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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  1. 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 is happening in America today, they instead take this path of denial. Any black college graduate knows that the reason that President Obama’s Americanism is constantly being questioned has nothing to do with where he was born, but everything to do with his color. Most AA college professors have at one time or another taught this, and most AAs who graduated from college and took one course in AA history also know this. During world war II, we were at war with Germany and Japan, but only Japanese people were put in internment camps. This fight that we are having in this nation over health care has nothing to do with health care. The same fight would be going on even if President Obama said that he was going to cut fifty percent off everyone’s taxes. This fight isn’t about health care but about who is leading the health care efforts. The most foolish aspect of this tragic expression of racism is that, by denying that it is going on, the AA and the media have allowed republicans–who know exactly what’s going on–to use these racists individuals to further their agenda. It is my belief that if AAs and leaders in the media don’t start seriously calling republicans out on their racism, the Tea Party will gain more strength and its followers will become embolden.

  2. 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 more to families with more dependents (why does a family with 8 children pay the same for their dependents as a family with 2 children?
    Charge more for smokers: why do smokers pay the same as non-smokers?
    Get discount for healthy weight: why do overweight insurees pay the same as health conscious insurees?

  3. 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 we show our kindness, reaching out to neighbors and Friends. This is one great Nation under God, and we have made great strides in Helping those when the Need is Apparent.
    Health Care is not for so many an apparent need, because the absence of primary Care,ends with urgent Care. To Little; To Late.
    What ever, the Negative emotional State of any individual; base on Jealiousy, Hatred, Envy, Bigotry, etc. The Result shall end in a self fulling Profitacy of sickness and a third World Decay.
    MESS-iah doesn’t cover mental illness.”
    Mr F. I would like to remind you that The Mental Parity Bill became LaW, in the Glourious Year of Our King George W. Bush Junior. Theirfore, God has deemed Fit to not only look after my phyisical Health but my mental well being as well. Thank You for your concern.

  4. 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

  5. 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 bitch to ask the tough questions, eh?

    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

  7. 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 over the progressive tax forum within this Bill. It covers so many items and Countries that it only forces the system to adjust itself. In some areas, increases against the people and the troubled economy, and in other areas, less effects will be felt.
    But this is my big problem, Government Officials seek help and they are to proud to ask us, “the true working force of Government.” It is understandable they have failed the People and within the United States Of America all we ask is to see us as who we are and not try to bring us into this world of the intellectual. I guess our Prime Directive is that of Star Trek, so it must be understood that for millions of people we are just as happy as can be making $13.00 per hour and we have no interest in this world of politics, and how to be a Enstine. Government Officials must understand that there is a level of people within different parts of this Country, that seek to be only that they find to make them happy.
    As for this economy well, it is said that the U.S.A. Arms Division has created enough arsenal to destroy every last creature in the world 2 times over,built with tax dollars. This would be funny if not for the irony of it. And now as time has passed Government Officials keep failing. Before 9/11 all the way to today.
    As it is in a world of a system, when employees continue to fail, one or two things happen, one; you get fired, two; if you see into a person a good, then it is political correct to implement a penalty or roll back in pay. But this implement of penalty is more favored in the course of action in the Federal Employment World. So how to fix the economy and unite it with the Health Care issue. It would be in the Countries best interest to implement a 10% per cent penalty against every State, County and Government Official within this Matrix of failures. Hey what is that old saying, what is good for the Goose is good for the Gander. I am serous about this, it is past due to show that our Government Officials they have failed, their system failure reaches into this world of warnings that they brush aside as if the information is not worthy noting. From Pearl Harbor to 9/11/2001 to 3/07/2010 of our tax system and Health Care Reform. This 10% per cent penalty should go into the Health Care Forum.
    The big problem that Government Officials have is that they have no street credit. President Obama still has some but if he does not take his family and step away from these dueling Parties, that fight over this Health Care Dollar, and stand with Us he will lose all credit from the streets to the county.
    President Obama, I would say to you, you have one last chance to regain the hopes and dreams of the American People. To reach out in a concept that states, if there is 250 million people in trouble because of these failures, I would give all my money to them and then I would say to all that I gave money to, “I have no money left, would you all please give me $1.00 back and then I would have $250. million dollars to start all over again.”
    As for this $100,trillion dollar in site………….
    Results 1 – 10 of about 685,000 for net worth of medicine development industry
    Just to show how deep this Health Care Tax split petition reaches. The term split petition is used because of the Tax factor plan that is not seen because of the intent not to show a capital Taxing of close to a $100 trillion dollar package, a yearly system income, not profit…..
    Some have stated that I clam to have spiritual in site or something of the sort. I assure you this is not true, so when I state that I asked God to help, it is my way of saying hey Bobby show me how to work on theses Chevy engines. But I do thank you for the consideration. Consider me a cross of Jethro Bodine from the Beverly Hill Billies with my 10th. Grade education and Vin Diesel from the move Pitch Black.
    So drop on by and see page 100 at our site and follow the blue pill link
    Health Care within a moral value, is to ,
    Henry Massingale
    FASC Concepts in and for Pay It Forward
    http://www.fascmovement.mysite.com on google. yahoo, and Aol.com
    please take the time and visit all my new friends on the net and if you wish to post with FASC Concepts you will be most welcomed. So join us and share your ideas as one in one voice.

