er·ror
   /ˈɛrər/ Show Spelled[er-er] Show IPA
–noun
1. a deviation from accuracy or correctness; a mistake, as in action or speech: His speech contained several factual errors.
2. belief in something untrue; the holding of mistaken opinions.
3. the condition of believing what is not true: in error about the date.
4. a moral offense; wrongdoing; sin.

A mistake. That’s how I think of an error.

Here’s how we’re to think of contextual errors apparently,

A contextual error occurs when a physician overlooks elements of a patient’s environment or behavior that are essential to planning appropriate care. In contrast to biomedical errors, which are not patient-specific, contextual errors represent a failure to individualize care.

The above appears in a work by Weiner, et al in the Annals of Internal Medicine last month. I’m terribly poorly read on healthcare QA and medical errors but it appears to be a relatively novel concept. A search by title or keyword for “contextual error” in Medline reveals a total of three articles. The two other than Weiner’s have nothing to do with the idea as his group defines it.

I like the idea; I think it raises important considerations.

I don’t like the way Weiner’s group designed a study to document the prevalence of contextual errors.

Here is how a Huffington Post blog summarized the study from the Annals,

He sent undercover patients into doctor’s offices with regular complaints: a diabetic with blood sugar out of control. Raging asthma. Need for a hip replacement. They functioned as the “secret shoppers” of health care.)

In each case the actors could present a standard version of the problem, or versions where they offered a clue to an extra fact, something all physicians would agree should change the plan of care, if it were known. For the patient with raging asthma, one clue was “it’s been worse since I lost my job.”

A smart doctor would ask if new financial problems meant the patient could not pay for medicines. With that information in hand, the doctor could readily change to cheaper medications or identify a source of support. If a doctor fails to pick up on that clue, however, then they are likely to add new prescriptions. That would be the wrong decision.

Physicians only asked follow-up questions about those clues to good care about half the time. When there was a problem in the patient’s life situation, like inability to afford medicines, doctors only came up with an appropriate plan of care one time in five. Four times out of five, the patient left the office without receiving good care.

I’m not sure the example given represents a mistake on the part of the physician. Not in full. Not enough to claim,

That error rate is unacceptable.

Patient non-compliance with therapy is a failure of the medical system, but it is largely a patient side error. I’m not denying the responsibility of providers to promote social health and situations that facilitate patient compliance. But a patient who presents to a physician with worsening of his symptoms and doesn’t offer the fact that he’s been non-compliant with the recommended therapy because he can’t afford it, well, that is fully on the patient.

Telling physicians they’ve made a mistake for not ferreting out the complex situations in which patients aren’t compliant during a fifteen minute office visit is bollocks.

There is no doubt that the United States treats primary care, preventative care and triage much differently than most of the rest of the developed world. The distribution of primary care to specialists, especially procedure based specialists, favors the specialists much more here than in any other health care system, at least that I’m familiar with.

But I’ve expressed serious doubts about how payment reform might reshape the distribution of primary care versus specialists considering the per capita primary care population has grown just as fast that of the specialist, if for no other reason than the ever increasing influx of foreign medical graduates. FMGs who have picked up whatever slack was left by U.S. doctor’s perceived abandonment of primary care. We haven’t lost ground on primary care, in terms of the numbers, as the inequality between the earnings of the general practitioner and the specialist have grown.

My point, articulated better elsewhere on this blog, is that there is no doubt that a redistribution of physicians towards primary care would benefit population health in this country but revolutionary payment reform is unlikely to achieve that redistribution alone.

And amongst the editorials and blog posts that focus on leveling the pay scale, sometimes, the very reasons originally articulated for paying more for a CABG as compared to an office visit are ignored.

And so I want to make the argument for why the orthopaedist, the cardiologist, the neurosurgeon deserves to earn more, and considerably more, than the primary care physician. And to make the argument that maybe we’re not so far off the mark with out current reimbursement structure.

I would lay out the argument for the specialist’s pay like this: the training is longer and more difficult, there is a disparity in early earnings and the assumed risk is something much more.

I’m going into a specialty with better earning potential than just about anything else in medicine. I’m also perhaps more intimately aware of differences in training amongst the specialties than most. I’m currently a neurosurgical resident, previously I started a general surgery residency, I watched my mother go through a pediatrics residency and a critical care fellowship as a single parent, and I’ve watched my fiancee through her internal medicine training at two different programs. Not bad breadth and more familiar and substantial than just observation of the day to day doings of various residents, in various specialties that anyone at a teaching hospital sees. Enough to speak on I feel.

