Key Senate Democrats push for health care public option

Washington (CNN) -- The fight over health care reform burst back into public view Tuesday as four Democratic senators asked Senate Majority Leader Harry Reid to hold a vote on a government-run public insurance option.

Most observers have considered the public option -- an idea long favored by liberal Democrats -- to be a non-starter since it was dropped from a Senate reform bill passed in December. But Sens. Michael Bennet of Colorado, Kirsten Gillibrand of New York, Jeff Merkley of Oregon, and Sherrod Brown of Ohio signed a letter urging Reid, D-Nevada, to hold a vote on the proposal under a rule known as a reconciliation, which would allow the measure to pass with only 51 votes -- a simple majority.

The letter was co-signed by 119 Democrats in the House of Representatives.

Liberal groups MoveOn.org, the Progressive Change Campaign Committee, Democracy for America, and Credo Action are pushing other Democratic senators to sign the letter as well.

Health care reform has long been considered President Obama's top domestic priority. Democrats, however, have been struggling to reach agreement on how best to pass a bill since Massachusetts GOP Sen. Scott Brown's upset victory last month in the race to fill the seat formerly held by Sen. Ted Kennedy.

Brown's win stripped Democrats of their 60-seat Senate supermajority and gave Republicans enough votes to block most legislation.

"We respectfully ask that you bring for a vote before the full Senate a public health insurance option under budget reconciliation rules," the letter states.

"There are four fundamental reasons why we support this approach -- its potential for billions of dollars in cost savings; the growing need to increase competition and lower costs for the consumer; the history of using reconciliation for significant pieces of health care legislation; and the continued public support for a public option."

Use of reconciliation is limited to legislation affecting the budget and therefore could apply only to certain elements of the health care reform agenda.

Senate Finance Committee Chairman Max Baucus, D-Montana, told CNN in January that he thinks reconciliation will ultimately be necessary to pass a health care bill in the chamber. However, multiple Democratic aides have warned that using the controversial maneuver would take time and evoke criticism of relying on a procedural trick to pass a bill.

"It looks too partisan," said Rep. Gerry Connolly, a freshman Democrat from Virginia. Democratic Rep. Earl Pomeroy of North Dakota likened the move to "legislative trickery."

Proponents argue there is a precedent for using reconciliation, noting that it was recently used to pass measures such as an expansion of the Children's Health Insurance Program.

A number of conservative Democrats are urging Obama to craft a more narrowly tailored health care bill -- excluding a public option -- that can win at least some bipartisan support. Increasingly frustrated liberals argue it is pointless to pursue negotiations with what they characterize as an ideologically rigid GOP minority determined to block every White House initiative for short-term political gain.

Obama is scheduled to hold a televised health care summit with Republican leaders on February 25. The president has said the talks should involve true give-and-take negotiations as opposed to mere "political theater."

Obama said last week he wants the meeting -- which also will include health care experts -- to "establish some common facts" on the health care issue and reach agreement on the most pressing health care problems facing the country.

To signal his willingness to compromise, Obama said he would consider a Republican push to include limits on medical malpractice lawsuits in a health care bill if the proposal can be shown to truly reduce overall health care costs.

However, Obama said bipartisanship on health care reform cannot mean only that "Democrats give up everything they believe in."

"Bipartisanship depends on a willingness among both Democrats and Republicans to put aside matters of party for the good of the country," he said.

Obama has not yet given any public indication he is prepared to make a renewed push for a public option.

GOP congressional leaders have repeatedly said health care legislation already passed by the Senate and the House of Representatives should be completely scrapped.

"What we need to do is start over, go step-by-step on a truly bipartisan basis to try to reach an agreement," Senate Minority Leader Mitch McConnell, R-Kentucky, recently told reporters.

"My members are open to doing that."

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Democrats say agree to conservatives' healthcare plans

House of Representatives' Energy and Commerce Committee chairman Henry Waxman said on Friday the Democratic-led panel will accept changes to healthcare legislation sought by fiscal conservatives in their party, signaling probable passage of the bill by the panel.

Representative Jane Harman, a member of the fiscal conservative group, said the bill will include "a robust public option" for a government-run healthcare plan and will include extra savings from the pharmaceutical industry.

Rep. Lois Capps told reporters "insurance companies will be held accountable in the bill."

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AMA backs House health-care bill

In what appears to be a pretty significant development in the fight over health care, the American Medical Association has written House Ways and Means Committee Chairman Charlie Rangel a letter supporting the $1 trillion-plus Democratic House health-care bill.

"On behalf of the Board of Trustees of the American Medical Association, I am writing to express our appreciation and support for H.R. 3200, the 'America's Affordable Health Choices Act of 2009,'" says Dr. Michael Maves, the AMA's executive vice president and CEO.

"This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform. We urge members of the House Education and Labor, Energy and Commerce, and Ways and Means Committees to favorably report H.R. 3200 for consideration by the full House."

Maves concludes, "The AMA looks forward to further constructive dialogue during the committee mark-up process. We pledge to work with the House committees and leadership to build support for passage of health reform legislation to expand access to high quality, affordable health care for all Americans."

Below is the full letter....

July 16, 2009
The Honorable Charles B. Rangel
Chairman, Committee on Ways and Means
U.S. House of Representatives
1102 Longworth House Office Building
Washington, DC 20515

Dear Chairman Rangel:

On behalf of the Board of Trustees of the American Medical Association, I am writing to express our appreciation and support for H.R. 3200, the "America's Affordable Health Choices Act of 2009." This legislation includes a broad range of provisions that are key to effective, comprehensive health system reform. We urge members of the House Education and Labor, Energy and Commerce, and Ways and Means Committees to favorably report H.R. 3200 for consideration by the full House.

In particular, we are pleased that the bill:
• Promises to extend coverage to all Americans through health insurance market reforms;
• Provides consumers with a choice of plans through a health insurance exchange;
• Includes essential health insurance reforms such as eliminating coverage denials based on pre-existing conditions;
• Recognizes that fundamental Medicare reforms, including repeal of the sustainable growth rate formula, are essential to the success of broader health system reforms;
• Encourages chronic disease management and care coordination through additional funding for primary care services, without imposing offsetting payment reductions on specialty care;
• Addresses growing physician workforce concerns;
• Strengthens the Medicaid program;
• Requires individuals to have health insurance, and provides premium assistance to those who cannot afford it;
• Includes prevention and wellness initiatives designed to keep Americans healthy;
• Makes needed improvements to the Physician Quality Reporting Initiative that will enable greater participation by physicians; and
• Initiates significant payment and delivery reforms by encouraging participation in new models such as accountable care organizations and the patient-centered medical home.

The AMA looks forward to further constructive dialogue during the committee mark-up process. We pledge to work with the House committees and leadership to build support for passage of health reform legislation to expand access to high quality, affordable health care for all Americans.

This year, the AMA wants the debate in Washington to conclude with real, long overdue results that will improve the health of America's patients.

Sincerely,
Michael D. Maves, MD, MBA

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The next chapter in healthcare reform

MASSACHUSETTS is about to write the next chapter of healthcare reform.

We have achieved near-universal access, which was the first step toward better health for citizens. The next steps are ensuring quality and managing the cost of care to sustainable levels. The leaders who facilitated the beginning of the journey understood that reform would have to be staged. Taking that first step was hard. The next steps will be even harder.

Healthcare costs are rapidly depleting state coffers and straining private employers’ ability to provide health insurance to employees. The current rate of spending is unsustainable.

The Payment Reform Commission issued its recommendations yesterday and called for the use of global payments. Global payments are a move away from the current fee-for-service - with its constant possibility of overuse or misuse of resources because providers can be paid more by ordering more visits and procedures - and toward giving providers adequate resources to care for “the whole patient.’’ The new system should include quality measures that give patients confidence that decisions made about their care are patient-focused and not driven by the desire to save money at the expense of their health. It is critical, in fact, to create a link between quality and payment.

