White House as helpless victim on healthcare

Nonsense. The administration is getting the bill that it -- more or less -- wanted all along The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives. The administration is getting the bill which they, more or less, wanted from the start -- the one that is a huge boon to the health insurance and pharmaceutical industry. And kudos to Russ Feingold for saying so:

Glenn Greenwald

Dec. 16, 2009

(Updated below - Update II - Update III - Update IV - Update V)

Of all the posts I wrote this year, the one that produced the most vociferious email backlash -- easily -- was this one from August, which examined substantial evidence showing that, contrary to Obama's occasional public statements in support of a public option, the White House clearly intended from the start that the final health care reform bill would contain no such provision and was actively and privately participating in efforts to shape a final bill without it. From the start, assuaging the health insurance and pharmaceutical industries was a central preoccupation of the White House -- hence the deal negotiated in strict secrecy with Pharma to ban bulk price negotiations and drug reimportation, a blatant violation of both Obama's campaign positions on those issues and his promise to conduct all negotiations out in the open (on C-SPAN). Indeed, Democrats led the way yesterday in killing drug re-importation, which they endlessly claimed to support back when they couldn't pass it. The administration wants not only to prevent industry money from funding an anti-health-care-reform campaign, but also wants to ensure that the Democratic Party -- rather than the GOP -- will continue to be the prime recipient of industry largesse.

As was painfully predictable all along, the final bill will not have any form of public option, nor will it include the wildly popular expansion of Medicare coverage. Obama supporters are eager to depict the White House as nothing more than a helpless victim in all of this -- the President so deeply wanted a more progressive bill but was sadly thwarted in his noble efforts by those inhumane, corrupt Congressional "centrists." Right. The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives. The administration is getting the bill which they, more or less, wanted from the start -- the one that is a huge boon to the health insurance and pharmaceutical industry. And kudos to Russ Feingold for saying so:

Sen. Russ Feingold (D-Wis.), among the most vocal supporters of the public option, said it would be unfair to blame Lieberman for its apparent demise. Feingold said that responsibility ultimately rests with President Barack Obama and he could have insisted on a higher standard for the legislation.

"This bill appears to be legislation that the president wanted in the first place, so I don’t think focusing it on Lieberman really hits the truth," said Feingold. "I think they could have been higher. I certainly think a stronger bill would have been better in every respect."

Let's repeat that: "This bill appears to be legislation that the president wanted in the first place." Indeed it does. There are rational, practical reasons why that might be so. If you're interested in preserving and expanding political power, then, all other things being equal, it's better to have the pharmaceutical and health insurance industry on your side than opposed to you. Or perhaps they calculated from the start that this was the best bill they could get. The wisdom of that rationale can be debated, but depicting Obama as the impotent progressive victim here of recalcitrant, corrupt centrists is really too much to bear.

Yet numerous Obama defenders -- such as Matt Yglesias, Ezra Klein and Steve Benen -- have been insisting that there is just nothing the White House could have done and all of this shows that our political system is tragically "ungovernable." After all, Congress is a separate branch of government, Obama doesn't have a vote, and 60 votes are needed to do anything. How is it his fault if centrist Senators won't support what he wants to do? Apparently, this is the type of conversation we're to believe takes place in the Oval Office:

The President: I really want a public option and Medicare buy-in. What can we do to get it?

Rahm Emanuel: Unfortunately, nothing. We can just sit by and hope, but you're not in Congress any more and you don't have a vote. They're a separate branch of government and we have to respect that.

The President: So we have no role to play in what the Democratic Congress does?

Emanuel: No. Members of Congress make up their own minds and there's just nothing we can do to influence or pressure them.

The President: Gosh, that's too bad. Let's just keep our fingers crossed and see what happens then.

In an ideal world, Congress would be -- and should be -- an autonomous branch of government, exercising judgment independent of the White House's influence, but that's not the world we live in. Does anyone actually believe that Rahm Emanuel (who built his career on industry support for the Party and jamming "centrist" bills through Congress with the support of Blue Dogs) and Barack Obama (who attached himself to Joe Lieberman when arriving in the Senate, repeatedly proved himself receptive to "centrist" compromises, had a campaign funded by corporate interests, and is now the leader of a vast funding and political infrastructure) were the helpless victims of those same forces? Engineering these sorts of "centrist," industry-serving compromises has been the modus operandi of both Obama and, especially, Emanuel.

Indeed, we've seen before what the White House can do -- and does do -- when they actually care about pressuring members of Congress to support something they genuinely want passed. When FDL and other liberal blogs led an effort to defeat Obama's war funding bill back in June, the White House became desperate for votes, and here is what they apparently did (though they deny it):

The White House is playing hardball with Democrats who intend to vote against the supplemental war spending bill, threatening freshmen who oppose it that they won't get help with reelection and will be cut off from the White House, Rep. Lynn Woolsey (D-Calif.) said Friday. "We're not going to help you. You'll never hear from us again," Woolsey said the White House is telling freshmen.

That's what the White House can do when they actually care about pressuring someone to vote the way they want. Why didn't they do any of that to the "centrists" who were supposedly obstructing what they wanted on health care? Why didn't they tell Blanche Lincoln -- in a desperate fight for her political life -- that she would "never hear from them again," and would lose DNC and other Democratic institutional support, if she filibustered the public option? Why haven't they threatened to remove Joe Lieberman's cherished Homeland Security Chairmanship if he's been sabotaging the President's agenda? Why hasn't the President been rhetorically pressuring Senators to support the public option and Medicare buy-in, or taking any of the other steps outlined here by Adam Green? There's no guarantee that it would have worked -- Obama is not omnipotent and he can't always control Congressional outcomes -- but the lack of any such efforts is extremely telling about what the White House really wanted here.

Independent of the reasonable debate over whether this bill is a marginal improvement over the status quo, there are truly horrible elements to it. Two of the most popular provisions (both of which, not coincidentally, were highly adverse to industry interests) -- the public option and Medicare expansion -- are stripped out (a new Washington Post/ABC poll out today shows that the public favors expansion of Medicare to age 55 by a 30-point margin). What remains is a politically distastrous and highly coercive "mandate" gift to the health insurance industry, described perfectly by Digby:

Obama can say that you're getting a lot, but also saying that it "covers everyone," as if there's a big new benefit is a big stretch. Nothing will have changed on that count except changing the law to force people to buy private insurance if they don't get it from their employer. I guess you can call that progressive, but that doesn't make it so. In fact, mandating that all people pay money to a private interest isn't even conservative, free market or otherwise. It's some kind of weird corporatism that's very hard to square with the common good philosophy that Democrats supposedly espouse.

Nobody's "getting covered" here. After all, people are already "free" to buy private insurance and one must assume they have reasons for not doing it already. Whether those reasons are good or bad won't make a difference when they are suddenly forced to write big checks to Aetna or Blue Cross that they previously had decided they couldn't or didn't want to write. Indeed, it actually looks like the worst caricature of liberals: taking people's money against their will, saying it's for their own good --- and doing it without even the cover that FDR wisely insisted upon with social security, by having it withdrawn from paychecks. People don't miss the money as much when they never see it.