My residency training is as long as it gets. The seven years I will put in are more than double what a family medicine resident will. More importantly, and controversially, I would argue that it’s more difficult as well. Even in the age of work hour restrictions, I would argue wholeheartedly that each 80 hour work week is not created equally.

Now to be fair, there is much intraspecialty variation. I’m sure if I was training somewhere else my work load would be something different. Even so, I am daring to argue that on the average a surgical subspecialists training will be more work, hour for hour, than a general practitioners. Sometimes substantially more.

This year, through 2 months, is poised to be exceptionally more work than my time in general surgery and, I will say, at my own peril with my family, exceptionally more work than what I’ve seen of medicine or pediatrics training. And I face seven years of such.

Granted, there are some reprieves in terms of the rotations (bless you neurology) but I would argue, as a percentage of my training, those “good” months are less than what is generally found in primary care training.

Specialists are poised to do, in my case, more than twice the years of training of primary care physicians and those years promise to be more difficult; even if it all adds up to 80 every week.

And, ignoring the questions of variability and reliability that surround physician income surveys, the median income in my specialty is somewhere between 2-3 times that of a family medicine physician. That doesn’t seem too unreasonable to me.

That might be the most substantial argument for the pay gap, at least between the surgical specialties and primary care.

But there are other arguments as well. Less substantial is the early earning potential. Consider a resident in a surgical specialty somewhere with a low cost of living earning $200,000 before taxes over four years of training. A family medicine physician, who started their training at the same time as the surgical resident, has already graduated and claims $600,000 over the same period.

Add low five figures for the compound investment potential over those four years, say $20,000, and the extra $5,000 the surgical resident. Now true that $400,000+ difference in gross income has the potential to be made up in just 3-4 years once the surgical subspecialist is out of training, but it is certainly something else, albeit small, to consider when discussing the earning gap between primary care and specialists.

Finally, there are inherent risks associated with the technical craft that proceduralists dare.

I’m not merely talking about the malpractice premiums. I’m talking about the hazards of a patient’s life and function in a physician’s hands.

There should be pay associated with increased risk for the patient. Such things require more skill, more focus, more stress. Not that the primary care physician can’t do their patients harm. But there’s something different than an adverse reaction to a statin and an aneurysm bleeding while you’re coiling it or a patient losing an airway during anesthesia.

The risks patients undertake at the hands of proceduralists and the acuity of the situations proceduralists often deal in deserves credit.

And yet, despite all this, I will admit I personally feel the pay gap needs some squeezing. The primary care physician is required to call forth a breadth of knowledge that I never will have to; at least if s/he is to be good at their job. Their care is intimately important to public health. That is something I certainly cannot claim as a future specialist. I’ll never contribute to improving any of the global outcome measurements that we rightly judge the health of any cohort by.

Just not too dramatic of a squeeze.

I’ve commented on this ‘trend’ before, of criminalizing risky behavior. Despite my earlier post on the issue, I’m pretty adamant that this shouldn’t be a criminal matter. It’s not that I’m concerned with the shadowing consequences such a trial and potential verdict will have on those who are HIV+, it is merely that there is shared responsibility here enough. Unless the trial brings to light some form of actual deceit, for instance if she lied about her HIV status, then I’m not sure unprotected sex with a person of unknown HIV status in the modern risk environment doesn’t exculpate the accuse somewhat.

But there should be penalties and if not in a criminal court then in civil opportunities for those she’s put at risk. I guess we’ll see just how aggressive this German court wants to be over the coming weeks.

This is taken from the WSJ Health Blog:

Usually so opinionated I’ve got mixed feelings on big pharma. Consider those feelings doubly mixed after reading this CNN special investigation concerning the COX-2 inhibitor Bextra which Pfizer (or at least, controversially, it’s subsidiaries) was accussed of marketing illegally.

By April 2005, when Bextra was taken off the market, more than half of its $1.7 billion in profits had come from prescriptions written for uses the FDA had rejected.

But when it came to prosecuting Pfizer for its fraudulent marketing, the pharmaceutical giant had a trump card: Just as the giant banks on Wall Street were deemed too big to fail, Pfizer was considered too big to nail.