  8. 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 dollars in a tax forum, this through my numbers off with the 1 to 3 year spread of taxes.
    Lets show you this way seeing how I run out of fingers to count on and I do not feel like taking my shoes off…..
    to get a $4 Trillion dollar tax spread, it is based at a 0.25% up to 4 years.
    To be able to see the amount taxed in one year as a whole at 50% is around $8.2 Trillion to $8.8 Trillion, please remember according to Government Officials this is to be a spread tax, 3 to 10 years.. There is over 10 thousand companies I have not even got to yet.
    President Obama has stated that he is against taxing the Health Care Industry…the link and story is next…
    1.Politico Live: Romer: Obama is against taxing health care …
    Mar 15, 2009 … Posted By: Obama Will Tax Healthcare | March 15, 2009 at 12:23 PM ….. Just think of the most evil high school teacher you ever had, …
    {Members of Arizonans Against the Hidden Health Care Tax} As for theses hidden taxes, they are not hidden. They are built into a split petition. They are meant not to be seen, only revealed as the Progressive Capital Tax Forum works the system in order to not over burden the money system. What is lost is trust because Government Officials by considering the public slow witted and as for this Bill, I want to read the Law that is to represent the Bill. This is because one word has a directive and a code and a sentence can lead to a different truth in concept.
    Health care bill’s hidden tax on pain relievers, Pedialyte, and …
    Dec 22, 2009 … And ironically, this tax that will raise health care costs substantially … While an over-the-counter drug is less expensive than the prescription … chronic health problems by regularly taking an over-the-counter medicine. … Ironically, the liberals and Democrats who normally rail against big …
    I ask you again to type in http://www.fascmovement.mysite.com in to to web search,{Results 1 – 10 of about 6,730 for http://www.fascmovement.mysite.com and you will see over 6000 post from aol, google and yahoo, by our friends and supporters plus ,page 19. pay it forward covers the web ,Please visit us on google.com and search for http://www.fascmovement.mysite.com. All we ask is that you PAY IT FORWARD. Henry Massingale . Threr is over 10,000 post that are active from over 6 months ago..
    http://www.fascmovement.mysite.com/blank_16.html – Cached
    Our goal is to start a trickle effect and the goal is President Obama and this Bill to Law. To merge 250 million veiws for a honest Health Care reform. The trickle effect is , Email President Barack Obama
    Mar 20, 2009 … How to contact President Barack Obama and other White House Officials.
    http://www.emailthepresident.com/ – Cached – Similar
    When many different views are emailed but not united in a course of action, government Officials do not pay attention. Within the our web site is the views of around 173 million people. Interfaced with the net. This was not a easy task, over 6 months work. Its like this, when I wrote The “International Boycott Of The Arabic Drug Empire” Some say that a boycott is a waist of time and never achieves its goal….. Really, When words written hold truth the people will sit back and their mind will open. Just read and see, truth of words….
    As for this economy and the jobs needed, I offer 3 job concepts that will build cities and a strategic placement of Mini Factories where they will support the needs of that town or city. The Adam Walsh School Communities, 52 Communities/ Schools, in each State, to get theses children off of the street before they become tomorrows criminals. The Great Wall Of China to our west, to close off our back door before the enemy walks across the border with that bomb they bought for the price of a Refrigerator. At the same time this Wall will bring life to that region on both sides of the boarder. David Krieger: Nuclear Terrorism and US Nuclear Policy
    February 13, 2002. Sen. Russ Feingold War Powers and the War on Terror … Aisha Ikramuddin on the Hidden Hype of US Food Bombs … Most Robust Heroin Market and Helped to Finance the Rise of the Taliban and Osama bin Laden … Since the likelihood of a terrorist using a missile to launch a nuclear attack against …
    http://www.counterpunch.org/kriegernukepolicy.html – Cached
    There has been so much of this God vs. the evil Health Care Plan that I wanted to see if people would allow me to be Gods Arbitrary, to Represent Him, and his views. Oh Im sorry, who am I to speak in behalf of God. I am a Hinzes 57 mix, Jethro Bodine from the Beverly Hill Billies with my 10th. Grade education and Vin Diesel from the move Pitch Black with my mentality.
    So what is your vote :
    Everywhere I turn people Bible thump in the name of God over this Health Care issue. So lets do this….
    In United States
    1 First Street, N.E., Washington, D.C. 20543.
    As acting arbitrary: I will write His words as best I can.
    Plaintiff ,God: vs. Defendants Republican and Democrat Party
    On this day of March 17, 2010, God has filed the following complaint that
    #1; That 2020 years ago my Son stated that to let Cesurer have that which is his.
    #2; The leaders of this Country have lost their way and this economy that is spoken of to me in prayers is of concern to all. It is of a moral offense for Cesurer to tax that which is not his.
    #3. You have placed my name on your money as In God We trust and as of this tax for the Name of Money my Name is lost.
    #4.Cesurer must sit down with these people as a one, it is said they who ready to fight in court, that which you wish to tax and work on a forum that is in the creative life of what this Health Care Is For. Become as one again with the People.
    #5 The People of this Country will step forward to help and all you have to do is believe in Me and ask theses people for help…..
    #6; You have created Laws against me within the lives of children and I do not harbor ill well, the lost vision of what this Country was built on in My Name is broken because of the lost connection between what Governing Officials use to be and the people once stood for…..
    #7; Unite this Bill with the Freedom Of Choice to be or not within, rebuild the life of this land of yours, These people will come forward. and help put a balance back into that which is lost….
    Health Care within a moral value, is to ,
    Henry Massingale
    FASC Concepts in and for Pay It Forward
    http://www.fascmovement.mysite.com on google. yahoo, and Aol.com
    please take the time and visit all my new friends on the net and if you wish to post with FASC Concepts you will be most welcomed. So join us and share your ideas as one in one voice.

