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3. why should people go to jail for not being able to buy health insurance but we are keeping and at many times giving free healthcare to illegal immigrants. Many parts of the bill could be good, but also very scary

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5. My question is this..If the goverment is going to help people with their healthcare costs who cannot afford it (medicaid) and if the health reform bill passes and more people must be helped in order to have insurance, many of those people choose to spend their money on non-life saving medicines but refuse to pay for the ones they really need. Also, why should people go to jail for not being able to buy health insurance but we are keeping and at many times giving free healthcare to illegal immigrants. Many parts of the bill could be good, but also very scary. But yes, we would be able to buy our own insurance with private money. Isnt that what a lot of people do now anyways?

6. If you don’t lower the economic barriers of entry into the profession, then you will not have enough providers……then all care can move offshore

7. jd-
   I think the will to reduce costs and lift quality is there. The White House, in particular, understands that spiralling health care costs represent “the greatest threat to the U.S. economy” (white house budget director Peter Orszag).
   We have no choice: we have to rein in health care inflation or watch Medicare go under (in six years the Medicare fund paying for hospitalizaions will be paying out more than it takes in.) And, in the private sector, if we don’t begin to change what we pay for, and how we pay for it (paying for quality and efficiency rather than volume) more and more middle-class and upper-middle class Americans will find healthcare unaffordable.
   Because I know the Medicare Payment Advisory Commission (MedPAC) reports very well, I can see their recommendations embedded in the legislation where it calls for reviewing the Medicare fee schedule, for instance, and looking at services where volume has been increasing, to see if we are overpaying.
   Will Congress have the will to implement cost-cutting?
   Maybe not. But this is why both President Obama and the Senate bill calls for an independent expert panel of physicians and other medical professoinals to oversee changes in Medicare spending. The panel woudl be insulated from Congress and lobbyists the same way we insulated the panel that oversaw closing military bases: it would present its recommendations in a package and the Senate would have a limited amount of time (60 days, I think) to say yea or nay to the whole package in an up or down vote. Congress couldn’t edit the package, picking out what it likes (for instance pay hikes for primary care docs) and vetoing what it doesn’t like (lower fees for some very lucrative specialty services that provide relatively little benefit to patients.)
   The reform legislation devote so much space to Medicare reform because it will pave the way for health care reform. The legislation makes it clear that the public plan will incorporate Medicare’s reforms. And private insurers have made it clear to MedPAC that if Medicare provides political cover, they will follow suit.

8. People are suspicious of 4000 pages of legislation written in language that lawyers can’t understand. I’d say most folks want health system reform or health insurance reform or both. However, there are too many devils in so many details. Thus far, these bills are less about healthcare and more about taxation and bureaucracy. That, my friends, is not reform; it’s a hostile takeover.

9. JD- Far be it from me to substitute my wisdom in a paragraph or two for the 2000 page monstronsities working their way through Congress’s large intenstine. I just think the timing’s wrong. There is not excuse for our having 46 million uninsured people. But even our fiscal capacity is limited and we reached it this spring when we hurled trillions of dollars at fixing our economy.
   We are a wealthy nation, but we will not remain wealthy if we continue spending money we don’t have. The proper sequence is to find the tools in changing healthcare payment to eliminate the 2.5% overage in health cost growth over GDP growth-THEN expand access. Lay the groundwork, THEN add the coverage. The reality is that of all the “pilots” and “demonstrations”, nobody, even the experts at Brookings and the Urban Institute know which of them are powerful enough to take the inflationary bias out of the present health care payment system.
   I’d love to have Maggie’s faith that Peter Orzsag and the President can somehow talk Congress into actually making sacrifices. It just ain’t going to happen. The problem is not the Administration- it’s the approval junkies in Congress. Look at what happened to the “independent” Medicare Commission- not even present in the House bill (Waxman won’t let go of the reins for one Beverly Hills second) and effectively forbidden from changing how doctors or hospitals are paid in the Senate. For all the huffing and puffing, this legislation does NOTHING, NOTHING to slow the growth in health costs. It’s simply lying to ourselves to say otherwise. It merely opens up a huge new public subsidy for which the only possible control point is health insurance price controls, a brain dead 1970’s idea.
   My formula;
   -eliminate the loopholes in fraud and abuse laws that permit the kind of medical self-dealing that Atul Gawande wrote about in his horrifying article on McAllen, Texas
   -eliminate the open ended tax exemption for first dollar coverage type health plans, like those that bankrupted the auto industry and our municipalities
   -tax the hell out of junk food, including soft drinks-obesity is absolutely a big part of our problem (40% of health cost growth in the last decade according to Ken Thorpe)
   -let boomers into Medicare early on their own (or their employers’ nickel) subsidizing the poor who cannot afford it. They don’t belong on Medicaid.
   – eliminate first dollar MediGap coverage so that all seniors have some (affordable)
   cost exposure
   -grade cost sharing for Medicare AND private insurance to income so that those in lower incomes do not have five times the cost exposure as those at upper incomes
   -pay hospitals a fixed amount for three days prior and thirty days after a hospital admission, including all the physician fees (forget the five year experiment- just do it now), and
   -dramatically increase what we pay primary care docs (by like double), taking the money out of hospital outpatient rates.
   You asked. . .

