Healthcare role? CBO projects that if current laws do not change, federal spending on major mandatory health care programs will grow from roughly 5 percent of GDP today to about 10 percent in 2035 and will continue to increase thereafter. Those projections include all of the effects of the recently enacted health care legislation, which is expected to increase federal spending in the next 10 years and for most of the following decade.

The Government launched its HealthGov website. The look and feel is very consumer friendly. It underscores the government’s desire to market the new healthcare plan and its benefits. I applaud efforts to bring information to consumers about choices. On the flip side, one can become cynical after reading the CBO report highlighted above compared to the rosy picture painted on the website.

The big political news was that Dr. Donald Berwick’s nomination to head the Center for Medicare and Medicaid by-passed the Senate confirmation process through a recess appointment. It just underscores how tense the implementation process is for healthcare legislation… summer is not the only thing bringing heat to DC. I wrote about his appointment in my June 7^th blog.

From a legislative impact perspective, we have now entered the period of “temporary” high-risk exchanges until permanent exchanges are in place in 2014. Under the new law, people who have been denied coverage due to a pre-existing condition and who have been uninsured for at least six months may qualify to buy insurance.

Maine became the first state to ask for a reprieve from the medical-loss ratio of 85% mandated by legislation. Again this underscores the immensity of the negotiations and discussions going on, especially amongst the federal government, the states and insurance companies.

From across the seas, the new UK government just announced the biggest changes to the National Health Service (NHS) since its founding. They are in many ways breaking up how the NHS functions with the hope of reducing bureaucracy and management layers and giving consumers more choices. It is a call for decentralization. These are incredibly interesting times to see how different countries are approaching similar financial challenges.

I just finished reading my June Health Affairs as the July issue arrived on my doorstep. It is my “academic” resource into the world of health policy. June’s issue focused 100% on reform. I’d summarize the thirty-plus papers as a picture of optimism and historical opportunity interspersed with pessimism and warnings of naïveté. Many authors underscored that the current political landscape will make an already challenging implementation all the more difficult, an issue all sides clearly understand. It underscores to me that the process used in developing reform legislation is having a material impact beyond the legislative process.

The takeaways? We are moving into August when Congress will recess and we’ll see the 2010 election campaigns heating up. My tip for fellow readers is to look to candidates who are willing to talk in concrete terms about the challenges we face and solutions to those challenges. I also encourage people to spend time focusing on state elections. From my readings, much of the legislative detail will be developed and shaped by how states approach healthcare reform.

I hope you are enjoying summer.

For those of you who are as questioning as my friend and doctor, I would like to share what I have gleaned about the legislation so far. For simplicity, I have broken the impact of legislation into four areas:

• Access to Insurance & Changes in Industry Practices
• Government’s Role
• The Costs of the Legislation
• The Impact on overall Healthcare Costs

1. Insurance Practice and Access to Healthcare

President Obama said “the legislation embraced the core principle that everybody should have some basic security when it comes to their health care.”  It puts in place significant changes around insurance practices and access to healthcare for those who did not have it or could face losing it.

Some of the most popular and straightforward provisions are enacted within a year or even sooner including:

• Preventing policies from excluding coverage for pre-existing conditions for children up to age 19.
• Prohibiting insurance companies from the practice of rescission which is when an insurance company cancels a policy after the fact because you had a pre-existing conditions that was undisclosed.
• Removing any payment burden on patients for immunization and preventive services.
• Requiring insurance companies to report medical loss ratio, which is the ratio of what they take in on premiums and pay out for medical care. The rest is left for administrative/operational costs and profit.
• Removing life time limits on benefits.

Even more immediate, states can create or expand their own high-risk pool or leave their residents to join a national one by June 23rd. This is for those who can’t get insurance right now due to pre-existing conditions. Access to this pool isn’t for certain. Some may not be able to join based on income levels and funding. Twenty states have notified the Department of Health and Human Services (HHS) that they are not going to set up one and will leave it to the federal government to handle.

An analysis by the Chief Actuary at the Centers for Medicare and Medicaid Services recently projected that money would run out for the state pools by 2012 versus 2014 when a permanent program is implemented, a serious issue for cash strapped states. As Governor Rendell of Pennsylvania shared recently, states would rather shift risk to the federal government and therefore the blame if it goes wrong.

