49 thoughts on “Why I Am Not Worried About Health Care Reform”

1. How do you think the CBO will score the House bill today? It sounds like many of the things you’re talking about are in there.

2. Maggie
   Nice summary.
   For those following this (mis)adventure, we are all learning how important CBO scoring is in the final analysis. As Orszag points out on his blog, so much of what is possible is a savings black box. How you view the final numbers can be skewed on ideology vs pragmatism. Seems so precarious. If I was a betting man, CBO will score more conservatively unless final bill includes some kind of trigger mechanism that automatically ratchets down fees. That will be a neat trick.
   Also, a little nugget I noticed from the HELP committee: over 600 amendments, one of which, and ironically is one of the early five adopted, is this gem from Hatch:
   **Sen. Orrin Hatch, R-Utah: To ensure that community health teams include doctors of chiropractic (adopted).**
   Now please, the right whines so about coverage mandates and unnecessary pork. Not that, a) chiropractic does not have its place/benefits, and b) is onerously costly, but please, when we are in the midst of talking about poverty coverage levels and “life or death” type stuff…to see this. How much you want to bet that some PAC is in his back pocket on this one.
   Brad

3. One other thing. On the reconciliation front, the issue of what the parliamentarian would do to a bill pushed through via this mechanism would render the bill useless. The term I have heard mentioned countless times is a “swiss cheese” mess. Most folks in the know seem to say that it simply wont work as an effective alternative to reform completion. A non-starter at this point, take it off the table.

4. Maggie Mahar says-
   “Those who have been gouging the system will have to be gored. Imagine a slaughterhouse with gobs of fat and pools of blood on the floor”-
   Ouch!- But correct. There will be real economic losers in this “game” but the correction is long overdue.
   The worst offenders know they are in deep trouble so, having little to lose, watch for some real dirty fighting.
   The President and his team will come out as winners.
   But the real winners will be the American health care consumer.
   Dr.Rick Lippin
   Southampton,Pa

5. While I oppose a public health insurance option, especially one that would pay Medicare rates or a slight premium and require providers to accept it if they want to continue to do business with Medicare, I strongly support giving MedPAC the power to use established science and current cost-effectiveness and comparative effectiveness data to drive coverage and payment policy. Bending the medical cost curve down toward a level the society can afford and sustain will depend a lot more on eliminating wasteful and ineffective utilization and reducing regional practice pattern variation than on just squeezing per procedure provider payments.
   If we are ultimately successful in bending the cost curve, the biggest losers will be hospitals, surgeons, oncologists and other highly compensated specialists. Hospitals in particular will find that lower utilization means less revenue and the need for fewer employees. Painful and unpleasant adjustments, especially in personnel, will be required. Highly compensated specialists will, as a group, see their incomes decline unless they are already salaried. Even then, we shouldn’t need as many of them relative to the population overall. At the same time, if more patients with heart disease get conservative drug therapy instead of stents, more diabetics take their medication regularly, and more of the currently uninsured get access to drugs and other appropriate care, the drug industry could actually benefit or at least largely offset any impact from lower prices for brand name drugs. Insurers, for their part, would benefit in the short term from lower utilization of healthcare services. They try to price their products based on their estimate of medical cost growth for the next year. When that trend comes in below expectations, profit margins expand. Conversely, when it rises faster than expected, margins are squeezed.
   I think we will see the greatest resistance to healthcare reform coming from hospitals and highly compensated physician specialists. Physician enthusiasm will be even further reduced without substantive tort reform which doesn’t appear to be a high priority for Democrats to put it mildly.

6. The “public option” remains the best way to restore competition into the “single-profiteer” health market, lower health care premiums, lead the way in innovation and improve health care quality.

