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Last Helicopter Out of Saigon!

Jeff goldsmith In popular psychiatry, a classic passive aggressive gambit is “malicious compliance”- intentionally inflicting harm on someone by strictly following a directive, even though the person knows that they are damaging someone by doing so. In Washington, the most skilled practitioner of this dark art is Speaker Nancy Pelosi If health reform craters, Pelosi will disingenuously claim that she did precisely what the President asked of her, and blame the Senate and the President for its failure.

In reality, Pelosi’s “leadership” almost fatally wounded health reform last summer. If the process does collapse, the blame should fall squarely on her shoulders. Her poor political judgment led directly not only to squandering a nearly 80 vote majority, but also exposed embarrassing and ill-timed disunity among Democrats on a signature domestic policy issue. It won’t be the Republicans that killed health reform, but incompetent Democratic Congressional leadership.

Last July 14, Speaker Pelosi unveiled the opening bid in the health reform process- HR 3200, America’s Affordable Health Choices Act of 2009. This bill was drafted largely without input from their Republican colleagues or from important Democratic moderates. It also put into legislative language virtually exactly what the President promised in his campaign, without considering seriously the political implications for the actual passage of the legislation- a political form of malicious compliance. Democratic moderates felt their input had been ignored and they were immediately trapped on the wrong side of this issue.

HR3200 had an immediate polarizing effect on the health reform debate, and the damage control process was on. In a sense, health reform has never recovered. Pelosi’s bill summoned the right wing talk radio demons (and the inimitable Betsy McCaughey) out of their caves, reviving long dormant rhetoric about a “government takeover of the health system”. This label has clung stubbornly to all subsequent versions of the legislation.

Unfortunately, the critics weren’t too far wrong. HR 3200 effectively federalized the employer health benefit. It mandated that employers offer a “one size fits everyone” health benefit to their workers, the benefit precisely defined by federal statute. It imposed an 8% payroll tax on employers who did not provide the benefit, pushing their federal payroll tax to 23% if you include Social Security and Medicare. It also moved the top tax rate for federal income taxes for businesses filing as “subchapter S” to 46%, a level not seen since Jimmy Carter was in the White House.

Given unemployment was climbing toward 10% at the time, HR3200 would have simultaneously diminished corporate cash flow and increased the cost of hiring new workers for firms that did not presently offer health coverage- a recipe for no recovery.

HR 3200 created new health insurance premium subsidy for workers covering and estimated 20 million new people, but without any meaningful brake on future federal subsidies. To enroll these new folk, however, health insurers would have to comply with provisions of a new federal health insurance exchange, whose rules would have effectively ended medical underwriting.

The health coverage gated through the exchange was no longer be “insurance”, but a federally defined health care entitlement financed largely by employers. The bill also created a public health insurance option, which had the effect simultaneously of competing with and financially undermining private health insurers. All of this was to be overseen by a politically appointed Health Choices Commissioner, in effect, a commissar for the health insurance system. This nominally private-sector approach had a distinctly Soviet flavor.

Almost immediately upon HR3200’s release and for the following seven months, the Democrats have been playing defense on health reform and losing. Democrats elected from Red or Purple states ran from the bill as fast as their legs would carry them. They rebelled against the “public option”, the employer mandates, as well as the tax increases required to fund the premium subsidies.

Moderate Democrats also objected to subsidizing private coverage of abortions and to any enrollment of people in the US illegally (roughly 7-8 million of the uninsured). It might have been possible to address these concerns “privately”, e.g. in the initial drafting process, but by the time HR 3200 was released, many After almost four months of contentious negotiations, a revised version of the House bill passed by only five votes, one of which came from a stray Republican.

By the time Democratic moderate concerns had been clumsily and publicly accommodated (in the late fall), the resulting House bill had gravely offended three core constituencies of the Democratic party- women, Hispanics and the single-payer advocates, without materially addressing the critics of a huge expansion of federal power (and spending). The Democratic base lost enthusiasm for the bill while Democratic moderates continued to struggle with the “government takeover” label. By late fall, the legislation had acquired the odor and toxic sheen of a rotten side of tuna.