The big news and one that has generated the legal challenges by twenty states is that starting in 2014, everyone must have health insurance. Both individuals and certain sized companies would face penalties for not having or providing insurance, which is why the IRS will be involved. Various levels of subsidies are planned if your income is four times poverty level or below to help offset that cost. The states have to 2014 to set up insurance exchanges for the individual and small group market (less than 100 employees).

In shopping for policies however there may not be as much variety, as the legislation sets a fairly aggressive minimum standards.

In total it is estimated about 32 million will have insurance who didn’t or about 10% of our population. Of those abut 15 million will be added to Medicaid. Medicaid is the health program for eligible individuals and families with low incomes and resources. It is a means tested program that is jointly funded by the state and federal governments, and is managed by the states.

2. Government’s Role:

Perhaps the biggest change is the federal government’s leverage and authority in managing the insurance market, a muscle they have already begun to flex. There was no public option created which many said would be the tool to keep the insurance market honest. Health Affairs founding editor John K. Iglehart wrote in the May issue that the Secretary of Health and Human Services is granted broad authority to launch an array of pilot projects to reform health care delivery and payment. He goes on to say that “thousands of pages of new federal regulations will have to be written, to govern everything from how the state insurance exchanges will operate to what must be in essential packages of benefits.”

In reading healthcare articles it becomes clear we will need to increase our vocabulary of new acronyms for public institutes and centers including:

O Independent Payment Advisory Board
O National Center for Workforce Analysis
O Patient Centered Outcomes Research Institute
O Office of Consumer Information and Insurance Oversight

These join other already established public entities such as the National Health Service (NHSC) Corps and the Office of the National Coordinator of Health Information Technology (ONC).

Of importance is the nomination of Dr. Donald Berwick to the Centers for Medicare and Medicaid Services (CMS), a post that has been vacant for several years. The government currently pays for more than half of health care in the US as of last year through Medicare/Medicaid. CMS is the largest single payer in the country by far.

Dr. Berwick is a well-respected advocate for patient safety and quality improvement and was the founder of the Institute for Healthcare Improvement. Dr. Berwick has played a key role of being a respected outsider, pushing the system to change, while actually having insider credentials.  His nomination is important as it underscores the administration’s belief in the power of enlightened leadership and more effective government intervention. It has also generated pushback, with detractors focusing on Dr. Berwick’s public support of UK health system.

Which leads us to the third area of focus, the costs of these new policies, laws, and institutions.

3. The Costs

The plan’s price tag is just over $1 trillion over 10 years (the CBO recently raised its cost estimate for the plan by $115 billion).  My back of the envelope calculation is that it will cost roughly $4500 to $5,000 per person per year to provide insurance for six years starting in 2014. There are other benefits such as support for community health centers, closing the Medicare Part D prescription drug coverage gap, and tax breaks for small employers who provide health insurance included in the bill.

This cost will be offset by a wide array of new taxes and cuts in Medicare spending in Medicare Advantage. The biggest tax will come from an increase in Medicare tax for couples earning more than $250,000. There is also new tax on unearned income such as dividends for the same earning bracket. There is a tax on almost all components of healthcare including pharmaceuticals, medical devices, and insurance policies. There is even a tanning tax.  Many expect these taxes to be passed on to consumers through higher costs.

I think of it as similar to my phone bill. While my basic package may be $29.99 there are four to five lines of additional taxes and while individually small, each one adds up to make my bill $43.99. Many are cynical that actual costs will not be as predicted. Adding to this worry was the debate whether the writers of the legislation were gaming the system to ensure the legislation was deficit neutral, for example, providing six years of benefits while initiating 10 years of taxes.

The sum total of the cost conversation is an American public leery of government legislation that isn’t funded and a perception that politicians have become experts at dispensing perks and favors. Spend now.  Pay later. A strong sign of this was the recent difficulty Congressional Democrats had in passing The American Jobs and Closing Tax Loopholes Act which extended unemployment benefits and offered the doctor fix of $65 billion to increase Medicare payments to physicians scheduled to be drastically reduced. This is something in years past that would have gotten little or no opposition.

4. The Impact on Overall Healthcare Costs

One goal of the legislation was to bend the cost curve of healthcare, on track to consume 20% of our GDP in less than 10 years. Proponents of the legislation say it will bring down the cost curve in general. How? The legislation funds the Patient-Centered Outcomes Research Institute to plan and help carry out comparative effectiveness research. The flip side is that the law actually states that its recommendations can’t be used to deny treatment. There are provisions for HHS to launch payment pilots for reimbursement for overall care of a patient or certain diseases. And finally there is a new Independent Payment Advisor Board with authority to recommend proposals to limit Medicare spending growth.