We have great faith in the possibilities of global payments combined with quality measures. Atrius Health, an alliance of Dedham Medical Associates, Granite Medical, Harvard Vanguard Medical Associates, South Shore Medical Center, and Southboro Medical Group, has years of experience with the benefits that global payments offer for patients. We know that global payments can help providers better allocate limited resources toward care that will ensure the best health outcomes. A well-designed system based on global payment will put primary-care physicians at the heart of healthcare, coordinating care for the patient.

We agree with the Payment Reform Commission’s conclusion that as our physicians acquire the tools and skills needed to accept global payment, we will get closer to reaching universal access to high-quality affordable healthcare.

What made the first step in health reform possible was that all the stakeholders were willing to work together, even though they didn’t always agree. This willingness to work together will continue to be critical because achieving true reform is never easy and requires everyone to make sacrifices.

The Payment Reform Commission has taken a bold step forward, but there remains more work to do. Many details will be left to a new board that will undoubtedly be the subject of heated debate. The board will oversee formation of “Accountable Care Organizations,’’ which will be at the heart of payment reform. Who gets to form an Accountable Care Organization will be critical because the organization will control the distribution of the global payments.

As a provider with a long history of working with global payments, Atrius Health is one model. Undoubtedly there are others.

For payment reform to succeed, there are certain requirements. There needs to be a way to connect patients to primary-care physicians so that payment is made to the organization providing the care. Optimal Accountable Care Organizations will need to have a scale large enough to accept the risk of providing care on a fixed budget and the expertise and infrastructure to manage risk. Smaller physician offices will need to partner with other groups or hospitals. An electronic medical record, access to claims data, and the ability to analyze the data are important to ensure quality outcomes while managing cost. Global payment will be more successful if all physicians have access to services that support great care, such as pharmacists, case managers, and nursing.

The work of those who led the Commonwealth to take its first step has given it the opportunity to envision and create its own future, to improve the quality of care for its citizens, and to reduce the rate of growth of health costs. Now we all need to embrace the change and help others move toward it.

Gene Lindsey is president and CEO of Atrius Health.

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Health Care Showdown

NY Times
June 22, 2009
Op-Ed Columnist
By PAUL KRUGMAN
America’s political scene has changed immensely since the last time a Democratic president tried to reform health care. So has the health care picture: with costs soaring and insurance dwindling, nobody can now say with a straight face that the U.S. health care system is O.K. And if surveys like the New York Times/CBS News poll released last weekend are any indication, voters are ready for major change.

The question now is whether we will nonetheless fail to get that change, because a handful of Democratic senators are still determined to party like it’s 1993.

And yes, I mean Democratic senators. The Republicans, with a few possible exceptions, have decided to do all they can to make the Obama administration a failure. Their role in the health care debate is purely that of spoilers who keep shouting the old slogans — Government-run health care! Socialism! Europe! — hoping that someone still cares.

The polls suggest that hardly anyone does. Voters, it seems, strongly favor a universal guarantee of coverage, and they mostly accept the idea that higher taxes may be needed to achieve that guarantee. What’s more, they overwhelmingly favor precisely the feature of Democratic plans that Republicans denounce most fiercely as “socialized medicine” — the creation of a public health insurance option that competes with private insurers.

Or to put it another way, in effect voters support the health care plan jointly released by three House committees last week, which relies on a combination of subsidies and regulation to achieve universal coverage, and introduces a public plan to compete with insurers and hold down costs.

Yet it remains all too possible that health care reform will fail, as it has so many times before.

I’m not that worried about the issue of costs. Yes, the Congressional Budget Office’s preliminary cost estimates for Senate plans were higher than expected, and caused considerable consternation last week. But the fundamental fact is that we can afford universal health insurance — even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts. Furthermore, Democratic leaders know that they have to pass a health care bill for the sake of their own survival. One way or another, the numbers will be brought in line.

The real risk is that health care reform will be undermined by “centrist” Democratic senators who either prevent the passage of a bill or insist on watering down key elements of reform. I use scare quotes around “centrist,” by the way, because if the center means the position held by most Americans, the self-proclaimed centrists are in fact way out in right field.

What the balking Democrats seem most determined to do is to kill the public option, either by eliminating it or by carrying out a bait-and-switch, replacing a true public option with something meaningless. For the record, neither regional health cooperatives nor state-level public plans, both of which have been proposed as alternatives, would have the financial stability and bargaining power needed to bring down health care costs.

Whatever may be motivating these Democrats, they don’t seem able to explain their reasons in public.

Thus Senator Ben Nelson of Nebraska initially declared that the public option — which, remember, has overwhelming popular support — was a “deal-breaker.” Why? Because he didn’t think private insurers could compete: “At the end of the day, the public plan wins the day.” Um, isn’t the purpose of health care reform to protect American citizens, not insurance companies?

Mr. Nelson softened his stand after reform advocates began a public campaign targeting him for his position on the public option.

And Senator Kent Conrad of North Dakota offers a perfectly circular argument: we can’t have the public option, because if we do, health care reform won’t get the votes of senators like him. “In a 60-vote environment,” he says (implicitly rejecting the idea, embraced by President Obama, of bypassing the filibuster if necessary), “you’ve got to attract some Republicans as well as holding virtually all the Democrats together, and that, I don’t believe, is possible with a pure public option.”

Honestly, I don’t know what these Democrats are trying to achieve. Yes, some of the balking senators receive large campaign contributions from the medical-industrial complex — but who in politics doesn’t? If I had to guess, I’d say that what’s really going on is that relatively conservative Democrats still cling to the old dream of becoming kingmakers, of recreating the bipartisan center that used to run America.

But this fantasy can’t be allowed to stand in the way of giving America the health care reform it needs. This time, the alleged center must not hold.

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Senator Bernie Sanders

Senator Bernie Sanders calls for a publicly funded single payer national health care system.

Whereas:

* 46 million Americans are currently without health insurance;

* 60 million Americans, both insured and uninsured, have inadequate access to primary care due to a shortage of physicians and other health service providers in their community;

* 100 million Americans have no insurance to cover dental needs;

* 116 million adults, nearly two-thirds of all non-seniors, struggled to pay medical bills, went without needed care because of cost, were uninsured for a time, or were underinsured in the last year;

* The United States spends $2.3 trillion each year on health care, 16 percent of its Gross Domestic Product;

* Americans spend $7,129 per person on health care, 50 percent more than other industrialized countries, including those with universal care;

* The U.S. does not get what it pays for. We rank among the lowest in the health outcome rankings of developed countries, and on several major indices rank below some third-world nations;

* The number of health insurance industry bureaucrats has grown at 25 times the growth of physicians in the past 30 years;

* In 2006, the six largest insurance companies made $11 billion in profits even after paying for direct health care costs, administrative costs and marketing costs.

And, whereas:

* Medicare has administrative costs far lower than any private health insurance plan;

* The potential savings on health insurance paperwork, more than $350 billion per year, is enough to provide comprehensive coverage to every uninsured American;

* Only a single-payer Medicare-for-all plan can realize these enormous savings and provide comprehensive and affordable health care to every citizen.

Now, therefore:

* We, the undersigned, urge the United States Congress to pass a single-payer Medicare-for-all program which will provide quality, comprehensive health care for all Americans.

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Insurance, health interests fill Baucus' coffers

But the senator 'puts Montana first,' his spokesman says

As Sen. Max Baucus has taken the lead on health reform legislation in the U.S. Senate, he also has become a leader in something else: campaign money received from health and insurance industry interests.

In the past six years, nearly one-fourth of every dime raised by the Montana Democrat and his political action committee has come from groups and individuals associated with drug companies, insurers, hospitals, medical supply firms, health service companies and other health professionals.

These donations total about $3.4 million, or $1,500 a day, every day, from January 2003 through 2008.