In essence, this reinforces all of the worst dynamics of Washington. The insurance industry gets the biggest bonanza imaginable in the form of tens of millions of coerced new customers without any competition or other price controls. Progressive opinion-makers, as always, signaled that they can and should be ignored (don't worry about us -- we're announcing in advance that we'll support whatever you feed us no matter how little it contains of what we want and will never exercise raw political power to get what we want; make sure those other people are happy but ignore us). Most of this was negotiated and effectuated in complete secrecy, in the sleazy sewers populated by lobbyists, industry insiders, and their wholly-owned pawns in the Congress. And highly unpopular, industry-serving legislation is passed off as "centrist," the noblest Beltway value.

Looked at from the narrow lens of health care policy, there is a reasonable debate to be had among reform advocates over whether this bill is a net benefit or a net harm. But the idea that the White House did what it could to ensure the inclusion of progressive provisions -- or that they were powerless to do anything about it -- is absurd on its face. Whatever else is true, the overwhelming evidence points to exactly what Sen. Feingold said yesterday: "This bill appears to be legislation that the president wanted in the first place."

UPDATE: It's also worth noting how completely antithetical claims are advanced to defend and excuse Obama. We've long heard -- from the most blindly loyal cheerleaders and from Emanuel himself -- that progressives should place their trust in the Obama White House to get this done the right way, that he's playing 11-dimensional chess when everyone else is playing checkers, that Obama is the Long Game Master who will always win. Then, when a bad bill is produced, the exact opposite claim is hauled out: it's not his fault because he's totally powerless, has nothing to do with this, and couldn't possibly have altered the outcome. From his defenders, he's instantaneously transformed from 11-dimensional chess Master to impotent, victimized bystander.

The supreme goal is to shield him from all blame. What gets said to accomplish that goal can -- and does -- radically change from day to day.

UPDATE II: I'll be on MSNBC this afternoon at 3:00 p.m. EST with David Schuster/Tamron Hall discussing this post.

UPDATE III: Over at Politico, Jane Hamsher documents how Joe Lieberman's conduct on the health care bill provides the perfect vehicle to advance the agenda of the White House and Harry Reid. Consistent with that, she independently notes media reports that White House officials are privately expressing extreme irritation with Howard Dean for opposing the Senate bill as insufficient, but have nothing bad to say about Lieberman, who supposedly single-handedly sabotaged what the White House was hoping for in this bill.

UPDATE IV: Immediately prior to the MSNBC segment I just did -- video for which I will post when it's available -- an NBC reporter explained how Robert Gibbs used his Press Briefing today to harshly criticize Howard Dean for opposing the health care bill. Why did Gibbs never publicly criticize people like Blanche Lincoln, Ben Nelson, Joe Lieberman and the like if they were supposedly obstructing and impeding the White House's agenda on health care reform (this is a point Yglesias acknowledges as a "fair" one)? Having a Democratic White House publicly criticize a Democratic Senator can be a much more effective pressure tactic than doing so against a former Governor who no longer holds office.

Meanwhile, as one would expect, health insurance stocks are soaring today in response to the industry-serving "health care reform" bill backed by the Democratic Senate and White House -- the same people who began advocating the need for "health care reform" in order to restrain on an out-of-control and profit-inflated health insurance industry (h/t Markos).

UPDATE V: Here's the roughly 4-minute segment I did with David Shuster today

Senate healthcare bill: Time to kill it?

Is reform without public option worth it? Markos, Ezra Klein, Paul Krugman, Howard Dean and others weigh in

Some progressives say that without a public option, it is. Others on the left say any progress is better than none

Thomas Schaller

Dec. 15, 2009

Is the watered-down, no-public-option healthcare reform bill worth saving? Or should it be killed? That is the question on everyone's lips today.

By Twitter, Markos of Daily Kos let it be known where he and many progressives stand on the issue: "Insurance companies win. Time to kill this monstrosity coming out of the Senate."

That specific tweet, and the broad sentiment that underlies it, is generating quite a bit of response. The WaPo's Ezra Klein writes on his blog:

The core of this legislation is as it always was: $900 billion, give or take, so people who can't afford health-care insurance suddenly can. Insurance regulations paired with the individual mandate, so insurers can't discriminate against the sick and the healthy can't make insurance unaffordable by hanging back until the moment they need medical care. The construction of health insurance exchanges so the people currently left out of the employer-based market are better served, and the many who will join them as the employer system continues to erode will have somewhere to go.

That's all policy. And as I spent yesterday arguing, it has a tendency to overshadow the lives in the balance. You can choose your estimate. The Institute of Medicine's methodology says 22,000 people died in 2006 because they didn't have health-care coverage. A recent Harvard study found the number nearer to 45,000. Since we talk about the costs of health-care reform over a 10-year period, may as well talk about the lives saved that way, too. And we're looking, easily, at more than a hundred thousand lives, to say nothing of the people who will be spared bankruptcy, chronic pain, unnecessary impairment, unnecessary caretaking, bereavement, loss of wages, painful surgeries, and so on.

A lot of progressives woke up this morning feeling like they lost. They didn't. The public option and its compromised iterations were a battle that came to seem like a war. But they weren't the war. The bill itself was. When liberals talked about the dream of universal health-care insurance 10, 20 and 30 years ago, they talked about the plight of the uninsured, not the necessity of a limited public option in competition with private insurers.

Salon reached out to others with strong opinions on this issue, and we will be updating this post as reactions come in, so stay tuned.

In contrast to Klein, Stephanie Taylor, co-founder of Progressive Change Campaign Committee, told us:

The "Joe Lieberman Senate Bill" is ugly. Democrats stand on the verge of ushering in a world of nearly unregulated mandates, in which we're all forced by the state to hand over our money to failed private monopolies, with no cost control in return. Without a public option and no hope of expanding Medicare coverage, this bill is not worth supporting.

We got to this point due to a complete failure of leadership by President Obama--who chose to negotiate with out-of-touch senators instead of rallying their own constituents against them. It's also a failure of leadership by Harry Reid, who failed to exert any leverage over Joe Lieberman--by threatening to take away his committee chairmanship or use reconciliation to make his vote irrelevant.

When Democratic leaders refuse to fight, they can't then ask progressives to cave with them. The Progressive Change Campaign Committee is continuing to fight for the best health care bill possible, and we're intent on holding Democrats' feet to the fire. But we need to think very seriously about whether there will be a moment when it is clear that the bill does more harm than good--we need to be prepared to kill the bill.

Part of being a great negotiator is being able to walk away.

Jonathan Cohn, author of Sick and writer for the New Republic, more closely echoed Klein's view:

Is health care reform without a public option still worth passing? Unequivocally, unambiguously yes.