Why? Because any company convicted of a major health care fraud is automatically excluded from Medicare and Medicaid. Convicting Pfizer on Bextra would prevent the company from billing federal health programs for any of its products. It would be a corporate death sentence.

Prosecutors said that excluding Pfizer would most likely lead to Pfizer’s collapse, with collateral consequences: disrupting the flow of Pfizer products to Medicare and Medicaid recipients, causing the loss of jobs including those of Pfizer employees who were not involved in the fraud, and causing significant losses for Pfizer shareholders.

[...]

So Pfizer and the feds cut a deal. Instead of charging Pfizer with a crime, prosecutors would charge a Pfizer subsidiary, Pharmacia & Upjohn Co. Inc.

The CNN Special Investigation found that the subsidiary is nothing more than a shell company whose only function is to plead guilty.

I suppose I can’t support the break up of big pharma for both practical and philosophical reasons. But this kind’ve three card monty prosecution game seems beyond the verge.

The 80 hour work week and the 30 hour work shift restrictions have been bemoaned by academic surgeons. Fears that resident’s hand offs of patients would harm continuity of care and thus patient outcomes were front and center, and voiced by all specialties. Fears that resident surgeons would get less hands on surgical experience were unique to surgery but no less concerning.

Talk that further restrictions on how much residents can work are coming brings the issue front and center again. A not too distant IOM report commissioned by the AHRQ recommended such further limitations on resident work hours. And decried by surgical specialists and others alike. I’ve heard prominent individuals from within organized surgery, of course being explicit that they’re voicing their opinions as individuals, decry any further attempt to limit the surgical resident experience.

The surgical specialties are poorly represented in the decision making process. The IOM committee which so recently commented on resident work hours had a single surgical subspecialists on it. The current ACGME Board of Directors has two surgeons sitting on it (and I’m explicitly excluding the ophthalmologists serving on it, and for reason I believe considering their training experience as compared to say that of an orthopedic surgeon). That is two representatives out of thirty or 6% of the vote on the body that will ultimately, at present, determine any further resident work hour restrictions.

With relatively broad coverage in the media of the issue, a decided bent in the public for support of work hour restrictions, and significant public advocacy money in play to influence the decision the whispers from within the ACGME are that further restrictions are inevitable in the next 2 years.

But what if the decision was taken out of the hands of the ACGME, at least for surgical residencies?

There is a growing movement amongst rather prominent academic surgeons for an Accreditation Council for Graduate Surgical Education. Organizing such would be no small feat. Getting the state boards, with public pressure in favor of restrictions, to recognize it may be even more of a hurdle. And that presumes that the inevitability of all of this mess isn’t Congress legislating resident work hours as say the Patient and Physician Protection and Safety Act [PDF] tried to do early last decade.

It’s true, work hour restrictions have worked the rest of the world over. European registars are limited to 48 hours a week and it is hard to demonstrate a qualitative difference between a CABG here and over there. And while the design of their health care system necessitates that many of them will spend years as SHOs (or even lower on the training pole) before a consultant spot opens up.

Drawing the analogy with other other surgical training experiences across the world would require a reimagining of how health care is organized in America. A more tertiary experience with fewer surgeons and lengthier training with further graduation of responsibility during it. That’s not something I’m personally willing to accept. As much as residents still bemoan their hours in the hospital, if push came to shove, and an ACGSE could postpone further reductions in my operative experience I am all for it.

Examples from the Associated Press,

Primary care physicians already are in short supply in parts of the country, and the landmark health overhaul that will bring them millions more newly insured patients in the next few years promises extra strain.

The new law goes beyond offering coverage to the uninsured, with steps to improve the quality of care for the average person and help keep us well instead of today’s seek-care-after-you’re-sick culture. To benefit, you’ll need a regular health provider.

And other media, tell us as much. Now in general the United States has fewer physicians per capita than other western nations. And there are no doubt huge regional differences in physician supply. Parts of this country suffer from a severe deficiency in physicians in general, and primary care in particular.

But the fact is that, as much as we hear about the difficulty primary care has in attracting future physicians, the United States’ per capita primary care population compares pretty equatable to those of other nations. Other nations whose primary care delivery is generally considered more impressive.