  9. 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 in their mission by the system. The bill does not fix that but perpetuates the system of failure.
    From your blogging site, it appears that you also believe that spending billions on computerization will solve the nations medical care problems and reduce costs. You are an academician: where is the beef to support those dreasm?

  10. speaking of lies and propoganda;
    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 extra Medicare benefits — they are all still there.
    Care to update your post and get the facts right this time?

  11. 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 to unite for a common cause.”
    Dems unite, odd its almost like they haven’t been holding off the vote for days while trying to unite dems. How do you define unite, all the fighting I read about every day and 30-50 no voting dems sure dont sound united to me
    “The bill will manage to cover most uninsured Americans.”
    You have zero proof of this. Every past reform from federal and state was suppose to achieve certain goals and as proven by our current state failed. Thebill claims it will cover, you can’t honestly say anymore then that, if honesty mattered.
    “Its new revenue streams are not magical:”
    more BS, no one with half a brain believes the cadilliac tax will raise a fraction of what they budget, he uses the same income twice
    Any comment on the illegal pressureing of government employees through government email?
    “The whole Death Panels thing made me ill”
    Do you deny liverpool care pathway exist or are you arguing it can’t happen here?
    “He added that some patients were being “wrongly” put on the pathway, which created a “self-fulfilling prophecy” that they would die.”
    “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!”
    Making this statement pretty much sums up your entire post and logic, truth mattersnot, only how you spin it

  12. 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 has the elements of Reform We Need Now! Stop Stalling!”

