159 Ways the Senate Bill Is a Government Takeover of Health Care

From the Senate Republican Policy Committee.

Here is a list of new boards, bureaucracies, and programs created in the 2,733 page Senate health care bill, which serves as the framework for President Obama’s health proposal:

1. Grant program for consumer assistance offices (Section 1002, p. 37)
2. Grant program for states to monitor premium increases (Section 1003, p. 42)
3. Committee to review administrative simplification standards (Section 1104, p. 71)
4. Demonstration program for state wellness programs (Section 1201, p. 93)
5. Grant program to establish state Exchanges (Section 1311(a), p. 130)
6. State American Health Benefit Exchanges (Section 1311(b), p. 131)
7. Exchange grants to establish consumer navigator programs (Section 1311(i), p. 150)
8. Grant program for state cooperatives (Section 1322, p. 169)
9. Advisory board for state cooperatives (Section 1322(b)(3), p. 173)
10. Private purchasing council for state cooperatives (Section 1322(d), p. 177)
11. State basic health plan programs (Section 1331, p. 201)
12. State-based reinsurance program (Section 1341, p. 226)
13. Program of risk corridors for individual and small group markets (Section 1342, p. 233)
14. Program to determine eligibility for Exchange participation (Section 1411, p. 267)
15. Program for advance determination of tax credit eligibility (Section 1412, p. 288)
16. Grant program to implement health IT enrollment standards (Section 1561, p. 370)
17. Federal Coordinated Health Care Office for dual eligible beneficiaries (Section 2602, p. 512)
18. Medicaid quality measurement program (Section 2701, p. 518)
19. Medicaid health home program for people with chronic conditions, and grants for planning same (Section 2703, p. 524)
20. Medicaid demonstration project to evaluate bundled payments (Section 2704, p. 532)
21. Medicaid demonstration project for global payment system (Section 2705, p. 536)
22. Medicaid demonstration project for accountable care organizations (Section 2706, p. 538)
23. Medicaid demonstration project for emergency psychiatric care (Section 2707, p. 540)
24. Grant program for delivery of services to individuals with postpartum depression (Section 2952(b), p. 591)
25. State allotments for grants to promote personal responsibility education programs (Section 2953, p. 596)
26. Medicare value-based purchasing program (Section 3001(a), p. 613)
27. Medicare value-based purchasing demonstration program for critical access hospitals (Section 3001(b), p. 637)
28. Medicare value-based purchasing program for skilled nursing facilities (Section 3006(a), p. 666)
29. Medicare value-based purchasing program for home health agencies (Section 3006(b), p. 668)
30. Interagency Working Group on Health Care Quality (Section 3012, p. 688)
31. Grant program to develop health care quality measures (Section 3013, p. 693)
32. Center for Medicare and Medicaid Innovation (Section 3021, p. 712)
33. Medicare shared savings program (Section 3022, p. 728)
34. Medicare pilot program on payment bundling (Section 3023, p. 739)
35. Independence at home medical practice demonstration program (Section 3024, p. 752)
36. Program for use of patient safety organizations to reduce hospital readmission rates (Section 3025(b), p. 775)
37. Community-based care transitions program (Section 3026, p. 776)
38. Demonstration project for payment of complex diagnostic laboratory tests (Section 3113, p. 800)
39. Medicare hospice concurrent care demonstration project (Section 3140, p. 850)
40. Independent Payment Advisory Board (Section 3403, p. 982)
41. Consumer Advisory Council for Independent Payment Advisory Board (Section 3403, p. 1027)
42. Grant program for technical assistance to providers implementing health quality practices (Section 3501, p. 1043)
43. Grant program to establish interdisciplinary health teams (Section 3502, p. 1048)
44. Grant program to implement medication therapy management (Section 3503, p. 1055)
45. Grant program to support emergency care pilot programs (Section 3504, p. 1061)
46. Grant program to promote universal access to trauma services (Section 3505(b), p. 1081)
47. Grant program to develop and promote shared decision-making aids (Section 3506, p. 1088)
48. Grant program to support implementation of shared decision-making (Section 3506, p. 1091)
49. Grant program to integrate quality improvement in clinical education (Section 3508, p. 1095)
50. Health and Human Services Coordinating Committee on Women’s Health (Section 3509(a), p. 1098)
51. Centers for Disease Control Office of Women’s Health (Section 3509(b), p. 1102)
52. Agency for Healthcare Research and Quality Office of Women’s Health (Section 3509(e), p. 1105)
53. Health Resources and Services Administration Office of Women’s Health (Section 3509(f), p. 1106)
54. Food and Drug Administration Office of Women’s Health (Section 3509(g), p. 1109)
55. National Prevention, Health Promotion, and Public Health Council (Section 4001, p. 1114)
56. Advisory Group on Prevention, Health Promotion, and Integrative and Public Health (Section 4001(f), p. 1117)
57. Prevention and Public Health Fund (Section 4002, p. 1121)
58. Community Preventive Services Task Force (Section 4003(b), p. 1126)
59. Grant program to support school-based health centers (Section 4101, p. 1135)
60. Grant program to promote research-based dental caries disease management (Section 4102, p. 1147)
61. Grant program for States to prevent chronic disease in Medicaid beneficiaries (Section 4108, p. 1174)
62. Community transformation grants (Section 4201, p. 1182)
63. Grant program to provide public health interventions (Section 4202, p. 1188)
64. Demonstration program of grants to improve child immunization rates (Section 4204(b), p. 1200)
65. Pilot program for risk-factor assessments provided through community health centers (Section 4206, p. 1215)
66. Grant program to increase epidemiology and laboratory capacity (Section 4304, p. 1233)
67. Interagency Pain Research Coordinating Committee (Section 4305, p. 1238)
68. National Health Care Workforce Commission (Section 5101, p. 1256)
69. Grant program to plan health care workforce development activities (Section 5102(c), p. 1275)
70. Grant program to implement health care workforce development activities (Section 5102(d), p. 1279)
71. Pediatric specialty loan repayment program (Section 5203, p. 1295)
72. Public Health Workforce Loan Repayment Program (Section 5204, p. 1300)
73. Allied Health Loan Forgiveness Program (Section 5205, p. 1305)
74. Grant program to provide mid-career training for health professionals (Section 5206, p. 1307)
75. Grant program to fund nurse-managed health clinics (Section 5208, p. 1310)
76. Grant program to support primary care training programs (Section 5301, p. 1315)
77. Grant program to fund training for direct care workers (Section 5302, p. 1322)
78. Grant program to develop dental training programs (Section 5303, p. 1325)
79. Demonstration program to increase access to dental health care in underserved communities (Section 5304, p. 1331)
80. Grant program to promote geriatric education centers (Section 5305, p. 1334)
81. Grant program to promote health professionals entering geriatrics (Section 5305, p. 1339)
82. Grant program to promote training in mental and behavioral health (Section 5306, p. 1344)
83. Grant program to promote nurse retention programs (Section 5309, p. 1354)
84. Student loan forgiveness for nursing school faculty (Section 5311(b), p. 1360)
85. Grant program to promote positive health behaviors and outcomes (Section 5313, p. 1364)
86. Public Health Sciences Track for medical students (Section 5315, p. 1372)
87. Primary Care Extension Program to educate providers (Section 5405, p. 1404)
88. Grant program for demonstration projects to address health workforce shortage needs (Section 5507, p. 1442)
89. Grant program for demonstration projects to develop training programs for home health aides (Section 5507, p. 1447)
90. Grant program to establish new primary care residency programs (Section 5508(a), p. 1458)
91. Program of payments to teaching health centers that sponsor medical residency training (Section 5508(c), p. 1462)
92. Graduate nurse education demonstration program (Section 5509, p. 1472)
93. Grant program to establish demonstration projects for community-based mental health settings (Section 5604, p. 1486)
94. Commission on Key National Indicators (Section 5605, p. 1489)
95. Quality assurance and performance improvement program for skilled nursing facilities (Section 6102, p. 1554)
96. Special focus facility program for skilled nursing facilities (Section 6103(a)(3), p. 1561)
97. Special focus facility program for nursing facilities (Section 6103(b)(3), p. 1568)
98. National independent monitor pilot program for skilled nursing facilities and nursing facilities (Section 6112, p. 1589)
99. Demonstration projects for nursing facilities involved in the culture change movement (Section 6114, p. 1597)
100. Patient-Centered Outcomes Research Institute (Section 6301, p. 1619)
101. Standing methodology committee for Patient-Centered Outcomes Research Institute (Section 6301, p. 1629)
102. Board of Governors for Patient-Centered Outcomes Research Institute (Section 6301, p. 1638)
103. Patient-Centered Outcomes Research Trust Fund (Section 6301(e), p. 1656)
104. Elder Justice Coordinating Council (Section 6703, p. 1773)
105. Advisory Board on Elder Abuse, Neglect, and Exploitation (Section 6703, p. 1776)
106. Grant program to create elder abuse forensic centers (Section 6703, p. 1783)
107. Grant program to promote continuing education for long-term care staffers (Section 6703, p. 1787)
108. Grant program to improve management practices and training (Section 6703, p. 1788)
109. Grant program to subsidize costs of electronic health records (Section 6703, p. 1791)
110. Grant program to promote adult protective services (Section 6703, p. 1796)
111. Grant program to conduct elder abuse detection and prevention (Section 6703, p. 1798)
112. Grant program to support long-term care ombudsmen (Section 6703, p. 1800)
113. National Training Institute for long-term care surveyors (Section 6703, p. 1806)
114. Grant program to fund State surveys of long-term care residences (Section 6703, p. 1809)
115. CLASS Independence Fund (Section 8002, p. 1926)
116. CLASS Independence Fund Board of Trustees (Section 8002, p. 1927)
117. CLASS Independence Advisory Council (Section 8002, p. 1931)
118. Personal Care Attendants Workforce Advisory Panel (Section 8002(c), p. 1938)
119. Multi-state health plans offered by Office of Personnel Management (Section 10104(p), p. 2086)
120. Advisory board for multi-state health plans (Section 10104(p), p. 2094)
121. Pregnancy Assistance Fund (Section 10212, p. 2164)
122. Value-based purchasing program for ambulatory surgical centers (Section 10301, p. 2176)
123. Demonstration project for payment adjustments to home health services (Section 10315, p. 2200)
124. Pilot program for care of individuals in environmental emergency declaration areas (Section 10323, p. 2223)
125. Grant program to screen at-risk individuals for environmental health conditions (Section 10323(b), p. 2231)
126. Pilot programs to implement value-based purchasing (Section 10326, p. 2242)
127. Grant program to support community-based collaborative care networks (Section 10333, p. 2265)
128. Centers for Disease Control Office of Minority Health (Section 10334, p. 2272)
129. Health Resources and Services Administration Office of Minority Health (Section 10334, p. 2272)
130. Substance Abuse and Mental Health Services Administration Office of Minority Health (Section 10334, p. 2272)
131. Agency for Healthcare Research and Quality Office of Minority Health (Section 10334, p. 2272)
132. Food and Drug Administration Office of Minority Health (Section 10334, p. 2272)
133. Centers for Medicare and Medicaid Services Office of Minority Health (Section 10334, p. 2272)
134. Grant program to promote small business wellness programs (Section 10408, p. 2285)
135. Cures Acceleration Network (Section 10409, p. 2289)
136. Cures Acceleration Network Review Board (Section 10409, p. 2291)
137. Grant program for Cures Acceleration Network (Section 10409, p. 2297)
138. Grant program to promote centers of excellence for depression (Section 10410, p. 2304)
139. Advisory committee for young women’s breast health awareness education campaign (Section 10413, p. 2322)
140. Grant program to provide assistance to provide information to young women with breast cancer (Section 10413, p. 2326)
141. Interagency Access to Health Care in Alaska Task Force (Section 10501, p. 2329)
142. Grant program to train nurse practitioners as primary care providers (Section 10501(e), p. 2332)
143. Grant program for community-based diabetes prevention (Section 10501(g), p. 2337)
144. Grant program for providers who treat a high percentage of medically underserved populations (Section 10501(k), p. 2343)
145. Grant program to recruit students to practice in underserved communities (Section 10501(l), p. 2344)
146. Community Health Center Fund (Section 10503, p. 2355)
147. Demonstration project to provide access to health care for the uninsured at reduced fees (Section 10504, p. 2357)
148. Demonstration program to explore alternatives to tort litigation (Section 10607, p. 2369)
149. Indian Health demonstration program for chronic shortages of health professionals (S. 1790, Section 112, p. 24)*
150. Office of Indian Men’s Health (S. 1790, Section 136, p. 71)*
151. Indian Country modular component facilities demonstration program (S. 1790, Section 146, p. 108)*
152. Indian mobile health stations demonstration program (S. 1790, Section 147, p. 111)*
153. Office of Direct Service Tribes (S. 1790, Section 172, p. 151)*
154. Indian Health Service mental health technician training program (S. 1790, Section 181, p. 173)*
155. Indian Health Service program for treatment of child sexual abuse victims (S. 1790, Section 181, p. 192)*
156. Indian Health Service program for treatment of domestic violence and sexual abuse (S. 1790, Section 181, p. 194)*
157. Indian youth telemental health demonstration project (S. 1790, Section 181, p. 204)*
158. Indian youth life skills demonstration project (S. 1790, Section 181, p. 220)*
159. Indian Health Service Director of HIV/AIDS Prevention and Treatment (S. 1790, Section 199B, p. 258)*