Interestingly, Dr. Atul Gawande, whose writings garner much attention, wrote a short commentary in the New Yorker in April saying, “The most interesting, under-discussed and potentially revolutionary aspect of the law is that it doesn’t pretend to have the answers.” I had a good chuckle when I read that line, as somehow I don’t think those were talking points many political leaders have been using.

A darker and more realistic picture is one painted in Michael Turpin’s excellent piece called Managed Care 2.0 which outlines what he envisions will be an environment of tense relationships as players try to deal with increasing costs.

My take is that the vast majority of Americans don’t expect to read headlines soon that healthcare costs are going down. I agree. Why? The fundamentals haven’t changed. Americans still by and large believe more healthcare is better. More now have access to it, we don’t pay the direct costs, and providers earn more the more they treat. This is a system destined for cost growth. It is incredibly complicated, and we just added more complexity. The government has shown equally disappointing job driving costs down in Medicare and Medicaid.  Past performance is the best indicator of future performance.

No mistake there will be intense “price” negotiations played out in the public such as those going on in Massachusetts and California between the states, insurance companies and providers. I see these more as power plays squeezing someone’s margin or costs but not changing the actual cost of service.  As a taxpayer, I glad to see the savings, but this will not get us where we need to be. It may force our best and brightest to leave healthcare and leave consumers actually at the mercy of negotiations and bureaucracy.

Which leads us to important question of participation and representation. If we are on a course for a future in which healthcare costs will consume the largest portion of government spending, we need to be vigilant as citizens. Warning signs of the future are the ones playing out in Europe. Government deficit spending has forced a very change in thinking about the cost of the financial and social safety net provided over the decades to its citizens.

Which brings us back to the statement from President Obama in heralding a new era of health security. In stepping back and reflecting on this statement, one has to wonder if we have purchased a false or short-lived security.

CBS Evening News shared results of a recent poll that one in two Americans say that life for the next generation will be worse than it is now, up from 32 percent last March. Just one in five expects it to be better. When I read this, I think we are talking about another country. Given our long national history of optimism, this is a sea change.

There is much at stake, and we need to be as engaged as possible. So next time you are at a summer barbeque and the conversation turns to healthcare, don’t look puzzled and go for the chips and dips, but offer what you know and see where the discussion goes. It is an important part of being a good citizen.

Having covered the reform process since last summer, I purposely took a break after passage.  We all need time off. I adore spring, especially Easter with its message of hope, rejuvenation and joy.

I needed that message having become disillusioned with the process, as did many Americans.  For the American public, that disillusionment continues today.  A recent Rasmussen poll found 63% of Americans support repeal of the law, and as writer Michael Gerson points out, is interesting considering the legislation offers significant benefits to millions.

Most importantly there is a growing unease about our country even as we are supposedly working our way out of the recession. This sense has been aggravated by the terrible oil spill we see every day but can’t seem to do anything to stop it.

The danger in all this is to give up, retreat into hiding or become a permanent cynic hoping somehow this will not affect me. But it eventually will. What impressed me this last year was how the American public did participate in healthcare debate. More so than ever we need people to be engaged. So I am back, hoping to help fellow Americans take a complex issue, healthcare, and break it down into in a way that we can all participate in the dialogue of improvement.

Most people love sports. In March, well it is about basketball with brackets, favorite teams and picking pools. But it is more than that. Even as my husband’s team fell in the first round, my boys were glued to the screen last night as Kansas fell to Northern IOWA. We are part of the magic so to speak. We understand the game, the discipline it takes, the hard work, and the glory of victory and agony of defeat. But most importantly, we realize there is or should be something in it for everyone.

There is another sport going on right now today, and it is called find 216 votes as the House of Representatives is set to vote on the Senate healthcare bill and then a reconciliation bill. Or so I think. It has changed almost daily. As I write this morning, there are still deals being made to get to the magic 216.

We have spectators. The opposing views appear in editorials like the LA Times and Las Vegas Review. You have protests and phone calls from both sides. Harry Reid himself used a sports analogy, saying the buzzer had gone off, and Republicans were only delaying the inevitable. The sports writers are there. David Brooks, David Leonhardt, and Ezra Klein are some I have published on this site.  The ESPN of politics – www.realclearpolitics.com – gives you the latest.