Baucus, who chairs the Senate Finance Committee, which is drafting a major health care reform bill this month, insists that this cascade of money is not unduly influencing his work. "No matter the issue, Max always puts Montana first," said his spokesman, Ty Matsdorf. "Max will continue to do what's right for our state, and groups like SEIU (a union representing thousands of health care workers) and AARP (a senior citizens' group) wouldn't line up in support of his health care reform effort if this wasn't true."

Baucus' office also lists numerous examples of how his proposed reforms are challenging the health care and insurance industries, such as requiring insurers to accept all customers, regardless of health condition.

Yet some reform activists and others who watch the political system say it's foolish to think this money doesn't hold some sway.

"When you spend so much of your time raising money, as members of Congress do, from those who have a compelling interest in the outcome of legislation, it has to change what you think about it, and the viewpoints that you have," said David Donnelly, director of Campaign Money Watch, a Washington, D.C., group that tracks money in politics. "It's just human nature. ... and members of Congress are human."

Advocates of national, public health insurance for all - a proposal largely excluded from the health reform debate - say their exclusion points to the power of moneyed interests in Congress.

"I'm convinced that this (money) has a profound influence," said Quentin Young, national coordinator for Physicians for a National Health Program. "Otherwise, how could Baucus, an otherwise respected and wise politician, say categorically that single-payer (national health insurance) is off the table?"

Only Baucus' Republican counterpart on the Finance Committee, Sen. Charles Grassley of Iowa, rivals him in terms of percentage of funds from these business sectors.

The Gazette State Bureau examined fundraising data for Baucus, Grassley, Sen. Edward M. Kennedy (who chairs the Senate Health Committee, which is drafting health reform legislation), the other two members of Montana's congressional delegation, and President Barack Obama.

The data are compiled by the Center for Responsive Politics, a nonprofit group that tracks and sorts campaign donors by profession and industry. Here's a summary of what the State Bureau discovered:

From 2003 to 2008, the Baucus campaign and his Glacier PAC, which raises money and distributes it to other candidates, received 23 percent of their $14.8 million from health care and insurance interests.

The $3.4 million from these sectors includes $853,000 from pharmaceutical and health products, $851,000 from health professionals, $467,000 from hospitals and nursing homes, $466,000 from health service and HMO interests, and $784,000 from insurance.

The insurance sector money includes donations from all types of insurance company interests, including health insurance.

• Five of the top 10 specific donor sources for Baucus were drug companies, health insurers or health-related firms. For example, employees of Schering-Plough Corp., a major drug firm, gave him $92,000 over the period, more than any other single source.

• Grassley, the highest-ranking Republican on the Finance Committee, received 23.5 percent of his funds from health and insurance interests but a lesser dollar amount than Baucus ($2.3 million out of $9.8 million total funds).

• Kennedy, a Massachusetts Democrat and a longtime advocate of health care reforms, received only 7.5 percent of his funds from health and insurance interests, or about $1.2 million.

• Sen. Jon Tester, D-Mont., and Rep. Denny Rehberg, R-Mont., had minimal contributions from the health and insurance sectors.

• Obama, whose campaign raised a whopping $745 million in 2007 and 2008, received a relatively small share from health care interests ($19 million, or 2.5 percent) and insurance interests ($2 million, or 0.3 percent).

Baucus has been leading the charge on health care reform in the U.S. Senate since early 2008, holding numerous hearings and Finance Committee meetings on the issue. He released a lengthy "white paper" last November, outlining his reform ideas, and a major bill is expected to be introduced this month.

The general thrust of his proposals is to require all citizens to buy health insurance while also forcing the private insurance industry to stop practices that make coverage unaffordable for many. He supports subsidies to those who may have trouble affording insurance.

However, on a reform bitterly opposed by the insurance industry and most health care interests - a public, nonprofit insurance plan offered by the government - Baucus has been more ambivalent, saying he supports the idea but declining to specify in what form.

Baucus's office supplied nearly 20 examples of stances he has taken in direct opposition to drug, insurance and banking interests that have donated to his campaign funds.

He has supported importing lower-cost prescription drugs from Canada, allowing the government to negotiate for lower drug prices for Medicare recipients, funding research that would show when generic drugs are a better deal than brand-name drugs and reducing Medicare payments to private insurers by $13 billion over five years.

His office also points to an April 2007 Wall Street Journal article in which Baucus was quoted as telling medical industry contributors at a fundraiser, "You should worry about me coming after you."

Donnelly, the Campaign Money Watch director, says the proof on health care reform will be in the final product - and that he's not terribly optimistic.

Health and insurance interests are clearly targeting Baucus and his Finance Committee, which often have shown themselves to be receptive to their influence, he said.

"This debate on health care is a microcosm ... that even after a 'change' election, how much the special interests view (Washington) as their fiefdom," Donnelly said.

Supporters of national health insurance are even less optimistic, noting how Baucus, Obama and leaders in Congress won't even consider their proposal, which they believe would have broad public support.

"I can't think of any reason other than fidelity to your donors, to explain why they would keep us out of the debate," said Young of the physicians group. "Until we get campaign finance reform, it will be very difficult to do anything to challenge the status quo (in health care), and the status quo had better be challenged, because it's a very bad status quo."

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Obama will talk to doctors on healthcare

President Obama plans next week to make his case for a healthcare overhaul to a group that has helped block major changes before -- the nation's doctors.

White House spokesman Robert Gibbs announced today that the president will speak next Monday to the American Medical Association's annual gathering in Chicago.

"He'll start with the recognition that the healthcare system status quo is unsustainable and he'll outline the case for healthcare reform," Gibbs told reporters at his daily briefing. "He'll make clear why we can't afford to wait another year or another administration to bring down costs that are crushing families, businesses, and government.

"In the speech the president will discuss the reasons why past efforts have failed and he'll address the consequences of failing to act again this year," Gibbs added. He'll lay out plainly what healthcare reform will mean for American families and their doctors and what it won't. The president will also address the importance of making sure that reform doesn't add to our deficit, and what we can do to strengthen what works in our health care system and to fix what's broken so that we can build -- what we build provides the best care in the world at the lowest cost.

Earlier today, Obama summoned key lawmakers to the White House again today to push them to reach a deal. Afterwards, there were reports that key Democratic and Republican said a compromise may be emerging on one of the biggest disputes -- whether to create a government-sponsored health plan to compete with private insurers.

The compromise would create nonprofit health cooperatives owned by groups of patients, similar to how electric or other cooperatives operate, and without the government involvement that troubles Republicans and business groups about the public plan, the Associate Press reported.

The senators said Obama was willing to listen to all sides but insisted that Congress must pass a bill this year that reins in costs and helps provide coverage to nearly 50 million uninsured people.

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UPDATE 2-U.S. Senate Democrats unveil healthcare bill

* Senate bill calls for insurance market overhaul

* Leaves blank details of proposed government health plan

* Obama promises Medicare and Medicaid savings (Adds new material throughout)

Leading Senate Democrats unveiled on Tuesday a plan to reshape U.S. healthcare that calls for sweeping insurance market reforms and prohibits insurers from denying coverage or charging more due to medical history.

The measure also would require individuals to buy insurance, provide subsidies to help make coverage affordable and set up a new government plan to help provide medical coverage for the uninsured.

The Senate Health, Education, Labor and Pensions Committee's bill is one of at least three healthcare proposals brewing in Congress, which Democrats hope will lead to legislation that President Barack Obama can sign into law by October.

"Our goal is to strengthen what works and fix what doesn't," Senator Edward Kennedy, chairman of the committee, said in a statement that accompanied the bill's unveiling.

Democrats in the U.S. House of Representatives and a second group of U.S. senators led by Senate Finance Committee Chairman Max Baucus are developing similar proposals. Baucus has been working with Kennedy's panel and is expected to unveil his version of the bill in the coming days.

Meanwhile Democratic members of the House Ways and Means Committee, one of three panels writing the House version of the bill, met with Obama to discuss the legislation. The White House issued a statement saying the group agreed that the cost of the overhaul, which some estimates put at about $1.2 trillion, should not add to budget deficits.

