I didn’t post about the vote earlier today, because I cannot begin to predict what will happen next. There are too many variables. At this point in the process, a few politicians can begin to make demands that could actually block any reform legislation this year.

I still feel strongly that Congress should try to pass a bill, even if it is legislation that I find terribly disappointing..  But –and this is crucial– it must be a bill that makes it clear that we, as a nation, believe that everyone deserves good, affordable healthcare, and that we are all willing to share in doing what it takes to provide that security for everyone.

That’s the bottom line. The bill must mark a turning point: we have made a decision that healthcare is something than any civilized society should provide to all of its citizens. If we do that, I think it will be like civil rights legislation. There will be no turning back.

This is why conservatives are so upset about the current legislation: they fear that there will be no turning back.

Going forward, I would say just one thing with some certainty: Beware of those who say that progressives must “go back to the drawing board” and work with conservatives to forge a bipartisan bill.

Conservatives don’t want reform, at least not as progressives define it:  “equal opportunity” for all who need care. “Universal coverage” is not the goal that conservatives seek. They would continue to discriminate against the sick and low-income families.  They believe that a competitive market could offer the soltuion to our health care crisis.  ((I’ll be writing about this tomorrow when I take a look at Safeway’s Solution.)

Conservatives blame the sick for being sick, and they fault the poor for being poor.  Health care reform must be compassionate, and it must be equitable.

The value of using antidepressants to treat mild to moderate depression came under fire recently after a study in the Journal of the American Medical Association found that the drugs didn’t work much better than a placebo in those with mild to moderate depression. These findings were widely reported because with 164 million prescriptions written and $10 billion in sales in 2008, according to IMS Health, these antidepressants (called SSRIs) were the third most popular class of therapeutics sold in the U.S.

Companies are promoting an ever-increasing arsenal of SSRI’s and a whole new class of drugs—the atypical antipsychotics—for treating depression and other mental disorders. But despite their widespread use, the JAMA study adds to an emerging body of research that raises more questions than it answers about the safety and efficacy of using current drugs in treating moderate or mild depression. Though sometimes extremely helpful, it has becoming increasingly clear that these drugs are no panacea for many patients, and may even cause harm.

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The Senate’s controversial “Cadillac Tax” on expensive health insurance plans was supposed to raise $149 billion to help fund reform. But now, we’re told it’s been “scaled back.” Some use the verb “gutted”—though that is probably a tad strong. Still, a number of changes have been made:

• Union employees will be exempt for the tax on expensive insurance plans until 2018, five years after the legislation takes effect
• Government employees will also be exempt until 2018
• The threshold defining “expensive” plans has been lifted from $8,500 to $9,000 for individual plans and from $23,000 to $24,000 for family plans.
• The threshold will rise further for plans where premiums are higher because the work force is older or includes more women 
• Adjustments will also be made to spare plans in 17 states with particularly high health costs.
• The value of dental and vision benefits won’t count toward the thresholds

Reportedly, the changes mean that the tax will raise about $90 billion over 10 years, down from $149 billion. But my guess is that, after you tally up all of the adjustments, the bill will raise far less.

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Everyone knows that Haitians are in desperate need of aid. Most people don’t know how they might help. Here is some useful information:

First, Paul Farmer’s organization, Health Partners, can be trusted. Farmer has spent more than two decades working in Haiti and has done extraordinary work.

As Pulitzer prize-winning journalist Tracy Kidder, author of Mountains Upon Mountains,” observes in a New York Times Op-ed: In Haiti “there are the many projects that seem designed to serve not impoverished Haitians but the interests of the people administering the projects. Most important, a lot of organizations seem to be unable — and some appear to be unwilling — to create partnerships with each other or, and this is crucial, with the public sector of the society they’re supposed to serve. . . “

But Kidder observes: “there are effective aid organizations working in Haiti. At least one has not been crippled by the earthquake. Partners in Health, or in Haitian Creole Zanmi Lasante, has been the largest health care provider in rural Haiti. (I serve on this organization’s development committee.) It operates, in partnership with the Haitian Ministry of Health, some 10 hospitals and clinics, all far from the capital and all still intact. As a result of this calamity, Partners in Health probably just became the largest health care provider still standing in all Haiti.

“Fortunately, it also offers a solid model for independence  . . ..”

Matthew Holt’s The Health Care Blog has published this appeal from Health Partners, addressed to:  Surgeons, nurses, and other medical personnel:  “We are deeply grateful for the multitude of people who have contacted us wanting to provide medical  assistance. As patients flood to our sites from Port-au-Prince, we’re finding ourselves in need of both medical personnel and supplies. In particular, we need surgeons (especially trauma/orthopedic surgeons), ER doctors and nurses, and full surgical teams (including anesthesiologists, scrub and post-op nurses, and nurse anesthetists).

“If you are a health professional interested in volunteering, please send an email to volunteer@pih.org with information on your credentials, language capabilities (Haitian Creole or French desired), availability, and contact information.”

 “As phone lines in Haiti remain down and transportation and communication are difficult, PIH is still in the process of determining where we can set up operations in Port-au-Prince, and how we can transport patients and volunteers to our sites. We will be able to offer more concrete information after these logistical matters are resolved.”

It might seem too late to volunteer. So many Haitians are dead or dying as we speak.  But those who were badly injured are hanging on– still hoping for  help. Over the longer term, they are going to need physicians and nurses as they try to repair lives. In many cases, those who survived but are injured are orphaned children.

If you’re like me and  can’t travel to Haiti, you still can contribute. Send as little a $10—or as much as you can. I’ve contributed  to Partners In Health’s website here.

The Washington Post reports that union leaders are close to cutting a deal with Democrats on the so-called “Cadillac tax,” the 40% tax on expensive insurance plans that the Senate has proposed to help fund health care reform. According to the Post, unions would be exempted from the tax, for two years following the 2013 effective date, giving them time to negotiate new contracts with employers. For other reports on the negotiations, see Kaiser Health News.

What about employees who are not unionized? Late this afternoon, The Wall Street Journal reports that “Democrats agreed to add a provision making the tax less onerous on older workers and women, a union official said. Union sources cautioned that the agreement isn't finalized because it is still being presented to the various unions.” Meanwhile, CNN has said that labor leaders are pushing to expand the deal to exempt health plans for all Americans making under $200,000 a year: “AFL-CIO chief Richard Trumka has made looking out for all workers — not just union members — a big part of his platform.” Watch to see if this happens:  if it does, it would be a major fix.

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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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Recently, a series of anecdotes appeared on the website People’s Pharmacy, posted by readers who suffer from depression. They detail how switching from name brand antidepressants to generics—or in some cases from one generic to another—caused a return in symptoms. Here’s one excerpt:

“I've been on the big yellow 300 mg Buproprion XL for about 6 months and my last refill was filled with Actavis (smaller white ones). While the old ones…made me feel great, I've been doing poorly on Actavis…I certainly feel more unmotivated, lethargic, and sadder.”

People’s Pharmacy isn’t connected to the Food and Drug Administration, a medical center or a mental health or other professional group. Joe Graedon, the site's founder is a consumer advocate and writer, not a health professional. But nevertheless, the New York Times prominently quotes him and includes similar anecdotes in a recent article that questions whether generic drugs are as effective as their name-brand counterparts.

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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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