  13. Oh MY God,Health Care Not a Privledge!Some 8 years of trillion Dollar spending on Two Wars. Billions of Dollars Handed out to Corporations that failed to live up to their Contracts. Entitlements and Subsidies for Eight Years. Not one quiver of Financial Responsibility!Not to mention Deficit Neutral. We Borrowed and still are borrowing Trillions of Dollars From CHINA to fund these two Wars.
    Oh MY God, We cannot allow people who can not afford to pay our prices;to be seen. It defeats the purpose of Capitalistic Profitability. People who do not meet the Prescribed guidelines of a Safe bet. Must be harvested and buried for the greater Good of the institutions.
    OH my God, I can not feel any emphany for anyone, for they do it to themselves. Such Bullshit needs to stay in the Barn! Your Simplistic Idealistic Tripe can easily be dissolved and Disproven.Smoking,Drinking and Over eating is all you Have? Heard of Genetic Pre-Disposition? Not To Mention eviromental and Industry Standards that increase Health Risks!
    Oh My God; A trillion Dollar Deficit over 10 Years.Don’t Mention 12 Trillion Dollars over the past 8 years to fund Two Wars.Oh, But Health Insurance has to Decide who is Healhy Enough To Live and Who Must Die Quickly. As long as You have Money! You have the Best Health Care Can Buy! So says the Institutions?However, I beg to Differ as I have Seen Health Insurance Interfer with a Doctors ability to practice Medicine in the interests of The Patient.
    Oh My God; Health Insurance companies do not want change because it is a determent to their lofty entitlement goals of sucking the life out of their Host and delivering a product that is unattainable.As time moves forward; Insurance delivers less and Less. While the Consumer is expected to pay much more to buy access to Health Care and support their way of life.
    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 has the elements of Reform We Need Now! Stop Stalling!

  14. Ditto Rob and kudos for such a reasoned conclusion!
    The chicken little sky is falling crowd will soon return to their dungeons of doom; since commiseration is an infectious dis-ease that requires company.
    Heard today, and may be context appropriate; though a pre-digital photography metaphor?
    >> ‘Isolation is a dark room where some go to develop their negatives.'<<
    Here isolation is from a reasoned and fact based discourse of the pros and cons of the reform proposal.
    Lots of negativity being sowed by the persistent 'echolalia' of the noise machine and their principal icons.

  15. …”didn’t used to need a rabies shot to read this blog.” HAHAHAHAAA!!!; that’s the best comment I’ve ever heard on this blog! Those are the caps I choose to use – otherwise my new criterion for not reading comments is capital letters…….

  16. Having taken my rabies shot, and with the serenity of knowing this will pass and succeed (in as much as one can know the future), I will ignore the unhinged yellers with their exclamation points(!!!!!) and ALL CAPS. They will soon fade away in the light of morning.
    Rob, excellent post. One problem with seeing sausage-making up close is that it grosses you out and makes you feel sick. Another problem is that when you watch the viscera being stretched and ground, sometimes it is hard to believe that the final product could be anything less than foul-tasting and harmful. You forget that every sausage every person has ever eaten has been made more or less the same way, and there have been no mass die-offs as a result. The Germans were still going strong, last I heard.

  17. Excellent post by Dr. Wachter. This reform package certainly isn’t perfect. The status quo however is far worse. Without intervention soon, the types of choices the nation will have later will be fewer and the options unthinkable.
    Davis Liu, MD
    Author of Stay Healthy, Live Longer, Spend Wisely – Making Intelligent Choices in America’s Healthcare System

  18. I would just like to be there when all these MD supporters, who are still practicing clinical care in 2014, get their first taste of what this “legislation” will do to the practice of medicine per politicians’ standards of care. I just hope there is a way to immortalize these words so these joyful supporters will choke on their words, or think no one will remember their position now when they cry out “FOUL” when the consequences play out!
    Hypocrisy is not Hippocratic, colleagues. Remember this now so you won’t be reminded later!!!

