First, congratulations to Jon. The reviews suggest that "Sick" is going to help legitimize discussions of radical national health reform. “Single-payer” is no longer a dirty word.

I understand why some believe that radical reform is politically impossible. But they remind me of those who said that we could never pass Medicare. Eventually, the pain became too great. Too many seniors could not afford care, and popular support trumped the then-powerful AMA. In 1962, Gallup polls showed public support at 69% and President Kennedy called for Medicare in front of crowd of 20,000 in Madison Square Garden.

Still, it wasn’t easy.

After Kennedy’s speech, the Medicare bill was defeated 52-48. This did not stop the Democrats—they understood what was at stake. They knew that the opposition would be fierce, but they also understood that this was like civil rights. It was not a time for caution. It was a time for politicians who cared about issues.

Ultimately, President Johnson succeeded by pulling doctors into his tent. This could be done today--polls show that roughly 50% of U.S. physicians favor national health insurance. But public support was key.

And today, public support is building, especially among aging baby-boomers.

If you are forty and healthy, you may not feel the change in the zeitgeist. But today, boomers over 50 are beginning to face serious health problems. They talk about healthcare with an intensity that they once reserved for real estate.

We never would have won Medicare incrementally, state by state. As for the current crop of state plans for health care reform, I defer to Matthew Holt who points out that “If instead [of genuine universal coverage] we try to do the kind of wraparound plans that are being pushed by Republicans, albeit liberal ones, in Massachusetts and California, then we will find that as employers retreat from providing insurance, the pool for everybody else will be regarded as welfare. And welfare payments in America are politically extremely vulnerable.”

In other words, we’ll wind up with a poor plan for the poor.

Half-way measures are dangerous because they could create the illusion of reform. On this point I was happy to read what Jon had to say about Safeway CEO Steve Burd (co-architect of Wyden's plan for reform) in his first post yesterday:

"Burd has become a vocal universal health care advocate - and he's trying to rally business to that option by warning them that, in the absence of such a compromise, single-payer will eventually become law. They, like he, don't want that.

"So that's why I think it's a mistake to settle on a compromise - at least for the moment."

Here Jon makes it clear that Burd (and Wyden, as well as others in the business world) are trying to hijack national health reform--to make sure that it is not real reform.

Wyden’s plan would simply pour more money into a broken system while giving consumers a “choice” between plans devised by insurers. (Here “choice” is Republican-speak for “pick the plan you can afford.”) Sure, the plans would be required to offer the same benefits Congressmen receive under FEHBP. But do a little research on FEHBP, and you find out that it’s not quite what it’s cracked up to be.

See this February 2007 white paper from the American Federation of Government Employees on spiraling co-pays, the effect of high-deductible plans on middle-class Federal Employees, etc.

By pumping more money into the system, Wyden’s plan would please the for-profit insurers, drug-makers, device-makers, specialists and hospitals who, today, are making exorbitant profits while covering and selling sometimes unnecessary, often overpriced goods and services. (For-profit insurers are no longer trying to tightly “manage” care. For a price, they’ll cover almost anything you see on TV, or hear about on the evening news, and then pass along the cost-- plus a profit--in the form of higher premiums.)

Meanwhile, patients watch their co-pays and deductibles climb.

The most honest physicians admit that in our system, over-treatment is driving healthcare inflation. Just today, I received an e-mail, out of the blue, from a physician who sits on the board of the American Society of Clinical Oncology. He wrote: “From where I sit, the problem is clearly one of perverse [financial] incentives which reward guys like me for giving folks lots of chemo--whether or not it will likely help them and whether or not they really understand the implications of their decision to have it.”

Here I disagree with those who suggest that private insurers are the “chief” problem in the system. (Though I absolutely agree that for-profit insurers are a serious problem---and ultimately we need to eliminate them, probably by forcing them to compete with Medicare on a level playing field. As others have said, this will take time. We cannot eliminate an entire industry in one fell swoop.)

But private insurers’ profits and administrative costs account for only 4.5% of our total health care bill—a sizable slice, to be sure, but eliminating them is not a long-term solution. It will not solve the ongoing problems of levitating costs and declining quality.

Probably most people in this discussion are aware of the medical research that has been done at Dartmouth over the past twenty-five years, revealing the waste in our health care system. In study after study, the Dartmouth team has shown that Medicare spends twice as much, per patient, in some regions of the country than in others--for reasons that have absolutely nothing to do with medical science, the severity of the patient’s illness, or even his or her preferences.

What’s driving the higher costs? Supply.

“Build the beds and they will come.” In areas where there are more hospital beds and more specialists per capita, patients invariably receive more aggressive, more intensive, and more expensive care. They spend more days in the hospital. They undergo more diagnostic tests and minor surgeries. They see 10 or more specialists during the final months of life. And they are more likely to die in an intensive care unit.

What’s shocking is that outcomes are no better—they are worse. In a landmark study of chronically ill patients the researchers show that in the towns like Manhattan, L.A. and Miami, where patients receive the most intensive, aggressive care, mortality rates are higher and function following treatment is no better. This is true even at the most prestigious academic medical centers. I’ve written about this—and about how Dartmouth’s research may change the way Medicare does business -- in an article that came online yesterday.

Based on their research, the Dartmouth team estimates that one out of three of our health care dollars are squandered on redundant tests, unnecessary hospitalizations, unproven bleeding-edge procedures and over-priced new drugs and devices that are no better than the products that they have replaced.

This is why I, like Diane, believe that we need a “true public insurance system [which] offers things that you cannot expect from [for-profit ] insurers”—things like “negotiated and lower prices; a public accountability as to what is covered; the ability to set protocols based on best practices, reduce misuse and overuse of services and promote quality care.” The VA health care system (which is not in any way related to Walter Reed) serves as an excellent example of a public health care system that has done just that. See Phillip Longman’s excellent book: “Best Care Anywhere.”

