Prior to that it was whites who led the fights against white oppression. Here we are again, when they should be taking a stand by being honest about what… Read more »

Tracy Johnson
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Tracy Johnson

Although I am in favor of health care reform, Obamacare is not the answer. There is not enough regulation of insurance companies to reduce premiums or to rein in healthcare costs. Just covering more citizens (cough, cough) in no way will reduce the budget. The only way the deficit is affected is by increasing taxes and cutting Medicare. Why not control the deficit first and then add uninsured? What is in the current bill to prevent health insurance from raising my premiums (because their costs are going up)? I didn’t hear any Senators or Representatives talking about these issues: Charge… Read more »

evision
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evision
Gary Lampman
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Gary Lampman

Oh My God;Can You Believe the House had passed this Bill? Can You believe that anyone of them can fanthom the breadth and Width of such a wide sweeping display of Human Kindness. My God; What about all of those unintended Consequences of Serving such a unworthy and undeserving group of working Class Americans. How Dare They, bring the uninsured and the uninsurable into the Fold of Humanity! Some time ago, a Million Dollars seemed difficult to understand. Now we speak in trillions to answer the call to our obligations. Is it only the spirit of the Christmas Season that… Read more »

Nate
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Nate

ya it makes about as much sense as the cadillac tax, you rely on the revenue to fund the bill but at the same time try to eliminate the revenue source. It either has no effect and people keep overly rich plans or it works and the revenue source is gone and the plan bleeds red.
This bill is full of contridictions, also add in cost containment by eliminating annual and life limits which are two of the few remaining cost containment features

ExhaustedMD
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ExhaustedMD

I’m just curious, as I have been asking this question for months NOW, and no one answers it: So, the government is taking over health care, as this legislation basically is doing, and yet, it continues to rely on tobacco monies for support. Isn’t that a contradiction, to want to improve health care needs, and still legalize and maintain the use of tobacco in this country? Aren’t the statistics still about 20% of Americans use tobacco products with regularity? So, will we support the health care needs of people who are engaged in behaviors that compromise health? It is a… Read more »

F.
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F.

MATTHEW HAS CONVINCED ME
Going on welfare. No need to excel now. Be just like the UK and France.
All you working slobs, have a nice time, supporting us welfare bums.
We don’t appreciate what you do, and if you try to stop working, we’re going to protest, like all the ILLEGALS in D.C. today.
Going for some beers now, and get some ‘rays. Keep working — Obama has created more welfare folks.
++++++++++
Gary- sarcasm is lost on a certain percentage of the population, but I appreciate it, and that was excellent!
Posted by: Carla Kakutani MD | Mar 21, 2010 5:20:24 AM

Henry Massingale
Guest

There is a unity lost between Governing Parties that is needed to help the people feel secure. The moral building block for Health Care. To see the true Health Care Tax forum you must stop thinking in 3-D,This multi tax forum is against a $100 Trillion Dollar system.. … To force pay into another system of failures within Health Care Insurance Groups. This economy will not balance with this concept of a tax forum against the Health Care System. The issue of how to force pay into this system of Health Care may have worked but I am still troubled… Read more »

Henry Massingale
Guest

3/21/2010 As you can see our elected officials are paying little attention to the public. As I reach out to my computer and I knock , knock, knock on the screen, and I say is there any body out there? This Health Care issue keeps taking turns and twist that bewilder the mind in thoughts. This $100 trillion dollar system ,as it would seem, I am counting up to $ 8 trillion 682 billion Dollars so far. On guy emailed me and he is up to $27 Trillion dollars. You see when Harry Reid added a extra ….almost, $2 Trillion… Read more »

Eddie Cramer, M.D.
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Eddie Cramer, M.D.

The system appears to work in your impression, Bob, but in reality, the way it has been working and the way the country is in desperate straits is consistent with slow implosion. If the bill would actually do something to corral the out of control big business interests and corporate nonprofit hospitals (including yours) that are sucking money out of the medical care system while mistreating patients, one could say the system is working. Bob, you have a generous salary at UCSF but the patients and those who accountably manage patients and their illnesses for a living have been injured… Read more »

Nate
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Nate

speaking of lies and propoganda; http://www.sfgate.com/cgi-bin/article.cgi?f=/n/a/2010/03/19/national/w131302D40.DTL&tsp=1 President Barack Obama would give federal authorities the power to block unreasonable rate hikes. Yet when Democrats unveiled the final, incarnation of their health care bill this week, the proposal was nowhere to be found. Ditto with several Republican ideas that Obama had said he wanted to include after a televised bipartisan summit last month, And those “special deals” that Obama railed against and said he wanted to eliminate? With the exception of two of the most notorious — extra Medicaid money for Nebraska and a carve-out for Florida seniors faced with losing certain… Read more »

Nate
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Nate

Wachter you might want to update your reading, or admit its blind propogands. CBA says after doc fix bill bleeds major red “The Congressional Budget Office said Friday that rolling back a programmed cut in Medicare fees to doctors would cost $208 billion over 10 years. If added back to the health care overhaul bill, it would wipe out all the deficit reduction, leaving the legislation $59 billion in the red.” only a couple of the dirty deal makings were cencelled, vast majority are still in there “it is amazing how a dour and monolithic opposition can cause even Dems… Read more »

Carla Kakutani MD
Guest

Gary- sarcasm is lost on a certain percentage of the population, but I appreciate it, and that was excellent!

F.
Guest
F.

GET A GRIP MESS-iah doesn’t cover mental illness. And the “30 million” (remember when it was 47 million) — are they going to stop smoking, drugs, booze, over-eating and “extreme living?” And cut costs by 40%? Sure. And there is a tooth fairy. This whole HCR MESS has been one big LIE. And a lot of people know it is a LIE. And Nov. 2 — payment will be due. ++++++++++++++ “OH, My GoD; This Bill; Sucks! Still it is The Best Suck I have had in Decades. No Life Time Limits. No Pre Existing. Covers 30 Million More Americans!It… Read more »