In the court of public opinion, the ensuing seven months (with a brief blip after Labor Day after a well- crafted Obama defense of health reform), were all down hill for health reform. Opposition to the process, as much as the substance, of health reform hardened, aided materially by a flurry of dealing making around the Senate bill (Medicare or Medicaid carve outs for Florida, Louisiana and Nebraska most visibly).

The late January loss of Ted Kennedy’s seat to an insurgent “Tea Party” Republican, Scott Brown, was an unmistakable warning sign that even formerly unassailable Blue State Democrats were now at risk. Political pundit Charlie Cook, who follows the Congressional races at a microscopic level, wrote recently that the Democrats have been in free fall since August. They lost gubernatorial races in New Jersey and Virginia, county executive races in solidly Democratic Fairfax County (VA) and Westchester and Nassau Counties (NY). A surge of inconvenient scandals- David Paterson, Charles Rangel and Eric Massa- all in New York- have further tarnished Democratic credibility. Cook placed the odds on the Democrats losing the House this November at 50-50 and sliding.

On the eve of the Presidential health reform “summit”, a Newsweek poll revealed that independent voters, crucial to re-election of Democratic moderates, opposed passage of health reform by a stunning 62-29% margin. Despite the White House’s feeling that the President could paint the Republicans into a corner and blame them for halting health reform, a Politico.com reader poll after the summit suggested the Republicans decisively outpointed the President (52%-19%) by stressing the fiscal and economic risks of the bill. There aren’t a lot of undecided voters left on the health reform issue- and strongly “anti-” sentiment outruns strongly “pro-” sentiment by almost two to one.

Now the White House and Democratic leaders are in the final scramble to find votes to send the President something he can sign and declare this endless and divisive process over. Speaker Pelosi suggested last week that, regardless of the damage they may suffer at the polls in November, House Democrats owe her and the President a reaffirmation of their support. Pelosi basically ordered her troops to swallow their reservations about this bill and fall on their swords.

Gloria Borger of CNN reported late last week that a “senior White House aide” characterized the coming vote on health reform as “the last helicopter out of Saigon”, the most unfortunate political metaphor of the Obama era thusfar. (For younger people, that helicopter was ferrying South Vietnamese collaborators with the United States off the roof of the CIA compound before the North Vietnamese Army flooded into Saigon). What did the “senior White House aide” mean? That the Communists are coming and congressional Democrats need to save themselves and run for the hills? It sure doesn’t sound like a clarion call to do the right legislative thing.

It isn’t the Communists that are coming. It’s a lynch mob. And the angry horde is going to discriminate between “progressives” and moderates. They are simply going to find and hang as many public officials as they can get their hands on – incumbent Congresspeople, Senators, Governors, state legislators, county executives. Unfortunately for the Democrats, the majority of those incumbents are Democrats. I’ve not seen such a toxic electoral atmosphere in my lifetime.

If she cannot find the votes to pass health reform, Speaker Pelosi will be deflecting blame and knifing her White House colleagues in the back all the way to the guillotine. If it passes, it will be in spite of, rather than because of, her advocacy. By maliciously complying with the President’s mandate, Speaker Pelosi and her arrogant, tone-deaf management of the legislative process badly damaged the prospect for lasting health reform. She should scramble for a seat on that last helicopter herself.

Antitrust Warfare

Palestrant

Not since the days of monopoly busting and Standard Oil has anti-trust been such a contentious topic in American politics. Today, Teddy Roosevelt has been replaced by Nancy Pelosi and the oil barons have been replaced by……doctors? The healthcare debate is quickly turning into a dog fight about monopolies and price controls, and in doing so, unveiling some of the dark truths about how the money really flows in this country’s largest industry.

Turns out antitrust law has become so contorted and subverted that it now serves the interests of those it was meant to regulate far more than those it was meant to protect. This past week, the FTC announced a consent decree with Roaring Fork IPA, a physician network in Colorado ( click here). Of course, this is less than a week after the Speaker of the House announced that she will pin her party’s hopes of resurrecting healthcare reform on repeal of the 1945 McCarran-Ferguson Act, a little known antitrust exemption that benefits the insurance industry ( click here).