Compare the primary care population to that of Australia and New Zealand or to the United Kingdom. Sure we trail two of the three, but not on the order of magnitudes.

Again, the anecdotes will be out there. No doubt incorporating a huge new patient population into the mess but a crisis is more difficult to believe.

The benefits of freestanding children’s hospitals and the problems pediatric care in my hometown faces should seem cognizant to even the layperson. While children’s hospitals certainly have higher charges they provide value for such, providing better care from everything in trauma to acute asthma exacerbation. The lack of a freestanding children’s hospital means tertiary pediatric care is fragmented. Pediatric services at hospitals around the city see fewer of each case of pediatric illness. Volume, as has long been shown, means quality. Concentrating tertiary care also promises to promote recruitment of everything from pediatric subspecialists to pediatric nurses.

I’ve always had a place in my heart for pediatrics. It represents unique challenges and at times can be tragic and gut wrenching caring for the young and critically ill. It is also incredibly rewarding. Your patients share no responsibility for their conditions and the promise they hold when you help heal them is virtually limitless. But of course, as easy as it is for pols to talk about children’s issues, they lack a constituency and children’s healthcare doesn’t exactly have the political will as, say, care for those over 65 does.

So I’m happy to see the movement for a new children’s hospital in San Antonio. A public-private venture the hurdles it faces are more than political but the backing of prominent politicians like Nelson Wolff is a very positive turn for pediatrics in this town. Amongst others in town, the former Mayor and long term head of Bexar County seems to have thrown his full weight behind a freestanding children’s hospital. That can only be a good thing.

Supportive media coverage as well is a positive. The local newspaper has it here and here, saying,

Far from standing still, San Antonio is losing ground in pediatric care as other cities expand theirs, Austin moves closer to getting a medical school, and local military realignments reduce pediatric care resources.

In July, Texas Children’s Hospital bought full-page ads in the San Antonio Express-News promoting its services, evidence that this city is seen as a lucrative market for other cities’ children’s hospitals.

As has local television media. Hopefully that forecasts well for the future. San Antonio needs a children’s hospital.

I’ve repeated myself a lot over the years on reform. The frequency of me going in circles has increased as passage of reform neared. That’s boring. As all encompassing as health care reform has loomed I clearly am not in the loop enough, not able to blog enough to comment on the minutiae. My general thoughts are well layed out, and I need to stop repeating them ad nauseum.

Consider this a last all encompassing post. One intended to look at the arguments for why reform was necessary, what the current reform entails, what the current reform proposes to cost, how the current reform will fund itself, how the current reform succeeds and how it fails.

Reform Is Necessary
Or so the argument goes.

I don’t support reform, not reform that requires the further redistribution of wealth. I have sideline relativistic moral arguments for such. But arguments that either reform isn’t necessary or that progressive/redistributive reforms cannot improve the population’s access to care in all the quantifiable ways, well, I don’t buy them.

Now let me concede and give those who disagree with me their due that: 1) measuring ‘health’ is an incredibly difficult thing and 2) the United States’ failings in terms of health (if we grant they even exist) are multietiological.

Things like our genetic heterogeneity, our economic inequality (independent of how that effects access to care), even the way we measure health outcomes and a multitude of other factors play into why the United States appears to trail many of its western counterparts in measurements such as life expectancy, infant mortality, hospitalization rates for chronic conditions, etc.

Granting all those, it must also be granted that in this country insurance status effects access to care and that access to care effects overall health. Arguments that we enjoy an established safety net and that our health care resources are distributed with some sort of uniformity so that all have some sort of baseline, appropriate access to care are beyond the pale. They’re ridiculous. It is a settled issue that your insurance status, as an independent factor, influences your health. It effects lifetime mortality (pdf), it effects baseline functional measurements, it effects the stage at which cancer is found, it effects mortality related to a whole host of chronic diseases such as heart disease. Without a doubt lack of long term health insurance is an independent culprit behind excess deaths in this country.

I refuse to even have a further discussion on whether, in our current financing system, insurance effects access and thus health. It is settled.

We can debate the economics of the un- and under-insured and the census of such people, but the lay down is, whatever the measurements and whatever the causes, that the problem is real and far from insignificant.

Reform is necessary if your goal is to improve the ‘health’ of this country because one of the key components of improving such is improving access to care.

And so we get the motivation behind an effort like the Patient Protection and Affordable Care Act.