7. Steve, Brad F.,Dr. Rick, Barry, Gregory–
   Seteve–There are still too many unknowns in the House bill to come close to accurately assessing the likely cost.
   For instance: Exactly what will insurance plans be required to cover? Just how comprehensive will they be?
   Just how stiff will the penalties be for those who do not buy insurance? (If they are stiff, more young, affluent individuals will buy the insurance, adding to the pool of $%% available for subsidies, and lowering the total cost of the plan for taxpayers.
   As the Times pointed out today, the House is not asking CBO to score it, knowing that there are still too many key details missing to make it scoreable.
   Braf F.–
   Thanks–
   Inevitably, there will be hundreds –even thousands– of amendments, as there were when Medicare passed.
   Making a place for chiropracty is probably far from the most trivial. (And I agree chiropracty does have benefits. For most people with back pain it beats back surgery, hands down. For my part, I’d like to see acupuncture covered as part of any basic plan.)
   But I have to disagree on the reconciliation bill.
   With reference to reconciliation, the “swiss cheese” phrase was coined and used by Kent Conrad—
   ad naseum, on every network and in every outlet where he could use it throughout the spring.
   Conrad’s primary goal: to protect the insurance industry’s interests. (Although he is from North Dakota, he has taken large sums from Connecticuts’ insurance industry. (And he doesn’t actually live in North Dakota– he lives in a lovely beach house in Delaware, financed by Countrywide Mortgage–i.e. Angelo Mozillo.)
   Here’s the kicker: Wnen it came down to a vote, Conrad “provided the decisive vote in House-Senate conference to allow reconciliation.” The Wall Street Journal wrote about this in an editorial titled “Kent for Rent.”
   As you know, I repect Peter Orszag immensely, and he insisted that reconciliation had to be on the table. I’d add that when it comes to being “in the know” as to how the legislative process works (or anything else), I would put Orszag far ahead of Conrad.
   Jonathan Alter had a very good column on reconciliation in which he wrote ” If we want to “put away childish things,” as President Obama urged in his Inaugural Address . . . we’re going to have to get used to the idea that transformational change in health, education and energy policy is more important than whether Republicans cry foul over being railroaded.”
   “Republicans are shocked (shocked!) at the idea that a tool they used when they were in control to pass huge tax cuts for the rich in 2001 and 2003 might now be used for Obama’s agenda,”Alter continued.”Republican Sen. Judd Gregg, only recently Obama’s Commerce secretary designee, now says that using reconciliation is “an act of violence” and that the majority is “running over the minority, putting them in cement and throwing them in the Chicago River.” In a strong bid for the hypocrisy gold, Gregg favored using reconciliation not just for President Bush’s tax cuts but for Bush’s plans to drill in the Arctic National Wildlife Refuge as well. Now he favors using reconciliation for obfuscation—to convince the public that the Democrats are somehow corrupting the process.”
   As for the idea that reconiciliation would undermine the strength or significance of a health-care bill in the eyes of the public, Alter quote Rahm Emanuel: “Rahm Emanuel scoffs at the notion that the public is going to tune in to an archaic debate. “‘Hell’—except he didn’t say ‘hell’—’half the press corps doesn’t understand what reconciliation is.'”
   As for the opinioni of the parliamentarian: in the past, when two parliatmentarians offered rulsings on two separate uses of reconciliation that the Republicans didnd’t like, the Republicans fired them.
   As Ezra Klein puts itin a detailed and in-depth primer on reconciliation: the paraliatmentarian’s opinion is merely “an obscure bureaucrat’s interpretation of an undefined Senate rule.”
   Klein concludes that it could be troublesome, but is certainly not a reason to take reconciliation off the table.
   Rick– It will be very messy. As you say, some of the interested parties have little to lose. The inusrance industry knows that its Medicare advantage windfall will be cut, and without that, the industry is in trouble.
   IT will no longer be able to cherry pick, shunning the sick. It will no longer be able to illegally cancel policies when people get sick.
   And if it has to compete with a robust, reformed version of Medicare . . . .
   But the fact is, taxpayer cannot afford to bail out another U.S. industry just because it cannot compete.
   Still, the insurers will kick, scream, and lie all the way down. And there is a lot of money out there, coming from people like Rick Scott who will support them.
   But not everyone will be gored–only those who gougeed.
   As Don Berwick says in the film of Money-Driven Medicine — a great many fear that they will be gored who,in fact, won’t be gored. Here I’m thinking of hospital and doctors who have been practicing fairly efficient evidence-based medicine. Reform will support them becuase reform will be paying More for quality. In teh past, hospitals were punished for quality– if they were efficient, and patients were not re-admitted, they received less, while inefficient hosptials were rewarded for inefficiency.
   That will change.
   Barry–
   Here is how business consultant Bob Laszewski described the for-profit insurance industry late last year: “…it rewards manipulation over innovation and speculation over genuine value creation, resulting in massive misallocations of capital and the accumulation of unheard-of wealth in the hands of money managers and top corporate executives who are more lucky than they are skilled.”
   Laszewski concluded “And it will be so treated.”
   And Laszewski is a centrist who believes in the market.
   Meanwhile, the President of the United States says that we need a public sector insurance option: “to keep private sector insurers honest.”
   The President of the United States believes that otherwise, for-profit insurers will not behave honestly.
   What does this tell you about the for-profit insurance industry?
   I agree that reformers should follow MedPac’s recommendations.
   But MedPac does not call for cutting hosptials across the board. For 2010 it calls for Full Funding of hospitals.
   What MedPac does call for is programs that provide financial carrots and sticks–penalizing hospitals with a high number of preventable readmissions, and bonuses for those approach bencharks of value (better outcomes at a lower price) like Geisinger and Mayo.
   So some hopsitals wil receive more Medicare money Only inefficient hospitals would suffer.
   Moreover, hospitals do not, buy and large, need to cut the number of employees that they have..
   Most hospitals are understaffed: too few nurses, too few lab techniciains; too few practical nurses and other nurses aids; too few people to input data into electronic meidcal records.
   (When you go into a hospital, do you see a lot of staff just lounging around??)
   Healthcare is and will always be a labor intensive business.
   When you “downsize,” people die.
   Better follow-up after discharge means you need more staff so that there are people available to make the follow-up phone calls and even, as needed, make home visits.
   What hospitals need to do is to reprioritize spending, focusing on spending that reduces errors and infections and improves patients’ health.
   Meanwhile, I suspect that many building and revovation projects will have to be halted. The hospital building boom has turned into a bubble.
   This will be bad news for those feeding at the trough of the hopsital construction industry.
   But health care workers–people who actually touch patients– are needed more than ever. (I spoke to someone yesterday whose mother had a major stroke.
   She had been in the hospital for quite a while when one day,one of the many specialists who consulted on the case actually touched her!)
   Gregory: I agree. And,
   more importantly, so does the president.

8. Maggie
   Re: reconciliation, I am very familiar with Ezra’s piece(not so sanguine a strategy based on my read, just me though), and I have read and heard other reports on this maneuver. While Conrad might have originated the label “swiss cheese” (I was not aware), it is irrelevant in my book.
   Republicans have used it in the past as it is widely known, yes, but a bill of this size is unprecedented.
   Are there any articles or references you could provide demonstrating how you could realistically push a bill through with this tactic? Yes, you could fire the parliamentarian a la Saturday night massacre, but given the magnitude of this legislation, my gut tells me its too unwieldy and blunt. I know you will say that if the negotiation gets to this point, who cares, but again, procedurally, it will be a mess.
   Anyway, it just might be we have a different read, but I would love to learn more if you have link or two that digs deep into how it could work–in reality.
   Brad

9. My PCP is going to work for one of our infamous local hospitals on July 1st. I understand that my PCP may be happy working for the hospital in the beginning but the bitter divorce rate is high in these situations, as physicians usually seem to wind up feeling cheated as the hospital gets the authority and the money while the physician is left with the responsibility.
   Merrit Hawkins & Associates, a physician staffing company, reported that the demand for primary care physicians spiked in the 1990s during the heyday of managed care but declined while demand for surgical and diagnostic specialists increased. Subsequently, in 2008, the demand for specialists remained strong but hospitals focused on recruiting family physicians.
   Hospitals largely assumed they could improve profitability of physician practices based upon three assumptions: physician practices are grossly mismanaged, improved economies of scale that hospitals can bring and hospitals have lower costs of captial, especially in the case of non-profit hospitals.
   The long-term trend continues to favor the growth of hospital-owned physician practices. They are being integrated because of the need for physicians in the community and the sophistication to manage physicians, financially and culturally.
   I understand that when physicians become employees, they lose the ability to price their time and the hospital controls this last bit of automony. I wonder how long this marriage will last?