So why has antitrust become all-the-rage-all-of-a-sudden?  The Sherman Antitrust laws were originally intended to prevent monopoly behaviors, however, it has become a key tool in keeping physicians as indentured servants in our healthcare system.  As Medicare continues to reduce payment rates, more and more providers are choosing to opt-out rather than contract to deliver services at a loss. Most notably, the Mayo Clinic chose to do this a few weeks back ( click here).  What is fascinating, however, is that the FTC is claiming that the Roaring Fork’s decision (unlike Mayo’s) constitutes an anti-trust violation so egregious that it is worthy of an investigation and the consent decree.  With 65 physicians, Roaring Fork represents well less than 1% of the physicians in Colorado, so why the anti-trust concern?

The answer lies in the cozy relationship between the insurance industry and the FTC.  Insurers are determined to make sure that physicians are kept from having any leverage nor allowing market forces to create a balanced supply-demand between physicians and patients.  The net goal of both is keeping physician payment artificially low, while maximizing insurance company profits.  For physicians, Roaring Fork should be a wake up call to accelerate their efforts to decrease their dependence on third party payers and their adoption of technologies and services that can even the playing field.

Today we are witnessing a Kafka-esque sequence of events.  Teddy Roosevelt, the original trust buster, would literally bust out laughing if he could see the incumbent political party pinning their hopes for their highest profile political effort on repeal of an anti-trust exemption, while the government chases after……..doctors, for ostensibly violating this same law.  Only in America.

Daniel Palestrant is the CEO of Sermo, the social networking site for physicians. He is a regular contributor to THCB.

Confused, Conflicted, Clueless and Cranky

Taylor

Humphrey Taylor is Chairman of The Harris Poll.  Prior to joining Harris, Taylor worked in Britain where he conducted all of the private political polling for the Conservative Party and was a close adviser to Prime Minister Edward Heath in the 1970 campaign and subsequently to Margaret Thatcher. After a year of debate, in which health care policy was covered in the media almost daily, very few people are even moderately well informed about the details of the proposals for health care reform.  But many of them have strong opinions.  Most people, our data would suggest, are confused, conflicted, clueless and cranky: confused because of the complexity of the many issues that are on the table; conflicted because they often favor policies that are mutually contradictory; clueless because they don’t know, let alone understand, most of what is being proposed; and cranky because Washington has failed, yet again, to provide a health reform bill they like.

The mind-boggling complexity of the system and the proposed reforms provide plenty of opportunities to attack the proposals, however unfair or unreasonable they may seem to advocates of reform.  Critics say the proposed reforms would lead to a government take-over of the system, higher taxes, less choice, lower quality, higher unemployment and rationing.

Confused? One huge problem is that the American health care “system,” as it is euphemistically called, is fiendishly complicated.  Health insurance coverage is provided by Medicare, Parts A, B, C, D, Medicare Advantage, Medicaid, employers and their insurance plans, the V.A., D.O.D., FEHBP, SCHIP, WIC, the Indian Health Service, community clinics, HMOS, PPOs, and the individual insurance market.  There are state regulated and ERISA plans.  Important federal government health care agencies include HHS, CMS, AHRQ , CDC and NIH.  There are solo, small and large practices, single and multi-specialty groups, and integrated medical systems.  Hospitals and doctors employ huge numbers of people at great expense to figure out how to get reimbursed by insurers, Medicare and Medicaid, and how to deal with uncompensated care.

Physicians are paid on a fee-for-service basis, by capitation, and by salaries, and can receive bonuses and pay-for performance incentives.  These payments come from thousands of different health plans, each with its own rules as to what is reimbursed and how.