10. Maggie,
    I had read your post and a couple others making similar points, and I would really like to believe that there are strong reforms to the delivery of care. I’m not yet convinced, though I’m warming to the idea. Basically, the bill seems to contain a number of provisions that could form effective mechanisms of cost and quality reform IF the political will is present to use the opportunities created by the bill. That is not a foregone conclusion.
    However, it’s a little hypocritical of me to be skeptical, since one of the main things I’ve been arguing these past two years is that its OK to engage in what is primarily access reform now, because in doing so we set the stage for much more rapid reform on cost and quality later than would otherwise occur. If I was willing to predict the appearance of new legislation as a result of universal healthcare, why not accept that features in the current bill will be employed to their full potential? I think I just need to get a better grip on the details of those parts of the Senate and House bills.
    Margalit,
    Short answer: if a reform isn’t politically possible, then it won’t pass Congress. If it doesn’t pass Congress, it doesn’t become law and it doesn’t actually become reform. Do you have a different understanding of political possibility?
    Obama doesn’t get to vote 60 times in the Senate, or even once. He can’t put significant pressure on Lieberman, from what I can see. Lieberman is determined to stick it to the liberals as payback for Lamont and who knows what else. The 3-4 conservative Dems in the Senate couldn’t be pressured to vote for a bill with a strong public option, let alone single payer, or deep cuts in provider pay (or even allowing the Medicare rate cuts to stick!), etc., etc.

11. jd, why does it have to be politically possible? Obviously the bills are moving up in both houses on Democrat votes alone. Why was it necessary to take the mandate awarded by the people to this President last year, and turn it over to Congress to do as it pleases with almost no guidance? I understand the fear of repeating Clinton’s mistake, but this is an error in the opposite direction.

12. Lisa,
    You are being wamboozled, big time.

13. Regulate the health care industry. Regulate the insurance industry. Don’t mandate individual citizens financially support same. Howcome the government isn’t mandating me to buy groceries every week? Put a roof over my head? I have a real problem being ordered by the government to buy insurance because I exist. If it were affordable, and a good value, most people would buy it. Otherwise, call it what it is, a tax, and just get rid of health insurance companies for whatever services our new taxes are paying for, which clearly we have no idea. I feel like somebody is trying to trick me.