*Section 10221, page 2173 of H.R. 3590 deems that S. 1790 shall be deemed as passed with certain amendments.

Healthcare Hangover, Part 3

An interesting article in National Journal, the blue-chip insider magazine, on the healthcare bill. Written by Brian Friel, Richard E. Cohen, Alexis Simendinger, Kirk Victor, James A. Barnes, and Peter H. Stone.

The sextet of coauthors pull out some interesting items, including a comment from Service Employees International Union president Andy Stern that the healthcare bill will "lead to the creation of 2.5 to 4 million new health care jobs."

Here at SMS, we have seen various claims that the healthcare reform would create jobs elsewhere in the economy, from the Center for American Progress and elsewhere, but if this NJ item is correct, then Stern sees millions of jobs blossoming out of the healthcare sector itself--and presumably many of them would join SEIU. And all this time, we were told that the goal was bend the curve downward, because we spent too much.

As Sen. Olympia Snowe observed to NJ in the wake of the bill’s passage, “We’re getting, I think, far more expansive policy than the American people are prepared to digest or think is practical in these economic times.”

But let's remember, while half the argument for Obamacare was compassion, the other half was budget-cutting. So which half was right?

Another person quoted in the NJ article, MIT economist Jonathan Gruber, described as an "intellectual architect" of the Obamacare, said in a March 11 speech in Massachusetts, "The only way we're going to stop our country from becoming a latter-day Roman Empire and falling under its own weight is to get control of the growth rate of health care costs." An interesting point, albeit perhaps a bit hyperbolic. But it will be interesting to see what the Obamans do to actually control costs.

Yes, there's a lot of activity, as reported by TalkingPointsMemo's Christina Bellantoni, but it's not so obvious that this scrambling toward implementation is oriented toward reducing costs, now that the bill is passed.

Indeed, as the "doc fix" is once again being fixed, restoring hundreds of billions to doctors, we see that once again, hundreds of billions to the cost of healthcare.

In the biting words of Hot Air blogger Ed Morrissey:

Of course, we knew that before Congress began to debate ObamaCare — and so did the Democrats. The AMA agreed to support their efforts only if Democrats rescinded those cuts. Instead of recalibrating the bill using honest accounting, they claimed deficit reductions that only exist without the doctor fix. For months, Democrats kept the rescission parallel to the overhaul of the health-care system to maintain the illusion of fiscal responsibility.

On April 1st, the illusion ends. When those cuts don’t go into effect, ObamaCare becomes a deficit-expanding program — and that’s assuming that the rest of it works as advertised, a very large assumption that flies in the face of experience from every government entitlement program ever created.