Complexity of reform proposals

A benign dictator who wanted to reform the health care system might decide to scrap it completely and replace it with a simpler system that would be much easier to understand, much less expensive to manage and much easier to improve.  But most Washington watchers who understand the politics of health care policy believe that this is politically impossible.  Too many powerful interests are involved.  Therefore, most major reform proposals with significant support build on the system we have now rather than replace it.  They would keep employer-provided insurance, private sector health insurance, Medicare, Medicaid, the V.A., the D.O.D., and the other third-party payers.  They would keep the many government agencies that manage and regulate different parts of the system.

And then, as if the system is not complicated enough, the congressional proposals would add more complexity, new agencies, and new regulations.  One or both of the House and Senate bills would create individual and employer mandates, with new subsidies for some employers and low-income individuals, reduced subsidies for Medicare Advantage, a “public option” to compete with private sector insurance, new taxes on “Cadillac plans” and the rich, the barring of medical underwriting based on health status (pre-existing conditions and recision), and health insurance exchanges.  Those proposals would encourage, expand and make use of electronic medical records, electronic prescribing, and other health information technologies, comparative effectiveness research, quality measures, price transparency, wellness programs, “medical homes,” patient-centered care, evidence-based medicine and outcomes research.

Another whole layer of complexity relates to the need for fundamental reimbursement reform.  Our 2008 survey of health care opinion leaders for the Commonwealth Fund found a large majority who believed that this is the most important step that needs to be taken to improve the efficiency of the system and quality of care.  Reimbursement reform means changing “perverse incentives” in the way that doctors are reimbursed, reducing fee-for-service payment and moving to bundled payments, payments for episodes of care, capitation or salaried physicians.  Experts argue that this would require many  more accountable care organizations (ACOs) and medical homes.

Are your eyes glazing over?  There are probably only a few thousand health care policy wonks who fully understand all the complexity of our system and of the proposed reforms.

What most people don’t know or don’t understand

In addition to the unbelievable complexity of the health care system and reform proposals, there are some simple and very important factors that most people do not think or talk about, and probably do not believe.

Most health care economists believe that present cost and coverage trends are not politically or economically sustainable.  They believe that we will have to make really tough choices as we try to satisfy potentially infinite demand with finite resources.  For how long can health care spending increase  2½ times faster than GDP?  How many more uninsured people will we tolerate?

Some political leaders and media seem to encourage this ignorance and the simplistic belief that if only their policies were adopted we could have it all – access to high quality care at an affordable cost with no new taxes, and secure access to all needed services for the rest of our lives.  Most people seem to believe that it would be possible for everyone to have access to all the wonders of modern medicine without much higher taxes or other costs.  Most people believe that insurers should insure anyone who wants insurance, without requiring the young and the healthy to buy insurance.  Adverse selection and moral hazard are not just incomprehensible insurance jargon; few people have ever thought about the concepts.

A recent Pew survey found that only two percent of all adults could correctly answer twelve very simple questions about politics (e.g., how many Senate votes are needed to break a filibuster; who, of four well-known politicians is the Senate Majority leader).  One can only speculate as to what percentage of the public would pass a similar test of “health reform literacy.”

Conflicted?

Most people believe that the health care system “has so much wrong with it that fundamental changes are needed.”  They believe health care costs too much and that everyone should have health insurance.  So where’s the conflict?  The problem is that many people tend to support contradictory positions.  They oppose cutting benefits but don’t want their taxes , their out-of-pocket costs, or their premiums to increase.  They believe that everyone should have affordable access to every test, treatment and procedure that they or their doctors want but don’t stop to think what this would cost or how it would be paid for.  They favor universal coverage but oppose an individual mandate.  They favor an employer mandate but don’t want to make it more expensive for employers to hire people.  They favor a “public option” but oppose a “government-run insurance plan.”  They believe every patient should have access to high quality care, but don’t think the young and the healthy should to have to pay for it.

Clueless?