The case for is simple and straightforward: 30 million additional people, maybe more, will have health insurance. Many more who have insurance will see their coverage become more stable. The ability of insurers to exclude people based on pre-existing conditions will diminish significantly, if not disappear. And that's on top of a host of delivery reforms which should, in combination, help make medical care less expensive over time. The bill could be much better, for sure, but to argue that it's worse than nothing you have to make the case that nothing will somehow lead to more progress in some reasonable frame of time.

I don't see that. Failure to pass health reform won't lead to a progressive revival or resurgence. It will cripple the Democrats, hand the Republicans more political power, and likely to send health care reform into hibernation for another ten to twenty years. It's theoretically possible we could get a better reform at that point. But the historical trend is in the opposite direction. Every new effort is a less ambition version of the old one. Meantime, millions of more people would suffer.

Pass this bill now. Improve it later. That's the way we do things in America, for better or for worse.

Sen. Franken Becomes A Cosponsor Of Vitter/Coburn Amendment

Sen. Sherrod Brown (Ohio) said he is trying to co-sponsor the amendment -- but that Coburn and Vitter won't let him. Coburn and Vitter are planning to offer the amendment during the Senate floor debate on healthcare reform."They've not said yes to allow me to be a co-sponsor," Brown told The Hill on Thursday.

First reported by The Hill, GOP Sens. Vitter and Coburn had ignored requests by Sen. Sherrod Brown to become a cosponsor of an amendment forcing members of Congress onto the public option.

The Hill continued:

Sen. Sherrod Brown (Ohio) said he is trying to co-sponsor the amendment -- but that Coburn and Vitter won't let him. Coburn and Vitter are planning to offer the amendment during the Senate floor debate on healthcare reform.

"They've not said yes to allow me to be a co-sponsor," Brown told The Hill on Thursday. "I've called their office four times. I'm proud of the public option, I think it would be great and we ought to join it and show the country how good it is. I think my interest may be more genuine than theirs, but I'd like to work with them if they'll let me. If they just want to score partisan points, I still want to work with them."

Undeterred, Sen. Franken beat them at their own game.

–Media Matters Action Network

America’s Defining Choice

By NICHOLAS D. KRISTOF, NY Times Nov. 12, 2009

President Obama and Congress will soon make defining choices about health care and troops for Afghanistan.

These two choices have something in common — each has a bill of around $100 billion per year. So one question is whether we’re better off spending that money blowing up things in Helmand Province or building up things in America.

The total bill in Afghanistan has been running around $1 million per year per soldier deployed there. That doesn’t include the long-term costs that will be incurred in coming decades — such as disability benefits, or up to $5 million to provide round-the-clock nursing care indefinitely for a single soldier who suffers brain injuries.

So if President Obama dispatches another 30,000 or 40,000 troops, on top of the 68,000 already there, that would bring the total annual bill for our military presence there to perhaps $100 billion — or more. And we haven’t even come to the human costs.

As for health care reforms, the 10-year cost suggests an average of $80 billion to $110 billion per year, depending on what the final bill looks like.

Granted, the health care costs will continue indefinitely, while the United States cannot sustain 100,000 troops in Afghanistan for many years. On the other hand, the health care legislation pays for itself, according to the Congressional Budget Office, while the deployment in Afghanistan is unfinanced and will raise our budget deficits and undermine our long-term economic security.

So doesn’t it seem odd to hear hawks say that health reform is fiscally irresponsible, while in the next breath they cheer a larger deployment of troops in Afghanistan?

Meanwhile, lack of health insurance kills about 45,000 Americans a year, according to a Harvard study released in September. So which is the greater danger to our homeland security, the Taliban or our dysfunctional insurance system?

Who are these Americans who die for lack of insurance? Dr. Linda Harris, an ob-gyn in Oregon tells of Sue, a 31-year-old patient of hers. Sue was a single mom who worked hard — sometimes two jobs at once — to ensure that her beloved daughter would enjoy a better life.

Sue’s jobs never provided health insurance, and Sue felt she couldn’t afford to splurge on herself to get gynecological checkups. For more than a dozen years, she never had a Pap smear, although one is recommended annually. Even when Sue began bleeding and suffering abdominal pain, she was reluctant to see a doctor because she didn’t know how she would pay the bills.

Finally, Sue sought help from a hospital emergency room, and then from the low-cost public clinic where Dr. Harris works. Dr. Harris found that Sue had advanced cervical cancer. Three months later, she died. Her daughter was 13.

“I get teary whenever I think about her,” Dr. Harris said. “It was so needless.”

Cervical cancer has a long preinvasive stage that can be detected with Pap smears, and then effectively treated with relatively minor procedures, Dr. Harris said.

“People talk about waiting lines in Canada,” Dr. Harris added. “I say, well, at least they have a line to wait in.”

Based on the numbers from the Harvard study, a person like Sue dies as a consequence of lack of health care coverage every 12 minutes in America. As many people die every three weeks from lack of health insurance as were killed in the 9/11 attacks.

Health coverage is becoming steadily more precarious as companies try to cut costs and insurance companies boost profits by denying claims and canceling coverage of people who get sick. I grew up on a farm in Yamhill, Ore., where we sometimes had greased pig contests. I’m not sure which is harder: getting a good grip on a greased hog or wrestling with an insurance company trying to avoid paying a claim it should.

Joe Lieberman, a pivotal vote in the Senate, says he recognizes that there are problems and would like reform, but he denounces “another government health insurance entitlement, the government going into the health insurance business.” Look out — it sounds as if Mr. Lieberman is planning to ax Medicare.

The health reform legislation in Congress is imperfect, of course. It won’t do enough to hold down costs; it may restrict access even to private insurance coverage for abortion services; it won’t do enough to address public health or unhealthy lifestyles.

Likewise, troop deployment plans in Afghanistan are imperfect. Some experts think more troops will help. Others think they will foster a nationalist backlash and feed the insurgency (that’s my view).

So where’s the best place to spend $100 billion a year? Is it on patrols in Helmand? Or is it to refurbish our health care system so that people like Sue don’t die unnecessarily every 12 minutes?

•

Health insurers protecting their own paychecks?

I'm startled that any portion of a CEO salary can be subsidized by tax payer dollars, let alone having a debate about whether or not to reduce it by $500k.

Mike Madden, Salon.com, October 16, 2009

WASHINGTON -- You can change the regulations, order them to stop dropping patients from the rolls, even mess with health insurance companies' profit margins. Just don't try to cut the pay of their top executives.

That, at least, seems to be the point of some recent objections reportedly raised by Karen Ignagni, the CEO of America's Health Insurance Plans, to the healthcare reform bill the Senate Finance Committee approved this week. Time's Michael Scherer reports on a phone call between Ignagni, Nancy-Ann DeParle, the White House's top healthcare official, and a senior Senate Finance staffer a few weeks ago. DeParle tells Scherer the health insurance lobbying group was particularly nonplussed by provisions in the legislation that would lower the amount of executive pay that insurance firms can deduct from their taxable corporate income. A Senate source gave Salon the same account of the call.