10. Gregory,
    Let me give you a little more information about the first wave of physician practice acquisitions which occurred in the early and mid 90’s and was (in general) a financial disaster for the hospitals.
    The thinking at that time was that everyone was going to belong to HMO’s and hospitals needed to capture “covered lives” and ensure a steady supply of patients to their hospitals. In essence hospitals saw themselves as the “Queen Bee” in the center of the hive directing their “drones” (doctors) and “worker bees” (nurses and employees) in the care of their “larvae” (patients). Obviously, physicians and insurance companies didn’t see it this way. (Of the three entities; hospitals, physicians and insurance companies, insurance companies have probably been the most successful in establishing control of the system)
    I know quite a few physicians that sold their practices to hospitals. You are right, most of the hospitals assumed that they could: “improve profitability of physician practices based upon three assumptions: physician practices are grossly mismanaged, improved economies of scale that hospitals can bring and hospitals have lower costs of capital…”
    This assumption proved to be very wrong for 2 reasons:
    1) Most physician practices were not as badly managed as hospital administrators thought they were. It turned out that hospital administrators were no better (and frequently worse) managers than physicians.
    2) Physicians put on salary tend to decrease their productivity.
    The net effect was that most of the practices lost money and after a while the hospitals divested themselves of the practices. I know several physicians who managed to sell their practices to 2 different hospitals and have the hospitals give the practice back to them both times. (they continue to run these practices successfully).
    The general consensus of hospitals at the end of the 90’s was that it was a bad idea to buy physician practices, except for certain specific circumstances in which a particular specialty (Neonatologist, Intensivist, Breast Surgeon) was needed to provide critical services at a hospital.
    I haven’t heard about a second wave of hospitals buying physician practices, but I am not as in touch with these trends as I was in the 90’s. I will be interested to see how this second wave works out, but I have my doubts that this will be any more of a “marriage made in heaven” than the last wave.

11. Legacy Flyer
    Steve Eisenberg, a health care industry attorney, has said that hospitals, physicians and health care lawyers have learned that many things are different in 2008 as compared to the mid-90s.
    Rather than large salaries and bonuses that were not supported by productivity, compensation is now more focused on both strategy and productivity. They feel that both physicians and hospitals need each other more than ever.
    Many physicians are seeking hospital employment to relieve the stress of administrative duties and the general risks and hassles of private practice. And hospitals are recruiting physicians for employment so their competitor does not employ the physician.
    This is something that happened directly in my county. The other competiting hospital wasn’t going to go in this direction (particularly after just opening a brand new hospital after 135 years), but they had to, so the other hospital wouldn’t buy up most of the remaining physicians in the county.
    In the hospital employment model today, the income guaranty length is just a year (instead of five). I think today, the employed physicians often have significant input on the employer’s governance and providing significant operational controls. The hospital leases the existing practice’s space, equipment and employees, which is what I think my PCP is doing.

12. Why is there no mention of legal reform as far as malpractice reparations are concerned? Are liberals that “in-the-pocket” of trial lawyers?
    If all options and sources of cost savings are to be considered this should be a central tenet. This alone would garner significant physician positivity as far as reform in general.
    There has been no agreed upon “expense” of defensive medicine but it is an absolutely undeniable expense in this bloated system.
    Conrad may very well be a little suspect as far as his history, however the co-op idea sounds as if it could have merit if the regional and/or state sponsored programs could garner enough clout.

13. Gregory and Legacy Flyer
    Once again, I think this is an area where the incentives that drive the payment system are critically important. Under a fee for service structure, I suspect most hospitals would view most PCP practices as money losers unless they can drive enough revenue through referrals and admissions to the “mother ship.” By contrast, if they are trying to build an accountable care organization (ACO), which is similar to an HMO, with payment via capitation for the management of chronic disease and general primary care, then keeping patients healthy and out of the hospital would work best financially for the organization. Of course, it is very difficult to forecast healthcare costs a year in advance which makes capitation a risky approach unless the patient base is quite large. Even then, with potential profit margins in the mid-single digits at best, estimating the medical cost growth trend even one percentage point too low could have a material adverse impact on profitability. That risk, of course, means that substantial reserves are needed to ensure that the organization can continue to function and serve patients through difficult financial times.
    I wish reformers would spend more time and effort trying to get the payment incentives right instead of spending so much energy arguing about for profit vs. non-profit insurers and whether or not we need a public insurance option to keep private insurers honest. With proper payment incentives, an appropriate regulatory structure, and more robust price and quality transparency with respect to both healthcare and health insurance, the rest will take care of itself. Just my opinion, of course.

14. Greg,
    Thanks for the info. It will be interesting to see how it works out.

15. Brad–
    I’m sure you have read what Ezra has written in his blog and Washington Post column, but I’m wondering if you have read the longer piece,devoted to reconciliation that he wrote for American Prospect here http://74.125.47.132/search?q=cache:5MFllksHesIJ:www.prospect.org/cs/articles%3Farticle%3Dthe_fifty_vote_senate+reconciliation+and+%22Ezra+Klein%22&cd=1&hl=en&ct=clnk&gl=us
    What’s key is the Byrd rule, which aims to protect Very Important legislation from filibuster–and allow it to go through on 50 votes
    (This is where many people are confused– they assume that reconciliation is supposed to be reserved for less important legislation).
    Specifically Byrd was concerned that bills that reduce the deficit be allowed to go thorugh on 50 votes–without filibuster. As Ezra explains: ” some priorities — deficit reduction and the budget among them — were judged too important to face the filibuster.”
    The beauty of reconciliation is that it restores the purity of the striaght up or down vote.
    Filibuster can obstruct any legialtion–even if the majoirty want it. The only way to break a filibuster is with 60 votes.
    (Ezra explains how reconciliation would lead to an omnibus bill in his American Prospect piece.)
    This is all that the paraliamentarian is supposed to rule on– does the legislation come under the Byrd rule?
    Argualably, health care reform is all tied up with deficit reduction–it is key to saving the economy.
    If we don’t rein in health care inflation, the defict will continue to spiral.
    Again, Ezra: ” an observer might wonder what renders deficit reduction so much more pressing than, say, ending the punishing human cost of the health-care crisis,”
    I imagine that the Obama administratoin and Orszag see the connection–and realize that, logically, there would be little reason for the parlaimentarian to rule against reconicliation in this case.
    The fact that Kent Conrad invented the Swiss Cheese metaphor and was practically the only person to use it with regard to reconciliatoin (excepting some reporters who repreated him, having no real understanding of reconciliation) is important becuae Conard:
    a) has an axe to grind
    b) is corrupt (see Countrywisde scandal) and
    c) doesn’t understand the Byrd rule (not our brightest legislator.”
    In other words concern about reconciliation turning health reform legislaiton into “Swiss Cheese” is a “red herring”
    (pardon he mixed food metaphors)

16. Pudge,
    You are absolutely right, the Democratic party is deep in the pocket of the trial lawyers. I think the Obama campaign got almost as much money from the trial lawyers as it did from Wall St. I think you can kiss tort reform goodbye for the next 4 years.
    The Republicans are deep in the pocket of the drug companies and insurance industry. That is one reason why Medicare doesn’t buy generic or look for bulk pricing and why a single payor system is being fought so hard by the Republicans.
    Based on personal experience, I believe that malpractice has a profound effect on the cost of medical care. It would be interesting to see a map plotting the density of malpractice attorneys/frequency of suits against medicare spending. I wonder if the Dartmouth data could be sliced and diced in that manner.
    (PS: I am a Democrat and voted for Obama)

17. CBO threw ice on the president’s campfire this week. Who can advocate a plan when we don’t know the cost or the funding source? See http://www.MDWhistleblower.blogspot.com. Shouldn’t Obama have addressed the funding issues first and then discussed them with the American people? Instead, we are to ‘buy in’ to his plan and trust him to figure out how to pay for it later. While sloganeering and issuing grand policy promises may be politically palatable in the short term, at some point the details and the risks emerge. I think that his coast is ending and is uphill climb has begun.