The White House said Obama -- under pressure from critics over his huge spending and deficit plans -- would soon spell out more cost savings for the Medicare and Medicaid health programs for the elderly and poor.

MORE WORK NEEDED

The Kennedy panel will hold a public hearing on its bill on Thursday and will begin considering amendments in public sessions beginning on June 16, the committee said.

"Much work remains, and the coming days and weeks won't be easy. But we have a unique opportunity to give the American people, at long last, the health care they need and deserve," said Kennedy, who is in his second year of fighting brain cancer.

Obama has called on Congress to pass legislation this year to overhaul the $2.5 trillion healthcare system, aiming to cut costs and ensure that millions of Americans now without health insurance get coverage.

But many congressional Republicans have criticized Democratic proposals for including a public insurance program that would compete with private insurers.

In a bow to Republican concerns, Kennedy's committee bill leaves open the details of how such a plan would operate. Panel Democrats and Republicans are set to meet this week to try to work out differences over the public plan.

Also still to be worked out are details on whether employers would be required to offer insurance to workers.

The House and Senate bills would establish an exchange, a kind of clearinghouse, where people and small businesses could shop for insurance. Lawmakers want the proposed new public plan to be an option offered in that exchange.

Democrats say a public plan that competes with private insurers is the only way to contain costs and keep premiums low. Republicans and insurers argue that it would drive insurance companies out of business and lead to an entirely government-run U.S. healthcare system.

"If you don't have a public option, who is going to keep the insurance companies honest?" said Senator Charles Schumer, a member of the Senate Democratic leadership. "Most of us don't believe that government regulation will be sufficient because they have the profit motive."

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U.S. House health bill to include government plan

Democrats in the U.S. House of Representatives are preparing to unveil a proposal for a sweeping healthcare overhaul that includes a new public insurance plan and would require individuals and businesses to obtain coverage, lawmakers said on Monday.

Similar to legislation being developed in the Senate, the House bill would establish an insurance exchange to help people without employer-sponsored insurance find medical coverage. A new government insurance program would be one of the options available, lawmakers said.

"The exchange will be the vehicle in which we would have the public option, and people can go there to go shopping to determine whether you want a private plan or a public plan," House Ways and Means Committee Chairman Charles Rangel told reporters.

The bill also embraces extensive insurance market reforms that would bar insurers from denying coverage to people because of medical history. The House bill also calls for a mandate for individuals and businesses to obtain insurance.

Rangel said the legislation would include incentives for small businesses and penalties should companies fail to offer their workers insurance. Penalties for individuals have yet to be worked out, he said.

The Ways and Means Committee is one of three House committees developing healthcare legislation.

President Barack Obama wants to overhaul the U.S. healthcare system, aiming to cut costs and ensure that millions of Americans now without health insurance get coverage.

Healthcare costs burden many U.S. businesses and families and eat away at federal and state budgets.

Democratic Representative Lloyd Doggett said a new public insurance plan was "an essential" part of the proposal.

Republicans and insurers oppose a new public plan that would compete with insurance companies.

People 65 and older, the disabled and the poor already are eligible for the public Medicare and Medicaid insurance plans.

Some Senate Republicans wrote a letter to Obama on Monday arguing against a new public plan, saying it would lead to "a federal government takeover of our healthcare system."

Obama backs the idea of a public plan, but also has said he wants healthcare legislation by October that enjoys bipartisan support.

Rangel and the heads of the other two committees working on the bill will brief House Democrats on the legislation on Tuesday. Democratic members of the Ways and Means Committee, which is also working on the financing of the plan, are scheduled to meet with President Barack Obama on Tuesday to discuss the proposal.

Lawmakers and a committee aide stressed that what is being discussed was an outline, not the final draft of legislation.

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Obama presses for action on healthcare

Just before leaving for his trip to the Middle East and Europe, President Obama summoned key Senate Democrats to the White House this afternoon to rally the troops for a healthcare overhaul.

Before the meeting, Obama said getting a healthcare bill passed is "not a luxury," and said the period between now and Congress's monthlong recess in August is the "make-or-break period."

He also said a bill must not only cover more people, but also reduce the cost of healthcare, according to the press pool report. "If we don't get control over costs, then it is going to be very difficult for us to expand coverage," he said. "These two things have to go hand in hand."

(His full remarks are below.)

But in the last several days, differences have emerged between the two main architects of the healthcare legislation in the Senate, Edward M. Kennedy of Massachusetts and Max Baucus of Montana.

Kennedy, chairman of the Health, Education, Labor, and Pensions Committee, is leaning toward creating a widely available Medicare-style public insurance option. But Baucus, the Finance Committee chairman, wants a bipartisan solution -- and Republicans consider Kennedy's public plan an intolerable threat to the private insurance industry.

The White House and Baucus also publicly disagreed today over how the bill should be financed, with the administration opposing Baucus's proposal to tax a portion of healthcare benefits provided by employers.

The list of senators expected to attend the White House meeting is below:

THE PRESIDENT: I want to -- thanks -- I want to say thank you to all of my former colleagues for taking the time to visit here today at the White House. I want to particularly thank Senators Baucus, Senator Dodd, all the senators who have been fighting tirelessly on behalf of health care reform -- for many years, in some cases.

I want to mention, by the way, that I spoke to Senator Kennedy earlier this morning. He is gung-ho, ready to go. He had a whole range of ideas in terms of about how he'd like to see this move, and he's grateful that Chris has been taking on a lot of the work in the health committee, but he is very enthusiastic about our progress.

This issue, health care reform, is not a luxury. It's not something that I want to do because of campaign promises or politics. This is a necessity. This is something that has to be done. We cannot avoid bringing about change in our health care system. Soaring health care costs are unsustainable for families, they are unsustainable for businesses, and they are unsustainable for governments, both at the federal, state and local levels.

All across the system what you are seeing are skyrocketing premiums, you are seeing people who are getting caught up in loopholes and end up not having coverage that they thought they had. We have a system here in the United States which is spending more money per capita than just about any other industrialized or advanced nation, and yet we're actually seeing worse health care outcomes in many cases.

And to give you a sense of what we're looking at down the road if we don't initiate serious reform, one-fifth of our economy is projected to be tied up in our health care system in 10 years; one fifth. Millions more Americans are expected to go without health insurance if we don't initiate reform right now. And outside of what they're receiving for health care, workers are projected to see their take-home pay actually decrease if we don't get a handle on this.

So we can't afford to put this off, and the dedicated public servants who are gathered here today understand that and they are ready to get going, and this window between now and the August recess I think is going to be the make-or-break period. This is the time where we've got to get this running.

I want to just make mention of something that I've talked to many of you privately about. I want to say this publicly. As we move forward on health care reform, it is not sufficient for us simply to add more people to Medicare or Medicaid to increase the rolls, to increase coverage in the absence of cost controls and reform. And let me repeat this principle: If we don't get control over costs, then it is going to be very difficult for us to expand coverage. These two things have to go hand in hand. Another way of putting it is we can't simply put more people into a broken system that doesn't work.

So we've got to reform the underlying system. And this means promoting best practices, not just the most expensive practices. And one of the things I'm going to be discussing with the health and the finance committees is how can we change incentive structures so that, for example, places like Mayo Clinic in Minnesota are able to provide some of the best health care services in the country at half or sometimes even less of the costs than some other areas where the quality is not as good. What we should be -- and by the way, that's not just unique to Mayo. The Cleveland Clinic in Ohio, same thing: top-notch quality, lower costs.

What we've got to figure out is how do we create the incentives in terms of how we are reimbursed, how we deal with getting doctors to work together more effectively, how we're working on prevention and wellness so that we're driving down costs across the board.

Now, I appreciate the efforts that are being made by these senators. I look forward to discussing with them their ideas. This is going to be a heavy lift, I think everybody understands that. But I'm also confident that people want to get this done this year. And under the leadership of Max and Chris and all the other participants here, I'm confident that we're going to get it done.

So thank you very much, everybody. And now we're going to get to work.