  19. This bill is in the category of halfway technology, as defined by the late Dr, Lewis Thomas. It might even be 1/8th technology.
    It is not until the doctors’ pens or clickers, which ever the case may be, become cost effectively utilized, will there be an end in site to the inflation.
    The health care economic policies of the last two decades have increased the use of pens and clickers, causing medical care to be a volume business; and the clickers and pens do not stop ordering at the meccas of medicine with multimillion dollar salaried CEOs exhorting their doctors to order, order, order rather than use the tincture of time to watch the clinical course unfold ( and increase length of stay).
    This bill does nothing at getting at the root cause of the inflation, namely the Medicare fee freeze and decrement. Of course, they can have doctor work at the wages of window washers for certain procedures and E and M services to cut cost, but you know what will happen, no one will do the work.
    A bill to pay appropriately for cost effective order writing and clicking is missing. Until then, forget about it.

  20. Wachter actually cites the CBO estimate that this will reduce the deficit.
    Surely, he cannot be serious. Does he really believe it will reduce the deficit, or is just using it as a hallow rhetorical point? Either way, I don’t trust him.
    And I support the bill! I just find people who cite the CBO estimate with any seriousness at all to be lacking in intellectual rigor.

    More than 40% of USA medical costs are SELF-INFLICTED — smoking, dope, booze, over-eating and “extreme lifestyles.”
    Why do I and other innocents have to pay for the BLATANT STUPIDITY of others?
    This is wrong, wrong, wrong. Shame on you, Barack Obama.
    P.S.: about cancers, diabetes, et. al — national/regional insurance pools HAVE bi-partisan support. That race has run — quit dragging it up, to sell your lousy “used car” of an HCR.
    Like the peanuts who keep saying “single-payer” — Obama threw you under the bus, three years ago. Deal with it.
    ” .. One thing is clear, you will remember the check that you write or click to pay for the insurance to cover your pre-existing condition, if you can afford it .. ”

  22. Excuse my presumption for offering up a little bi-partisan lampooning to lighten up these posts. http://wp.me/pvs8f-ls
    To Adam: I understand where you are coming from completely. However Carla is actually right. Less than 2% of medical graduates are going into family practice. The government and private insurance has serially underpaid these critical health partners for years. We need to provide educational incentives to practice family medicine – especially in rural areas where there are only Medicaid and Medicare patients.
    To free up dollars to spend on the high quality specialty care you ( and all of us ) want to be there when we need it, we need to return primary care docs back into care coordinators to help keep the well, at risk and asymptomatically ill from becoming tomorrow’s catastrophically ill. We must make the chronically ill stable and to help lifestyle based chronic illness from ballooning into preventable illness borne out of multiple comorbidity illnesses arising out of obesity.
    Disappointingly, reimbursement reform is only tangentially a part of the President’s reform – requiring Medicaid to eventually pay up to Medicare rates for primary care. Since 15M of those who will be covered will be on Medicaid – we need to get them to a primary care doctor or they will continue to access the healthcare system through the most expensive entry point in America – the ER.
    By creating Accountable Care Organizations ( ACOs), we can also help seniors who have good coverage through Medicare but the care is uncoordinated through multiple access points leading to overtreatment, under treatment and over medication. Electronic health records that were part of fiscal stimulus will also improve the delivery dramatically – – if we can get medicine digital. We have too much tertiary and specialty care and not enough primary care – it’s a fact. We need to flip the pyramid and in doing so, we can free up dollars to preserve quality and specialization.
    I have been critical of reform for its general failure to address cost drivers but this legislation is not the end of the world. We will have many more bites at the apple as we confront the inevitable reality that we have finite resources and infinite demand. Something, literally, will have to give……

  23. Adam-
    Smart people may disagree on many things, but the unbalanced specialty care to primary care ratio in this country is a significant driver of health costs. Please read the works of Tom Bodenheimer and Kevin Grumbach at UCSF, Barbara Starfield at Johns Hopkins, etc

  24. Dear Wendy Murray,
    “The statements on political issues by adam are even more laughable nonsense.”
    Now now, Wendy, be nice. You do not have control over the market of “sense” nor did you take the vaccine to prevent your spewing “nonsense”.