18. Legacy Flyer and Michael K
    Legacy Flyer–
    You write: “I think the Obama campaign got almost as much money from the trial lawyers as it did from Wall Sttet .”
    Legacy, I am afraid that this is the type of totally uninformed, and unsupported lie that conservatives docs who listen to Rush Limbaugh like to spread. (Not the sharpest knives in the drawer of doctors.)
    I’m surprised you would swallow it.
    This is the sort of very dumb lie that becomes conventional wisdom–and just make me want to tear my hair out.
    Think about it for one minute. How much wealth does Wall Street represent?
    How many trial lawyers are there in the U.S.? How much wealth do they represent?
    Compared to all of Wall Street, trial lawyers are tiny. They loom large in the minds of doctors who have no basic grasp of economics–and conservatives who have down their best to scare doctors that theses bogeymen have great power and influence. Simply not true.
    As a Senator, Obama (and many other Democrats) have supported legislation to reform malpracrice law.
    There is widepsread agreement that the current system doesn’t work– but we also know that capping awards doesn’t worok either. (In the states hta have done it it has been a failure–it’s a simple-minded solution to a complex problem–like cutting docs fees across the board.)
    Legacy, do yourself a favor. Before you utter another word about malpractice, read this excellent article on malpractice that just came out in the New England Journal of Medicine. http://content.nejm.org/cgi/content/full/NEJMp0903765v1.
    Michael K.
    I am afraid that the media has created a great deal of confusion here– and you have bought into it.
    I wonder if you even read my post above?
    Let me try to cut through the confusion: Obama does not have a “plan” in the sense of anything that spells out exactly what would have to be covered by all plans; who would receive subsidies (up to what income level); how stiff the penalty would be if people didn’t sign up for insurance; how much employers who don’t proviode benefits would have to pay into the pool; which small employers would be exempted (based on size? profits?) etc. etc.
    So how could anyone estimate its cost?
    There is no way for CBO or anyone else to “score” it.
    If people bother to read CBOs letter (cited in my post) they would realize that.
    CBO looked at a PARTIAL draft of a rough draft of a plan. They did not officially “score” it. (Someone leaked numbers that they were tossing around as they looked at a parital plan with many blank lines in it.)
    The newspapers got the facts wrong But headlines saying that “obama’s plan” will “cost $1.6 trillion” sell newsappers.
    Last week, the same newspapers were saying hte Democrats were close to a final plan and victory. They needed a new story. “Plan Dooomed–will cost $1.6 trillion” gave them a new story.
    I’ve worked at the New York Times as an editor. Trust me, I know how these things happen.
    It is premature to begin to talk about what Obama’s vision for healthcare reform will cost –without knowing what is in it. THERE IS NO “OBAMA PLAN” except in a very general sense. There is abroad outline with many, many blank linesthat still need to be filled in.
    OBAMA IS NOT SAYING WE’LL WORRY ABOUT WHAT IT WILL COST LATER.
    Have you read or listened to his speeches? Have you read or listened to what the White House Budget Director Has been saing?
    OBAMA IS TRYING TO FIGURE OUT HOW MUCH MONEY CAN BE RAISED FOR REFORM AND WHERE IT CAN BE FOUND (a combination of cutting waste and taxes on the very, very wealthy (people earning over $250,000) before getting more specific about his plan.
    HIS OPPONENTS HAVE CRITICIZED OBAMA FOR WORRYING SO MUCH ABOUT THE MONEY. They say he should just cover everyone first, and worry about paying for it later. He has refused to do that. He has told Cognress there will not be a plan unless it is fully funded ahead of time. He will not fund it with deficit spending.
    So Obama is putting finding the money first–before trying to spell out how comprehensive the insurance will be etc etc.
    Obama is not ” asking us to ‘buy in’ to his plan and trust him to figure out how to pay for it later.”
    He is doing just the opposite.
    I am afraid that you have been mis-led by conservatives who are perfectly happy to simply flat -out lie while trying to scare people about healthcare reform.

19. In a review of a book by former long time NJ Senator, Rhodes Scholar, and NY Knicks star, Bill Bradley, called “The New American Story, NY Times book reviewer, Michiko Kakutani wrote the following:
    “After drubbing the Republicans for requiring “lockstep adherence to narrow party positions” and pandering to corporate interests, Mr. Bradley writes that Democrats must learn to “assert the general interest” over the agendas of their party’s special friends” – namely, teachers’ unions (which he says tend to “defend the status quo in school organization, student performance and teacher accountability”); trial lawyers (whose litigiousness, he says, has led to higher costs in health care delivery”); and the autoworkers’ union (which he says “opposed higher mileage standards” and “opposed requiring companies to shore up private pension systems”).”
    The doctors keep pounding away at the notion that defensive medicine pervades the medical culture and is a significant contributor to high healthcare costs, though it is impossible to measure precisely. While I don’t think capping awards for non-economic damages is the answer, I do think that special health courts instead of juries made up of ordinary people would be better qualified to adjudicate medical disputes and could bring more consistency and objectivity to the dispute resolution process. I have not seen any Democrat from President Obama on down provide any leadership or meaningful support for this concept whatsoever. As long as Democrats control both the Congress and the White House, without support from trial lawyers, I won’t hold my breath waiting for substantive malpractice reform. Unfortunately, if we expect doctors to learn to practice more cost-effectively, they are going to need some meaningful help with the malpractice issue. Specifically, at a minimum, they will need protection codified in law from lawsuits based on a failure to diagnose a disease or condition as long as they followed evidence based protocols. Nobody is talking about protecting them from egregious negligence like wrong site surgery.