So spending is going up again. Faced with the prospect of cutting, politicians, in both parties, back away. Who wants to cut Medicare? Who wants to cut Medicaid? Who wants to cut back on care to the sick? Nobody. Maybe that means--and this has been the argument here at SMS all along--that people want to spend more on healthcare, not less. And the people are speaking.

Is it possible, after all, that there is no real constituency for controlling costs? Is it possible that all Establishmentarians who write reports on deficit-cutting have no real support in the country? That would seem to be the case.

But if the Establishment is right, and long-term deficits are going to prove ruinous to the country, then we will need to be more creative about controlling costs. As we say here at SMS, a cure is cheaper than care.

The iPad and Healthcare--The Future Must Be Fun and Cool

Everybody knows that the iPad--which will be available to consumers this coming Saturday--is going to be a big deal. But various seers and sages are now starting to think about how it will affect their industry, including the healthcare industry. All of us who have been to the doctor's office and filled out the same information, two or three times, even during the same visit know how great it would be if there was the equivalent of an electronic clipboard, in which all that information would go. Not just for the convenience, but also for the life-saving power of good information. What allergies? What prescriptions? What medical history? One hates to think that lives are being lost because of poor handwriting, or because the wrong box was checked, or because the paper was misfiled, or because a fatigued--or lazy--doctor or nurse didn't go through every last page of a fat file.

And yet a tablet computer, by itself, is not the answer--we've had those for years, and they have had no great impact, on healthcare, or anything else. To be effective, the tablet has to be fully functional, of course, but it also must be cool and fun. And that means, among other factors, that it needs to be connected to the Internet, and not just the Internet, but also the Cloud. The Cloud being the more specific area of interactivity: not just e-mail and Google, but specific information, specific computations, specific feedback.

So it was noteworthy that Marc Benioff, the chairman and CEO of Salesforce.com, writing in TechCrunch, took so much time to sing the praises of the iPad:

The future of our industry now looks totally different than the past. It looks like a sheet of paper, and it’s called the iPad. It’s not about typing or clicking; it’s about touching. It’s not about text, or even animation, it’s about video. It’s not about a local disk, or even a desktop, it’s about the cloud. It’s not about pulling information; it’s about push. It’s not about repurposing old software, it’s about writing everything from scratch (because you want to take advantage of the awesome potential of the new computers and the new cloud—and because you have to reach this pinnacle). Finally, the industry is fun again.

It's important to understand that Benioff is not some fanboy. His company, Salesforce.com is a major player in the fast-growing field of software-as-a-service, which comes, of course, from the Cloud. Here's more of what Benioff has to say about the iPad and healthcare:

What’s most exciting is that this fundamental transformation—cloud + social + iPad—will inspire a new generation of wildly innovative new apps that will change entire industries. Take health. We have all been waiting for the health application that will revolutionize how we share and communicate with our doctors, and help us make better health care decisions. The apps we have seen as first generation EHR/PHR just have not cut it, and now with ObamaCare there is no killer app to accelerate through the new EHR reimbursement program. The shift ignited by the iPad will allow the proliferation of these new missing apps, and automate the industries and professionals left behind by the last generation of technology. Now, no industry will be left behind.

Benioff, of course, would stand to benefit from a transformational iPad, because then his software, which exists in the cloud, will all the more valuable. That is, if everyone is walking around with an iPad, including in doctors' offices and hospitals, then there will be the virtual equivalent of a mainframe up in the cloud somewhere, and Benioff hopes to sell--more accurately, rent--some of that cloud to each iPad user.

Let's hope it works out for him, and all the other entrepreneurs who wish to improve healthcare. They are the ones who will genuinely reform the system. They will make it better and cheaper, both. They will also make it cool, and even fun.

The Healthcare Hangover, Part 2

"Law May Do Little to Help Curb Unnecessary Care"--that's the headline atop Gina Kolata's story in The New York Times today. As Kolata notes, people still want to be treated. (We can leave aside, just this once, the question of who decides what is unnecessary.)

As the Times explains: "It is no surprise that Congress shied away from a serious effort to hold down overuse. The public has made it clear that it does not want to be told what medical care it can and cannot have." And she adds a colorful quote from a well-known expert:

“The minute you attack overutilization you will be called a Nazi before the day is out,” said Uwe E. Reinhardt, a health economist at Princeton.

Ouch! Of course, "Nazi" might be too strong, but "death panelist" will certainly be heard. Continuing, Kolata adds these skeptical grafs on a major article of healthcare reform faith--comparative effectiveness:

Some hold out hope for the comparative effectiveness studies.

But “there is no direct link between the development of that evidence and the use of that evidence,” said Bryan R. Luce, senior vice president for science policy at United Biosource Corp., a Washington consulting firm.

The idea of the comparative effectiveness guidelines is a sort of an “if you build it, they will come” notion, said Dr. J. Sanford Schwartz, a health economist and internist at the University of Pennsylvania. But that is not going to be sufficient, he said. There needs to be a way to effectively link what the guidelines say and how they are put into effect, how they are interpreted, what insurers pay for and what doctors do.

One way to make those links is to do what some other countries do — say that there will be no payments for care that is not deemed the most cost-effective. But politicians shy away from such measures, Dr. Luce said. “That is not likely to happen soon, particularly at a national level,” he said.

It would mean rationing, said Dr. Robert D. Truog a professor of medical ethics, anesthesia, and pediatrics at Harvard Medical School. “That’s the word nobody wants to use. It’s just a firecracker. Nobody wants to touch it.”

So what, exactly did get cut? We know that we will add 31 million people to the insurance rolls, but if the thrust of Kolata's story is accurate, then it sure seems as if the cost-curve was bent upward, not downward. Yes, Peter Orszag made great arguments about controlling costs and all that, but those arguments don't seem to have gone very far beyond the marbled palaces of Washington. It doesn't appear that either doctors or patients have paid much heed. The bogies of demanding patients, defensive-medicine-ing docs, and overall inefficiency still seem to be with us. So we'll be waiting to see if Orszag & Co. now wade into the details of cutting costs, and how Congress, and the American people, react to such wading-into-ing.

But for now, we might ask: Is this why we passed this bill? To spend more? Interesting.

Here at Serious Medicine Strategy, we have long argued that spending is not the problem. Instead, the problem is what we get for the money we spend. The "get" can be improved, of course, but not by talking about cutting costs. The get can only be improved by improving the quality of care, and the quantity of cures. That's how to save money. Nothing else works.

The Healthcare Hangover and the Reality of Universal Coverage

So the healthcare party is over--now we have to read the fine print. With the political equivalent of a hangover. Yes, the last year has been wild and raucous, but we ain't seen nothin' yet. We’re going to need a lot of coffee to get through the policy wrangles ahead--or maybe another drink. But in the meantime, we are going to continue stumbling our way toward some sort of universal coverage.

The New York Times headlines, “Coverage Now for Sick Children? Check Fine Print.” As reporter Robert Pear notes, President Obama expressed great confidence that his healthcare bill would force the coverage of pre-existing conditions. On March 19, Obama said, “Starting this year, insurance companies will be banned forever from denying coverage to children with pre-existing conditions.”

That was the promise. But the reality seems to be different. Pear quotes insurance lawyer William G. Schiffbauer: “The fine print differs from the larger political message. If a company sells insurance, it will have to cover pre-existing conditions for children covered by the policy. But it does not have to sell to somebody with a pre-existing condition. And the insurer could increase premiums to cover the additional cost.” Oops.

For their part, Democrats are mad: “The ink has not yet dried on the health care reform bill,” snaps Sen. Jay Rockefeller of West Virginia, “and already some deplorable health insurance companies are trying to duck away from covering children with pre-existing conditions. This is outrageous.

But one must wonder: If Schiffbauer and the insurance companies are correct in their assessment--that “the fine print differs from the larger political message,” as the Times’ Pear, who has been following healthcare for decades, seems to accept as true--then that difference must have been obvious ten days ago, been obvious a week ago, or a month ago, or a year ago.