What The Bill Does
There are a lot of great resources out there laying out the health care reform bill in plain terms (see The New York Times or The Huffington Post). I want to create a brief Prezi presentation explaining the bill and its financing in general terms. Until then here’s a non-inclusive run down of what the bill does year by year. That phrase, ‘year by year,’ is our first hint at what the bill is. It’s incremental. The world didn’t end for the tea partierers the day after Obama signed it because, well, right now the bill doesn’t do a whole lot.

This coming year we start seeing the limits on the insurers come into play. For instance lifetime coverage limits on policies will be dead soon. We’ve also heard a lot about how kids will be able to stay on their parent’s insurance plans through 26.

This year also sees the donut hole in Medicare Plan D start to close with a $500 reduction in the gap; until it does years from now, those Medicare patients who reach the donut hole will get a $250 tax rebate.

Small businesses with less than 25 workers who do choose to provide insurance and contribute to premiums will get a small tax rebate, which will phase out as the exchanges come into play later.

It is the next year where we see some alterations in Medicare reimbursement scheme. Primary care specialists and general surgeons serving in census designated underserved areas would get a 10% bonus in Medicare reimbursement in 2011. The bonus is actually Medicare budget neutral (i.e. radiologist cpt codes aren’t reimbursed at a shittier rate to pay for the primary care bonus).

As well this year Medicare Advantage begins to die. Payments to insurers who run the plans are frozen at 2010 levels and begin to contract year by year from here on out. All insurers have to start reporting what percentage of premiums are paid out in reimbursement. Employers start calculating and reporting the value of paid for insurance premiums on W-2 forms.

All payees, Medicare and the private insurers, are required to start allowing a single yearly physician wellness visit without charging deductibles for the visit itself.

In 2012, a voluntary pilot program for accountable care organizations come into play for Medicare. The incentivization for such organizations is meager. Hospitals get some bogus pay for performance type reimbursement changes where CMS is instructed to track readmission rates and punish acute care hospitals at their discretion.

The year following, 2013, is pretty boring as well. The Medicare ACO pilot goes national but remains voluntary and with questionable incentives.

The final year, 2014, sees the major reforms finally come into play.

The individual mandate comes into effect. In general you are required to have insurance or pay a fee of 2% of your annual income up to $750. Of course those who can claim religious exemptions or whom can demonstrate that even with subsidies premiums would cost more than 8% of household income. Subsidies are in place for those households earning up to 400% of the poverty level.

The health insurance exchanges come into place in 2014 as well.

Employers with more than 50 employees who do not provide health insurance are subject to a fine of $2,000 per every employee over thirty who have to get insurance as an individual within the exchange or 8% of wages, whichever is greater. Employers will be limited to a waiting period of 60-days before they insure new employees, otherwise there are further penalties.

Private health insurers come into their limitations. Already limited from placing lifetime caps and dropping individuals who become sick while on insurance, they are now prohibited from not insuring someone because of a pre-existing condition. As well annual caps are no longer allowed.

There’s more after 2014, but not much. For instance, by Medicaid eligibility eventually has a basement of eligibility the individual state programs must meet under which any adult living in a household at 133% of the FPL would be eligible. The federal government in addition will pay 100% of Medicaid expenses for new enrollees between 2014 and 2016. As well, by 2019 CMS is supposed to have implemented an as yet completely undefined pay-for-performance reimbursement scheme for Medicare. Amorphous at best, at current. There’s plenty missing from the above rambling survey of the health care bill but it should give you an idea of the extent of what we’re dealing with.

What I didn’t mention at all above is when the various new ‘taxes’ and ‘fees’ go into effect to help fund some of these provisions.

What The Bill Costs
The reconciled health care bill was scored by CBO at costing less than a trillion dollars over ten years and reducing the federal deficit by $138 billion over the same period. As I’ll discuss below these estimates aren’t without criticism.

The health care bill has a number of new government revenue streams to attempt to fund it and generally garner the positive deficit influence rating from CBO. The funding mechanisms come on line at various times between now at 2015. I’ll leave out some of the penalties we’ve discussed above – such as the penalty associated with the limited employer mandate and the penalty for those failing the individual mandate. There are some other ones as well, such as penalties for hospitals who fail readmission rates and other quality measures as to be determined by CMS by 2012.