The insurers had been on board, shakily, with healthcare reform plans all year, but broke with the White House and Democrats in Congress earlier this week by issuing a widely mocked study saying the proposals would actually raise costs. (The accounting firm that wrote the study, PriceWaterhouseCoopers, later put out a statement distancing itself from its own work.)

Might an industry that makes money by refusing to pay for its customers' healthcare have been driven to the split by a more personal form of greed? The provision on pay was added to the legislation by Sen. Blanche Lincoln, D-Ark., during the Finance panel's debate in the last few weeks. It would lower, from $1 million to $500,000, the amount of executive salary that can be written off as a business expense. The effect would be either to raise taxes on insurance companies, by as much as $60 million a year over the next decade, or -- worse! -- force them to cut pay for their executives to avoid the tax hike. A Lincoln aide said "she didn't think it was right" to require millions of Americans to buy health insurance, providing the insurance companies with new revenue, and also continue to give tax breaks for high salaries at the firms.

Ignagni tells Scherer she never raised the issue of executive compensation, in any form, with DeParle. "I'm very sure about having no discussions about executive compensation," she says. "I'm not saying that they are lying. I'm saying that maybe they are mistaken in confusing me with some other person in our industry. But I very clear about what I raised and what I didn't." That doesn't mean, of course, that she's happy about the potential pay cut for her association's members.

White House and Senate staffers will work through the weekend trying to merge the Finance Committee's bill with a more liberal one passed earlier in the year by the Senate Health, Education, Labor and Pensions Committee. Now that the insurers have decided to oppose reform, though, don't expect the merged bill to go particularly easy on them -- or on their executives' paychecks.

― Mike Madden

Baucus earns his healthcare industry funding

Joan Walsh, Salon.com, Tuesday September 29, 2009 18:30 EDT

On "The Ed Show" Monday night I said Montana Sen. Max Baucus had to decide whether he represented Montana or the insurance industry. Tuesday he made his choice, voting against both public option amendments to the healthcare reform bill in the Senate Finance Committee.

All the Democrats who voted against the public option should be ashamed, but Baucus most of all. The Senate Finance Committee chair's reasoning was bizarre. According to Salon's Mike Madden, whose coverage today was terrific, Baucus admitted "the public option would help hold insurance companies' feet to the fire," then added, "But my first job is to get this bill across the finish line."

No, Sen. Baucus. Your first job is voting for what will work to extend healthcare to more Americans and reduce costs. (And Harry Reid, you might want to have a little talk with your boy from Montana, since it's my understanding the Senate majority leader is in charge of getting the bill across the finish line.)

So let's get this straight: Baucus admits the public option would "hold insurance companies' feet to the fire," but he voted against it? Is there any clearer evidence that Baucus is in the pocket of the health insurance industry? Between 2003 and 2008, according to the Washington Post, Baucus took $3 million from the health and insurance sectors, 20 percent of his total contributions. And he collected half of that money in just the last two years, as the committee he chaired began holding hearings on healthcare reform.

It's possible Democrats can't muster the votes, or the procedural savvy, to pass a bill with a public option, even though a majority of senators, and a decisive majority in the House, support it. But we don't know that yet. It's not Baucus' role to prejudge what can or can't ultimately prevail, when the real action is probably going to come in the conference committee that reconciles what the more liberal House passes with what the Senate decides on. In the meantime, the Obama administration will have to leave the political sidelines and decide which arms to twist: Democrats shilling for the insurance industry, or the progressives who've pledged not to vote for a bill without a public option. There's plenty of political drama yet to come, Max. You didn't decide the bill's outcome with your self-contradictory vote today.

The harder I struggled to understand Baucus' nonsensical self-defense, only one meaning seemed possible: Baucus didn't vote against the public option despite the fact that it would "hold insurance companies' feet to the fire," but because it would. His insurance industry contributors got their money's worth today, but the people of Montana did not. Montana is one of the states with the least health-insurance competition -- 75 percent of its residents are covered by Blue Cross-Blue Shield, according to a 2007 American Medical Association report.

The public option isn't dead, no matter how hard Baucus or Democratic disappointments Blanche Lincoln and Kent Conrad fought to kill it on Tuesday. Not coincidentally, the Institute for Southern Studies reports that Conrad's North Dakota and Lincoln's Arkansas are, like Montana, among the worst states for insurance-company concentration, with 89 percent of North Dakotans and 75 percent of Arkansans covered, again, by Blue Cross-Blue Shield. These are the states where competition from the public option is needed the most.

After the Senate Finance Committee voted, the White House issued a statement saying President Obama still believes in the public option. Sen. Tom Harkin told Bill Press on Tuesday that the public option can pass the Senate "by a comfortable margin." I'm not sure that's entirely true, but Harkin is right to push Reid to include the option in the Senate's version of the bill, and force opponents to muster the votes to strip it out. How would Baucus vote, when a majority of Senate Democrats are sure to reject such a move? There's still time for Baucus to serve his constituents, not the insurance industry, but it's a shame he didn't do so on Tuesday.

-- Joan Walsh

Rick Scott profits off the uninsured

A leading foe of healthcare reform owns a chain of clinics aimed at people who would benefit from a public option

-- By Tristram Korten Sep. 30, 2009 Salon.com

For months now multimillionaire healthcare entrepreneur Rick Scott has been at the center of the aggressive campaign to derail healthcare reform in Washington, D.C. Reprising the role he played nearly 20 years ago, when as the head of a national hospital chain he helped kill Clintoncare, the former hospital-chain executive founded the group Conservatives for Patients' Rights, raising $20 million to fight Obamacare, including $5 million of his own money. The tall, lean Scott, whose shiny bald head swivels in exasperation at the idea of government involvement in healthcare, even stars in its nationwide ad campaign comparing Democratic proposals to socialized medicine. Through this group, he has fomented the conservative strategy to disrupt town hall-style healthcare meetings around the country by shouting down elected officials. (CPR sent schedules of the meetings to so-called Tea Party activists.) He can justifiably claim some of the credit for the Senate Finance Committee's two votes Tuesday against a public option. But in Rick Scott the right has found a frontman whose baggage threatens to overwhelm his message.

A linchpin of Scott's 2009 campaign has been the use of anecdotes from abroad -- horror stories from Britain and Canada meant to illustrate how government-controlled healthcare systems "clearly kill people" by controlling their access to care, as he told Fox's Sean Hannity in June. He even funded a documentary titled "Faces of Government Healthcare" cataloging the horror stories of British and Canadian patients who were purportedly denied medical attention for life-threatening illnesses until it was too late.