March madness for most Americans is a good thing. But there is a madness in Washington that reminds me of a scene in Alice in Wonderland where everyone tells the Queen exactly what she wants to hear, afraid of the repercussions. Just as we talk about this historic vote and that to do nothing is not an option, the question to the American Public was “never do nothing”. We just expected more, something different than this.

I coach soccer and find great joy working with kids. My biggest message before every game and during practice is that it doesn’t matter if you win or lose. It is how you play the game. Whichever way the vote goes today, it will leave the majority of Americans feeling that game we just watched over the last 15 months wasn’t the game we sent our politicians there to play.

Share/Save]]> http://www.healthcareletter.com/2010/03/21/march-madness/feed/ 0 http://www.healthcareletter.com/2010/02/25/never-too-late-for-a-new-year%e2%80%99s-resolution/ http://www.healthcareletter.com/2010/02/25/never-too-late-for-a-new-year%e2%80%99s-resolution/#comments Thu, 25 Feb 2010 15:17:02 +0000 admin http://www.healthcareletter.com/?p=1358 I used to think January was a boring month, pushing through the snow until the arrival of Valentine’s Day and a much-needed dose of chocolate as a winter anti-depressant. Not so. January proved anything but boring: from the “Scott Heard Around the World” story in the Massachusetts special U.S. Senate election to the visit by the President to the Republican Congressional Retreat in Baltimore on January 29.

February saw both sides re-trenching, and the headlines have focused on the bipartisan healthcare summit hosted by The White House with invitations to Democratic and Republican congressional leadership.

The activity prior to the summit may be telling. The White House released a proposed bill costing roughly $950 billion that is similar to the one passed by the Senate in December, and the pre-summit talking points do not bode well for a collaborative open-ended process to determine how to attack one of our greatest challenges.

While we continue to watch Washington, I am afraid our political leaders are losing sight of a key lesson from Massachusetts: the notion that leaders should never ever underestimate those they lead.

Six months ago, from the viewpoint of a mother, patient and healthcare-industry worker, I wrote A Healthcare Letter to friends and family asking them the following:

Ultimately please don’t think of healthcare reform as a one-time political process happening this fall or not at all. That is the how we can start to change the reform process. Think of it as an evolving transformation in changing the way Americans think about our health, how we manage it, how we improve it and how we finance it. And if we do this right and we are involved, we can achieve successes and breakthroughs along the way.

January’s events have given this country time to pause at least for a moment, so let us use it wisely.  Dr. Kent Bottles, writing for the Institute for Clinical Systems Improvement (ISCI), hit the nail on the head in the first line of his recent blog:

The task of healthcare reform in the 21^st century is to decrease per-capita cost of care and to increase the quality of care delivered to patients.

He later concludes what most of us feel: Healthcare is incredibly complex. Adding to this is the fact that a majority of Americans don’t understand nor trust what is contained in the 4,000 plus pages of healthcare bills. While some politicians may pivot and try new media tactics or out-reach campaigns, I vote for creating an environment in which many more can engage in the conversation and join together for a common cause just as we did in World War II.

I ask for a simple national New Year’s Resolution: Let us individually better understand the healthcare problem – and opportunities.

If we are to tackle the challenge Dr. Bottles presents, there are key issues that we need to understand if we are to be part of the solution, not just a mob to be manipulated. First, the healthcare problem is our national financial problem. The numbers speak for themselves.

The second key premise is that with all that money spent and borrowed we get a mixed bag.

• We have the best hospitals and doctors in the world. The Ranking Web of World Hospitals reports 30 out of the 50 Top Hospitals in the World are American. My family has personal experience with three of them.