14. Dear Robert:
    You ask how Democrats can can get reform done in the face of soaring costs and disapproval of the American people. From out of blue heaven, this inspired ten part Eureka and Nirvana-based answer came to me.
    One, kill the lawyers! Shakespeare and the American people distrust lawyers, especially lawyers in the House and Senate. Americans consistently rank lawyers down there with used car salesmen. As I write, Congressional job approval is at a minus 65 percent, meaning nearly two-thirds of Americans disapprove of the job Congress is doing. Therefore, we can start reform by ridding ourselves of lawyers, particularly incumbent lawyers who double as politicians.
    Two, ban the lobbyists! Everybody knows special interest lobbyists shape health reform legislation. For every legislator, there are over 30 lobbyists collecting roughly $300 million in misbegotten fees. Lobbyists are even writing the press releases and talking points for Congressmen and Senators. Politicians, in turn, are gathering contributions to assure their reelection. Outlaw lobbyists!
    Three, put doctors on salary! Remove incentives for doctors to do more for patients. Herd doctors into large groups, into integrated organizations like Mayo, Kaiser, and Geisinger, salary them, strip them of incentives to make more money, regulate them. Remember: once you’ve got them by the tender part of their anatomy – their wallets – their hearts and minds will follow.
    Four, put Washington in charge of who gets what at what price! Only Washington knows what constitutes “rational” thinking; how federal dollars should be distributed and for what reasons; and who should get the money. Reform is about social and redistributive justice. Patients and doctors, in short, who get the short end of the stick, must bow to superior beltway wisdom.
    Five, adopt health systems of other countries! Everybody knows other countries aremorally superior countries. They cover more people at half the cost that we do and with better results. Ignore the fact that these countries have more homogeneous populations; supply health care by suppressing access to life-saving and life-style restoring technologies, and offer systems much less responsive to patients with fewer amenities.
    Six, move lower-cost health systems off shore! Follow the example of an India physician who is building a high tech hospital in the Cayman Islands, one hour by plane from Miami that will perform open heart surgery for $2000, versus $20,000 to $100,000 in U.S. Focus on volume. Restructure. Introduce new business models. For details, see “Indian Doctor Tagged ‘Henry Ford of Heart Surgery’ Drives Down Costs,” WSJ, November 23.
    Seven, digitize health care! Everybody knows that the American economy is moving at Internet time, that the computer promotes transparency, clinical efficiency, outcome effectiveness, price comparisons, relevant provider value, and empowers consumers to make the right choices for the right reasons at the right places with the right results. Never mind that it may be personally intrusive, violate privacy, and disrupt the patient-physician relationship. Data uber alles. Digitize upper alles.
    Eight, Base everything on scientific evidence! Everybody knows medicine is Science not Art, and that government, health plans, and consumers should pay only for what works and what is rational in the eyes of payers. Never mind that what is paid for may not fit the hopes, needs, and expectations of patients and that human values, such as the quest for individuality and personal freedoms, may be subjective and irrational.
    Nine. standardize everything! In a top-down system, everybody knows that everything must be certified, standardized, and homogenized – the contents of every plan, the benefits provided, the choices offered – regardless of age, sex, socioeconomic conditions, cultural or health status. Everybody is equal, but some are more equal than others, depending on your politics.
    Ten, end the profit motive, and you can’t end it, tax it! Everybody knows profit is the root of all health care evils. Therefore, all incentives to innovate to make more money must be eliminated. If the profit motive persists among hospitals, doctors, health plans, device makers, and drug firms, tax their profits. Let no good innovation go unpunished.
    Do it all it once to overcome public resistance.

15. Merle, Sheila and jd
    Merle, I agree.
    Sheila & Jd. The legislation under consideration is better than you think.
    Journalists just haven’t done a very good job of reporting on it.
    It’s certainly far from perfect, but represents a big step forward. See this post on what has been accomplished, what still needs to be done: http://www.healthbeatblog.com/2009/11/heath-care-reform-looking-at-the-glass-halffull-.html
    And, as Sheila says, over the next three years, it can be strengthened and refined.
    In a weak economy, will they go forward with the mandate, subsidies and exchange?
    Absolutely. They have no choice. As White House budget director Peter Orszag has pointed out, the single greatest threat to the U.S. economy today is the spiraling cost of health care.
    And Orszag is a powerful force in the White House. He will make sure that they stay on track. (And I very much hope that the target date remains 2013, as in the House legislation)
    In order to share the cost, we must get everyone into the boat–everyone in, no one out, including the young and healthy. (The Mandate) In order to bring down the cost of premiums, everyone must be part of a group so that they can get group rates. (The Exchange When people buy individual insurance the administrative costs are way too high.) In order to participate, low-income and middle-income households must have Subsidies.
    But you left out the fourth crucial part of reform: saving money by weeding out waste. First we need to steer doctors and patients away from less efefctive tests, treatments and drugs, and toward the most effective treatments. Often (but not always) these will be less expensive, less agreessive and less “hyped” products and services.
    We’ll do this the way we steered people toward generic drugs– higher co-pays on the less effective (or no more effective) treatment, lower co-pays for the more effective (or equally effective and less expensive) treatment.
    IN order to reduce the waste in the system,, we need to continue to spread the word that in medicine, Less can be More.
    Finally, we pay too much for a great many products and procedures. The House legislation would let Medicare negotiate for discoutns on drugs. Both bills woould have Medicare begin to use financial carrots and sticks–refusing to pay for inefficient care (a high number of preventable hospital admissions) while rewarding doctors adn hostpials for quality, not volume (“bundling payments” providing bonsues for doctors who join accountable care organizations where they work, on salary, to co-ordinate care.)