Yet even as Scott makes the rounds of Congress and talk-show green rooms, a wrongful death lawsuit has been working its way through the Florida courts against a doctor employed by the chain of walk-in clinics Scott founded. Scott has repeatedly bragged that the 27-clinic, Florida-based company, Solantic, is an example of the free-market ingenuity needed to fix our ailing medical infrastructure. The lawsuit, however, alleges a Solantic doctor misdiagnosed a patient's deep-vein thrombosis as a sprained ankle, leading to a pulmonary embolism and death. That same doctor was reprimanded by the state for misdiagnosing deep-vein thrombosis in a patient who died two years earlier. It's the kind of anecdote you'd expect to hear in Scott's documentary -- except that it condemns a free-market system where profit and patient volume may take precedence over care.

And this isn't the first time that Scott's warnings about the ills of socialist medicine have found an ironic echo in his own healthcare business. Scott argues that socialized medicine rations care and strangles competition, yet just after his first stint as anti-reform spokesman in the 1990s, while he was running the world's largest healthcare company, he was accused of monopolizing markets and choking out the competition while slashing the chain's costs to the point that it affected patient care. And while he asserts that two of the core principles of healthcare reform are "accountability" and "personal responsibility," Scott ran a company that ultimately pleaded guilty to defrauding the government in one of the nation's largest Medicare frauds ever. Two executives went to prison, the company paid almost $2 billion in fines, and Scott was pushed out of the company. Before he could retake the political stage, he had to build his healthcare business all over again.

In the end, Scott's virulent opposition to Democratic healthcare proposals may simply be a business decision. The post-millennial incarnation of Rick Scott has plunged into several new healthcare businesses that could be adversely affected by reform. Among other healthcare businesses, Richard L. Scott Investments has invested in a pharmacy company, Pharmaca, where one of his employees sits on the board of directors. Drug manufacturers are opposed to a Medicare-type entity that could negotiate bulk purchases of drugs and drive down the cost of their products. More important, Scott's Solantic bills itself as a low-cost alternative to people who would otherwise go to emergency rooms for their immediate care needs -- i.e., the uninsured and people paying out-of-pocket expenses as a result of diminished insurance plans -- the very people reforms are intended to cover.

Solantic's very existence is an implicit acknowledgment that healthcare costs have not been reined in by free-market forces. Scott himself boasts that a person paying out of pocket will spend at least 10 times less at a Solantic clinic than in a hospital emergency room. That's because hospitals have to charge insured patients a premium to help cover the costs of the uninsured, who often can't pay the full price for medical care, and may skip out on paying altogether. (The Center for American Progress, a liberal think tank that supports a public option in healthcare reform, estimates there is an $1,100 cost shift to family premiums in order to cover the uninsured.) As insurance premiums rise as a result, businesses are turning to higher-deductible plans for their employees, which forces Americans who do have health insurance to pay more in out-of-pocket expenses.

Solantic makes its profit on the spread in this system. "He's there to catch everyone who doesn't have access to regular healthcare," says the Center for American Progress's Igor Volsky. "It's just a business opportunity."

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Richard Lynn Scott was raised in Kansas City, Mo. His father was a truck driver, his mother a department store clerk who sold encyclopedias door-to-door to augment their income. After high school he joined the Navy, then attended the University of Missouri, while working full-time at a grocery store. It was also during college that he exhibited his entrepreneurial drive, buying two doughnut shops for his mother to manage. Ultimately, he decided to become a lawyer, and attended the law school at Southern Methodist University in Dallas, staying in town afterward to practice at a large firm, Johnson & Swanson, where he represented hospitals in mergers and acquisitions. It's there that he began to see healthcare in terms of its business components and profit potential.

He had no medical background and never operated a hospital or ran a clinic, but at some point decided he wanted to own hospitals. In 1987 Scott made a failed bid on behalf of some investors to buy the Hospital Corporation of America, a hospital chain founded by members of the Frist family, including Dr. Thomas Frist Sr., the father of then-U.S. Sen. Bill Frist. But the Frists rejected the offer. The move, however, brought him to the attention of Richard Rainwater, a politically connected investor with ties to the Bush family. Rainwater had made a fortune investing for the wealthy, including George W. Bush. At one point Rainwater, who owned a big chunk of the Texas Rangers and brought Bush in as the team's managing partner, brought in Scott as an investor in the team as well.

In 1987 Rainwater and Scott partnered, and with the initial purchase of two hospitals in El Paso, Texas, formed the Columbia Healthcare Corp. They took their company public and used the money to buy hospitals at a fast clip, focusing on dominating specific markets by buying several hospitals in a region and closing the poor-performing ones. They slashed costs, cutting jobs and hours, and bought bulk supplies at discount. Wall Street rewarded them. By 1994 they had enough capital to buy Scott's original target, HCA. The combined company, rechristened Columbia/HCA, would grow to more than 340 hospitals, 135 surgery centers, 550 home health locations in 37 states and two foreign countries, making it the largest healthcare company in the world. Scott moved to HCA's corporate headquarters in Nashville, Tenn., as CEO.

Although Scott, through Rainwater, hobnobbed with politicos, he was not known as a political animal. He was a workaholic. His political contributions in those days were to trade groups like the Federation of American Health Systems, and to people associated with his business, like Bill Frist's Senate campaign. "I do not recall that he was a major political player back in either the '80s or early '90s, even though he had these connections to Bush through Rainwater," says R.G. Ratcliffe, a veteran political reporter for the Houston Chronicle, who has covered Texas politics, and Rainwater, for 30 years.

Scott himself was an unassuming man, even as his company made financial news across the country. Maggie Mahar, a journalist for the business magazine Barron's in those days, flew down to meet Scott in order to write a profile, but found a man so undynamic she had to change the focus of her story. "He was supposed to be a new up-and-comer, and I just didn't get it," she recalls. "Usually someone who runs a large corporation has a large personality, if not intelligence. With Scott there just wasn't enough there, so I wrote about whether tax breaks for nonprofit hospitals were unfair to for-profit hospitals."

Yet when the Clinton White House began aggressively pushing healthcare reforms, it was Scott who took up the role as frontman for his company, voicing opposition to industry groups and the media. "What's happening in Washington is not healthcare reform," he was quoted in the New York Times as saying to a group of Tampa hospital executives in 1994. "Healthcare reform is happening in the market place." Many suspect he was urged to do this by the Frists, who still retained much control of the company.

The Center for American Progress put together a video montage showing that Scott's talking points today are almost exactly the same as they were in 1993 and 1994. He was at the top of his game then, a man Time magazine praised in 1996 as one of the 25 most influential Americans, alongside Jerry Seinfeld and Sandra Day O'Connor. "In an industry notorious for waste and inefficiency, Scott aggressively consolidates operations and imposes cost controls," Time lauded in its article. One of the examples Time cited was Scott and Rainwater's investment in the two El Paso hospitals, followed by the purchase of a third nearby, which they promptly closed to drive up revenue at the other two.