Senator Christopher Dodd (D-CT)
Senator Tom Harkin (D-IA)
Senator Barbara A. Mikulski (D-MD)
Senator Jeff Bingaman (D-NM)
Senator Patty Murray (D-WA)
Senator Jack Reed (D-RI)
Senator Bernard Sanders (I-VT)
Senator Sherrod Brown (D-OH)
Senator Robert P. Casey, Jr. (D-PA)
Senator Kay Hagan (D-NC)
Senator Jeff Merkley (D-OR)
Senator Sheldon Whitehouse (D-RI)
Senator Max Baucus (D-MT)
Senator John D. Rockefeller (D-WV)
Senator Kent Conrad (D-ND)
Senator John F. Kerry (D-MA)
Senator Blanche L. Lincoln (D-AR)
Senator Ron Wyden (D-OR)
Senator Charles E. Schumer (D-NY)
Senator Debbie Stabenow (MI) - D
Senator Maria Cantwell (D-WA)
Senator Bill Nelson (D-FL)
Senator Robert Menendez (D-NJ)
Senator Thomas Carper (D-DE)

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Let's get the facts straight on health care reform

With the debate over health care reform getting hot and heavy, opponents of President Barack Obama’s proposal have been feeding the public a lot of misinformation. Unfortunately, one of my Examiner colleagues has joined them.

In an April 12 post, Watchdog Politics Examiner Martha Gore falsely characterized Obama's health care reform proposal as a “nationalized health care plan,” and Media Matters for America rightly took her to task for misinforming the public.

Let’s get our terminology straight. Nationalized or socialized medicine is a health care system that is publicly financed and delivered, such as Great Britain’s National Health Service. That is not part of Obama’s proposal or the Single Payer plan put forward in HR 676 and S 703.

The public health insurance option in Obama’s proposal and Single Payer both provide for health care that is public financed and privately delivered. In effect, both would extend Medicare beyond the elderly, with everyone covered under Single Payer or having an opportunity to choose such a plan under Obama’s proposal.

While Single Payer would automatically cover everyone, the Obama option would give consumers a lower-cost alternative to private insurance. Since the overhead for private insurance averages 30 percent, compared to only 4 percent for Medicare, such competition could force private insurers to become more responsive to consumer needs.

It should also be noted that under both Single Payer and the Obama proposal, patients have a free choice of doctors, while private insurance limits those covered to doctors within each insurer’s system. It can sometimes be difficult to build a doctor-patient relationship under such an arrangement, as I personally found when I twice had to change primary care physicians when they stopped taking my insurance.

By putting profits ahead of everything else, the insurance companies are the primary cause of our broken health care system, and they are now fighting tooth and nail to maintain their racket. Their fear is that they can’t compete profitably with the cheaper public insurance alternative proposed by Obama, leading many businesses to switch to it for employee health insurance. Under this scenario, the public alternative would likely evolve into Single Payer.

Opponents of the Obama proposal also claim that it would undermine consumer choice in health care, but this argument is absurd. When health insurance is provided by the employer, as is now the case, there is usually no choice for the employee. They are stuck with whatever deal their employer can get, complete with co-pays, deductibles and exclusions that limit coverage.

Details on the Obama proposal are currently being worked on, and it is expected to be introduced in Congress in June. We can look forward to a fierce debate, but don’t expect honesty from the opposition.

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Opinion: Support Obama’s approach to health-care reform

Have you heard about the exciting debate going on in Washington about health-care reform? It is very important that we all pay close attention and realize that we all have a say on what happens.

This week, the New York Times editorial board joined Dr. Howard Dean, Paul Krugman, and progressive champions in Congress in support of President Obama’s public health insurance option. Why is this such a big deal? The public health insurance option is the key to finally covering everyone and lowering insurance premiums by as much as 30 percent. It will take the power away from the private insurance companies that have driven up costs and denied coverage for years.

This is the biggest fight in the health-care debate. Consider this: During the election, President Obama promised to give everyone the choice of private insurance or a public health insurance plan like Medicare, with lower premiums and better benefits. Obama’s public health insurance option would save us up to 30% on our insurance premiums by being more efficient and driving down prices across the board.

The insurance lobbyists are fighting against Obama’s public health insurance option. Insurance companies know that lower costs for us mean lower profits for them. A public health insurance plan achieves universal health care and lowers costs by giving people the choice of their existing insurance or a new, more affordable health-insurance plan sponsored by the government. Either way, you get to pick your doctor.

The choice of a public health insurance plan is considered a crucial part of health-care reform by many economists and health-care groups. Please contact your representatives and let them know this past election we voted for change and now is the time to act and stand up for what is right for all the American people. Everyone deserves proper and affordable health care. Let’s not go back to the same old, same old.

Reform…yes we can.

Gerri M. Veith
Baldwinsville

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Health Critic Brings a Past and a Wallet

Richard L. Scott is unusual in these tough economic times: a rich, conservative investor willing to spend freely on a political cause.

Mr. Scott is starring in his own rotation of advertisements against the broad outlines of President Obama’s health care plans. (“Imagine waking up one day and all your medical decisions are made by a central, national board,” he warns in a radio spot.) He has dispatched camera crews to other countries to document the perils of socialized medicine.

He visited with lawmakers on Capitol Hill this week, and his new group, Conservatives for Patients’ Rights, has hired a leading conservative public relations firm, CRC, well known for its work with Swift Boat Veterans for Truth, the group that attacked Senator John Kerry, Democrat of Massachusetts, during his presidential campaign.

Mr. Scott’s emergence this spring as the most visible conservative opponent to Mr. Obama’s not-fully-defined health care effort has former friends and foes alike doing double takes, given Mr. Scott’s history.

Once lauded for building Columbia/HCA into the largest health care company in the world, Mr. Scott was ousted by his own board of directors in 1997 amid the nation’s biggest health care fraud scandal. The company’s guilty plea and payment of $1.7 billion to settle charges including the overbilling of state and federal health programs was taken as a repudiation of Mr. Scott’s relentless bottom-line approach.

“He hopes people don’t Google his name,” said John E. Hartwig, a former deputy inspector general at the Department of Health and Human Services, one of various state and federal agencies that investigated Columbia/HCA when Mr. Scott was its chief executive.

Liberal groups planning to defend the administration’s health care plan, whatever form it takes, are seizing on Mr. Scott’s background through Web videos, fact sheets, blog postings and unflattering additions to his Wikipedia entry, which until recently did not mention his ouster from Columbia.

“He’s a great symbol from our point of view,” said Richard J. Kirsch, the national campaign manager for Health Care for America Now. “We cannot have a better first person to attack health care reform than someone who ran a company that ripped off the government of hundreds of millions of dollars.”

Conservative health care activists, while glad to have a potential ally willing to spend $5 million out of his own pocket, are not fully embracing Mr. Scott, noting that he is entering a changed landscape in which some Republicans and industry groups that opposed President Bill Clinton’s health care proposals now view some form of change as necessary and inevitable.

“At the end of the day, they may come up with something we like,” said John C. Goodman, a leading conservative health care policy expert. “We shouldn’t just assume that this is something horrible — if this is something horrible, we will be against it.”

“There is no Obama plan that’s been made public yet, so what’s the point of running ads?” Mr. Goodman added. “I don’t see that you gain anything except attention for Rick Scott.”

Some former allies are more hostile toward Mr. Scott, painting him as counterproductive to their efforts for compromise.

“I just don’t understand why he would be a messenger people would listen to,” said Charles N. Kahn III, who was a senior executive with the insurance industry group that ran the “Harry & Louise” advertisements credited with helping to kill the Clinton plan 15 years ago but who is working for a deal now. “I don’t think people are waiting to hear from him.”

Mr. Kahn, a Republican, is now the head of the Federation of American Hospitals, a private-hospitals group.

Mr. Scott is showing more support from some Republicans in Congress, though. Representative Michael C. Burgess, Republican of Texas and a member of the House health subcommittee, said in an interview that he had invited Mr. Scott to meet with him on Tuesday because he liked what Mr. Scott had been saying.