This loophole, if that’s the right word, is supposed to close in January 2014. As the Times puts it, “Insurers say, until 2014, the law does not require them to write insurance at all for the child or the family. In the language of insurance, the law does not include a ‘guaranteed issue’ requirement before then.” And that grace period, which could mean, of course, that everyone concerned has nearly four years to figure out some new loopholes.

But for the time being, we might ask: We the Democrats simply careless in the way that they wrote the bill they just passed? Or, perhaps more cynically, we might wonder: Did they deliberately leave the loopholes, to ease the bill’s passage? And now, faced with those loopholes, what are Democrats going to do for the next four years? Are they going to simply fulminate against the insurance companies (perhaps while collecting campaign contributions) or are they going to seek to rewrite the Obamacare legislation? If they do seek a rewrite, there will, of course, be a fight.

And then, of course, will come the question: Can the health insurance industry exist if the government mandates that everyone be covered for everything? There are some on the left who don't want the industry to exist, of course, because they want the government to run the whole of healthcare--it's called "single payer." But there are plenty of others who don't want the government to have that power--the Tea Partiers, and many others who are simply fearful of too much power in Washington. And so the political and economic battle is joined, now, and for many years to come.

Meanwhile, the heart-tugging stories continue to appear, and what we see is that neither the left nor the right seems interested in cutting back on the sort of heroic medicine that saves lives.

Over the weekend, ABC News headlined, “Family Learns Pre-Existing Conditions Apply at Birth/Newborn Was Denied Health Insurance Coverage Days After Life-Saving Surgery.” As ABC’s Lauren Cox and Lara Salahi report:

Houston Tracy, a 12-day-old boy, has already survived a rare birth defect, a feeding tube and open heart surgery. Now his family is waiting to see how the battle with an insurance company will fare. Last week, Houston's parents found out that the term “pre-existing condition” can apply the moment someone is born.

It seems that little Houston was born with “d-transposition of the great arteries,” meaning the primary aorta and pulmonary arteries are transposed where they should meet the heart. Houston was born on Monday, March 15, within days, doctors at Cook Children’s Medical Center had operated, saving his life. “In Houston's case he would not have survived had he not gotten the care,” Dr. Steve Muyskens, the pediatric cardiologist who treated Houston told ABC. “Most children with this [would] have a demise within days to months in life.”

We might pause, of course, to admire the Serious Medicine that went into saving this little boy’s life--his arteries fixed, Houston can look forward to a normal childhood. That's what matters most. For Houston's parents, the surgery is primary, the insurance is secondary.

And of course, in this generous country, people are always going to find ways to save the life of a newborn, if at all possible. (That's a picture of the baby above, who doesn't want to help?)

But now the plot thickens. As ABC also reports, just days after Houston’s operation, the Tracy family formally heard their son was denied health insurance by Blue Cross and Blue Shield of Texas. ABC adds, “The provision in the health insurance reform act that prohibits health insurance companies from denying coverage to children with a pre-existing condition will only take effect six months after the bill was signed into law.” But wait a second--the Times said not until January 2014. As noted, this stuff is complicated.

Yet interestingly, ABC tells us, the Tracy family did get insurance:

Doug Tracy said his family has found an alternative route to get his child coverage through the Texas Health Insurance Risk Pool, and the policy will only cost $277 a month -- $10 more than the premium on the policy he tried to take out for his son. However, he said he's confused since he will still have to apply through Blue Cross and Blue Shield of Texas if he goes through the Texas Health Insurance Risk Pool.

So we might wonder--what sort of shell game is going on here? The Tracy family can’t get private insurance, so they get public insurance, administered, it seems, by a private company. Indeed, it's interesting that such a program as the Texas Health Insurance Risk Pool exists in the home state of Gov, Rick Perry and so many Tea-Partying opponents of Obamacare. Yes, they opposed Obamacare, but do they also oppose the system that brought the Tracy family its health coverage?

Maybe this is the way it has to be. For their part, Democrats wanted a bill, even if it didn't so what they said it would do, at least not yet. And for their part, Republicans oppose Obamacare, even if they seem to quietly support programs that do much the same thing.

The really important thing, as we have seen, is that Houston Tracy got his operation; his little life has been saved. Now the adults will have to figure out the financing mechanism.


But what seems clear is this: We are going to end up covering everyone, out of one “pot” or another. The only question is how.

Repeal vs. Reform: A New Poll in The Washington Post Shows the Majority--and the Intensity--Against Obamacare. Cue Up The Blogosphere!

A Washington Post poll published Sunday morning shows the country still sharply split on Obamacare, with the edge in numbers and intensity going to opponents. Forty-six percent of Americans support the bill, 50 percent oppose. Yet remarkably, a quarter of all those asked said that they had taken the step of contacting an elected official to express an opinion on the bill. So there's plenty of intensity.

And among opponents of the bill, 86 percent support efforts to cancel Obamacare, by either legislation or litigation. Eighty-six percent of the 50 percent who oppose the bill is 43 percent of the country as a whole.

And if, as I suspect, the flaws in Obamacare will look even more egregious in the light of information-age scrutiny from critics, then those opposition numbers are likely to rise. That is, if critics, poring through the 2800 pages of legislation, and the 15,000 pages of regulation to come, find obnoxious or dubious provisions--and they will, of course--then those will be highlighted in ways that they could not have been highlighted in the past. It could be Cornhusker Kickback times 10. Or 100.

One such take, for example, comes from a publication, Seeking Alpha, that I am sure didn't exist during the Clintoncare debate, to say nothing of Medicare. Blogger Andy Sutton writes of "Healthcare's Imminent Double Dip." In 1600 words, he cites job- and growth-killing specifics in the bill, and then concludes:

With all the debt being accumulated, the money being pulled from the real economy in favor of the centrally planned utopia sought by so many on Capitol Hill, and the pressures brought to bear on businesses by this ‘reform’, it is hard to contemplate a set of circumstances under which we avoid another steep contraction in the real economy. It will be interesting to see how long it takes to go from recovery to contraction. My guess is about as long as it takes for a Baskin Robbins double dip to melt.

Most likely, Suttons' voice would not have been heard in the past, but now, thanks to the Internet, it will. And if he is right in his doomy projections, Obamacare will be in deep trouble. Obama, too. And America.

UPDATE: The Washington Examiner's Byron York adds this on the unintended consequences--or were they the intended consequences?--of Obamacare:

On Thursday and Friday, the companies -- so far, they include AT&T, Verizon, Caterpillar, Deere, Valero Energy, AK Steel and 3M -- said a tax provision in the new health care law will make it far more expensive to provide prescription drug coverage to their retired employees. Now, both retirees and current employees of those companies are wondering whether the new law could mean reduced or canceled benefits for them in the future.

But that's not all:

Rep. Henry Waxman, chairman of the House Committee on Energy and Commerce, has summoned some of the nation's top executives to Capitol Hill to defend their assessment that the new national health care reform law will cost their companies hundreds of millions of dollars in health insurance expenses. Waxman is also demanding that the executives give lawmakers internal company documents related to health care finances -- a move one committee Republicans describes as "an attempt to intimidate and silence opponents of the Democrats' flawed health care reform legislation."

So is that the new pattern? Companies complain, and they risk getting worked over by Washington?

SECOND UPDATE: Hot Air's Ed Morrissey argues, persuasively,that the poll oversampled Democrats, thus making the numbers mor pro-Obamacare.

Repeal vs. Reform, Update

The intellectual momentum within the conservative/libertarian movement is for repeal of Obamacare. The political reality, over the next three years, or more, might be different.

Yuval Levin, a thoughtful and prolific thinktanker at the Ethics and Public Policy Center, makes a forceful case for repeal; he has written cover story of the April 5 issue of The Weekly Standard, entitled, simply, "Repeal: The Overthrow of Obamacare." No doubt Levin is correct when he suggests that Obamacare will raise prices and degrade coverage and treatment.