It is tough to win public support for proposals when very large numbers of people are misinformed and believe many of the strange criticisms made by those opposing reforms.  In recent polls, two-thirds (65%) of the public believed that “the proposed reforms would result in a government-run health care system,” even though the reforms would greatly increase the number of people with private sector insurance. More than half the public believed that the proposed reforms would “reduce the choices many people have now” (55%), that health insurance would be “too expensive for many people to buy” (52%), or “would make it harder for many people to get the care they need “ (51%).  A 45% to 30% plurality believed that “the proposed reforms would hurt Medicare.”  And more than a third (37%) that the “proposed reforms would create death panels that would decide who should live and who should die.”

The public was split 41% to 41% as to whether health care would be “rationed,” and do not realize that we already ration care by reimbursing or not reimbursing it. Large minorities believed that “Medicare will be phased out” (32%), that the “plan promotes euthanasia to keep costs down (25%), and (where did this come from?) that “the government will be able to access individual bank accounts to help pay for services” (23%).

Cranky

The polls sometimes mislead their readers by suggesting that people already have opinions when they ask questions about the details of the policy.  These polls can be useful; they can test the public’s reactions to issues and policies and the language used to present them.  But reactions to a question do not mean that people actually had opinions on the issue (let alone understood it) before they were surveyed.  However, most people do have opinions about health care reform, even if they do not know much about what is being proposed.

What is striking now is the contrast between the large 78% majority of the public who thinks that “fundamental reforms are needed” or that the “system needs to be completely rebuilt” and the hostility to the proposed reforms.  Attitudes to proposed reforms seem to have much more to do with the popularity of who is proposing them than what is being proposed.  In September 2009, we found that a 53% majority thought that President Obama’s proposed reforms were “a good thing” while a 54% majority believe the proposals of the Democrats in Congress were “a bad thing.”  But what was the difference between their policies?  Since September, support for the president’s proposals has declined along with his job rating.  And while the Democratic proposals are unpopular, the Republican proposals (whatever they are) are much more unpopular.

In conclusion

The polling data underline the truth of the advice to “keep it simple, stupid.”  Unfortunately, the system we have now is absurdly complicated and health care reform could only be simple if we nuked the system we have and re-built it from scratch.  And that won’t happen.

Rhetoric trumps substance.  In the absence of a simple, comprehensible reform, it is easy to criticize any package of reforms.  People who are misinformed and have little understanding of what is actually being proposed often hold very strong opinions.

The introduction of Social Security and Medicare (which were bitterly opposed at the time) involved relatively simple concepts that could be explained to most people.  The health reform proposals now on the table, and some of those proposed in the past, cannot.   This helps explain why so many presidents, Democratic and Republican, have failed to pass substantial health care reform that would greatly reduce the number of uninsured and help contain costs.

The White House Healthcare Summit – Democrats 0 Republicans 0

Laszewski

There is politics and there is policy.

On the policy front what we saw today was the same exchange of the old talking points we have watched for a longtime. No progress was made toward any kind of health care bill. That is no surprise–this was never going to be the place to
fashion any kind of compromise.

At the end the President asked the Republicans if it was worth it to spend another month or six weeks trying to come to some agreement. I am glad he did that. I am not optimistic but a “yes” from the Republicans would be the right answer for the country.

On the political front this was a win for Republicans because it was a draw. Granted, they have a very thin health care agenda but all they had to do was hold their own over the course of the day. Politically, if not on policy, they did that. No minds were changed in the room and likely none out in the country. The left will still say get on with passing this, those on right will say kill it, and the majority of critical swing voters will still be concerned that the Democratic bills are going too far too fast in the face of the Great Recession. This is the biggest reason I don’t hold out a lot of hope there will be a lot of Republican willingness to come to the table–at least before the November elections.

Ironically, this “bipartisan summit” may have just increased the political cynicism in the country because it went off so predictably.Continue reading…

The President’s Proposal

You might be wondering why I haven’t written about the President’s Health care bill. The reason is that I have very little to say.

This, I realize, is unusual. But the truth is that the president’s proposal is very similar to the Senate bill—which is not a surprise.

Nevertheless, I am very glad to see the proposal. I was worried that the White House had put reform on the back burner.