Mr. Scott declined several interview requests. His public relations firm, after initially offering to make him available for a discussion, later declined to answer questions about him, citing an exclusive arrangement with another publication.

In recent years, Mr. Scott, 56, has settled into a comfortable life in Naples, Fla., where he has built an investment portfolio that includes a chain of urgent-care clinics, some located in Wal-Mart stores, which Mr. Scott promotes as inexpensive alternatives to emergency rooms, especially for the uninsured.

Mr. Scott has said his sole policy interest is to see to it that whatever overhaul Mr. Obama and Congress consider does not move the country toward a socialized system and away from what he calls his four pillars of reform: “choice, competition, accountability and personal responsibility.”

“After spending over two decades in the health care provider industry, I’ve seen these principles work firsthand,” Mr. Scott said in a recent statement in which he also criticized Mr. Obama for seeking a $634 billion reserve fund for unspecified changes to the health care system.

Mr. Scott’s supporters say that he has been unfairly attacked over the years for challenging the longstanding orthodoxy of the nonprofit health care establishment.

“He has a much more businesslike approach to health care than anybody I’ve ever seen, and it is much more bottom-line-driven,” said Joshua Nemzoff, a hospital consultant based in New Hope, Pa., who has represented nonprofit hospitals in several deals with Mr. Scott. “He’s aggressive, and sometimes that rubs people the wrong way.”

Mr. Scott, a former Navy radar operator, built what would become Columbia/HCA from two hospitals in Texas into the largest health care chain in the world over just a few years. He seemed to relish publicly lambasting the nonprofit hospitals against which he competed and which he described as “non-taxpaying hospitals” impervious to real-world business concerns.

His approach earned him plenty of enmity, but also high praise. In 1996, Time magazine named him one of the “25 most influential Americans” for “transforming how American hospitals do business,” with an operation that “consolidates operations and imposes cost controls.”

Though Mr. Scott was not directly implicated in the fraud scandal — with whistle-blower suits filed against some hospitals before his acquisition of them — critics said his drive for profits had created incentive for fraud.

“The practices did pre-exist Rick Scott,’ said Stephen Meagher, a lawyer who represented some of the ex-employees whose complaints prompted the initial investigation. “They were aggravated by the pressure he put on HCA employees.”

In an interview this week with The Washington Independent, Mr. Scott said of the charges against his former company, “If you go back and look at the hospital industry, and the whole health care industry since the mid-1990s, it was constantly going through investigations.” He added, “Great institutions, like ours, paid fines.”

One defender of Mr. Scott, Mr. Burgess, the Texas lawmaker and a former HCA doctor, said of the investigation, “A lot of us just looked at it as somebody in Washington playing politics.”

Others say the scandal took place so long ago they can hardly remember it. “I remembered reading a newspaper article about it all,” said Merrill Matthews Jr., director of the Council for Affordable Health Insurance, a group that formed to fight the Clinton proposals and expects to fight Mr. Obama’s. Mr. Matthews said he would not shun Mr. Scott. “He’s bringing a lot of money to the table,” he said.

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Crunch Time for Fixing Health Care

You wouldn't know it from the headlines, but it's crunch time on health-care reform. In a series of high-level meetings at the White House and on Capitol Hill, critical decisions are being made that will help decide whether the comprehensive health reform that has eluded policymakers for decades finally comes to fruition -- and what the system will look like for decades.

What's being fitted together right now -- in ambitious hopes of a public unveiling this spring and floor action this summer -- are interlocking parts of an intricate jigsaw of clashing ideologies, interest groups, political personalities and congressional fiefdoms.

The stakes are enormous. "If it isn't done this year, it won't be done for the next four years," Iowa's Charles Grassley, a key player as the senior Republican on the Senate Finance Committee, said last week at a breakfast sponsored by the Kaiser Family Foundation. "If we do something incremental this year, we're never going to have comprehensive health-care reform."

Here are Five Hard Pieces on the way to that goal:

Piece One: Should there be a public insurance option? This is a question that evokes near-religious fervor and that could crash the whole enterprise. Republicans hate the notion of a government program because they fear, with ample reason, that it is a slippery-slope step to a single-payer program. Liberals demand a public insurance alternative for precisely that reason.

Potential solution: Have the public program abide by the same rules as private plans, so it has no inherent advantage.

Drawbacks: In that case, what's the point? Plus, anything that smacks of a public program will be unacceptable to Republicans.

Piece Two: How to pay for the program? Specifically, should employer-provided health insurance, no matter how generous, continue to be treated as tax-free income? This is a huge pot of money -- more than $200 billion annually. The current arrangement is not only unfair, it's also counterproductive, encouraging overconsumption of health care. But unions, which have negotiated generous health packages, oppose changes, and during the presidential campaign, Barack Obama denounced John McCain's proposal to eliminate the exclusion as a $3.6 trillion tax hike.

Potential solution: Go partway, taxing benefits above a certain dollar amount and/or for those at a higher income level. A cap on benefits has the added cost-dampening advantage of encouraging insurers to offer policies in this range.

Drawbacks: This approach produces a lot less money, somewhere between $30 billion and $90 billion, depending on how it's structured. At some point, all the burden of reform can't be put on the wealthiest.

Piece Three: Should individuals be required to purchase insurance? The argument is that this individual mandate would keep spending and premiums down by spreading costs over a healthier population, ensuring preventive care. Health insurers have embraced such a mandate (more customers!) in exchange for having to insure applicants regardless of their health status. But Obama condemned Hillary Clinton's proposed mandate as a scheme to "go after people's wages."

Potential solution: Go for the mandate because it makes sense and the politics are reasonably uncomplicated: insurers are for it; unions aren't opposed; small business won't go ballistic, as with an employer mandate. Use automatic enrollment to get people covered and a relatively "soft" mandate, without draconian penalties.

Drawbacks: The mandate is difficult to structure and enforce. It will be effective only with generous low-income subsidies, which will be expensive. (See Piece Two, above.)

Piece Four: What mechanism should there be to control costs? Specifically, should there be some kind of national health board to determine what benefits should be covered -- or not? Electronic health records and comparative-effectiveness research are important steps, but not enough on their own to bend the curve of ever-increasing health-care costs.

Potential solution: Have a board that makes these decisions only for federal programs. As with Medicare now, that ends up influencing private insurers' behavior.

Drawbacks: This opens the door to charges of rationing and government-controlled health care -- and ads that make "Harry and Louise" look like "Sesame Street."

Piece Five: How much muscle should Democrats use to get health-care reform done? The temptation is to use special budget procedures known as reconciliation that would allow Senate Democrats to approve health reform with just 51 votes. House leaders, fed up with being held hostage by Senate gridlock, are pushing this approach.

Potential solution: The White House is already floating one: hold out the stick of using this shortcut down the road -- say, September -- if agreement can't be reached.

Drawbacks: The rules limit how much policy change can be done this way and give huge power to the Senate parliamentarian to rule things in or out. Simply including this technique as a possibility in the soon-to-be-unveiled budget resolution would be incendiary. And wielding the stick would be the end of bipartisanship as we never got a chance to know it.

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Senator urges healthcare overhaul this year

Congress must enact a sweeping overhaul of the U.S. healthcare system by the end of this year or risk waiting at least another four years to get the job done, a senior Republican senator said on Thursday.

Charles Grassley, who as the Senate Finance Committee's top Republican will help write healthcare legislation, acknowledged that some senators suggest putting off the overhaul while lawmakers grapple with the financial crisis.

But he said such a move could sink the revamp of the $2.5 trillion healthcare industry that President Barack Obama said is essential to promote long-term U.S. economic growth.

"If it isn't done this year, it won't be done for the next four years," Grassley told reporters at a briefing, saying election politics will put off any meaningful action.

Republicans are looking to next year's congressional elections to win back some seats lost to Democrats last year. After that, Democrats and Republicans will begin political maneuvering for the 2012 presidential elections.