But a dilemma is seen early on in the piece. Levin sets up a dichotomy between liberals, who favor government-mandated universalism, and conservatives, who favor a free market. As we shall see, conservative thinking is a bit more complicated than that. But let's let Levin make his case:

Liberals argue that the efficiency we lack would be achieved by putting as much as possible of the health care sector into one big “system” in which the various irregularities could be evened and managed out of existence by the orderly arrangement of rules and incentives. The problem now, they say, is that health care is too chaotic and answers only to the needs of the insurance companies. If it were made more orderly, and answered to the needs of the public as a whole, costs could be controlled more effectively.

So liberals heart "one big system." But then Levin sets up the conservative view, describing it as the hope that healthcare would be the sum total of private-sector choices, choices to be clarified by more transparent pricing. That's the ideal, anyway, according to Levin:

Conservatives argue that the efficiency we lack would be achieved by allowing price signals to shape the behavior of both providers and consumers, creating more savings than we could hope to produce on purpose, and allowing competition and informed consumer choices to exercise a downward pressure on prices. The problem now, they say, is that third-party insurance (in which employers buy coverage or the government provides it, and consumers almost never pay doctors directly) makes health care too opaque, hiding the cost of everything from everyone and so making real pricing and therefore real economic efficiency impossible. If it were made more transparent and answered to the wishes of consumers, prices could be controlled more effectively.

And so, Levin concludes, "Liberals and conservatives want to pursue health care reform in roughly opposite directions." Yes, there's plenty of division between liberals and conservatives, tut there's more to what conservatives, and their business allies, think. Many free-marketeers also favor universalism, aka "one big system," and they think, correctly, that government action can help establish universalism; indeed, government action should establish univeralism.

That's why many--although by no means all--conservatives and liberarians have supported the interstate commerce clause of the Constitution, so the individual states could trade freely with each other. Such a focus on universality has also spearheaded the efforts, over the centuries, to harmonize and rationalize railroad gauges, commercial law, weights and measures, time zones, and production standards. And that's why, today, most libertarian theorists have joined with the business community--at least the big business community, the businesses that are most heard in Washington DC--to support free trade and free trade treaties and umbrella groups, such as NAFTA, CAFTA, and the World Trade Organization. Libertarians embrace the theory, while big business, and many small businesses, may or may not embrace the theory, but they definitely embrace the idea of big market. For the past 60 years most big businesses, for example, have supported European integration, including the European Union.

In other words, many on the business-oriented right embrace "one big system," because it's good for business, by creating a large and predictable common market, even if critics say that such integration comes at the expense of national sovereignty.

And back in the US the same phenomenon could happen on healthcare. Levin and many others want repeal of Obamacare, but the US Chamber of Commerce doesn't, or at least won't work for it, according to USCC president Tom Donohue. Plenty of businesses, and others who count themselves on the side of large-scale harmonization and rationalization, might well decide that they like the new system, or will find themselves in the "reform" camp, but not the "repeal" camp.

Healthcare for all? Or deficit reduction? Are We Seeing a Case of Quality vs. Quantity?

The Washington Post's Ceci Connolly published a behind-the-scenes look at the healthcare battle over the last two months.

Reading the piece, one is struck by the two strands of thinking that animated the Obama administration to push healthcare through. One the hand, they were clearly in love with the history they were making. On the other hand, they also loved the idea of deficit reduction.

In public, as Connolly notes, Obama was saying grandiloquent things about his bill. When it passed the House, for example, Obama said:

In the end, what this day represents is another stone firmly laid in the foundation of the American dream." He added: "Tonight, we answered the call of history as so many generations of Americans have before us. When faced with crisis, we did not shrink from our challenge -- we overcame it. We did not avoid our responsibility -- we embraced it. We did not fear our future -- we shaped it.

And in private, Obama was, if anything, more sweeping: "It's the greatest thing Congress has done in 50 years."

But at the same time, Obama seemed focused on healthcare as a way of reducing the deficit, telling one Democratic Congressman, "We have to do this. It is essential to bringing down the deficit." According to reporter Connolly, Obama cited estimates by the =Congressional Budget Office would soon show that the measure would reduce the deficit, while by contrast, the status quo "blows the deficit."

So which is it? Is healthcare about putting Obama in the entitlement pantheon, alongside Franklin D. Roosevelt and Lyndon Johnson, or it about reducing red ink?

Obama partisans will say that it's both, of course, at the same time. We shall see.

But one sort of gets the impression that the plan is a give and a take. That is, increasing the quantity of care, spread across 30 million or so more people, while reducing the quality of that care.

NHS Spending Up, NHS Output Down -- Are We Being Warned?

So what do we have to look forward to Obamacare? One cautionary straw in the wind comes from the United Kingdom.

"The management of the NHS has been characterised by 'monumental incompetence'"-so declared Lord Norman Warner, to the left-leaning Guardian earlier this month. As reporter Randeep Ramesh explained:

Warner was behind the push for market-based reforms who by his own admission lost the fight with Gordon Brown, then chancellor, over how to make public services in health run more efficiently. "Gordon reverted to the traditional Labour line in health, which was to support the unions who are the paymaster of the Labour party in the runup to the election," he said.

But this meant putting off vitally needed change and left a gaping "productivity gap". "Between 1997 and 2007 NHS inputs – by that I mean cash – went up by 60%," he said. "But NHS outputs went down by 4%. Two thirds of the money we put in just went into pay."

A sixty percent increase in spending for a four percent decrease in output--that's not very good.

In the caustic commentary of Theodore Dalrymple, writing for City Journal, published by The Manhattan Institute:

No doubt the spending of a Soviet-style organization like the NHS is more easily measurable than its output, but the former minister’s remark certainly accords with the experiences of many citizens, who see no dramatic improvement in the service as a result of such vastly increased outlays. On the contrary, while the service has taken on 400,000 new staff members—that is to say, one-fifth of all new jobs created in Britain during the period—continuity of medical care has been all but extinguished. Nobody now expects to see the same doctor on successive occasions, in the hospital or anywhere else.

More on the NHS in the news here.

The Audacity of Scientific Hope: PepsiCo Shows How to Bend the Curve for Better Health

Salt is tasty, but too much of it is bad for you. Americans ingest way too much salt, but it's hard to cut back. So who is going to help? How will we "bend the curve" on salt consumption, and thus "bend the curve" for better health? How will we lower costs for high blood pressure and heart disease? Science might bring us the answer, although PepsiCo, which financed some of the science, deserves credit, too.

A March 2009 press release from the Centers for Disease Control and Prevention put the case in strong terms:

Most Americans consume more than double the amount of their daily recommended level of sodium. A new study by the Centers for Disease Control and Prevention shows that more than 2 out of 3 adults are in population groups that should consume no more than 1,500 milligrams (mg) per day of sodium. During 2005-2006 the estimated average intake of sodium for persons in the United States age 2 years and older was 3,436 mg per day.

A diet high in sodium increases the risk of having higher blood pressure, a major cause for heart disease and stroke. These diseases are the first and third leading causes of death in the United States.

“It’s important for people to eat less salt. People who adopt a heart healthy eating pattern that includes a diet low in sodium and rich in potassium and calcium can improve their blood pressure,” said Darwin R. Labarthe, M.D., Ph.D., director of the CDC’s Division for Heart Disease and Stroke Prevention. “Reducing sodium intake can prevent or delay increases in blood pressure for everyone.’’

These are sobering points: The average American consumes more than twice the recommended amount of salt, and excess salt greatly raises the danger of heart disease. We might wonder: What will increased heart disease do to the cost projections of Obamacare?

Mindful of these dangers, as well as these costs, governments have been pushing lower salt intake for a long time, but there's been plenty of pushback from American consumers. People like salt. Or, more precisely, they like the taste of salt on food. So the challenge is to keep the taste, but lose the salt--at least most of it. And now, perhaps, PepsiCo has figured out how to do just that.

