On the first page of his new book, The Checklist Manifesto: How to Get Things Right, Boston surgeon Atul Gawande tells the story of a man who arrives at an ER with a stab wound on Halloween night. The doctors cut off his clothes and examine him head to toe. There it is: “a neat two-inch red slit in his belly, pouting open like a fish mouth. A thin mustard yellow strip of omental fat tongued out of it—fat from inside his abdomen, not the pale yellow superficial fat that lies beneath the skin.”

The patient is stable, though pie-eyed, and babbling incoherently. It seems that he had become involved in a disagreement that turned nasty at a Halloween party.

The injury doesn’t look too bad. The team leaves the patient waiting on a stretcher while the OR was prepped.

Then, a nurse notices that he has stopped babbling.  On closer inspection, it turned out that his heart rate is skyrocketing, and his blood pressure barely detectible. The trauma team can’t get his blood pressure up. They are losing the patient, and have no idea why.

They “crash” into the operating room, “stretcher flying, nurses racing  . . ..”  There the surgeon grabs “a fat no. 10 blade and slices down through the skin of the man’s abdomen in one clean determined swipe from rib cage to pubis.”

He then parts the fat underneath the skin and pierces his way into the abdominal cavity when “suddenly a ocean of blood burst out of the patient.”  The blood is everywhere.

“The assailant’s knife had gone more than a foot through the man’s skin, through the fat, through the muscle, past the intestine, along the left of his spinal column, and right into his aorta, the main artery from the heart.”  Hence, the blood..

One physician notes that he hadn’t seen a wound like this since Vietnam.

Indeed. They later discovered that “the other guy” at the costume party was dressed like a soldier and carrying  a bayonet.

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Under reform, insurers will still do their best to shun the sick. Over at AlterNet, health care editor Adele Stan points to one way they may do it: by using “wellness programs” to penalize those who can’t meet health targets. If the financial penalties are high enough, some employees just won’t sign up for insurance.

Stan explains: “A little-discussed provision of the Senate bill allows insurers to expand so-called wellness programs that let insurers  penalize subscribers by hundreds—and even thousands—of dollars for not meeting certain ‘wellness targets,’ such as a particular cholesterol number, blood sugar measurement or body-weight target.

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If you drive from Buffalo, New York to Ontario, Canada, you’re likely to see this message on highway billboards: “Fast-track Your Medical Procedure Here.” The red arrow on the sign points Canadians to Buffalo’s Kaleida Health, a five-hospital health care system located minutes from the U.S.-Canada border. (Thanks to HealthBeat reader Brad F. for spotting this story.)

Kaleida’s marketing blitz is designed to encourage Canadians to come south and avoid wait times for medical services that include bariatric surgeries, colonoscopies, joint replacements, fracture repairs and MRIs. The campaign began in November and includes local television print and radio ads as well as more than 30 billboards near major routes in Southern Ontario cities.

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The story of the “Norway Solution” to hospital infections reminded me of a letter that I received in the fall, written by Svein U. Toverud, a Norwegian who lived in the U.S. from 1969 to 2003. While he was in the U.S. Toverud taught medical and dental students pharmacology at the University of North Carolina, Chapel Hill, and received medical care there. When he returned to Norway in 2003, he had an opportunity to reflect on the difference between health care in Norway and in the U.S.

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“Aker University Hospital is a dingy place to heal. The floors are streaked and scratched. A light layer of dust coats the blood pressure monitors. A faint stench of urine and bleach wafts from a pile of soiled bedsheets dropped in a corner.”

This is how an Associated Press story, published in the New York Times last week, begins. The next sentence comes as a surprise:

“Look closer, however, at a microscopic level, and this place is pristine. There is no sign of a dangerous and contagious staph infection that killed tens of thousands of patients in the most sophisticated hospital of Europe, North America and Asia this year, soaring virtually unchecked.

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“Cadillac Health Care Plans.”  Even the phrase suggests gilt-edged insurance for Greedy Geezers at Goldman Sachs . No wonder the Senate wants to slap a tax on insurers and self-insured employers who offer over-the-top policies beginning in 2013.

After all, plans that fetch more than $23,000 for families (or $8,500 for individuals) must encourage over treatment, right? 

If you’re not sure, that’s hardly surprisingly. In recent days, New York Times columnist Bob Herbert,  the Washington Post’s Ezra Klein,   MIT economist Jonathan Gruber,  and  Merrill Goozner, editor of Gooz News on Health,  have offered sharply conflicting reports on the tax and its likely effects.

I decided to compare the arguments, and check the facts.