The most famous tax, but one with likely limited revenue benefit, is the excise tax on Cadillac health plans. The premiums subject to the tax are scaled, but a good estimate by the time most of the features of the reform are implemented in 2014 is annual premiums between $8500 and $9000.

There’s a new tax on the pharmaceutical industry based on their revenue. A similar one on medical device makers as well. And a tax on health insurers based on net premiums. Those are pretty easy to simply lump together.

There’s a 5% tax on the cost of any non-deformity related cosmetic procedures and a 10% national sales tax essentially on the purchase of tanning equipment and the rental of such at salons.

The bill increases income tax rates for those earning more than $200,000. There’s a 0.5% increase for those making between that and $350,000, a 1% increase on wages from $350,000 to $500,000, a 1.5% increase for wages up to $1,000,000 and a 5.4% increase for wages earned over that.

There is also an increase in the penalty for withdrawing planted income from an HSA and using it for non-medical related expenses. That tax goes from 10% to 20%.

What The Bill Doesn’t Do
There are 31 million who would otherwise be uninsured in 2014, who will have coverage that year because of this bill. Or so the CBO says. The heart tugging, anecdotal stories of those with chronic illness stumbling through the wilderness with their pre-existing condition will be a thing of the past. Let’s give some credit. But I’m willing to end it there.

To be honest this bill is something less than health system reform. It does essentially nothing to alter the way we finance health care in this country or deliver it. There will be no seismic shifts in favor of a more tertiary delivery system, no monumental moves to truly bring primary care into the lime light, no dramatic telling of providers what is acceptable and what is not (certainly not on a scale bigger than what payers already dictate to exacerbated physicians), no global budget or truly more capitated reimbursement system, no real move towards more transparent rationing.

Indeed, I’m surprised at the level of outcry from the right. Conservative elements faced broad public dissatisfaction with health care, huge democratic majorities in the legislature, a generational democratic president and all they conceded was this?

Restrictions on who insurers can refuse to insure, subsidies to pay for private insurance, and relatively small taxes on some biomedical industries and the wealthy to pay such.

There is almost nill reimbursement reform (don’t let the fear mongers scare you about the ill defined future of qualitative reimbursement and ACOs), there’s no public option, there’s no road to a single payer system, there’s no hope for reversing the cost curve, there’s no ‘universal’ access, there’s no drug negotiation, there’s no patent reform for devices or pharmaceuticals. There is not a true progressive accomplishment in the bill from where I’m sitting.

It is a boon for physicians, for hospitals, for big pharma, for device makers. And to be honest, despite the new restrictions they face, even for health insurers who now have millions of new customers dumped into their laps in the next four years. There are downsides, no doubt. Medicaid expansion without reimbursement increases isn’t really enticing. But in general it is all rosy from where most of the health care industry sits. Even the Canadians can see this ‘reform’ is essentially a concession to the industry.

Health care stocks, outside the insurers which are a mixed bag, are almost universally up since the bill was signed.

The major failing of this effort are that it holds limited promise of cost control. Without such; with continued growth in health care spending, this improved access to care the reform promises is unsustainable. If premiums keep rising, subsidizing them and maintaining the individual mandate is untenable.This bill is far from deficit positive or even neutral.

Beyond the traditional criticism of how the reconciliation bill was scored (and such criticism of the CBO isn’t unique to this bill) with the double counting of Medicare savings, the more major fact is the CBO assumes Medicare savings to take place in the form of standing provider reimbursement cuts under the SGR formula. Nevermind that yearly those cuts are held by Congress. Indeed we’re likely as close as we’ve ever been to a permanent SGR fix, which is probably one of the reasons national organized medicine threw their half hearted weight behind reform.

With an SGR fix reform contributes to the deficit over the next ten years.

True reform has to include provisions for cost control. Ideal reform, in terms of improving global utilitarian health metrics, would center around a global budget where costs could be met and rationing would be rational and evidence based. Savings from such a system would come from many places, including from providers. The reality is that, even factoring the expenses of education, American physicians on the mean have far greater lifetime gross earning potential than their counterparts just about anywhere in the world. That includes the primary care physicians. Not to say that they’re overpaid if you try to value physician services in a vacuum; just that there’s an argument when looking at comparative international data that American providers have something to give up to help pay for health care reform.