Will it pass? As always, I’m trying to be optimistic. But I think that everything depends on whether the White House decides to twist arms. The president will have to persuade House liberals that this is a good first step—and that we can worry about improving the plan over the next three years.

I would still like to see a public option, and I hope that, in the end, the federal government will wind up overseeing the state-based exchanges. But the legislation doesn’t goes into effect until 2014; that gives us more than enough time to improve on it.

The President also will need to keep an eye on Senate moderates. I would favor sending Joe Lieberman on a special mission to South Korea. A relative who is stationed there tells me that the demilitarized zone is particularly bleak this time of year.

There is no need to worry about the Republicans. They can be counted on to vote against any reform bill that even attempts substantive reform. Universal coverage is not their top priority, and they definitely don’t want to pay for it.

Continue reading…

Wellpoint: just incompetent?

I’m viewing the latest rumblings in the US health care debate from the confines of a clear but cold Britain, where the big news is that the country is joining the PIGS in entering economic meltdown—or at least being a lot more broke than it thought it was. (PIGS are Portugal, Greece, Ireland & Spain, not farm animals). And yet it appears that health reform is making if not a comeback then at least vigorous palpitations. The reason for this seems to be the strength that the Anthem Blue Cross/Wellpoint premium rises have imbued into the Administration.

Those of you reading THCB over the years will know that I think the individual insurance market is doomed to fail and should be replaced. It has its apologists; for example Cato’s Michael Cannon here criticizes Paul Krugman who explained last Friday why the individual market goes into a death spiral. Michael claims that Mark Pauly’s research shows that the individual market works. What Pauly’s work (and I despair at having to read it again, so this is from memory) tends to show is that insurers are incompetent at charging sick people to the full extent that they cost them, but do charge them roughly three times what they charge healthy people. Pauly also said in Health Affairs that the individual market works pretty well for 80% of the people in it, but he seems to think that screwing the remaining 20% is OK. Coming from a tenured Ivy league professor who’s probably never had to buy health insurance in his life, that was pretty rich. But apparently Wellpoint’s latest performance shows that it’s not OK for much of the other 80% either—hence their dropping out, leading to Krugman’s death spiral.Continue reading…

Wellpoint and Their “39%” Rate Increase

Wellpoint is getting killed in the press over a “39%” rate increase for their individual health insurance block in California.

HHS Secretary Sebelius has pointed to the Wellpoint individual rate increases demanding an explanation. The President even brought it up in his interview on Sunday. At a time Democrats are fond of calling insurance executives “villains” this story just adds more fuel to the fire.

No less than five reporters  called me the day the story broke asking me to explain it all.

Falling back on my industry experience it is probable:

  • The “39%” headline is anecdotally the biggest increase the press has found—the average is probably less albeit in the high 20% range.
  • This is likely driven by a combination of increasing medical cost trend, a bad economy, and anti-selection as healthier people disproportionately drop their coverage leaving a sicker group in the pool.
  • The rate increase is probably “defensible,” at least actuarially, based upon the actual experience in that block.

When the day is done this probably says more about why systemic health care reform is so critical than about any one company’s behavior. Last week we heard national health care spending skyrocketed to 17.3% of the economy. This is a real life example of what that macroeconomic statistic really means.

Continue reading…

Massachusetts’ Problem and Maryland’s Solution

While health care reformers argue about what it would take to “break the curve” of health care inflation, the state of Maryland has done it, at least when it comes to hospital spending.

In 1977, Maryland decided that, rather than leaving prices to the vagaries of a marketplace where insurers and hospitals negotiate behind closed doors, it would delegate the task of setting reimbursement rates for acute-care hospitals to an independent agency, the Maryland Health Services Cost Review Commission.