20. Barry and Gregory–
    Brad– If you haven’t seen any Democrat trying to fix malpractice, then you haven’t been reading about proposed legislation.
    See this very good article in the most recent New England Journal of Medicine which talks about legillation sponsored by Barack Obama (when a Senator) and other democrats. http://content.nejm.org/cgi/content/full/NEJMp0903765v1.
    Conservatives like to say that Democrats have never attempted to put forward legislation to reduce malpractice suits and rationalize rewards.
    Conservatives say this over and over again.
    Another flat-out-lie.
    (What Hitler referred to as “the Big Lie”– something that is totally untrue. If you say it frequently enough, people will think it is true. They can’t believe that someone would repeat something totally untrue that often.
    I’m glad we agree that capping awards isn’t the answer. A crude solution.
    But there are solutions out there that are worth trying.
    That is what Obama said at the AMA conference. He did NOT say he was against malpractice reform. He said that he was in favor of malpractice reform, and realizes that something needs to be done. But that he is against capping rewards.
    Not the solution, as you say.
    Bradley was a fine Senator–at one time, he was my favorite candidate for president.
    Gregory–
    My guess is that physicains who join hospitals after having run their own practice for many years may have trouble adjusting
    Many of them are accustomed to being “lone rangers’–doing things their own way. They don’t like being asked to use checklists (a hospital CEO has told me about this),
    follow guidelines, or have
    nurses speak up when the doctor is failing to follow best practice. (Some hopsitals now encourage nurses to speak up).
    On the other hand, many med students are choosing to become hospitalists (who work for a hospital).
    And hospitals are jsut beginning to realize how valuable they are.
    We do know that fully integrated hospital/doctor groups tend to provide the highest qualtiy care for
    patients. (See Dr. Gawande’s article in the June 1 New Yorker.)

21. Barry–
    Sorry– I addressed you as “Brad” in my most recent reply to your comment–

22. Maggie,
    I Googled: “TRIAL LAWYERS POLITICAL CONTRIBUTIONS”. Here is a smattering of what I came up with:
    1) “the American Trial Lawyers Association was the largest PAC contributor to the Democratic party in the last full political cycle” – National Review Online, referring to the 2004 elections cycle
    2) THE TRIAL LAWYERS WERE THE NUMBER TWO CAMPAIGN CONTRIBUTOR TO POLITICAL CANDIDATES DURING THE 2008 CYCLE, they gave $235,455,724.00, 76% of which went to Democrats – OpenSecrets.Org
    3) “Trial Lawyers Pour Money Into Democrats Chest” – New York Times
    4) Trial lawyers are among the most prolific contributors to Members of Congress….. A mere four percent of the group’s contributions went to Republicans. – Washington Examiner
    The above 4 references are consistent with what I have read in other sources including The Economist and The Wall Street Journal. So it appears from what I was able to find that:
    1) In fact trial lawyers are large contributors to political candidates, number 2 in the 2008 campaign, number 1 in 2004
    2) Their money goes primarily to Democratic candidates
    I didn’t find a breakdown of contributions to Obama, so perhaps I was being unfair to him, but I think my statement that “the Democratic party is deep in the pocket of the trial lawyers” is an accurate one.
    Your link: http://content.nejm.org/cgi/content/full/NEJMp0903765v1. is also wrong, it leads to: “Page not found”. The correct link is: http://content.nejm.org/cgi/content/full/NEJMp0903765 . I skimmed the article and found this quote: “However, in the current political environment, the chances are nearly nil that tort reform of this sort (caps on non-economic damages) could pass – it is anathema to most House Democrats.” I think this also bolsters my point.
    I have downloaded the article and will read it in depth, but I have been reading articles on malpractice for 30 years. One article in one Journal, written by 2 lawyers (although a well respected and prestigious one) does not a consensus make.
    You also say: “we also know that capping awards doesn’t work either. (In the states that have done it, it has been a failure…..” I also don’t think this statement is accurate. I have read articles on the situation in California and Texas which suggests that caps have been effective in both those states.
    As for “totally uninformed and unsupported lies”, “dumb lie” and docs who are “not the sharpest knives in the drawer” – don’t worry about rhetoric like that causing me to want to “tear my hair out” – I don’t have enough to make it a make it a major issue anyway.

23. Roughly 30 million lobbying dollars since 1990 from a trial lawyer assoc., the AAJ. 90% OF WHICH HAVE GONE TO DEMS IN OFFICE. These contributions rank in at 6th in the top 10 of contributing “donors” from 1990 until now.
    These donations are only 1.5% less than Goldman Sachs since 1990 (who ironically donated more $$ to Dems than Repubs: seems the Dems spin-machines are working quite well also). I do not consider that amount negligible.
    Sadly nearly 40% of reviewed medical malpractice cases did not have any malpractice at all(http://content.nejm.org/cgi/content/full/354/19/2024). In all fairness these rarely resulted in any punitive damages, BUT there is a stigma and psychological affliction that results for physicians from having these actions taken.

24. Seems my link got screwed also. Here, hope this works.
    http://content.nejm.org/cgi/content/full/354/19/2024

25. I read the article “The Role of Medical Liability Reform in Federal Health Care Reform” by Mello and Brennan; NEJM July 2, 2009. Mello is a JD and Brennan is an MD and JD.
    Here are some quotes:
    “Democrats have been suspicious of reform proposals and, perhaps mindful of the heavy support they have received from the trial bar.”
    “… One piece of conventional wisdom that is shared by those on both sides of the political aisle is that “defensive medicine” …. is a substantial driver of … health care costs. These costs are notoriously difficult to estimate, and analysts disagree about the magnitude … But trimming even 1% of total health care spending would save $22 billion per year ….”
    “The warhorse of federal tort reform efforts in the past has been caps on noneconomic damage awards. However in the current political environment, the chances are nearly nil that tort reform of this sort could pass-it is anathema to most House Democrats”
    The article is silent on the issue of whether caps on noneconomic damages are effective. I believe that they have been shown to be effective in both California and Texas.
    It does propose three different strategies other than a cap on noneconomic damages. They are:
    1) Disclosure and offer programs – “Sorry works”
    2) Specialized tribunals for malpractice
    3) “Safe harbors” for adherence to evidence based practices.
    It also lists a series of pros and cons for each. (one of the cons for “Disclosure and offer programs” is that “Evidence base for effectiveness in reducing costs consists solely of programs’ self-reports”)
    I agree with Maggie that this is a good article and support all three proposed reforms. I think we should establish trials to test whether “Sorry Works” actually works and if it does adopt it. I support the establishment of specialized tribunals for malpractice. I strongly support the use of “safe harbors” for doctors who follow “best practices”.
    I also predict that none of the above reforms will pass our current Congress. There is too much money (and too much in campaign contributions to Democrats) riding on the current system.