I know that’s an unpopular opinion in the medical community, but it’s reality. There are trade offs of course in a global budget system in terms of choice, in terms of promoting innovation and development, in terms of treatment for comparatively rare peripheral disease processes requiring highly specialized care. But really it’s nearly beyond argument that such a system, if managed with any half level of confidence, can’t both reduce costs and promote population level ‘health’.

The examples are all over the world. For all the anecdotal problems you can pull from the various single payer and socialized systems throughout Canada, western Europe and east Asia the fact is by any reasonable measurement of population ‘health’ they’re successful, at least as compared to here. I challenge anyone to come forth with something more than anecdotes of wait times or prominent foreigners traveling abroad from those countries for care; to come forth with data of something less than those system’s success in terms of broad public ‘health’ metrics. The argument is well cited elsewhere in this blog.

To be fair, I’m not a fan of such a system. I have philosophical problems with the redistribution of wealth. And I certainly don’t think American physicians are overpaid. But I’ll concede to proponents of a single payer system that it’s likely to achieve what they want it to achieve in terms of improving the health of this country and turning our sky heading health care expenses around.

This reform is far from that. It doesn’t even sniff of a future of that. It includes no public option, the obvious path to an eventual global budget system.

It poses essentially no risk to physicians in this country and if an SGR fix is mustered out of this congress then it even holds great promise.

Liberals can dream about what might be built off of this reform, and indeed if this reform is anything they better hope it is a building block. But, as is, there is nothing progressive about this reform.

Everyone needs to read Firedoglake’s look at the failings of this bill.

It is a giant concession to the health care industry beyond the insurers. And that is not promising for progressives. Future reforms will have to muster reimbursement reform, a public option, more transparent rationing of care. Having taken a first step may indeed make the next ones a little bit easier. But a once in a lifetime White House and congress failing to stand up to any of the money or lobbyist from the industry, beyond the AHIP, doesn’t bode well for reform in the future. If Democrats couldn’t get it done in this environment, it is unlikely to ever be this easy again. There is too much in play for too many stake holders. If this effort has shown us anything I think it’s that.

I suppose we’ll see what the future holds, and when we do I’ll write about it, but as is this bill does a lot of minutiae, and oh so little on the meaningful side.

As fun as all this is I am now of the opinion of Yglesias,

[T]here’s some critical mass of votes you need, short of a majority, at which point you start the doomsday countdown. Now that the count is underway, you can’t change the bill. So there’s no point in holding out for changing. And you “scale the bill down” or “start over” either. You have a victory, or you have a humiliating defeat. And everyone’s in the same boat. At that point, the votes will materialize.

Book this one, the House will pass the Senate’s bill tomorrow.

I’ve made my lack of faith in the Democratic caucus obvious. But when due give them some credit. Pelosi will come up with the votes and give nothing further away for such.

Pelosi told reporters there will be “no separate vote” on abortion or any other measure.

And Rep. Jan Schakowsky (D-IL), a leading pro-choice progressive, said they’re moving ahead without him. “There’s not going to be any deal made with Mr. Stupak…there’s been no deal whatsoever. He’s been told that his language is not going to be added to the legislation,” she told me this morning.

“We think we have the votes regardless, and we’re going to be moving forward,” Schakowsky said. “Yes. We do think we have the votes without him.”

Things have fallen into place from the CBO scoring (here’s the full CBO report),

According to reports, CBO estimates that the combined package will cost $940 billion over the first 10 years and reduce the deficit by $130 billion during that period. In the second 10 years, 2020 to 2029, it will reduce the deficit by $1.2 trillion. The legislation will cover 32 million Americans, or 95 percent of the legal population.

To last minute stake holder support. To the abandonment of Stupak.

My pessimism on any sort of reform was ill placed. That’s not to give the Democratic leadership a full pat on the back. The reform they’ve mustered can hardly even be called such with a straight face. I continue to contend it’s long term prospects for expanding access to care enough to, say, do things like effect our broad health care metrics are dismal. My pessimism on this issue may however be tapered by the idea of this bill as a ‘building block’. It remains however that the progressive caucus has conceded the vast majority of semblance of cost control, and thus long term expansion of access to care, in this bill. The liberal Firedoglake bemoans the same and has a great table looking at what is promised with insurance reform and the realities of it.

The fact the democrats have struggled to pass even this bill is something less than impressive. But to be fair I didn’t even give them that much credit.