• We have amazing life saving treatments in the U.S. The five-year cancer survival rate in the U.S. is 63% compared to 55% in Europe for women.
• But while our health has improved in the U.S. as measured by life expectancy, other countries that spend considerably less on healthcare have higher life expectancy. The average life expectancy of Americans is 78.1 or 49^th on the world list. Countries such as Japan, Canada, France and Switzerland are higher.
• We have world-class science, technology and healthcare providers, but many Americans still don’t get the right care or care at all: A famous Rand study concluded that Americans receive only 55% of the care that science dictates.  Other research shows that on average 50% of the 2 billion prescriptions filled annually are not taken appropriately. It is also estimated that non-compliance to prescriptions generates 10-25% of nursing and hospital admissions.
• What and how we eat may cost us more than we think. Americans get a “bargain” for their food. Or so we think. On average we spend 10% of our disposable income on food. In 1933 it was 25%. Looking across the ocean to Europe, we see a different picture. While Europeans spend less on healthcare, they spend more on food. More interestingly, the disparity increases when we look at food consumed at home. In fact Americans spent only 6.1% on food at home while Germans spent 11% and France close to 14%.
• The great American entrepreneur and the power of the consumer have been held captive in Healthcare. The average price of a new PC last year was only $581. The average cost of care was $7681 per American. One keeps going down; the other keeps going up.

When you look at these issues you see why a traditional political course of making deals and sharing the pie to court votes will not come close to helping us improve our situation. As importantly, making promises to Americans that, if you like what you have, you can keep it and nothing will change, paints a false sense of security and lacks integrity.

While we may hope and wait for our politicians to change, let’s look within. An old notion is that liberty’s very foundation is rooted in knowledge and learning. It might not be too hard to become better informed than those walking the halls of D.C. The experience of last year should underscore to every American that this is our challenge to undertake, and it starts with us understanding not just our own personal situation but that of our country. The oft-neglected concept of the common good remains valid.

In the throes of World War II, a reporter asked Winston Churchill what made him such an extraordinary leader. He replied that these were extraordinary times and extraordinary times make extraordinary people.

Perhaps the real lesson of last year is that America’s savior is not a person but ourselves. We must understand the challenges that face us.

Oakleigh Ryan lives with her family in Janesville, WI with her husband Tobin, and two children. She writes at healthcareletter.com and can be reached at oakleighryan@healthcareletter.com

In short it is like reading tea-leaves. At this point all I can say for certain is that there will be a Healthcare Summit sponsored by the White House with an invitation to Republicans to attend and participate. Mark your calendar February 25. My guess is it will be a mixture of American Idol and Twelve Angry Men.

While our politicians pontificate and ponder, please take two minutes to watch this video and you will see why at the core of any healthcare reform needs to be the engagement of the patient/consumer if we are truly going to wrestle this cost beast to the ground. You also will get a good chuckle. That to me is priceless these days.

In the meantime I am going to offer at least a step forward. Stay tuned.

I realize my guest’s core reactions stemmed from feeling overwhelmed by the seemingly inscrutable nature of the problem, while wanting to assure healthcare for his fellow citizens. Americans want to do something when faced with a problem. This is a sentiment that bespeaks the essential decency underlying the debate, a concern for fellow human beings.

As a reasoned response to the “We’ve got to do something” instinct, I’m suggesting an op-ed by David Brooks in the New York Times, appropriately entitled “Hard Call.” In a few minutes of the reader’s time Brooks outlines the pros and cons of voting for Senate package as it was shaping up in mid-December. Today his points and insights are still relevant.

An important passage reads, “If this passes, we will never get back to cost control. The basic political deal was, we get to have dessert (expanding coverage) but we have to eat our spinach (cost control), too. If we eat dessert now, we’ll never come back to the spinach.” As the mother of two young children this analogy struck home.

As we seek and sort out options and solutions, respecting each other’s hopes and fears, I remind myself that the tone and style of the dialogue is as important as the content many times.

Here is some of December’s key dialogue which seemed to me less influenced by political leaders, who were buried away behind closed doors.

In my first post on Healthcare Letter to Americans, I quoted an important article written by Dr. Atul Gawande in the New Yorker comparing the staggering differences in costs of healthcare in two comparable Texas towns. Even President Obama referred to this oft-cited article. Dr. Gawande espoused that meaningful change had to come from within the industry. “Dramatic improvements and savings will take at least a decade. But a choice must be made. Whom do we want in charge of managing the full complexity of medical care? We can turn to insurers (whether public or private), which have proved repeatedly that they can’t do it. Or we can turn to the local medical communities, which have proved that they can.”  My sense was he saw the current reform process missing the bigger picture.