  25. Sorry, adam, but you might want to make assertions based on facts rather than ideological nonsense.
    “the problem isn’t primary care. Most middle-class Americans could easily afford to pay out-of-pocket for routine medical costs.”
    This is a statement without the least bit of fact behind it. The “middle-class” by and large already pays for routine medical costs out-of-pocket.
    The less than middle class – those most exposed to the cruelty of the marketplace – cannot afford much of anything beyond the cost of food and shelter, when they can afford those.
    The statements on political issues by adam are even more laughable nonsense.

  26. There are not any restrictions on what the insurance carriers can charge when these regulations take hold: “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.”
    One thing is clear, you will remember the check that you write or click to pay for the insurance to cover your pre-existing condition, if you can afford it.

  27. Dr. Kakutani: the problem isn’t primary care. Most middle-class Americans could easily afford to pay out-of-pocket for routine medical costs. The problem arises when you have a serious and costly medical condition, such as cancer. That’s precisely when you need specialists, not primary care physicians. Ever wonder why Canadian politicians and hockey players always trek south when they need quality specialist care care? It’s because Canada dosen’t have any.

    Sir, if this is so great —
    who has guaranteed, with his/her own money at stake, that this will not explode into another 900% over-run like Social Security?
    Answer: none. Zero. Nada.
    So much for “it ain’t that bad.”
    This is a joke. A farce. Something that, if you proposed it anywhere else, would get you fired, on the spot.
    Next: “failure to fund” lawsuits and service cuts. Orwell would have a field day with this B.S.

  29. Funny, you didn’t used to need a rabies shot to read the comments on this blog!
    Life will go on, with near universal coverage we will be forced to address costs more honestly and put some serious effort into primary care instead of just lip service. It’s going to be challenging at first to catch up all the unmet needs and I’m sure there will be growing pains. But I seriously doubt most sane Americans would purposely march backwards away from increased health security.

  30. By 2012, the Republicans will almost certainly have more than 50 senate seats. There are 20 Dem incumbents up in 2012 vs. 9 Republicans. Almost every Republican is in a safe seat, while 15 of the Dem seats will be contested. The House will likely be Republican by 2012 (reapportionment and Republican-controlled redistricting will help). Only question is: will Obama survive?
    Obviously, that depends on the economy, on lingering anger about the HC bill, and on who the Republicans nominate. Best bests: Paul Ryan, Marco Rubio, or Rick Perry. Sure losers: Romney, Huckabee, Pawlenty. In between: Palin.
    If the Republicans control everything, roll-back will be easy, as no benefits will have kicked in, and so there will be no constituencies to save Obamacare.

  31. @mymillionsite: Just for the reason stated in your petition is the reason we need Healthcare for All. Hospitals can not refuse treatment. Millions of people use the hospitals for their General Practioner, that is why we the people with insurance have to pay for those that don’t. It is costing this country billions of dollars to cover those that don’t have insurance. Wake up!