Grassley said he is optimistic that Congress will act this year on a bipartisan overhaul of the healthcare industry that Obama has said is needed to rein in soaring costs that are crippling U.S. global competitiveness and to provide coverage to 46 million uninsured Americans.

It is a giant legislative undertaking and already Republicans and Democrats are split on a central issue of whether a government plan should be one of the insurance options available to consumers.

Grassley said compromise on that issue will be difficult.

Democrats want it as an option, arguing that the competition will hold down private insurance premiums. Republicans counter that a public plan would drive private insurers out of the market, eventually leaving the United States with a government-run healthcare system.

The Senate's Finance Committee is working with its Health, Education, Labor and Pensions Committee headed by Democratic Senator Edward Kennedy to get healthcare legislation to the Senate floor by July.

House of Representative committees are working to get a House vote on legislation by the time lawmakers break for a month-long recess in August.

If lawmakers can stick to that schedule, it would give the two bodies plenty of time to work out their differences and send a bill to Obama by the end of the year.

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Legislation Could Strengthen Primary Care Workforce to Prepare for Health Care Reform

Sen. Bernie Sanders, I-Vt., and House Majority Whip James Clyburn, D-S.C., have introduced the Access for All America Act, a bill that would provide funding increases for the nation's community health centers, or CHCs, and the National Health Service Corps, or NHSC. If enacted, the legislation could strengthen and expand the nation's primary care infrastructure to accommodate health care reform efforts and meet the nation's growing need for primary care services, according to Dan Hawkins, policy director for the National Association of Community Health Centers, or NACHC.

"Health care reform is trying to get as close to universal coverage as possible," Hawkins told AAFP News Now. "But coverage is just a vital first step. You also have to build care delivery systems to get care to the people who need it the most. This is a necessary complement to the health care expansions contemplated under health reform, and it therefore has to take place at the same time."

The legislation would increase funding for CHCs from $2 billion to $8.3 billion during a five-year period, thus expanding the number of people who receive services from the centers from 18 million to 60 million, according to a summary of the bill released by Sanders' office. The legislation would increase the number of CHCs from 1,100 facilities to 4,800 facilities by 2015, which is enough of an increase to virtually eliminate federally designated medically underserved areas, says the summary.

The bill also would increase the number of primary care health professionals supported by the NHSC from 4,000 to 28,000 during the five-year period.

The legislation seeks to build on the recently enacted economic recovery legislation, which provides $2 billion in one-time funding for CHCs and another $300 million for the NHSC. It is based, in large part, on an Access for All America Plan proposed last year by the NACHC, which calls for expanding CHC coverage by 2022 to 56 million Americans who are considered medically disenfranchised. The Access for All America Act, by contrast, would extend CHC coverage to 60 million people -- including 56 million Americans who are considered medically disenfranchised -- by 2015.

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Democrats, GOP draw battle lines on healthcare plan

Democrats and Republicans are battling over what is shaping up to be one of the most contentious issues in the healthcare debate: whether the government should establish a Medicare-style public insurance option for people under 65.

Last week, the liberal activist group MoveOn.org began running TV ads accusing insurers of opposing a government plan, which advocates say could provide cheap, portable coverage for anyone who buys it, out of fear that it could undercut profits.

"Don't let them get away with it," the ad warns.

Meanwhile, top Republican senators declared in a letter to President Obama last week that they would oppose any healthcare bill with a public plan because it would force insurers to compete on an "unlevel playing field" with the government, which could theoretically set artificially low prices and subsidize any shortfalls with taxpayers' money.

The issue will be among the most difficult Obama will have to address as he seeks a sweeping healthcare overhaul designed to lower costs, improve quality, and provide coverage for some 46 million uninsured. He has promised voters both a choice between private and public health insurance - and that his healthcare plan will be bipartisan.

"Right now, there is no middle ground," said John Rother, policy director for the AARP.

Interest groups have begun digging in. Conservatives, the insurance industry, and the small business lobby regard a public insurance plan as anathema, contending that it would drive private insurers out of business, leading to a Canadian-style single-payer plan.

Liberal groups and unions passionately support it, saying it would offer a plan with much lower administrative costs and greater stability, and could help drive systemwide innovations, such as the implementation of electronic health records.

Doctors and hospitals, whose income could be profoundly affected by dramatic changes in the insurance market, are waiting to take sides until there is an actual proposal with details about how a public plan would work and how it would fit into the overall system.

At the White House summit on healthcare last week, Obama tried to strike a diplomatic tone, saying he understood both sides: Those who favor a public plan saw it as a way to "keep the private sector honest," he said, but insurers might "feel overwhelmed" by a government-run plan, which he said is a serious concern. But he did not suggest a way to reach a compromise.

Without a bill on the table, Rother said, all the sniping back and forth is "almost comical" since no one has laid out how such a plan would work - who it would cover, how big it would be, and how it would relate to private insurers. Yet with so much at stake, the temperature of the debate is rising, though a bill is not expected until late spring.

Bryan Dowd, a health policy professor at the University of Minnesota, said years of fights over the Medicare program illustrate how politics can disrupt a hybrid public-private system. In the portion of Medicare that covers outpatient treatment, patients can choose either the traditional, government-run Medicare or a private plan.

For years, he said, Democrats and many Republicans have succumbed to political pressure to keep the public plan premiums lower through subsidies, contributing to huge government cost overruns. In addition, Republicans and many Democrats voted to provide subsidies to private insurers in certain parts of the country to help them provide better benefits. Obama has provoked an outcry from insurers by proposing to dramatically lower those extra payments.

Both parties, Dowd said, are "running the program into the ground while squabbling over whether [it should be] all private or all public."

But Jacob Hacker, a political science professor at UC Berkeley, believes there are ways of setting up a hybrid system that allows both public and private plans to thrive. An outside body could set rules for both types of plans to follow and prevent the public plan from drawing on tax dollars to stay solvent, or from paying doctors unfairly low rates, he said. While a public plan might offer lower premiums and better portability, he said, private plans could compete by tailoring benefits to better suit customers' needs, or by providing smaller, higher-quality networks of providers.

"I see a public-private competitive system as one that allows you to have something of the best of both worlds," he said.

James Roosevelt Jr., the president and chief executive of Tufts Health Plan, said the Massachusetts system offers a glimpse of how private insurers could accomplish most of the goals of having a public plan: The federal government could set criteria for a basic benefits package, make it available to anyone in the country, and forbid insurers from discrimination against the sick while requiring everyone to buy insurance. Insurers would design new products, tailored to the government's criteria, and compete for customers, who would have stable and affordable insurance no matter where they lived.

But many public-plan proponents say the Massachusetts law enriches insurers at the expense of middle-class people who cannot afford the insurance but are forced to buy it anyway.

"Our position is, let's compete," said Representative Eric Massa, a Democrat from New York and a strong supporter of public plans. "If your product is better, people will flock to you."

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Insurance group reverses on health-care overhaul

Sixteen years ago, the opposition that killed President Bill Clinton's massive plan for universal health-care coverage was distilled in a 30-second ad showing "Harry and Louise," a fictional middle-class couple, shuffling papers and complaining about "government bureaucrats" who limited their choices.

But last week, at the conclusion of the White House summit on health-care reform, the head of the trade association of insurance companies - the successor to the group that spent millions on those commercials - pledged to support President Obama's push for a comprehensive overhaul of the health-care system to cut costs and expand access.

"We understand we have to earn a seat at the table," said Karen Ignagni, president of America's Health Insurance Plans, addressing Obama in the gilded East Room. "You have our commitment to play, to contribute, and to help pass health-care reform this year."

The turnabout was a striking illustration of how much health-care politics have changed, analysts say. Former adversaries are agreeing that something must be done: Costs are spinning out of control, harming business and government alike, and 47 million Americans lack insurance. The sharpest economic slide in six decades has only intensified the discussion.