If we are going to have sustainable universal healthcare, we have to rein in the waste and get health care inflation under control. Right now, health care costs are growing two to three times faster than GDP. This is not sustainable—even if we don’t try to offer care to everyone. It also is not inevitable. It can be fixed.

The good news is that the independent advisory panel that advises Congress on Medicare spending (MEDPAC) understands what needs to be done. In a March 1 report studded with references to the Dartmouth research, it makes numerous suggestions for eliminating over-treatment—including scrapping fee-for-service payments to physicians.

If Congress is not willing to give up fee-for-service, MedPac offers an alternative: Medicare could start paying physicians less per service in areas where patients receive the most aggressive care (like Manhattan and Miami) while paying doctors more in areas (like Minnesota and Iowa) where doctors practice more conservative medicine.

I don’t see Senator Hillary Clinton voting for this one. Like it or not, Medicare is going to have to move away from fee-for-service—another sign that major changes are coming.

The report also suggests that Medicare raise reimbursements for primary care physicians-- and consider paring reimbursements for some specialists. In addition, the report calls for more independent research on the “comparative effectiveness” of various drugs, devices and treatments, noting that today, when for-profit industry controls such studies, researchers tend to be biased. MedPac suggests that the government should play a greater role in head-to-head comparisons of products and services.. Read MedPac’s entire 236-page report here. Or get a summary of it in the Dartmouth Medicine article cited above.

If Medicare begins addressing the problem of waste over the next few years, that will make “Medicare for All” a much more plausible solution. To me, it seems the best, simplest solution. Everyone understands Medicare and almost everyone prefers Medicare to for-profit insurance.

Meanwhile, if Medicare insists on unbiased comparative-effectiveness data—and negotiates prices—it could become an honest broker for universal care.

But to build public support for reform, we have to let the public know what is driving health care inflation.

Most Americans still believe that more care, and more expensive care, is better care. When talking about reform we need to stress what is wrong with the system: people are selling overtreatment that is hazardous to your health.

Too many angioplasties, too many bypasses, too many Caesarians, too many newborns are put into neo-natal ICUs. . . . (See The New England Journal of Medicine, 16 May, 2002). We have to make it clear that we are not talking about rationing necessary care; we are talking about eliminating the profiteering, while making sure that “the right patient” gets “the right care” at “the right time.”

To build public support for radical health care reform we also need to train our sights on those on those who are making excessive profits in our money-driven health care system. A good campaign needs a good enemy—and the for-profit health care industry fits the bill perfectly.

Even Obama has suggested (however cautiously) that we should being to question the profitability of U.S. healthcare: “Another, more controversial area we need to look at is how much of our health care spending is going toward the record-breaking profits earned by the drug and health care industry,” he noted in January. “It’s perfectly understandable for a corporation to try and make a profit, but when those profits are soaring higher and higher each year while millions lose their coverage and premiums skyrocket, we have a responsibility to ask why."

That Obama would dare to make such a remark shows how the mood of the country is changing. A few years ago, it's hard to imagine any politician suggesting that "record-breaking profits" in virtually any American industry might be cause for concern. (Oil is the exception; but then we don’t tend to think of oil as an ‘American’ industry.) Yet, here, Obama--who has taken a lot of Wall Street money--is suggesting that one of the Street's most beloved industries may have become too greedy. (Wall Street likes healthcare for the same reason it likes tobacco: you have a gun to the customer's head. he'll pay whatever you ask.)

Of course challenging the for-profit industry will be “controversial.” As Matthew pointed out earlier in this discussion: “genuine universal coverage requires such substantial government intervention in the market that nobody in the current health care industry will be continuing to do business as usual.”

We are talking about massive change to a massive system.

But it can be done. Post-Enron, Americans are much less trusting about the motives of for-profit corporations. The public is not likely to be swayed by the private insurance industry the way it was when that industry defeated the Clinton plan. And as drug-makers and device-makers withdraw one product after another from the marketplace—while admitting that they didn’t tell patients and doctors the truth about risks and benefits—we are becoming more and more skeptical that they have our best interests at heart.

The health care industry’s lobbies will fight tooth and nail. We should not delude ourselves that we can persuade the industry’s stakeholders to willingly give up double-digit profits (or the executive compensation packages that come with those profits.)

Forget about enlisting their support. Forget about a liberal/conservative coalition. Some moderate Republicans will get on board if they see public support building. But the only way that we will win public support is if the public understands what’s wrong with the system—and demands change.

Here, baby-boomers could provide an important base. Those who say “We shouldn’t try to discuss what type of plan would work best because we don’t know what the political climate will be in 2009 or 2010” ignore what is baked into the cake: In 2010, baby-boomers will be three years older. And healthcare will be three years more expensive. (With costs rising 6% a year, it’s likely to be nearly 20% more expensive.) Meanwhile, there is every indication that the economy will be in worse shape. We’re going to have to pay for the economic follies of the Bush years. This means that Americans will be even more anxious about having a safety net.

Healthy, well-insured forty-year-olds may be harder to convince. Some may say “I like things the way they are—why change?” (At least they’ll say that until their employer slashes their benefits—or stops offering healthcare altogether.)

But boomers in their fifties are beginning to find out what their for-profit insurance does and doesn’t cover— just how much chemo costs—and just how crafty insurers can be when it comes time to pay up.

In other words, the boomers are not just worried about becoming UN-insured—they are anxious about being UNDER-insured. This is why so many of the Pepsi generation are counting the days until they become eligible for Medicare. To many of them, “Medicare for All” sounds like a splendid idea.

And remember, boomers like to march.