Health reform may be stalled in Congress, but you need only look to the overburdened Medicaid program to find evidence of the continued toll the current economic crisis is taking on Americans’ ability to afford and access medical care.

At the same time that states are experiencing huge budget deficits, more and more of their residents are unemployed; more and more are joining the ranks of the uninsured and clamoring for Medicaid benefits. The result: Even with emergency federal infusions of funding, state safety nets are being stretched dangerously thin.

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The New York Times’ David M. Herszenhorn reports that, “If Democrats break down their major health care legislation into components that could be approved separately, the first bill up for consideration could be a proposal to end the exemption from federal antitrust laws that insurers have enjoyed since 1945.”

If reformers want to pass just one piece of the reform legislation, this is the wrong piece.

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Massachusetts Attorney General Martha Coakely has just released a report which reveals that the state’s health care costs are spiraling in large part because he state’s primo hospitals and physician groups –those  with brand name recognition– -are demanding exorbitant reimbursements from insurers.   Providers who control the market in geographically isolated areas also are insisting on reimbursements that far exceed what other providers receive for the same services.. http://www.mass.gov/Cago/docs/healthcare/Investigation_HCCT&CD.pdf

These providers have market leverage. Patients want both marquee names and providers close to home in their insurers’ network. If these providers are not included, customers will switch to a different insurance plan.  Thus, insurance companies have no choice but to pay what the providers demand.

The investigators “found no evidence that the higher pay was a reward for better quality work or for treating sicker patients,” the Boston Globe reports.  http://www.boston.com/news/local/massachusetts/articles/2010/01/29/attorney_general_says_clout_drives_up_health_costs/?page=1  

“In fact, eight of the 10 best-paid hospitals in one insurer’s network were community hospitals, which tend to have less complicated cases than teaching hospitals and do not bear the extra cost of training future physicians.”

Sometimes hospitals claim that they charge more because they treat poorer patients who are sicker.  But the truth is that, often, poorer patients receive fewer services because they have limited access to care. In addition the public hospitals and “safety-net hospitals” that treat indigent patients frequently have fewer resources: shriveled budgets, fewer specialists, less equipment. As I reported in Money-Driven Medicine, often “safety-net” hospitals must ration care.

The new Massachusetts report confirms what many already know about spending on low-income patients: the investigation discovered that hospitals that treat large numbers of poor patients  . . . are paid 10 percent to 25 percent less than average by commercial insurers.

Meanwhile, Coakley’s report made me wonder: Maybe Massachusetts should consider Maryland’s solution?

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In his address to the nation, President Obama made it clear: Jobs are now his #1 priority.

This is what most Americans wanted to hear. They fear that he has spent too much time on health care, and has not paid enough attention to climbing unemployment. This does not mean that they oppose  health care reform legislation—it’s just  that there are tired of hearing about it.  And the need for jobs is more pressing.

It was a strong speech—particularly when the President acknowledged that  “The only way to move to full employment is to lay a new foundation for long-term economic growth, and finally address the problems that America's families have confronted for years.”  One jobs bill will not solve the problem.

President Obama  also opened the door to a college education for many students when he pledged: “let's  . . .give families a $10,000 tax credit for four years of college and increase Pell Grants. And let's tell another one million students that when they graduate, they will be required to pay only ten percent of their income on student loans, and all of their debt will be forgiven after twenty years – and forgiven after ten years if they choose a career in public service.”

These are good ideas. But what about health care?

Hours before the State of the Union address, some believed that the President  would save health- care reform for the very end of his speech. The pivotal question was this: would health care seem an after-thought  or a climax?

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According to the headlines, 10 percent of Americans are unemployed. The truth is that closer to 17 percent of  the population cannot find full-time work; this number includes workers who have become discouraged and have given up looking for work as well as those who have settled for part-time jobs because they cannot find the full-time employment that they need.

The situation is not going to change anytime soon. As Princeton economist Paul Krugman recently warned: “We are facing mass unemployment — unemployment that will blight the lives of millions of Americans for years to come.”

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Over at the Disease Management Care Blog, http://diseasemanagementcareblog.blogspot.com/2010/01/welcome-to-tree-of-blogs-avatar-movie.html Jaan Sidorov hosts the most recent edition of Health Wonk Review, a round-up of some of the best healthcare blogs of the past two weeks.  I find that the Review is a good way to find out about excellent blogs that I haven't heard about–while also keeping up with favorites.

Sidorov, who is a primary care general internist and former Medical Director at Geisinger Health Plan., highlights some posts which suggest that physicians are thinking about how to reform their own specialties.

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The media continues to report that the Massachusetts vote was a referendum on health care reform—and that this has the White House worried.

If so, the White House is wrong.

Take a look at polling conducted by Hart Research Associates for the AFL-CIO on the evening of the election, revealing who voted for Brown –and what those voters said.  Then consider separate polling done by the Washington Post together with the Kaiser Family Foundation and Harvard University.  Read both reports, and you’ll have a very hard time believing that Scott Brown’s election represents a mandate on healthcare legislation.

Finally, factor in the eye-opening Kaiser Family Foundation January tracking poll,  and what it reveals about what voters do and don’t understand about health reform legislation.  If most voters have only a hazy idea of what is in the legislation, you really can’t say that they voted against the Senate bill.

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When explaining why the voters of Massachusetts turned Ted Kennedy’s seat over to a Republican, some commentators are suggesting that voters were appalled by the corruption they saw in Washington as Democrats struggled to put together health reform legislation:

Over at The Health Care Blog, Brian Klepper and David Kibbe write:  “The distaste expressed yesterday probably has little to do with the specific provisions of the bills . . . . But along the way, voters have witnessed  . . .  lawmaking in its worst tradition. There was the White House's deal making with powerful corporate interests like the drug manufacturers even before the proceedings began. And the tremendous lobbying contributions by health care and non-health care special interests in exchange for access to the policy-shaping process. Or the outright bribery of specific Senators and Representatives in exchange for votes. Last week's White House deal with the unions that exempted them from the tax on ‘Cadillac’ health plans until 2018 must have seemed like a perfectly OK arrangement to the people in the center of all this activity, but to normal people who read the paper, it was emblematic of the current modus operandi: If you have power and support the party in power's muddled agenda, you get a special deal.”

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Just in case you were wondering what the public thinks about the recent upheaval over health care reform, a USA TODAY/Gallup Poll taken Wednesday finds some 55% of Americans say President Obama and congressional Democrats should suspend work on the health care bill that was this close to being passed and consider alternatives that would draw more Republican support.

What might these alternatives be? Besides attacking every major Democratic version of reform, the Republicans have been fairly quiet about their own grand vision for the future of health care. Still, there is a vision. At the end of July, the Republican Study Committee, led by Rep. Tom Price (R-GA) (an orthopedic surgeon) introduced the “Empowering Patients First Act” (H.R. 3400) as their contribution to the debate.

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