Jump four months forward, and my ever-faithful mother sent me (yes – I share the trade secrets of a blogger) an article written by the same author in the December 14 New Yorker.  Titled, “Testing, Testing,” this latest article took a different bent. It compared the current Senate reform full of pilots, incentives and other regulatory pushes with the government intervention in our agricultural industry in the early twentieth century and ensuing successful outcomes. To quote Dr. Gawande at the end of the article, “But if we’re willing to accept an arduous, messy and continuous process, we can come to grips with a problem even of this immensity. We’ve done it before.” Most importantly though Dr. Gawande was taking the stand that what we have now in the Senate was worth pursuing, meaning, let’s get on board here folks.

No sooner than the ink had dried but the Wall Street Journal wrote an editorial, “The ‘Cost Control’ Bill of Goods,” citing the growing number of people who had abandoned the idea that reform would reduce costs but were looking for other reasons to support the bills. It highlighted the Leonhardt article in the New York Times (posted here in November), the just-printed Gawande article, as well as others. The WSJ editorial board summed up by saying, “They might have piped up earlier: What they’re finally admitting is that all the grandiose talk about “bending the cost curve” used for months to sell ObamaCare really comes down to their hope that bureaucratic improvisation will make a difference over the long term.”

Perhaps more interesting, on December 22, in an article written for Health Affairs, The Policy Journal of the Health Sphere, Professor Alain Enthoven wrote a very structured argument identifying three flaws in Dr. Gawande’s position and positing that the current reform is an economic recipe for disaster. He also advocated ideas for reducing costs that he has been espousing for several decades.

In his opening paragraph, Prof. Enthoven intertwines policy and politics by writing, “Atul Gawande, MD, is one of the best medical writers of our time. I subscribed to the New Yorker just so I could read him. I reached eagerly for my December 14, 2009 New Yorker when I read he had an article there. I was deeply disappointed. What worries me is that his article will be used to support a political campaign to gloss over the failure of proposed legislation to significantly moderate health expenditure growth.”

When I finished this article and got a moment between holiday preparations to reflect, I had a satisfying moment of feeling included in the conversation.

As a Christmas present to yourself, please take a break this Holiday Season and sit at the table with Dr. Gawande, Professor Enthoven and others. Join in a fascinating and necessary conversation.

I have two posts from The Health Care Blog. To start, a little about The Health Care Blog. Its web banner proclaims: “Everything you always wanted to know about the health care system. But were afraid to ask.” They mean it! There are typically 2-3 articles a day. Some can be long, technical and full of jargon. Some are not. There is also a certain perspective you pick up quickly from each of the routine contributors.

What strikes me is that here is where real debate goes on. To read something on this site and then pick up what the political leaders are saying shows the wide gulf between real debate and political rhetoric. To an outsider such as myself, it can appear at times like an intellectual fraternity but it is worth reading. Bottom line: There are things discussed here that we, the general public, should be exposed to for our own benefit. Since many of our political leaders are less inclined to do so, here you go:

One article appearing last week, “Saving Health Care, Saving America” by Brian Klepper, David Kibbe, Robert Laszewski and Alain Enthoven, condemns the current reform legislation for its total avoidance of dealing with the real issues of cost reduction and provides the overriding reason for this. When you read this article you will see why I am suggesting it for your reading list.

The other post, “Time to Put Aside the Intellectual Disputes for Now,” is by Matthew Holt who founded Health Care Blog in 1993. This particular piece is telling as it gives insight into the thinking of those who support the current legislation and why they are willing to overlook the so-called short falls to realize the dream of universal coverage.  I don’t necessarily agree with Mr. Holt, but understanding his logic is critical to understanding reform and the people driving it today.

I share an article by David Leonhardt that appeared in the New York Times Magazine on November 8th. A friend recently recommended it, saying excitedly “This is what we should be talking about.” I was so gratified to find that someone who had gotten the spark to pursue and examine healthcare issues from this website was now contributing to it! We are acting and reacting together, learning and sharing with each other information on life’s most important issues. A recent AP opinion poll, conducted from October 28^th through November 8^th, suggests the public is becoming more attuned to the fact that when it comes to health care, details often make all the difference.

As for the article itself, my favorite part is how it points out that the best reform ideas will most likely come from within the industry itself, especially from physicians. This is something I’ve advocated in A Healthcare Letter.

To end, I have a “lighter” article from the November 10th New York Times that sums up some of the latest thinking coming out of the Senate.

In case you missed it, I did update my latest opinion on the output of the reform process in a post dated October 21st. Sometimes I offer others’ opinions, while sometimes I offer mine. Most importantly I hope this helps you to form your own.