"Now is exactly the time for us to deal with this problem," Obama said. "It's one of the greatest threats not just to the well-being of our families and the prosperity of our businesses, but to the very foundation of our economy."

His approach shows that Obama has learned the lessons of the downfall of the Clinton plan, the last major systematic attempt at a goal - universal health-care coverage - that has eluded presidents since Harry S. Truman.

Exhibit A was Thursday's summit, which gathered 150 people with diverse stakes in the system: congressional leaders; representatives of the insurance and pharmaceutical industries; doctors, nurses, and hospital administrators; union leaders; and corporate executives.

In 1993-94, a plan was drafted, largely in secret White House meetings, by a task force headed by first lady Hillary Rodham Clinton. With little public input, the group coughed up a 1,324-page bill that interest groups picked apart for months. And because members of Congress had not been consulted, they either opposed the bill or, at best, were unwilling to defend something they had no hand in creating.

The Clinton plan was complex - relying on government's shepherding of people into managed-care plans through purchasing cooperatives - and it was presented all at once, in mind-numbing detail. By contrast, Obama has been vague, preferring to build consensus around general principles. He has made clear that Congress would write the legislation; congressional leaders say they want to pass a bill this summer.

Obama eased some fears by signaling that he wanted to build on the current system rather than create a nationalized single-payer system. That, analysts say, has eased fears in the health industry and among the middle class, though Obama has angered some liberals.

In addition, Obama has taken an incremental approach and proposed a down payment. He included a $634 billion health-care reserve fund in his 2010 budget proposal. That money would be raised, in part, through targeted cuts in government health-program payments to insurers, doctors, hospitals, and drugmakers - and through a rollback of the Bush-era tax cuts for the wealthy.

Driving the medical lobby into the administration's arms: the lure of tens of millions of new customers. If Obama succeeds in covering many more Americans, they will take their insurance to go to the doctor, buy drugs, and have surgery - increasing revenue for providers.

Other businesses want relief from the ever-rising costs of health care.

"A lot of businesses have decided recently they have more to fear from the status quo than from change - that's the opposite of 16 years ago," said Robert I. Field, professor of health-care policy at the University of the Sciences in Philadelphia. "Insurance companies see costs escalating out of control, and themselves losing customers as fewer and fewer businesses are able to buy insurance."

Rep. Allyson Y. Schwartz (D., Pa.), who attended the summit, said change is a "fiscal imperative" for the private sector and the government. "A double-digit increase in the cost of health care every year is just unsustainable," Schwartz said in an interview.

Fear is at work, too. Tom Donahue, president of the U.S. Chamber of Commerce, said that momentum was clear toward major change and that the stakeholders wanted to try to shape it. "If you don't get in this game, then . . . you're on the menu," he said.

Still, hard questions lurk beneath the cheery surface of consensus. Should the government mandate that people buy insurance, or that employers provide it? How will it be paid for? Should a government health-insurance plan compete with private insurers? Such an approach might get insurance to more people, but would it be unfair to private-sector firms because the government could undercut them on price?

Already there is opposition, even among Democrats, to an Obama proposal to raise money for reform by taking away the tax deduction for health-care benefits. Some oppose the rollbacks of the Bush tax cuts. And the AARP objects to a proposal to have wealthier senior citizens pay more for Medicare.

"Everybody agrees we ought to get rid of inefficiencies, focus on primary and preventive care, and get everybody in the system with affordable coverage," Schwartz said. "The difficulty, of course, is what do we mean by that? . . . Now the hard work begins."

Senate Finance Committee Chairman Max Baucus (D., Mont.) agreed. "This is going to be incredibly difficult," he said at the summit. "Let's not be naive on the cost."

But lawmakers told Obama they were willing to try. Leaders in both houses also have said they would let Republicans help write the legislation, raising hopes that the process will be more bipartisan than the recent fight over the economic-stimulus package.

"Bipartisanship is not just a nice thing we say to each other before we touch gloves, go to our corners, and come out swinging when the bell rings," Sen. Robert F. Bennett (R., Utah), a veteran of the battle over Clinton's plan, said at the summit.

Overhauling health care would represent "wrenching change," Bennett said, and the only way to bring that about is if leaders in both parties are willing to "join hands and jump off the cliff together."

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Franklin Delano Obama

Opinion - NICHOLAS D. KRISTOF

Most presidents are tacticians, but President Obama is a strategist. His budget suggests that he aspires to be an echo of Franklin Roosevelt and Ronald Reagan, harnessing his charisma, vision and political capital to transport America to a different place.

The best measure of that is Mr. Obama’s “down payment” to move closer to universal health coverage from womb to tomb. That is something that Roosevelt also sought, a lifetime ago.

The absurd system of health coverage we now have is a historical accident from World War II. Because of wage controls, employers competed for workers by offering health insurance as a fringe benefit — and so we’re stuck today with a system in which the loss of a job is compounded by the loss of health insurance.

Titanic ambitions encounter titanic opposition, and opponents of health reform are already rehearsing the arguments that they successfully used in the past:

We have the best health care in the world, and you want to create a socialized bureaucracy? You want to wait months for a necessary operation, as in Canada? And you really want higher taxes to pay for this, stifling the economy and undermining our long-term competitiveness?

So let’s examine those arguments.

It’s true that the existing system offers top-line medical care. The top five American hospitals conduct more clinical trials than all the hospitals put together in any other country in the O.E.C.D., the club of industrialized nations.

Yet over all, it is preposterous to argue that we have the best medical care in the world. Partly because so many Americans fall through the cracks and don’t have insurance, life expectancy is higher in most of Europe than in the United States. Even the people of Cyprus live longer than Americans, according to United Nations figures.

Meanwhile, American children are twice as likely to die by the age of 5 as children in Portugal, Spain or Slovenia. And the World Health Organization found that an American woman’s lifetime risk of dying in childbirth is more than three times that of a woman in Greece, Spain or Germany.

Meanwhile, Americans spend $6,800 per person to get these second-rate results, about double what is paid in Canada or much of Europe.

It’s true that Canadians and Britons wait longer for non-urgent medical procedures than we do. But we have to wait a bit longer than Germans do.

McKinsey Global Institute found that the United States spends about $650 billion more on health care each year than one would expect for a country at its income level. That’s $2,100 per American, and it’s one gauge of the waste of our existing system.

Repairing the system is thus not only a moral imperative but also an economic one. American businesses are at a competitive disadvantage when they have to pay for health care and foreign companies don’t. Among General Motors’ burdens is that it has to pay health costs equivalent to $1,500 for each car it sells.

Sometimes the financial incentives for aggressive care even lead to excessive treatment. One study found that Medicare patients admitted to high-spending hospitals were up to 6 percent more likely to die than patients admitted to lower-spending hospitals.

So if our health system is broken, is it really so awful that we increase taxes for the wealthiest Americans to make repairs? In 1980, the top-earning 1 percent of Americans accounted for 8 percent of the total income pie; by 2006, they grabbed nearly 23 percent.

Think of the way the system treated Michelle Morse, a full-time student at Plymouth State University in New Hampshire. Michelle was found to have colon cancer in 2003, and her physician recommended that she take a leave of absence for chemotherapy.

But if she took a leave, she would lose her insurance. Michelle stayed in school and underwent her treatments, while campaigning bravely for a law (eventually passed nationally last year) to let students remain on their parents’ health insurance while on medical leave from college. The law came too late for her: she died in 2005.

Would it have made a difference if Michelle had been able to take a leave and focus on treatment? “We’ll never know,” said her mother, AnnMarie Morse.

“It was horrible,” she said of her dealings with the insurance companies. She said that when one executive told her indignantly that the company had already paid out a lot of money for Michelle, she responded, “I would give my life for you not to have to pay one cent for my daughter.”

Not surprisingly, Mrs. Morse fervently hopes that Mr. Obama will be able to move the country toward a national health care system. If he can lead us there, even gradually, he has a chance to join the pantheon of truly great presidents like F.D.R. himself.

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