16. The problem with these simplistic polls is that they do not address what the “oppose” side believes in. The 50% opposed to the current HCR plan comprises all sorts of different viewpoints.
    Some are opposed because they do not want more government involvement in health care. Some are opposed because it subsidizes private insurance without a meaningful public option. Some are opposed because it’s too expensive. Some are opposed because it doesn’t cover enough people. Some are opposed because it doesn’t bend the cost curve. Some are opposed because it is not single payer. Some are opposed because they think it is unconstitutional. Some are opposed because it doesn’t limit unnecessary medical procedures. Some are opposed because it will lead to rationing. Some are opposed because it will give health care to illegal immigrants. Some are opposed because it limits access to immigrants, including legal ones. Some are opposed because it subsidizes abortion. Some are opposed because it restricts access to abortion.
    As the bill gets more and more specific, it is normal that more and more people will find things they don’t like in it. But the real question is whether the “NO” side has a common alternative or not, and it clearly does not.
    To govern is to choose among disadvantages.

17. I think the answer is that the Democrats are in a worse bind if, after wedding themselves in the public eye to this mess, they can’t even pass anything. They are better off passing something – at least they have something to brag about to those who do support the effort. Otherwise it is all the negatives and no positive. PoliticsDaily had an article on this topic that makes this point(http://www.politicsdaily.com/2009/11/23/the-fate-of-health-care-reform-changes-dynamics-of-next-years-m/).
    But what if it does pass? Much of the infrastructure for the subsidies and the exchange would not come into being until 2013 or 2014. In the meantime, some of the taxes and fees to support the structure will begin, and there will be plenty of time to slice and dice the plan. There will be time to more thoroughly understand the implications of the plan – including the affordability and adverse selection issues that you have emphasized in earlier posts. And this will be in an environment of continued high stress on employers and households (continued high unemployment, one-quarter of home-owners “under-water”, rising fiscal crisis for Medicaid and Medicare). In this climate, will they ever implement the central mandate+subsidies+exchange core of this thing – or will it be rolled back before much of it sees the light of day?

18. I’ve been saying for two years now that the first round of reform would, should and must be partial and focus on access rather than cost and quality. The way this has played out has only reinforced those beliefs.
    To these critics: please tell me what your preferred reform is that simultaneously can get past the healthcare lobbies, a Republican party that opposed any reform on the Democrats’ watch, and a mis-informed electorate…oh, and by the way would get costs under control, by which I mean at least freezing the share of GDP spent on health care in the short term, and slowly reducing it by a few percentage points in the long term.
    Those of you who are harsh critics must have at least as aggressive a cost saving goal as this, or I don’t see where your harshness comes from. Unless, of course, it is of a more personal nature. For some, it seems that their own pet reforms are not being included or they are not being listened to in the halls of congress as much as they would like, and this has soured them on the process well beyond what is justified when you take a look at the forces arrayed against any meaningful reform.
    tcoyote and Bob, I just don’t believe you could do better if you were in Congress or had the President’s ear. Not because you don’t have good ideas, but because you couldn’t get them passed. And no, I don’t think waiting for 10 more years is a good idea. It’s a really terrible idea, since every time we wait we have a larger and more powerful health care sector to deal with, and the proposed reforms are less extensive than before. Meanwhile, costs balloon.
    What I think you fail to remember is that the modest cost reforms in the bills are only being accepted by industry to the extent they are because they are coupled with more reliably paying customers. If you think we can get better cost reforms without also expanding coverage, that seems just out to lunch to me.
    And if you think the people will rise up and demand real reform, based on what evidence? Most of the public still thinks all the extra money is going to insurer and pharma profits and salaries, and have no idea about the biggest cost drivers. People on the left and right had an aneurysm when the mammography recommendations came out. There is no appetite for stricter reliance on best practices and guidelines when they have any whiff of denying people care on demand.
    Even most policy wonks, let alone the general public, have not come to grips with the fact that we pay twice as much per unit of care delivered here as in other nations. They think it’s all about Americans being too fat and lazy, or about the Dartmouth research showing 30% variation in practice without meaningful health impact. I hear all the time about how Medicare and Medicaid underpay, when the reality is that we would have solved our problem if every provider was paid Medicaid rates. We wouldn’t have to reduce how much care is delivered at all. I’m not saying that we should focus entirely on payments or that to do a frontal assault on them is politically possible, just that this is the single biggest factor and to focus on population health or on best care practices alone is not at all sufficient.
    So, tcoyote and Bob L and others, what is your proposed solution that is also politically possible? If you want to direct me to a past post of yours, I would certainly read it.