In a Wall Street Journal, piece headlined, "PepsiCo Develops 'Designer Salt' to Chip Away at Sodium Intake," Betsy McKay offers a peek into scientific research to reduce salt intake without reducing the enjoyability of food. As McKay explains:

Working with scientists at about a dozen academic institutions and companies in Europe and the U.S., PepsiCo studied different shapes of salt crystals to try to find one that would dissolve more efficiently on the tongue. Normally, only about 20% of the salt on a chip actually dissolves on the tongue before the chip is chewed and swallowed, and the remaining 80% is swallowed without contributing to the taste, said Dr. Khan, who oversees PepsiCo's long-term research.

PepsiCo wanted a salt that would replicate the traditional "salt curve," delivering an initial spike of saltiness, then a body of flavor and lingering sensation, said Dr. Yep, who joined the company in June 2009 from Swiss flavor company Givaudan SA.

"We have to think of the whole eating experience—not just the physical product, but what's actually happening when the consumer eats the product," Dr. Yep explained.

The result was a slightly powdery ingredient that tastes like regular salt.

Thus a lesson: Science offers the prospect of making the problem go away without a political fight. That is, science can change an unhealthy and expensive status quo--painlessly.

Of course, if we want to fight over public health issues, we should seek legislation or regulation to change behavior on salt intake, and we'll get a good fight. But of course, incumbent politicians should remember that such fights should not be started too often, because public patience with fight-starters has a way of wearing thin. Instead, if we want actually to improve public health, we should look to science to see if it's possible to change the equation, so that harmful things are no longer so harmful.

PepsiCo has already spent hundreds of millions of dollars on this effort, and will probably spend billions more to bring this product to market. PespiCo's goal is clear:

By 2015, PepsiCo aims to cut sodium in its salty snacks 25%. "What we want to do with our 'fun for you' products is to make them the healthiest 'fun for you' products," Chairman Indra Nooyi said. "We want our potato chips to be fried in the healthiest oils with the lowest salt."

We will have to see how the various public-health constituencies react to this news. Most likely, the political class will ignore this news, because, looking through their political prism, they have a hard time seeing the value of science. Politicos see transaction. Scientists see transformation.

PepsiCo's new invention will have to survive regulatory scrutiny, of course. And then we'll have to see if consumers like it.

But all Americans should be mindful that if we don't develop these sorts of innovations, we will never get out of the trap of bad public health on the one hand, or a nanny state on the other. Science offers the way out. Science offers hope.

Obamacare: 59 Percent Against. Next: Repeal or Reform?

Republicans are rushing to demand repeal of Obamacare, even before it is signed into law on Tuesday. Some top GOPers already calling for repeal include Mitt Romney, John McCain, and Jim DeMint. No doubt many more will be eager repealers, even millions more; Americans For Prosperity has set up a petition site, here. Indeed, a new CNN poll shows 59 percent of Americans against the bill.

But as CNN's Rich Barbieri observed about his poll, that 59 percent is inflated by opponents from the left, as well as the right:

Roughly one in five of respondents who said they opposed the bill did so because it was not liberal enough, and those people are unlikely to vote Republican. Take them out of the picture and opposition to the bill because it is too liberal is 43 percent.

Still, it's easy to see voters across the spectrum punishing the Democrats for a) the way the bill was enacted; b) the likelihood that the Senate will leave at least a few of the egregious provisions in the bill, thus making the House look worse than it already does; c) the reality that more time-bomb provisions will be discovered; and d) the way that the Democrats will manage its implementation in the months and years to come. Those four factors--does anyone doubt for a second that the anti-abortion-funding Executive Order, in particular, will be shot full of holes?--as well as other negative factors, most obviously the economy, will make it likely that Republicans will win the Congress back in 2010, and the presidency in 2012.

But it won't be so easy, or so popular, to achieve an outright repeal of Obamacare. We might consider, for example, this taunting chart, shown above, produced by House Majority Leader Steny Hoyer.

Yes, people will be fired up against Obamacare, but will they be as whipped up against coverage guarantees? Against filling in the "donut hole"--that is, providing more help for seniors to buy their prescription drugs? Against covering young people? Republicans are looking forward to more Chris Christie/Bob McDonnell/Scott Brown-type elections in 2010 and beyond, but they should not forget the elections of 2006 and 2008. Public opinion is fickle.

One who seems to sense this instability of public opinion is Sarah Palin. In her Facebook post, she thundered against "detached and imperious government" and "corrupt deals," but her "clarion call" to action fell short of calling for complete repeal:

We must look to November when our goal will be to rebuke big government’s power grab, reject this unwanted “transformation” of America, and repeal dangerous portions of Obamacare that will bury us under more Big Government control.

Note the key modifier: "dangerous portions of Obamacare." By that formulation, the portions of Obamacare that are deemed not dangerous will survive. Whatever happens, Palin is giving herself plenty of leeway.

America can do much better than Obamacare. That's been the argument of Serious Medicine Strategy all along. But if Republicans want to benefit from popular energy against Obamacare and the sort of rationing/restrictionist mindset at the core of the bill--and benefit from it long term, as opposed to just a one-off jolt--they will have to come up with a better healthcare plan of their own, and sell it to the American people.

And the beginning of a better plan is the realization that cures are cheaper than treatment, and that a thriving domestic healthcare sector could also be the medicine chest for the world.

UPDATE: From The Wall Street Journal on Monday afternoon, US Chamber of Commerce President Tom Donohue minimizes prospects of repeal: "Chamber Won’t Push for Health Repeal."

And in Tuesday's Journal, the edit page makes this point:

Many Republicans are already calling for "repeal" of ObamaCare, and that's fine with us, though they should also be honest with voters about the prospects. The GOP can't repeal anything as long as Mr. Obama is President, even if they take back Congress in November. That will take two large electoral victories in a row. What they can do now is take credit for fighting on principle, hold Democrats accountable for their votes and the consequences, and pledge if elected in November to stop cold Mr. Obama's march to ever-larger government.

Two elections in a row, minimum. Which is to say, it won't be good enough to win on a backlash in '10. Republicans will need an agenda for '12.

Access vs. Outcome: Steve Jobs: "I could have died." What saved him was Serious Medicine, not health insurance.

As Obamacare moves toward enactment, it's time to ask: Which is more important, healthcare access, or medical outcomes? Or, to put it another way: Health insurance, or true health care--in the sense of medicine that cures? It's possible to answer "both," of course, but we might note that in political terms, "access" is overshadowing "outcomes." Indeed, it's likely that increased access, as engineered by Washington DC, will result in decreased health outcomes.

Do you want to be able to go to the doctor so that the doctor can offer perhaps obsolete treatments, or do you want to go for a cure? It's an important conceptual distinction. Over the last weekend, that distinction was obvious--in words from Steve Jobs, the Apple visionary, and from John Larson, the chairman of the House Democratic Conference.

On Saturday, Jobs said he "could have died" waiting for a liver transplant last year, as he made a rare foray into public policy, endorsing Gov. Arnold Schwarzenegger's push to increase organ transplantation in California. We are all glad that Jobs received his liver last year, and we hope that everyone gets the liver he or she needs. We should also hope, of course, that visionaries figure out how to expand the supply of livers, legally and ethically. And that means transformative technological innovation, of the sort that's routine in Silicon Valley, but that's barely understood in Washington DC, where zero-sum politics is the name of the game--that is, if somebody gets more, somebody else gets less. (And of course, if liver transplants could be Silicon Valley-ized, applying the power of transformative technology, liver procedures would likely get a lot cheaper.)

What gave Jobs his liver, and saved his life, was medical innovation. Back in the 60s, Dr. Thomas Starzl pioneered liver transplantation--and he was a doctor, not a politician. He was a creator, not a redistributor. Liver transplants were a bold and daring procedure back then, and it took years for Starzl and others to perfect the process; today, perhaps 5,000 liver transplants are performed every year. That's 5,000 lives saved. But again, it's not health insurance that saves lives, it's healthy medicine. (Meanwhile, there's a backlog of 17,000 people waiting. Such procedures are expensive--what will their fate be now that the government is going to take such an active interest in "bending the cost curve"?)