Others were not so smitten. Journalist Mahar studied Columbia/HCA's business model for her book "Money-Driven Medicine: The Real Reason Healthcare Costs So Much." Hospitals were traditionally seen as a nonprofit business because they provide an essential service to society, Mahar explains. "Hospitals are a necessity like gas and electricity," she says. "We regulate those industries. We don't allow prices to skyrocket. The same thing in healthcare. We don't want hospitals gouging sick people." But in the 1980s, she says, ambitious investors began to see healthcare as a way to make money. Chief among them was Scott.

"What Rick Scott wanted, and his shareholders wanted, was for healthcare to be a growth industry where revenues go up every year," says Mahar, now a fellow at the public-policy think tank the Century Foundation. "I think it's basically impossible to achieve the level of profitability they wanted in the hospital business. You can't expect double-digit profits from a hospital. It's a very tough business. You need a lot of people. You need a good nurse-to-patient ratio to keep patients comfortable and respond to emergencies. And it's unpredictable; you don't know how many patients on a night shift are going to get sick. So you can't trim down to the bone. When you do, people die."

Columbia/HCA regularly posted double-digit growth that paid big dividends to shareholders. BusinessWeek recognized it as one of the 50 best-performing companies on the S&P 500. But in her book Mahar cites examples of how the cost cutting at Columbia/HCA impacted care. One technician complained of having to watch 72 heart monitors at one time. Nurses at an Indianapolis hospital complained to state authorities that babies in the neonatal unit were left unattended for up to three hours. In one case a nurse caring for seven infants was so busy she failed to hear an alarm when a baby stopped breathing; the child was saved when a parent rushed in. The state fined the hospital.

Other, bigger problems were looming. In the mid-1990s, aided by a former accountant who became a whistle-blower, the feds opened an investigation into suspicions that Columbia/HCA hospitals were routinely defrauding the government by inflating the expenses of procedures billed to Medicare, and paying illegal kickbacks to doctors who steered patients to Columbia/HCA hospitals. In July 1997, a year after Time's coronation, federal agents raided Columbia/HCA hospitals in more than half a dozen states, and carted away reams of paperwork. Some hospitals were discovered to have two sets of books, one reflecting the true costs for procedures and another with inflated expenses charged to Medicare. Four executives were indicted; two were found guilty and sent to prison. Rather than continue to fight the government, company executives decided to have Columbia/HCA plead guilty to 14 felonies. The hospital giant ended up paying $1.7 billion in fines and settlements.

Scott was not indicted in the scandal and has protested that he never condoned any illegal activity. He has asserted that federal agents never even interviewed him. But Columbia/HCA's board found him an unpleasant symbol of the problem and voted to oust Scott almost immediately after the scandal erupted in 1997, paying him a $9.88 million severance package, along with 10 million shares of stock worth up to $300 million at the time, to walk away.

Mahar lays much of the blame for Columbia/HCA's illegal acts at Scott's feet. He cultivated a corporate culture where profit was the most important thing, and, as she put it in her book, "executive salaries hinged not on such criteria as reducing infections or lowering death rates, but on meeting financial targets like 'growth in admissions and surgery cases.'"

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Scott was stung by his fall. He retreated into finance, starting the investment firm Richard L. Scott Investments in Connecticut, that bought stakes in a variety of industries, including a TV network devoted to health news (later acquired by Fox) and a computer security firm. But he clearly wanted to reestablish himself as a healthcare player.

A few years after his HCA ouster he got his chance when he and a former Columbia/HCA marketing executive named Karen Bowling conceived of a chain of urgent-care clinics. They collaborated on a business plan for a company that would provide a retail experience not unlike Starbucks or McDonald's -- convenient, affordable, with a focus on "customer satisfaction." In 2001 Scott funded it. The company, based in Jacksonville, Fla., was formed as a service to people who would otherwise visit overburdened emergency rooms with relatively routine problems, such as broken bones, sprains and minor infections, to patients who need to see their primary care doctor for matters such as immunizations and physicals but would have to wait days or even weeks for an appointment. The clinics were designed to be open 12 hours a day, seven days a week. Today, there are 27 Solantic clinics, all in Florida.

Karen Bowling is a cheery former Jacksonville TV reporter. She began working for Scott in the late 1980s when Columbia/HCA gobbled up the Jacksonville hospital where she was the marketing director. She has been a faithful Scott ally ever since, even leaving her job with Columbia/HCA when Scott was ousted. She worked for various of his companies before starting Solantic. "We both really believed healthcare should be more convenient for patients," Bowling says.

Bowling insists the majority of clients are insured, and just want the no-wait convenience of a Solantic clinic. But Scott's repeated emphasis on the cost savings for those paying cash implies the company sees the uninsured as a market to be tapped. "We're probably one-tenth to one-fifteenth the cost if you're just writing a check and going to the E.R.," he boasted to Texas Rep. Michael Burgess in a made-for-YouTube interview the congressman shot. And most press reports identify Solantic as targeting the uninsured. The New York Times described Solantic as a "chain of urgent care clinics which Mr. Scott promotes as inexpensive alternatives to emergency rooms, especially for the uninsured." And why not? With an estimated 45 million to 47 million Americans without health insurance right now, it would seem a smart business move. But just as happened with his first healthcare empire, Scott's newest business raises questions about the compatibility of a corporate bottom line with quality patient care.

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One of Scott and Bowling's initial hires at Solantic was Dr. David Yarian, the company's first regional medical director. His job was to create the clinical design for the urgent-care centers. Yarian lasted roughly five months. He clashed repeatedly with Scott over hiring practices. They also had philosophical differences about how to set up the clinics. Solantic initially designed them so that there would be one doctor and one physician's assistant on staff for 12-hour shifts to meet a steady stream of patients, Yarian says.

"The whole design was for people to get in and out quickly," Yarian says. "I believe the target was 50 patients a day based on a 12-hour day. But no clinic works that way, especially urgent-care clinics where people don't make appointments." The business is too unpredictable. "But Rick and Karen had never run a clinic. He wanted to turn it into a McDonald's. His whole point was volume and speed."

Yarian knew about Scott's past, and he worried that Scott was emphasizing profits over patients again.

"It was made very clear to me this was a numbers game," Yarian says. "The doctors were going to be evaluated on the number of patients they saw. This is exactly what happened at his hospitals."

After one clash too many, Scott and Bowling fired Yarian in November of 2001. Yarian sued for breach of contract and ended up settling with the company.

Scott, in a statement to Salon, declined to address Yarian's criticisms and dismissed him as a "disgruntled employee."

In 2004, three years after Yarian's brief tenure, Solantic hired Dr. Nadeem Maalouli as one of the doctors for its Orange Park clinic just outside Jacksonville. It's not clear if the company knew it at the time of his hire, but Maalouli was being investigated by state health officials for a botched diagnosis. In September 2002 Maalouli was working in a hospital emergency room when he treated a 32-year-old woman complaining of shortness of breath, chest pain and possibly blood-tinged sputum, according to a complaint by the Florida Department of Health. But after Maalouli examined her, the complaint states, he found her "normal." In fact, Maalouli had failed to detect the woman's deep vein thrombosis (DVT). Four days later the woman suffered a pulmonary embolism and died. In 2007 the state's Board of Medicine ultimately ruled that Maalouli's failure to detect the DVT had violated medical standards and reprimanded him. Maalouli agreed to pay a $15,000 fine and to take a continuing education course in detecting pulmonary embolisms.