The first thing you need to know is that a pricey plan is not necessarily chock full of benefits. When setting premiums, insurers are not thinking about how much value you will get from the policy; they are contemplating how much it will cost them to reimburse you. Here, two factors weigh heavily on their minds:  your age, and the cost of health care where you live.

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Below, an excerpt from an article in the most recent (December 23 ) New England Journal of Medicine titled  “Medicine’s Ethical Responsibility for Health Care Reform — The Top Five List, by Howard Brody, M.D., Ph.D. ”    (At the end of the excerpt, I offer my commentary. )

“Early in 2009, members of major health care–related industries such as insurance companies, pharmaceutical manufacturers, medical device makers, and hospitals all agreed to forgo some future profits to show support for the Obama administration’s health care reform efforts. Skeptics have questioned the value of these promises, regarding at least some of them as more cosmetic than substantive. Nonetheless, these industries made a gesture and scored some public-relations points.

“The medical profession’s reaction has been quite different. Although major professional organizations have endorsed various reform measures, no promises have been made in terms of cutting any future medical costs. Indeed, in some cases, physician support has been made contingent on promises that physicians’ income would not be negatively affected by reform.

“It is appropriate to question the ethics of organized medicine’s public stance. Physicians have, in effect, sworn an oath to place the interests of the patient ahead of their own interests — including their financial interests. None of the for-profit health care industries that have promised cost savings have taken such an oath. How can physicians, alone among the “special interests” affected by health care reform, justify demanding protection from revenue losses?   . . .

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By Naomi Freundlich and Maggie Mahar

This year the rhetoric around health care reform reached historic levels. Barely a week went by without pundits dissecting some new fact, policy detail or wording change implicit in the various reform plans emerging from Congress. The result was a barrage of media reports, often conflicting, that heralded the demise or success of reform on a regular basis. Twisted facts, reactionary politics and just plain scare tactics have been pervasive.

\Below, “The 10 Most Destructive Lies about Health Care Reform in 2009” and “ The Ten Most Constructive Insights, Suggestions and Questions.”

Heath Care Reform:   The 10 Most Destructive Lies

1.) Seniors and the disabled "will have to stand in front of Obama's 'death panel' so his bureaucrats can decide, based on a subjective judgment of their 'level of productivity in society,' whether they are worthy of health care."

Sarah Palin made these comments on her Facebook page, responding to a provision in the House health care bill that would provide compensation to doctors who consult with patients about end-of-life care. The lie quickly spread—repeated at town hall meetings, tea parties, on Fox TV and throughout the Conservative blogosphere.

2) “You lie!” Joe Wilson’s angry shout-out to President Obama in the middle of his speech before the joint session of Congress made headlines this fall. Wilson was responding to Obama’s promise that health reform will not include coverage for illegal immigrants. 

3)"President Obama . . . wants to mandate circumcision." (Rush Limbaugh)

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Few observers have commented on how older Americans will fare under the amended Senate health reform legislation, but as things stand, many could be priced out of the health care market. The Senate bill lets insurers in the Exchange charge an elderly person up to three times as much as they would charge a younger customer. Thus many middle-class and upper-middle class Americans in their late 50s or early 60s who don’t have employer-based insurance could find themselves locked out of health care reform.

Under the bill that passed the House, insurers could only double premiums for the elderly. In the past, I had assumed that the House bill would prevail on this point.  I also thought that the public plan might be more generous. After all, it would be hard to argue that a government plan that made insurance unaffordable for middle-class, unemployed and self-employed Americans in their late 50s and early 60s was serving the public good. Surely some in Congress would protest, and the public plan would find a way to keep a lid on premiums, probably by incorporating Medicare reforms that lower costs. If private insurers wanted to complete for customers in that 55-64-year old market, they would have to follow suit.

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A Close Look at the Details

You have to hand it to them: on a Saturday, at the 11th hour, in the midst of a blizzard that shut down the nation’s Capitol, Senate Democrats finally nailed that 60th vote needed to bring health care reform home in time for the Holidays.
In the end, Nebraska Democrat Senator Ben Nelson decided that he didn’t want to play Scrooge. Though his heart  melted only after he  had won: 1) tighter restrictions on insurance coverage for abortions (health insurance plans will be allowed to cover abortions, but states can prohibit the coverage of abortions by plans that are offered in their exchanges); 2)  a special holiday present for his state (the amendment includes, solely for Nebraska, an extension of increased federal contributions to the cost of an expansion of Medicaid);  and 3) a pledge that no major changes will be made to the Senate bill in conference.
Nelson has made it clear that if any provisions from the House bill that he doesn’t like are added to the Senate bill, he will vote against it.

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