When setting rates, the Commission takes into account differences in labor markets and how much a hospital pays in wages; the amount of charity care the hospital does; and whether it treats a large number of severely ill patients. For example, the Commission sets the price of an overnight stay at St. Joseph Medical Center in suburban Towson  at $984,  while letting  Johns Hopkins, in Baltimore Maryland, charge  $1,555. For a basic chest X-ray, St. Joseph’s asks  $81 and Hopkins’ is allowd to  charge  $155. The differences reflect Hopkins’s higher costs as a teaching hospital and the fact that it cares for generally sicker patients.Continue reading…

EHR Redux

Kibbe It’s time to revive the discussion of electronic health record software in light of the new federal regulations that define criteria for meaningful use and also set criteria for the EHR technologies that must be implemented by doctors and hospitals in order for them to become, and be paid for being, “meaningful users of certified EHR technology.”

While most of the public commentary so far has been directed to the NPRM on meaningful use, the real news here relates to the de-construction of EHRs that is described in the interim final rule covering EHR standards and implementation specifications. Of course, the NPRM and IFR are by design tightly linked. But the NPRM on meaningful use is primarily a set of instructions for doctors and hospitals about how to participate in the incentive payment programs established statutorily under ARRA/HITECH. The rule on EHR technology certification criteria, on the other hand, is a playbook intended for vendors and developers who want to qualify their products to meet the expected demand by meaningful users in those programs.Continue reading…

The Silver Lining

Brian Klepper Massachusett’s voters’ stunning rejection of Democrat Martha Coakley, in favor of a not-very-impressive Scott Brown, should be exactly the splash of cold water that the Democratic party – and Congress as a whole – needed. The defeat can be understood in two ways: one large and one fairly small.

First, the large one. This will probably send reform back to the drawing board. Health care is too much in crisis and too pressing to be pushed completely off the table until certain issues – including both access AND cost – are addressed.

Second, this election marks the loss of a single critical Senate seat, but it is also very loud warning shot. The mandate received at the end of 2008 was a resounding call to throw out the Republicans who for more than a decade had ridden roughshod over American values. Yesterday, the Democrats, in one of their most secure strongholds, received the same message. Whatever people in DC think, rank-and-file Americans – not those on the right or left, but the swing voters in the middle who actually determine election results – are very unhappy with the gaming that’s been vividly displayed over the last year under the guise of health care reform.

The distaste expressed yesterday probably has little to do with the specific provisions of the bills, except for the largest generalities: that they expand coverage while avoiding a commitment to changes that could significantly reduce cost. But along the way, voters have witnessed — with an immediacy and transparency that has only been available as a result of the Web — lawmaking in its worst tradition. There was the White House’s deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week’s White House deal with the unions that exempted them from the tax on “Cadillac” health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power’s muddled agenda, you get a special deal.

The most tempting mistake now for the Democrats would be to dig in. President Obama’s most appealing characteristic — the one that got him elected — was his embrace, his embodiment even, of approaches that would revise the traditional kinds of politics we’ve seen for the last year throughout the health care reform process. Of late, the most telling complaint about this Presidency so far has been disappointment that, once in office, he seemed to cave in so easily.

Undoubtedly, many Republicans are now rejoicing over the Democrats’ loss and the possible defeat of any health care reform legislation. That’s unfortunate. The health care crisis is real and remains unaddressed. The pressures it creates, particularly for powerful interests like business, will force Congress to return to it and develop meaningful solutions. Hopefully (though probably unlikely), Congress and particularly the Democrats, will be chastened and wiser. There’s a big opportunity here to make lemonade.

There is a new, bipartisan movement in Congress, highlighted on NPR two weeks ago, that would revisit the rules around the relationships between special interests and lawmakers. This is an issue that trumps and is more important than all others, because if every policy is ultimately shaped by those with enough money to buy Congress’ favor, then our democracy will be unable to hold.

The silver lining in yesterday’s election was that it was a mild, if critical, reminder that, whatever DC thinks, America’s center is just as displeased with the current governance as it was with its predecessors. Faced with a much larger rejection in the 1994 elections, President Clinton went on TV, took full responsibility, and then spent his time rebuilding. The good news is that today is a new day, and that, if they’re interested in what’s good for America over the long term rather than simply themselves over the short term, Congress has the ability to start again in ways that could please the American people and actually work to our collective advantage.

Brian Klepper and David C. Kibbe write together about health care technology, market dynamics and reform.

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