26. Maggie,
    I read the NEJM article that you linked to. I’ve consistently supported the special health courts idea as well as the safe harbor concept insulating doctors from lawsuits if they follow evidence based protocols. I also heard President Obama tell the AMA last week that he is open to malpractice reform ideas. However, Democrats may find that they need to take on their friends in the plaintiff bar to actually bring these ideas to fruition. I’ve heard, for example, Senator Kennedy tell a small audience in Washington that I was part of several years ago in response to a question that medical malpractice is just not a significant cost issue for the healthcare system and no changes are needed.
    Separately, for the record, the co-author of the article you linked to, Dr. Troyen A Brennan, was appointed EVP and Chief Medical Officer for CVS Caremark in November, 2008. Prior to that, he was EVP and Chief Medical Officer for Aetna. Before that, he was at BWH in Boston. I met him personally once and heard him speak several times at investor conferences. He struck me as very reasonable, knowledgeable and sensible.

27. Legacy–
    First thanks so much for
    reading the NEJM article.
    This is the sort of thing that reassures me that I’m not simply insane when I spend a good part of a Sunday afternoon answering comments.
    The NEJM piece is a balanced article–as the quotes you cite indicate.
    It doesn’t say anything about caps on awards probably because other articles in medical journals (maybe NEJM–can’t remember) have pretty much reached a consensus that they haven’t worked in Texas and Califronia. (Either Niko or I wrote about this on HealthBeat a while ago– maybe a year ago.)
    I’m very glad that you agree that the NEJM piece is a good article. And that the possible reforms it proposes are potentially excellent.
    IThese are the types of reforoms that Obama is interested in.
    When he told the AMA that he wants to reform malpractice, I am quite certain that he was telling the truth.
    Obama has no strong ties to trial lawyers that I know of–that’s not his bailiwick.
    Moreover, our current malpractice system is needlessly expensive–adding to the waste and excessive costs in the healthcare system as q whole..Obama understands this.
    Finally, the best malpractice attorneys agree that the current system needs to be overhauled.
    Malpractice attorneys have been demonized by conservatives (who object to any consumer suits against corporations) and the AMA.
    There are some excellent, very intelligent and courageous malpractice attorneys out there–people like Jim Moriarty, who defended a group of the many patients who received totally unncessary heart surgery at the for-profit Tenet hosptial in Redding California (a notorious case.)Some were permanently disabled.
    An FBI investigation confirmed that the operations were unncessary.)
    Look up Moriarty in the index of my book. He really is one of the good guys.
    That doesn’t mean there are not ambulance-chasers out there. There are.
    But the top-drawer malpractice attorneys don’t need to do that. And they don’t.
    I suspect that, assuming Obama is re-elected, over the next 8 years, we will see meaningful malpractice reform in Congress. All it takes is intelligent, good government– government that is primarily interested in the public good.
    Let me add, that I don’t think the Obama administration is perfect.
    I am very disturbed by some of the things they are doing in terms of foreign policy.To hawkish for my taste.
    And I am not impressed by our Treasury Secretary.I know too much about Wall Street. .
    But this blog is about healthcare, and on that front, the Obama adminisration has an impressive brain trust and they are listening to people who know what they are talking about . . .

28. Barry–
    Thank you for also reading the NEJM article!
    (Your comment came in while I was replying to Legacy)
    That two readers actually went to the article does make me feel very good about the amount of time I spend replying to comments . . .
    (See my recent reply to Legacy.
    I agree with you about the
    malpractice reforms that might work.
    I think there is a very good chance that we will see reforms like these in coming years.

29. Most people in the United States support a government-backed health care. The overwhelming majority of Americans support substantial changes to the country’s health care system, including a government-run health insurance option. A NYT/CBS News survey also indicated most Americans would be willing to pay higher taxes so everyone could have health insurance.
    Eighty-five percent said the health care system needed to be fundamentally changed or completely rebuilt. Seventy-two percent supported a government-administered insurance plan, something like Medicare for those under 65, that would compete for customers with single-profiteer health insurance plans.

30. There are what, 122, give or take, accredited medical schools in the USA? And every year someone is the “last in class” graduate? So just how many Doctors are drummed out, or have their license pulled? Oh yea, that’s private information.
    Like they say, Doctors bury their mistakes, and anyone can just go to the emergency room!

31. Dickylee,
    Actually, malpractice cases are frequently publicized in the newspapers.
    In addtion, disciplinary actions against physicians are a matter of public record. Here the a website for the Maryland Board of Physicians (http://www.mbp.state.md.us/)
    which report disciplinary actions.
    In addition it is routine for any malpractice suit to be accompanied by a complaint to the Board of Physicians.
    Sorry to bother you with facts.

32. Wall St. Journal – May 17 08
    “In 2003 and in 2005, Texas enacted a series of reforms to the state’s civil justice system. They are stunning in their success. Texas Medical Liability Trust, one of the largest malpractice insurance companies in the state, has slashed its premiums by 35%, saving doctors some $217 million over four years. There is also a competitive malpractice insurance industry in Texas, with over 30 companies competing for business. This is driving rates down.”
    “Texas succeeded at enacting .. simple but effective reforms. … capped medical malpractice awards for non-economic damages at $250,000, changed the burden of proof for claiming injury for emergency room care from simple negligence to “willful and wanton neglect,” and required that an independent medical expert file a report in support of the claimant.”
    Seems like the WSJ thinks that caps on non economic damages worked in Texas.

33. Legacy Flyer,
    Caps on economic damages have done nothing to improve care. As I’ve said before, the patient is not the beneficiary of malpractice “reform” the patient is again, the victim. Medical Boards have done a woefully inadequate job weeding out dangerous practicioners and once they finally do (revoke a license, for example), what’s to stop that doctor from moving to another state and starting all over again? Why isn’t the focus on improving care? The focus is always malpractice “reform”, the focus is always on somebody or something else, not the patient. There needs to be accountability when one person causes egregious harm to another, not immunity. There needs to be a mechanism in place so problems are corrected instead of repeated. Focus on improving care and the lawsuits will dwindle.

34. Back in 2004, GE Medical Protective, the nation’s largest medical malpractice insurer (during a regulatory filing with the Texas Department of Insurance), had admitted that medical malpractice caps on non-economic damage awards and other limitations on recoveries for injured patients would not lower physicians’ premiums.
    They made that revelation while raising physicians’ premiums 19 percent, six months after Texas enacted caps on medical malpractice awards.
    Company executives said that non-economic damages are a small percentage of total losses paid, and capping non-economic damages would show a loss of savings of only 1 percent. So the company did not even provide doctors any relief and imposed its rate hike on its physician policyholders.
    The insurance industry cannot be trusted on the issue of malpractice caps. Actuarial data submitted by the company contradicted the importance of caps. Insurance regulation, rather than malpractice caps, would be the solution to high premiums.
    In Texas, California and throughout the country, malpractice insurers continue to push for higher premiums for doctors, regardless of whether or not the state has caps on damages. Insurance regulation, not caps, has been the only successful weapon in the battle against skyrocketing premiums.