And for his part, Starzl was dependent on earlier transplantation work. The first successful organ transplant was a cornea transplant, was performed by Dr. Eduard Zirm in 1905. In 1912, the The Frenchman Alexis Carrel was awarded the Nobel Prize for Medicine for his work on vascular grafts--the beginning of vein and artery transplants. Human skin was successfully transplanted during World War One, and doctors began experimenting with kidneys and other organs in the 20 and 30s, with no real success until the 60s.

So we see more than a century of medical-science progression, leading up to the successful transplant for Jobs in 2009. And it was science leading the way. Politics might well have helped, in terms of funding research and care, but the driver was science.

Meanwhile, in Washington, a completely different dynamic is evident--and a completely different historical chronology. "This is a historic day, and we are happy warriors,'' said Rep. Larson of Connecticut. "We will be a part of history, joing Franklin Delano Roosevelt's passage of Social Security, Lyndon Johnson's passage of Medicare and now Barack Obama's passage of healthcare.''

That's Larson's history: Roosevelt to Johnson to Obama. Meanwhile, Jobs' history is Zirm, Carrel, and Starzl to the surgeons in Tennessee who performed his surgery.

Which is more important to keeping us alive?

Obamacare Is The New Roe vs. Wade

Published at Fox Forum.

"Hatch Says It’s ’Nuts’ to Think House Vote Ends Health Issue"

And the beat goes on, per Bloomberg News.

Republican Senator Orrin Hatch said Democrats in the U.S. House of Representatives are “nuts” to think tomorrow’s vote on health-care legislation will resolve the issue.

If the measure passes, Senate Republicans have enough votes on at least two points of order to alter the measure and send it back to the House for a second round of votes, Hatch said in an interview on Bloomberg Television’s “Political Capital with Al Hunt,” airing this weekend.

“If those people think they’re only going to vote on this once, they’re nuts,” Hatch said as House Democratic leaders rounded up support before the scheduled vote on President Barack Obama’s top domestic priority.

The senator from Utah also said the approach Democrats are using to pass the legislation in the House may be unconstitutional because the House and Senate aren’t voting on “exactly the same language.”

Somewhere up in American Valhalla, Tony McAuliffe is amused to hear the word "nuts."

Healthcare on Bloggingheads.tv

David Corn and me talking about the healthcare bill--who benefits, politically, if it wins, who benefits, politically, if it loses.

“Politicking Myopia” -- Obamacare Meets Theodore Levitt

As of Saturday afternoon, the Obamacare forces have what might be called “O-mentum.” The above-the-fold headline in The Washington Post this morning reads, “Late push yields more votes for healthcare,” and underneath we see a shirt-sleeved President Obama, speaking Friday to a rally at George Mason University, looking, as he likes to say, “fired up and ready to go.” Meanwhile, the Intrade number for passage of the bill, after dipping down to 55 on Wednesday, out of a possible 100, has now surged to 88.6.

If President Obama has been willing to bet his presidency on this bill, then chances are, at the beginning of his second year, he will get his wish--a wish granted to him solely by fellow Democrats. And although Obamacare momentum screeched to a halt after the January special-election victory of Sen. Scott Brown, that momentum started up again in the wake of Anthem Blue Cross’s announcement of a 39 percent rate increase in California, which, along with other rate increases, caused a nationwide uproar and jolted Obamacare back to life. So we are reminded of the power of unpredictable, or at least unknown, events to change outcomes. And that reminding should keep us humble about predicting an outcome even now, barely 24 hours ahead of the House vote. Things could change.

But assuming that the Obamacare bill does pass, one question in particular continues to nag. And that question is, what exactly are the Democrats offering to the American people? Does anybody in Washington really know what’s going to come? Frankly, I’m not sure that those doing the offering really care that much--they just want to get a bill signed. And so details can go by the boards. Some Obamacare supporters declared the goal to be universal coverage, although that’s gone now. Others declared the goal to be cost control, and that, too, is gone. Some even promised full transparency and no special favors--another lost promise. And yet still the bill grinds onward, because top officials have said it’s too late turn back. The only thing left is to go full speed ahead.

Yet while the progress of the bill--“reconciliation,” “deem,” “sidecars”--has been confusing to the point of opacity, that’s nothing compared to the the complexity of the bill itself. Nearly 3,000 pages of text will have to be converted into a trillion-dollar program, as all the hidden provisions are unpacked and splayed out in the months and years to come. Many billions will be spent on lawyers and consultants, but even then, nobody will really understand all the details of Obamacare.

That’s why many are predicting chaos to come. The same federal government that couldn’t run the bailout, that couldn’t manage the stimulus package, that couldn't supervise grantees such as ACORN, will now be dominating one-sixth of the economy as never before.

For their part, the politicians--the bill’s proponents, at least--will wish to move on to other topics. Democrats, having checked a box they believe has been left unchecked for decades, will move on to other agenda items, such as “jobs.”

But here’s the problem for politicians, at least for those who vote for the Obamacare bill. If the program causes problems, if it breaks down in key places, or if it costs more in every place, then Obamacare supporters will get the blame. That’s exactly what Republicans, of course, are hoping for this November--and a big comeback for the loyal opposition. But if the GOP does win the House back, and maybe the Senate, too, what then will its stance be toward Obamacare, now that it has obtained some real power? Some Republicans will say, “Repeal the whole thing!” but that’s not going to happen, at least for as long as Obama is president. And other Republicans, mindful that some provisions of Obamacare--a ban on exclusions based on pre-existing conditions, as well as drug subsidies to seniors, to name two examples--are extremely popular, will be reluctant to support repeal.

So inevitably, Republicans, too, if they share power in Washington, will be trapped in management issues, as some GOpers seek to defend, and maybe even expand, parts of the program. Thus GOP fingerprints, too, will end up on the bill.

And yet, as we have seen, nobody, in either party, will be able fully to comprehend the system that’s been created. So whom will Democrats trust to advise them on the workings of their own progam? Whom will Republicans trust? The same experts? Or dueling sets of experts? Will there be any overlap at all? And which think-tankers? Which cadre of costly consultants? And we haven’t yet addressed the noise from clamorous constituencies, out beyond the Beltway, and their inevitably clashing desires and demands.

So now we see the uneasy relationship between the politicking class and the policy-implementing class. The policy-implementers might work for the politicians, but once the program is in place, the politicians, to a large extent, are hostage to the policy-implementers. If the policy-implementers do a bad job--or if it merely seems that they are doing a bad job--the politicians get the blame. The political equivalent of Three Mile Island, or the subprime mortage meltdown, could be exploding inside the various healthcare bureaucracies, and the politicians who are theoretically in charge of the system will likely not know until it is too late.

Thus we see the fundamental flaw in the political system, as it applies to healthcare and other complicated undertakings. The political science word is “delegation.” If the politicians don’t really understand the programs that they are supporting, they must delegate power to others. The chasm between political delegators, on the one cliff, and policy delegatees, on the other cliff, is simply too great to be spanned by anyone in Washington. And yet if those programs are troubled to begin with, chances are that support for such programs will bring politicians to grief--and it’s the visible politicians who will be blamed by the public, not the invisible policy-implementers.

To further illustrate this chasm point, we might consider a classic work from the realm of marketing. Back in 1960, Harvard Business School’s Theodore Levitt published “Marketing Myopia,” an article zeroing in on a business chasm: the gap between production managers, including engineers, on one side, and marketers on the other--that is, between the people in a company who make things and the people tasked with selling those things.

The differences were stark, Levitt asserted: “Engineers and scientists are at home in the world of concrete things like machines, test tubes, production lines, and even balance sheets.” To these people, tangibles are good. It’s the intangibles that bother them, and so, Levitt wrote, they ignore the intangibles for as long as they can. Producers produce, and then hand over the product to be marketed.

In this environment, Levitt continued, “Marketing gets treated as a residual activity, ‘something else’ that must be done once the vital job of product creation and production is completed.” In other words, producers produce the product, because that’s what they do, and only then does somebody else have to worry about selling it.