That case was winding its way through the state's bureaucracy when Maalouli started at Solantic. (Maalouli through his lawyers declined to comment for this article). Then, on March 16, 2005, Tanieta Ogden Shuler, a 31-year-old Jacksonville woman, limped into his clinic, according to information taken from court and medical records. It was around 8 p.m., right before closing, and Shuler complained of a pain shooting from her right heel up the back of her leg. Dr. Maalouli, who was finishing a 12-hour shift, examined Shuler and diagnosed a sprained ankle. He recommended she keep her foot elevated, treat it with ice, and use crutches for the time being. Then he prescribed Motrin 800 and Darvocet for the pain.

Six days later Shuler followed up with a podiatrist who recommended an MRI to see why the pain was persisting, a task Shuler put off. The next day, at about 7 p.m. on March 29, Shuler was rushed to the emergency room at Memorial Medical Center, where she died. An autopsy revealed that Shuler suffered from DVT in her leg, which caused a pulmonary embolism.

In their lawsuit, Shuler's family asserts that Maalouli's examination fell below the accepted standard of care because he didn't send her off to get a sonogram or other tests to double-check his assessment (the clinics don't have sonograms). Maalouli's and Solantic's lawyers dispute that, saying all indications pointed to a sprained ankle, and that it's likely Shuler didn't even have the DVT when she came in to be examined.

Questions likely to come up at trial include whether the company's supposed emphasis on numbers pushed Dr. Maalouli to see Shuler as the clinic was closing, after he had worked a 12-hour shift, and whether Maalouli did not send her off for further tests because he might have lost a client to another facility.

Bowling declined to comment on this case because it is still in the court system. "It's important to say it hasn't gone to trial and it's outcome hasn't been determined yet," she says.

And of course, one wrongful death case, amid the 1.7 million visits to Solantic's 27 clinics, according to company statistics (counting multiple visits by the same patient), is not a condemnation of the entire business model. But it is an uncomfortable fact for Scott to deal with as he travels the world cherry-picking horror stories from countries that use government run systems.

After all, a doctor at a for-profit clinic that relies on high patient turnover, who is called to account for two alleged misdiagnoses ending in two deaths, is right up there with the examples from Scott's documentary -- the English woman denied routine pap smears for two years until she was diagnosed with fatal cervical cancer, or the Canadian man who had to wait 20 months for an appointment regarding his heart arrhythmia, and finally came to the U.S. for treatment.

Aside from the paradox the wrongful death suit puts Scott's example-rich campaign against socialized medicine in, it also counters his boast that Solantic is the kind of free-market exemplar that can fix our healthcare industry. Urgent care clinics provide a service, but only for the most uncomplicated procedures. Doctors don't review a patient's past medical history. There is no ongoing primary care offered. They have limited testing abilities. Other than X-ray machines the facilities don't have any advanced equipment. This is not the solution for the nation's uninsured.

"For very limited things it could work," says author Mahar. "But one problem with this transparent pricing is that if I go in with a terrible stomach pain, no one knows where this is in the price plan until they start examining me. How can they possibly tell me when I stagger in how much it will cost to treat me? Even something as simple as a headache, well I could have a tumor. Basically healthcare is not a commodity that can be neatly priced."

Even Bowling concedes it is no replacement for ongoing care from a physician. "I think people should rely on us for episodic care," Bowling explains. "As a policy we refuse patient requests to be the primary care physicians."

And Rick Scott has never proposed his own full-length healthcare plan, though he has ventured a few specific proposals -- transparent pricing by insurance companies and standardized forms for insurance submissions. Mostly, Scott knows what he's against.

Solantic's target customers -- not only the uninsured, but the self-employed, and small businesses seeking to provide insurance to employees -- are the ones advocates say would benefit most from some kind of affordable healthcare option, even if it was provided by the government. Reforms that would make sure every American had access to affordable health insurance might put Solantic's business plan in jeopardy, giving Scott incentive to gum up the works. "I think those kinds of clinics will become less popular as everyone becomes insured," notes the Center for American Progress's Volsky.

It was only after founding Solantic that Scott began to invest heavily in politics again. He moved from Connecticut to Naples, Fla., along with the bulk of his investment company, and became increasingly active in Republican activities. From 2004 through 2009, he has given $67,000 to Republican candidates and organizations, according to the Federal Election Commission, including $25,000 to the Republican National Committee in 2004, and another $28,000 in 2008.

Then, in February 2009, after the Obama administration announced that reforming healthcare was a priority, but before any concrete plans were announced, Scott reclaimed his mid-'90s soapbox. He charged in with his money and organizational support and helped the diminished GOP galvanize the anti-reform cause, quickly emerging as perhaps the most vocal and prominent conservative voice on the issue. He launched Conservatives for Patients' Rights, which promotes what it sees as the four pillars of healthcare reform -- choice, competition, accountability and personal responsibility. He chose to become its spokesman, appearing in a series of ads put together by Creative Response Concepts, the P.R. firm involved in the Swift Boat Veterans for Truth campaign to discredit Sen. John Kerry's presidential bid. The healthcare ads have aired on CNN and Fox, as well as the Web site Politico.com, and he has penned opinion pieces on RealClearPolitics.com.

In mid-July Scott's group organized a conference call with 104 conservative leaders, plotting a strategy to drag out the healthcare debate in Congress until they have enough popular momentum against reform. Participants in the meeting came out energized. "This healthcare issue is D-Day for freedom in America," South Carolina Sen. Jim DeMint was quoted in Politico.com as saying. "If we're able to stop Obama on this it will be his Waterloo. It will break him."

For Scott that would no doubt be good for business.

Cantor To Uninsured Woman With Growing Tumors: Get ‘An Existing Government Program’ Or Find Charity

From Think Progress

At the Richmond Times-Dispatch “public square” forum yesterday, Rep. Eric Cantor (R-VA) fielded open questions from his constituents on the health reform debate for the first time this summer.

Patricia Churchill relayed a story about a close family member who recently lost a high paying job and her health insurance. Churchill told Cantor that her relative was dying of stomach tumors and needs an operation as soon as possible. Cantor responded by suggesting that Churchill’s relative should seek “existing government programs” or find charity.

Cantor, who serves as the chief whip for his party, has said that he cannot support a health reform bill with a public option. But despite his political opposition to government insurance programs, Cantor then emphasized to Churchill that every American should be given an “option” for health care, including a government program:

CHURCHILL: I have a very close relative, a woman in her early forties, who did have a wonderful, high-paying job, owns her own home and is a real contributing member of society. She lost her job. Just a couple of weeks ago, she found out that she has tumors in her belly and that she needs an operation. Her doctors told her that they are growing and that she needs to get this operation quickly. She has no insurance. [...]