35. Hospitals are very interesting organizations in regard to staffing. It is true that in general terms hospitals have been running very tight ships in the direct patient care side of the business. The shortage of nurses (real or not) it is partially explained by the difficult working conditions that they continue to face(High patient staff ratios, low pay, long hours,etc)However, hospitals are not very efficient. There is way too many people handling the complexity of a system that is so byzantine that is just incredible that something is done. There is ample room for improvement.

36. Thank you for bringing the level of hysteria down a notch, Maggie. I too am not worried about where we are on health reform. If everyone panics every time we hit a snag, then this is going to be a very long and painful journey! We are in such a different place from 1993. What will happen next is that Baucus’ markup will be much more conservative than Kennedy’s or the House and the negotiations will begin. I just hope people can keep their eye on the prize — which to me is a “start” on health reform. We don’t have to do everything perfectly right away. But we need to put the process in place. Once it’s in place, we can work on it. Much like Massachusetts, which has had to tweak their program a lot, but at least they have one!!

37. Lisa and Gregory,
    Lisa: Maggie has told me that your husband was a victim of bad medical care and for that I am sorry. I too would like to see bad medical care rooted out. However, even Maggie would agree that malpractice does not do that.
    Malpractice is a system that fails at both its stated objectives; punishing bad behavior and compensating injured people. It is a system that rewards some plaintiff’s attorneys with a very good living and results in the practice of “defensive medicine”, which raises medical care costs by billions.
    As for “bad” doctors being able to move to another State, Medical Boards should share information with other states – that should not be too difficult in this day of the Internet. As for the statement: “Focus on improving care and the lawsuits will dwindle”, that is a lot like saying “end poverty and injustice and crime will dwindle”, in the meantime while poverty and injustice exist do we dismantle the court system and fire the police?
    Gregory: I would be interested in reading a good analysis of the effectiveness of caps on non-economic damages – do you know where I can find one? The comments of one carrier in one state are interesting, but not much of an analysis. What I have read in multiple sources, including the Wall St. Journal (quoted), is that caps on non-economic damages have been effective in California and Texas.
    I will add another way that a cap can be effective in reducing malpractice costs in addition to actual damages paid out. This is in discouraging the filing or pursuit of a case. And since the malpractice system has such high “transaction costs”, avoiding a case is worth a lot of money regardless of whether anything is paid on the case. I will also make an unproven and cynical observation – the fact that the plaintiff’s bar so bitterly opposes caps may be a good piece of information that they do work.
    I would also be interested is seeing if the Dartmouth data can be sliced and diced in such a way as to compare it with the density of plaintiff lawyers and the number of malpractice cases filed. The idea being; “What is the effect of malpractice on the cost of Medicare” using the Dartmouth data. (tried finding it on their website, but my computer kept crashing when I tried to download their PDFs)

38. Gregory,DickeyLee, Pudge, Legacy
    Gregory– Yes,polls show very strong support for a public option
    And other polls show that Medicare is much more popular than private insurance–which helps explain why so many people support a public-sector option.
    Most people over 35 or 40 know someone on Medicare (a parent, a grandparent, a neighbor) and know that while Medicare has co-pays and deductibles, they are lower, and ocverage is better and far more certain than with the vast majority of for-profit plans.
    Dickeylee–
    You make a good point. Your comment reminds me of the old joke circulating among med students when my college friends were in med school:
    “What do you call the person who graduates last in his/her medical school class?”
    Answer: “Doctor.”
    As Dr. Atul Gawande (who wrote the recent New Yorker article that has gotten so much attention) has pointed out: doctors, like plumbers, journalists and everyone else live on a bell curve. (To find the aricle, Google Gawande, “Bell Curve” and “New Yorker.” )
    A relatively small percentage of doctors are exceptional, or at least, very, very good.. A small percentage are terrible to barely competnent. And the vast majority are in the middle– “mediocre” as Gawande puts it.
    But the middle can be very, very good. We just need better guidelines for best pracice, financial incentives that reward quality (not quantity) and other changes to move the whole curve to the right-hand side of the scale (toward exceptional).
    Pudge– As I said, the trial laywers group is tiny when compared to WAll Street.
    Goldman Sachs is only one of a number of large Wall Street firms.
    Legacy–
    Since you were kind enough to read the NEJM article, I’m hopeful that you will read this post that I wrote last year about malpractice. (I spent some time finding it)
    Lots of facts: http://www.healthbeatblog.org/2008/05/medical-malprac.html (See Part 1 for more facts.)
    I totally agree that our way of dealing with malpractice needs fixing.
    But tort reform hasn’t done it (If memory serves, I document that in part 1 of this post).
    Finally, in your next post: Your quote from the WSJ– I wonder if it isn’t from a WSJ editorial??
    Most of the WSJ’s news stories on health care have been excellent. But, for years, the WSJ editorial pages have been viewed by people on Wall Street ( traders, money mangers and others) as extreme to the point of being ridiculous. (“The Russians are Coming! The Russinas are Coming !)
    I report this from experience. I worked at Dow Jones (which publishes the WSJ) for many years.

39. Gregory, Esteban,-
    Gregory–Thanks very much for your information on the failure of caps on rewards to solve the malpraice problem. “GE Medical Protective, the nation’s largest medical malpractice insurer (during a regulatory filing with the Texas Department of Insurance), had admitted that medical malpractice caps on non-economic damage awards and other limitations on recoveries for injured patients would not lower physicians’ premiums.”
    Esteban–
    I totally agree that U.S. hospitals are not efficent.
    But, as you say, there is a shortage of nurses.
    And, overall, the problem is not too many workers, but a lack of top-down co-ordination.
    Hospials need to insist that healthcare workers (including doctors in various pecialities) collaborate (with nurses, lab workers, etc. as well as with each other.)
    If the majority of doctors who admit patients to the hopstial are in private practice, they are less likely to collaborate.
    In accountable care organizations–where doctors and the hospital work togehter–ther ei far more collaboration.

40. Lisa &
    Lisa– you write: “Focus . . on patients . . aon improving care — and the lawsuits will dwindle.”
    You are entirely right that we should focus on the patients.
    I do think that our malpractice systems needs to be reformed– but our hospitals don’t take nearly enough care to put systems in place to reduce infections and errors.

41. We need to focus on one fact here: the evidence shows that the malpractice environment does not have a significant impact on medical costs in general and on over-utilization in particular.
    States that have adopted malpractice reforms have not seen any improvement in utilization. In particular, Texas and California, two of the states with the longest history of malpractice reforms, continue to be among the highest in over-utilization. Atul Gawande points out that the malpractice environment in Texas is among the best in the country, but has not impacted medical costs.
    We doctors would all like to see malpractice reform because malpractice issues are very upsetting to us. However, to suggest that malpractice reform will fix over-utilization is clearly wrong. Malpractice reform is an issue that is seperate from fixing the major things wrong with our health care system, and is too often used as a screen to avoid the real issues.