And the customers--the folks on the receiving end? The world of customers, outside of the factory labs and the production line, is seemingly unknowable. To producers, Levitt explains, “Consumers are unpredictable, varied, fickle, stupid, shortsighted, stubborn, and generally bothersome.” Levitt continues:

This is not what the engineer-managers say, but deep down in their consciousness, it is what they believe. And this accounts for their concentrating on what they know and what they can control, namely, product research, engineering, and production.

In other words, the producers do what they like to do. And if the results for the company are disastrous, the producers can always blame the marketers. Such blaming won’t help the bottom line, but it might at least protect the self-esteem of the producers.

The point here is not to elicit pity for marketers--although Levitt was on their side--but rather to show that only a working cooperation between production and marketing can enhance customer satisfaction and increase shareholder value.

The challenge to business, therefore, is fully to integrate the production process and the marketing process. And indeed, much ferment within the business world is oriented toward just that--toward the inclusion of marketers, who presumably reflect consumer wishes, in the production process. Some companies are even reaching out directly to consumers; the multinational 3-M, for example, has set up 23 “customer innovation centers” around the world, usually near company research facilities, to facilitate maximum personal interaction between producers and consumers. And a vast new field of information technology, known as CRM, for Customer Relationship Management, has opened up in the last three decades. CRM includes all the computer-based tools that companies use to track their interactions with customers, from sales to accounting to returns. CRM is a big business; the three leading companies in the field, SAP, Oracle, and Salesforce.com, are all multi-billion dollar firms. According to the Gartner Group, CRM revenues in the US totalled nearly five billion in 2008. So while CRM is hardly an altruistic exercise, to a customer who gets exactly what he or she wants as a result of a better information flow with the producer, CRM can be a great gift, indeed. And of course, newer tools, such as social networks, permit even more interaction with customers. Coca-Cola, for example, has 5,225,090 “fans” on Facebook; to become a fan is to give Coke access to one’s own personal data. So Facebook is a new kind of CRM tool, and yet those 5.22 million Coke fans are presumably happy in their relationship with the company.

We might pause to ask: Is Obamacare going to feature “customer innovation centers” where Americans can examine government healthcare policies? Will Uncle Sam deploy CRM to help ensure healthcare customer satisfaction? Will he have a Facebook page that offers real value to “fans”? And even non-fans?

We might further ask: If such features, now standard in business practice, are absent from the Obamacare portfolio, will ordinary Americans notice? Will Americans, having grown accustomed to nimble software programs for e-commerce, object if such services are unavailable for their health concerns? The answer is that many of them will notice, and they will object.

And so we see the bombshell ahead for the over-optimistic politicians, who gave their fate away to policy implementers; those implementers will inevitably fall short of customer expectations. The politicians spent all their energy getting the bill passed, when they should have thought more about what would happen after it passed. With apologies to Levitt, we might call it, “Politicking Myopia.”

In this telling, we can see politicians as the equivalents of the producer-managers. In politics, the product is politics. It’s a highly specialized field; most politicos have done little else in their life except politics. So they know the political game, and little else. Politics is the product--it’s up to others to move the policy.

And right now, as we have seen, this political class--at least the Democratic part of it--is giddy with the thought that it might finally be producing a healthcare bill. And headlines, written by reporters mostly caught up in the same political enthusiasm, will be resounding with words such as “historic” and “watershed.”

But when the product is enacted into law, what happens then? Then the real challenge will present itself, because the real customers for Obamacare have not yet been heard from. So far, the audience for Obamacare has been the ardent proponents, as well as ardent opponents, of the bill. For all the intensity we see--pro and con, 24/7 on cable news--we must remember that the vast majority of Americans have not been engaged in the debate either way. Barely more than half of adult Americans vote in presidential years, and less in midterm elections. Plenty of Americans are completely tuned out of politics, and so they have not been heard from in the debate that has transfixed Washington for a more than year.

Yet while only a small percentage of Americans are involved in what we might call the political production process, 100 percent of Americans, some 307 million people, will be involved on the receiving end of the Obamacare marketing process--something to be figured out after the main act of political production has been completed.

It might not have seemed that way, but selling a healthcare plan to Democrats was easy--as long as Democrats controlled the White House and both chambers of Congress. The hard part is yet to come, as the politicians will have ceded management of their hard-wrought program to policy implementers. Those policy implementers, improbable as it might seem, will be the marketers for Obamacare. It is they who will set up “customer innovation centers”--or not. It is they who will set up user-friendly CRM--or not. Facebook--or not.

The Democrats seem to have won the Washington battle for political production. But the bigger war, for the hearts and minds of American healthcare consumers, is about to begin--because we all consume healthcare, whether or not we believe in conspiracy theories, whether or not we speak English, whether or not we are old enough to vote. And each of us will have an opinion on the healthcare we are receiving.

The political reverberation of Obamacare will be loud--maybe even deafening. Maybe even shattering.

UPDATE: In Sunday's Washington Post, William D. Eggers and John O'Leary offer a fascinating sneak peek of their new book, If We Can Put a Man on the Moon: Getting Big Things Done in Government. Eggers and O'Leary offer five points of which, one, the idea of a "bridger," is germane to what was mentioned above, about getting across "the chasm," in re: making the healthcare system work. Here's that portion:

What do the Apollo mission, the 1964 Alaska earthquake recovery and the Iraq troop surge all have in common? Critical to the success of each was the presence of a "bridger." This is a leader who can move between the political and bureaucratic worlds -- the rare person who can translate bureaucratic language to politicians and tell the political masters when they are off course.

With Apollo it was NASA Administrator James Webb; in Alaska it was career civil servant Dwight Ink; with the surge it was Gen. David Petraeus. Such individuals are critical to executing history-making undertakings but are often undervalued at the time.

Webb was a quintessential bridger. President John F. Kennedy chose him to lead NASA through the political, administrative and technical challenges of putting a man on the moon, and it proved a wise decision. Though an early draft of Kennedy's 1961 man-on-the-moon speech had set 1967 as the goal for a lunar landing, Webb added what he called an "administrative discount" of two years to account for unforeseen contingencies. He also doubled the cost estimates developed by NASA for the Apollo mission before sending them to the president, adding his administrative realism to counter the optimism of his technical staff.

Two Visions of Healthcare: One Political, One Medical. Unfortunately, Obamacare Beats Out Treatment for Tremors and Epilepsy.

Last night on ABC World News, we saw, once again, the divide between two visions of healthcare. One, healthcare as a political football, and two, healthcare as a life-enhancing, even life-saving undertaking of doctors and scientists.

Alas, the politicos got top billing. Diane Sawyer led the newscast with a live report from Jon Karl, on the vote count for Obamacare. All the discussion, of course, was about the politics of Obamacare, whether or not it has the votes. And for all the talk of "healthcare," not a word about health.

And then, 20 minutes into Thursday night's broadcast, ABC News' medical editor,Dr. Richard Besser, introduced a beautiful story of a medical miracle taking place in Minnesota, where Roger Frisch, a concert violinist with the Minneapolis Orchestra, has had his ability to play the violin restored to him. As Besser explained, "essential tremors," based on faulty brain activity, cause tremors in one-seventh of senior citizens, or 10 million Americans nationwide. And so doctors at the Mayo Clinic conducted deep brain stimulus surgery, drilling holes in Frisch's head, allowing electrodes to thwart the tremors. Not an ideal solution, of course--medicine is better, when it works--but the therapy has restored Frisch's ability to play the violin--see screen grab above. And, Dr. Besser added, a similar procedure--the use of a pacemaker-like device for the brain--developed at Stanford can dramatically reduce epileptic seizures.

So which is more important to our ultimate health? An insurance card that says we can visit a doctor--or a cure from that same doctor?

And yet if the healthcare bill passes, and policymakers decide to really "bend the curve," on healthcare costs, will procedures such as the one Dr. Besser described be judged as too expensive? How will the Congressional Budget Office score the gift of a life restored? If it doesn't score positively, according to CBO metrics, then chances are, we will see a lot fewer of these sort of heroic medical interventions, no matter how successful they are.

But of course, such concerns will be lost amidst the high-five-ing to come in Washington DC, if the bill passes. Why worry about brain disorders and epilepsy when you can ration care?