CANTOR: First of all I guess I would ask what the situation is in terms of income eligibility and the existing programs that are out there. Because if we look at the uninsured that are out there right now, there is probably 23, 24% of the uninsured that is already eligible for an existing government program [...] Beyond that, I know that there are programs, there are charitable organizations, there are hospitals here who do provide charity care if there’s an instance of indigency and the individual is not eligible for existing programs that there can be some cooperative effort. No one in this country, given who we are, should be sitting without an option to be addressed.

In an interview with ThinkProgress after the event, Churchill explained that her relative, who needs help now, probably won’t qualify for a low-income government program like Medicaid and that there are very long waiting periods for charity programs. Asked about Cantor’s response to her question, Churchill said, “it was helpful in a sense, but of course nowhere near as helpful as having this healthcare reform bill passed so that we could know that she could definitely go and get taken care of.”

Today, Cantor called for “scrapping” President Obama’s proposed public option insurance program

Cantor to Uninsured Woman: Get a Government Option or Public Charity

The Numbers and Health Care Reform

NY Times Editorial, Sept. 22

Two authoritative surveys in recent days have underscored why all Americans have a stake in successful health care reform. Too many people are being hit with relentlessly rising premiums or are at serious risk of losing their coverage to allow the status quo to continue.

A survey by the Kaiser Family Foundation found that, once again, health insurance premiums rose faster last year than either wages or general inflation. A study by the Treasury Department found that almost half of all Americans below Medicare age have gone without insurance at some point over the last decade.

The Kaiser study, conducted jointly with the Health Research and Education Trust, an affiliate of the American Hospital Association, found that the average premium for a family policy offered at work rose above $13,300 in 2009 — up from $5,800 in 1999. The average employer paid more than $9,800 of that, while the workers contributed more than $3,500. The workers were also hit with larger co-payments and deductibles, while their policies often offered fewer benefits.

The premium increase this year was a relatively modest 5 percent, far below the 13 percent rate in two previous years. But that still far outpaced a 3.1 percent growth in wages and a small decrease in inflation. Absent meaningful reform, worse is sure to come.

Kaiser estimates that, if increases revert to the average of the last 10 years, health insurance premiums in 2019 will average a whopping $30,800, which it calls “a very scary number.” More immediately, a fifth of the employers surveyed said they are very likely to increase the amount that employees pay for premiums next year.

Meanwhile, the Treasury Department’s study highlighted how vulnerable Americans are to losing their coverage.

It found that, between 1997 and 2006, 48 percent of nonelderly Americans went without health insurance for at least one month, 41 percent lacked coverage for at least six months and 36 percent were uncovered for a year or more. That happened during a decade of strong economic growth. The number of uninsured is likely to be higher over the next decade, the study warns.

The argument for reform seems clear. Americans without insurance need guaranteed access to coverage. Those with insurance need a guarantee that they will not be dropped by their insurers and will be able to buy an affordable policy if their employers decide to drop coverage. And ways must be found to slow the rise in health care costs and ease the burden of paying for insurance.

Poll Finds Most Doctors Support Public Option

by Joseph Shapiro
September 14, 2009 , NPR

Among all the players in the health care debate, doctors may be the least understood about where they stand on some of the key issues around changing the health care system. Now, a new survey finds some surprising results: A large majority of doctors say there should be a public option.

When polled, "nearly three-quarters of physicians supported some form of a public option, either alone or in combination with private insurance options," says Dr. Salomeh Keyhani. She and Dr. Alex Federman, both internists and researchers at Mount Sinai School of Medicine in New York, conducted a random survey, by mail and by phone, of 2,130 doctors. They surveyed them from June right up to early September.

Most doctors — 63 percent — say they favor giving patients a choice that would include both public and private insurance. That's the position of President Obama and of many congressional Democrats. In addition, another 10 percent of doctors say they favor a public option only; they'd like to see a single-payer health care system. Together, the two groups add up to 73 percent.

When the American public is polled, anywhere from 50 to 70 percent favor a public option. So that means that when compared to their patients, doctors are bigger supporters of a public option.

Doctors' Support For Public Option 'Broad And Widespread'

Enlarge Mario Tama/Getty ImagesDoctors and other supporters of health care overhaul attend a candlelight vigil in New York City in September 2009. The gathering was one of hundreds nationwide honoring those suffering under the current health care system.

Mario Tama/Getty ImagesDoctors and other supporters of health care overhaul attend a candlelight vigil in New York City in September 2009. The gathering was one of hundreds nationwide honoring those suffering under the current health care system.
The researchers say they found strong support for a public option among all categories of doctors. "We even saw that support being the same whether physicians lived in rural areas or metropolitan areas," says Federman.

"Whether they lived in southern regions of the United States or traditionally liberal parts of the country," says Keyhani, "we found that physicians, regardless — whether they were salaried or they were practice owners, regardless of whether they were specialists or primary care providers, regardless of where they lived — the support for the public option was broad and widespread."

Keyhani says doctors already have experience with government-run health care, with Medicare. And she says the survey shows that, overall, they like it. "We've heard a lot about how the government is standing in between patients and their physician," Keyhani says. "And what we can see is that physicians support Medicare. So I think physicians have sort of signaled that a public option that's similar in design to Medicare would be a good way of ensuring patients get the care that they need."

The survey was published online Monday by the New England Journal of Medicine. It was funded by the Robert Wood Johnson Foundation, a health care research organization that favors health reform.

AMA Doctors Also Support Public Option

The survey even found widespread support for a public option among doctors who are members of the American Medical Association, a group that's opposed to it. The AMA fears a public option eventually could lead to government putting more limits on doctors' fees.

"The American Medical Association has traditionally been probably the loudest voice for physicians across the United States," says Federman. "And part of our reason for doing this research was really to get at the real voice of physicians as opposed to the voice of one physician organization."

Keyhani and Federman belong to another, smaller group, the National Physicians Alliance. It supports a public option, and Keyhani has spoken publicly about her own support for a public option.

What Would A Public Option Look Like?

It's hard to know for sure what doctors mean when they speak about a public option, says Dr. James Rohack, president of the AMA.

"Because when I say public option, or you say public option, it means different things to different people, kind of like the Rorschach ink blot test — when you look at it, to some people it means one thing, to other people it means the other thing."

Politicians in Washington turn to the AMA for support and guidance, even though fewer than a third of practicing doctors belong to the lobbying group.

The AMA's own position on a health overhaul has, at times, been hard to pinpoint. In July, it praised the bill that came out of the House of Representatives. That bill included a public option. But the AMA made it clear that what it really liked was that it eliminated cuts in doctors' fees from Medicare.

"And so I think that's why we need to be very clear about what does the AMA articulate for," says Rohack. "It's to make sure that everyone has coverage that's affordable, that's portable and that is quality — that is, it covers the things you need to cover because you've got a medical condition or developed a medical illness."