42. Another thing:
    If we really are worried about malpractice, the best things we can do are to focus on the underlying issues.
    Adoption of strong quality assurance programs and of strong practice guidelines and then not only following them but documenting that we are following them are the most important steps that health care providers and systems can adopt to address malpractice.

43. Pat S,
    What evidence shows that the malpractice environment does not have a significant effect on medical costs? I think we agree that the malpractice environment is not the sole determinant of over-utilization, but is it not one of the factors? I have previously stated that I think over-utilization is due to a combination of; habit, ignorance, fear (malpractice) and greed.
    If you look at the Dartmouth Atlas (http://www.dartmouthatlas.org/interactive_map.shtm), it is clear that there are huge variations in Medicare usage even within a state (Brownsville vs. Dallas, LA vs. San Fran, New York City vs. Upstate). These differences cannot be explained by state laws which are the same. There may be differences between how many malpractice attorneys per capita are present in the NYC area vs. the Rochester/Buffalo area. There could also be significant differences in how many cases per capita are filed in those two areas. Thus the “climate of fear” (how is that for non-sensational terminology) and the resultant practice of defensive medicine could be very different in the Buffalo/Rochester area than it is in NYC – even though the same state laws apply.
    As I have said before, I would love to see a study comparing the “climate of fear” by region (? Plaintiff attorneys per capita?, ? Rates of malpractice filing per capita?) with rates of Medicare utilization. (If this has been done, can someone point me to the data. I have tried to download PDFs from the Dartmouth web site, but they have crashed my computer)
    As for why rates of utilization have not come down in Texas, I can offer two explanations. The first is that without malpractice reform, utilization would be even higher. The second and more likely explanation is that doctors, like other people, are (at least to some degree) creatures of habit and that it will take more than a few years for people’s ordering habits to change.

44. The fact that there is no or poor correlation between malpractice environment and over-utilization very strongly suggests that malpractice is not a critical factor in over-utilization. In particular, California — which you cite elsewhere as a state with better control of malpractice — is a leader in over-utilization.
    In addition, variation in utilization in the same metro areas is evidence that malpractice environment — the same for all players — does not correlate very well with over-utilization. For example, Mayo in Scottsdale and Kaiser in the Bay Area fly in the face of patterns of over-utilization typical in their areas. Mayo in Scottsdale, in a high malpractice area, actually does a better job than Mayo in Rochester.
    I do not oppose the idea that malpractice could stand some reforms, with the proposals in the recent NEJM article a good start for discussion. I also feel sorry for doctors who are in specialties under assault by high malpractice exposures — OB is the obvious example — and who work in regions with very high exposures. I do not even argue that malpractice makes some contribution to over-utilization. I would also personally love to practice without the worry of malpractice suits.
    However, I reject the notion that malpractice is at the root of the problems with our health are system in general and over-utilization in particular, and also do not believe that malpractice reform would have a significant positive effect on the problems we have in US health care.

45. It’s not that malpractice reforms are not a good idea, but malpractice reforms are not anywhere near central to the issue of health care reform. We need to be paying less attention to the “malpractice” and more attention to the “health care” reform. Malpractice reform is a true red herring in the health care reform debate. I’ve notice a number of conservative media outlets and people trying to bring malpractice reform into the debate, as a central issue.

46. Gregory, Pat S. Legacy–
    Gregory– Yes, I agree. Those who oppose reform have been using the malpractice issue to distract from the main issue: we need to rein in health care inflation by using comparative effectiveness reserach to begin to squeeze out ineffective care.
    Pat S.– I, too feel sympathy for doctors in certain specialities–particuarly OB/GYN. It is so hard for parents to accept the death of an infant–or a serious problem. This makes doctors who deliver babies very vulnerable . .
    Some of the solutions mentioned in the NEJM article could work. And this is an area where I think lay juries are likely to render very emotional judgments . ..
    The Dartmouth Reserach shows that in extremely litigious regions, fear of malpractice may account for 10% of the difference between high-spending and low-spending regions.
    But spending is double in the high-spending regions– so that means fear of malpratice May account for 1/10 of the difference.
    Legacy– See the final paragraph of my reply to Pat S.
    I now declare discussion of malpractice on this thread closed.
    This was never supposed to be a thread about malpractice–see the original post.
    I’m always troubled when a couple of people “hi-jack” a thread, crowding out the issue at hand: did the CBO’s estimate matter? Is there reason for reformers to be so discouraged?
    Everyone interested in malpractice has had a chance to weigh in numberous times, and as Gregory points out, malpractice distracts from the larger issue.

47. I don’t know if this thread is dead, but coming back to Maggie’s original premise, Ezra Klein has a very interesting entry today about the roll of conference in the eventual health bill.
    Here’s the key quote:
    “The overriding imperative right now is to keep health reform alive. That’s all that matters. Get it out of the Finance Committee. Get it off the Senate floor. If it’s cut down to half a loaf, fine. You don’t fix it now. You fix it in conference. Or you let Henry Waxman do it for you.”
    Or read the whole thing in the link:
    http://voices.washingtonpost.com/ezra-klein/
    Maggie, Klein, and Jonathan Cohn at New Republic are doing a lot of work right now to swim against the tide of Krugman, the mainstream media, and others who are suggesting that health care reform is falling apart.
    I like to think that Obama, Rahm, Zeke, Pelosi,and Orzag are all smart enough to have thought of all this AHEAD of Klein. In fact, I would bet good money that they are.

48. Pat S–
    You wrote: “Ezra Klein has a very interesting entry today about the roll of conference in the eventual health bill.
    Here’s the key quote:
    “The overriding imperative right now is to keep health reform alive. That’s all that matters. Get it out of the Finance Committee. Get it off the Senate floor. If it’s cut down to half a loaf, fine. You don’t fix it now. You fix it in conference. Or you let Henry Waxman do it for you.”
    Or read the whole thing in the link:
    http://voices.washingtonpost.com/ezra-klein/
    Pat– Yss, this was an
    excellent post.
    Max Baucus is not going to shape the final bil.
    Whatever comes out of the Senafe will have to reconciled with the very different bill that comes out of the house.
    Then, the two will have ot go through the conference committee..
    Ezra and I agree that , in thse final days, the actual bill will emerge.

49. Analysis of the effectiveness of caps on non-economic damages.
    http://www.law.duke.edu/features/pdf/vidmartestimony.pdf

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