    We The Undersigned Wish To Convey By Their Signatures Below That They Wish To Have The Same Rights Under The Current Health Care Legislation. That Allows The Individual States That If This Would Place An Economic Burden On That State They Have The Option To Opt Out Of This Mandate.
    Currently Over 35 Of The 50 States Have Or Will File A Legal Action Against Washington To Claim This Is An Unconstitutional Bill.
    If The States Are At 35 against and 15 Not Yet Heard From, It Would Seem That
    “We The People” Are More That 51% Against This Health Care Bill.
    If Would Seem Logical That It Should Also Be AVAILABLE TO THE INDIVIDUAL PERSON AS WELL.
    We the Undersigned Wish To Opt Out Of The Average
    $12,000.00 Per Year Price Tag
    The Current System We Have In Place by Law Already Mandates That Any Hospital Cannot Refuse Medical Treatment to Anyone That Is In Need Currently Any One Who Asks For Help Will Receive It
    This Bill Will Be Imposed By A Federal Mandate On Each Man, Woman, Child, And Even Unborn Children That Live In This The United States If This Bill Passes.
    That This Mandate Is Actually an Unconstitutional Bill in Many Ways
    The Federal Government Does Not Have the Right to Mandate that it’s Citizens Will Have to Purchase a Product Such As Health Insurance Policy.
    To Mandate That An Unborn Child Will Have To Purchase This As Well Is The Same Taxation Without Representation.
    We As Citizens Are Now Already Over Taxed the Federal Government It Takes the First 4 Months of Our Income
    The States Take Another Two Months Of Our Income.
    If You Live You Pay Sales Tax on All Purchase’s And Even More On Other Taxes Such As Property Taxes, City Taxes, Cigarettes, Alcohol, Death Taxes, And Soon Even A Carbon Tax On Breathing.
    At The Present Time With All Of The Visible Taxes And The Taxes That Are Hidden In Every Item That Is Purchased We Are Taxed At If Not More Than 50% Of Our Income’s An Additional $1000.00 Per Month $12,000.00 For A Federal Health Care Product That Once Implemented Will Only Cover 60% Of Medical Expenses After An Already High Deductable This Will Place A Large Burden On Any If Not All United States Citizen’s.

  33. How can we say the system works when only 38% support this legislation (per Gallup) and when the Dems were reduced to a variety of dodgy legislative and parliamentary tricks to enact this monstrosity? If the Republicans had attempted to “Demon Pass” some grossly unpopular bill in a similar manner, I have no doubt Dr. Wachter and all his friends on the left would be screaming that this was a coup or that the Republican president was a dictator. H-Y-P-O-C-R-I-T-E-S.
    Oh, and BTW, please don’t prevaricate about CBO estimates. We all know this process was carefully gamed, ie to include revenue from 2010 which will never be collected! Dr. Wachter, you undermine your credibility when you go pretend to believe the scoring fiction.
    As to this bill, it’s going to be litigated for years. There are myriad consitutional questions. The Arizona referendum is just the first step in an incipient “opt-out” movement. Never find the economic and fiscal questions. We all know this bill will kill jobs by the millions, bankrupt the federal and state governments, and create growth-destroying tax hikes.
    If this bill passes, we will talk about nothing else for decades. The Republican platform will consist of one plank: Roll-Back. This isn’t Pandora’s box, it’s Pandora’s shipping container, Pandora’s warehouse. Oh what a mess ye lefties have created.

  34. “This is, by far, the best and sanest article I’ve read during this long Health Care Reform season.”
    Margalit – Believe it or not, I agree with you on this one. I also think Massachusetts is leading the way, first in driving toward universal coverage and now in starting to tackle the difficult cost issue. There were several days of hearing this week which Paul Levy wrote about extensively on his Running a Hospital blog. A lot of good information about the healthcare cost drivers is coming out supplemented by a lengthy investigation spearheaded by the state’s AG, Martha Coakley. The most important point being emphasized, I think, is that the rapid increase in medical prices and cost is being driven by large hospital and physician groups plus community hospitals that dominate a geographic area and have amassed significant regional or local market power. They are using that power to push their reimbursement rates up well beyond the rate of general inflation even though the care they provide is generally not demonstrably better than competing providers with less market power and who are, accordingly, paid less for the same work.

  35. If lying, obsfuscation, deal making, special interest catering, cheating, refusal to bend to the will of the people is considered working, best of luck to you.
    America has made it clear that they do not want this bill and the party in power has made it clear they will ram it down our throats.
    We will make it clear that we do not want the Democrats or any other party that opposes our collective will in power.
    Best of luck midterm and beyond to the Dem’s out there.
    Richard Raffield

  36. This is, by far, the best and sanest article I’ve read during this long Health Care Reform season.
    The system does work, not perfectly, but no worse than it worked since it was put in place.
    I’m sure if we were taken back in time to, say, the Log Cabin – Hard Cider campaign, we would have witnessed the same outraged expertise regarding the system’s corruption and failure.
    It didn’t fail then and when you look at it as thoughtfully as Bob does, it’s not really failing today.