19. Many of our elected representatives within the Democratic Party are no longer following in the time-honored footsteps laid down by the founding fathers of our great Nation. More importantly, we as democrats see our elected representatives within the Democratic Party abandoning the values and principles as set forth within the Declaration of Independence and the Constitution of the United States.
    At the very minimum, most Democrats already know their pleas to the Democratic Party are only being answered by repeated insult and injury. Many of our elected officials are no longer thinking of themselves as being our representatives, but instead refer to themselves as leaders in the true form of tyrants.
    Altogether, this is only the beginning of our problems as Democrats. The current Democratic Party leadership is tainted by corruption, and the liberals among us are supporting Socialists with their agendas based on implementing Fascist, Marxist and Communist political doctrines into our own government. These Socialists are clearly a threat to everything we hold sacred in America, and they are gaining evermore control over our Democratic Party, our Nation, and the American people.
    Despite this, we as Democrats can restore control of the Democratic Party back to the party members. All we need to do is cut off donations to the local, state, and national headquarters of the Democratic Party, and to make sure the donations are made directly to patriotic and honorable Democratic Party candidates that are not corrupt or Socialists.
    So please help spread the message to everyone of our fellow Democrats. Also, don’t forget to contact and request the Unions and other outside contributors to follow our lead as patriotic Americans.
    Thank you, and God Bless America.
    Web site: http://www.democraticreformparty.com
    Blog site: http://blog.democraticreformparty.com

20. Thanks, Maggie. It’s a shame many posters don’t practice full disclosure and, instead, twist facts to advance their argument.

21. Anxiety turns to fear turns to rage turns to rejection. People should rise up and retake their own government. This is evil.

22. Rasmussen Reports isn’t may raise questions in a particular methodology but I wouldn’t say they are a partisan-hack organization driven largely by an ideological agenda. There numbers get viewed and utilized by some of the heavy-hitters in both political parties especially because of their quick and constant turnaround times.
    Real issue with them is just how valid their 100% automated dialing methodology approach for surveys and the populations they are able to reach utilizing that method.

23. Actually, Broder’s got deep health reform credentials. With Haynes Johnson, he wrote (in 1996) probably the most comprehensive autopsy on the failed Clinton health reforms, The System (Little Brown). It’s worth rereading as this mess lurches toward a conclusion. Broder’s followed both Congressional and Presidential politics for forty years. He’s the Scotty Reston of his generation, and is ordinarily very sympathetic to the Democrats. If he says there’s a problem with the credibility of the fiscal estimates, there’s probably a good reason: he’s right. If either of these bills is even close to budget neutral , I’m Bullwinkle Moose.
    There’s a really good reason the President wanted this done by the end of the summer. The evolving national mood is not a friend to this process.

24. For my money, Rasmussen polls ought to be printed on that scroll of paper I keep in the small room in my house that has all of the plumbing fixtures in it.
    And as fine a writer as he is, I have to ask: is David Broder relevant with respect to health care?

25. Robert:
    You omitted these two sentences from the Ramussen report:
    “Rasmussen Reports is continuing to track public opinion on the health care plan on a weekly basis. Next week’s Monday morning update will give an indication of whether these numbers reflect a trend of growing opposition or are merely statistical noise.”
    And while the Rasmussen poll suggests a wide divergence, it’s worth noting that many polls don’t;
    Washington/ABC poll– 48% support 49% opposed
    AP poll– 41% support 43% oppose
    On the CNN poll, you are correct that 46% favor, 49% oppose.
    but you ommitted CNN’s follow-up question: “If you oppose that bill is it because you think it’s approach toward health care reform is too liberal, or is it because you think it is not liberal enough?”
    34 percent said they opposed the bill because it was too liberal.
    10 percent said they opposed the bill because is was not liberal enough
    3 percent said they opposed the bill for other reasons.
    “As Texas Tech University professor Alan Reifman points out, those results mean 56 percent of Americans “favor either the House-passed version of health care reform or something further to the left.”
    A check of the Nexis news search shows that CNN broadcast results of the follow-up question as part of their poll stories several times on the day they were released. And the story that ran on CNN’s online Political Ticker featured the same numbers prominently, including this characterization from CNN Polling Director Keating Holland: ‘That may indicate that a majority opposes the details in the bill, but also that a majority may approve of the overall approach taken by House Democrats and President Obama.'”
    http://www.nationaljournal.com/njonline/po_20091123_5799.php