CBO also says in its letter to Rangel that this letter doesn't take into account other parts of the proposal that would raise taxes or reduce Medicare spending.

This bill essentially means a surtax on small businesses, which will be passed on to all of us in the form of increased prices; and will make it more difficult for small business to keep jobs.

The fabled 97% coverage would happen "eventually", whatever that means and I'm sure it means a lot.

Someone who makes $45,000 or so and has no insurance now because they can't afford it are going to get totally screwed by this bill. They are not going to qualify for subsidies, but will have to pay an income tax penalty if they don't buy insurance.

The biggest irony is that Candidate Obama actually OPPOSED this mandate proposal (buy insurance or pay a fine).

Since employers will be required to provide insurance, a single person making $45,000 will likely be getting insurance from their employer, so they are hardly screwed. And if you are going to cite self-employed folks, they will be big winners since the insurance exchange means that they will qualify for health care rates equivalent to rates available for big employers -- a big win for such individuals.

As for the surtax on small businesses, few have the profits to be effected by the increased taxes on the wealthy. Most small businesses reinvest revenues back into their business. If they're making profits that qualify for the high-end surtax, they're probably not really a mom-and-pop shop.

I'm actually not a fan of the individual mandate but the subsidies are large enough and the employer incentive to provide health care strong enough that few people will find it much of a problem.

the President’s Council of Economic Advisors has just released a report predicting that healthcare jobs will be among those showing the biggest gains between now and 2016.
Employment in home health care, outpatient care and medical laboratories, is expected to add the most positions.
Healthy society buils up sound economy, this common sense comes to my mind.

"we live in a deformed country saddled with a Senate where a minority of Senators from tiny states can block reforms"

The problem isn't the minority from small states; the problem is the majority who live in the vest pocket of the insurance industry.

The health care reform debate, dictated and controlled by The Industry, seems to be focused on Universal Coverage and Financing instead of the REAL problem: Cost.

Throughout this discussion try to remember 60% of all health care dollars are already public money AND private insurance premiums are inflated by 15% to cover the cost of the uninsured. We are all paying for everybody anyway. That said, there is nobody in the health care non-system that is responsible for asking the question, "How do we get the most health and the least suffering for the unbelievable amount of money we are spending on each other?"

We aren't going to be able to afford to cover everybody with our overpriced, over-utilized, dysfunctional health care non-system unless we first, find some savings then control the rising costs. Just mandating that everybody have insurance might reduce the unit cost of insurance because a lot of the uninsured are healthy, but it will not do anything to control total cost. In fact, since then we will have a bunch more people who expect to get something, it will increase the demand for services, that will add to total cost. The dysfunctional non-system has to be fixed by attacking the perverse incentives that drive up cost. These include the overuse of technology, the fear of liability that forces physicians invoke every crumb of that technology, the mass marketing of prescription drugs, the chaos of medical records, the primary care crisis, unrealistic expectations (especially at the end of life), and the multitude of insurance companies that add 20-30% to total cost without adding anything to health.

The Industry has succeeded in preventing anything that resemble a single payer solution from being put on the table for the CBO to evaluate. Although the "great compromise" might be a public plan option, it isn't going to solve the problem... even if the there is a mythical level playing field. Multiple insurance companies, even with the public plan, don't have enough authority to do what is necessary to control costs. All they can do is raise premiums, deny claims, deny coverage, and cancel policies. If we adopt a public plan, the insurance companies, in the name of a level playing field, won't be able to deny coverage, or cancel policies, or deny reasonable claims. So what is going to happen to rates?

IF we had a single payer, that payer would be responsible for both raising premiums and paying bills. IF it came to ratepayers (taxpayers) three years in a row (as our insurance companies have) with 12-15% rate (tax) increases, we would say "You must control costs." There are lots of really important ways to control costs in the long run, like paying primary care docs more, specialists less, limit the mass marketing of prescription drugs... and make difficult public decisions about what we can and can't afford for everybody with our public money, which is most of it. Yes, that is rationing. And if we are going to empower a body to actually take a leadership position in the health care chaos, why not make it the single payer? I might note, for all our fear of rationing, we are already doing so... irrationally based on insurance coverage. Instead, shouldn't we be doing it rationally, based on scientific evidence and social justice?

As for the mythical level playing field, it's a fantasy. The Industry is pouring $1.6 Million each day into lobbying for health reform that will sustain their profits. If the public plan option becomes the compromise, the focus of that money will be to manipulate the rules of engagement for the public plan so the other insurance companies to do what they do best, manipulate the public so that they only have to care for the healthiest people while the sickest, oldest, most expensive patients get dumped on the public. Of course Universal Access by individual mandate means the taxpayer will subsidize the cost of insurance for those who can't afford it. Restated, that translates into the Insurance Industry continuing to thrive with more taxpayer subsidies at the same time that they make a huge contribution the inefficiency of the system. This is our uniquely American solution?

We aren't going to get the reform we need until Congress focuses on Cost instead of Financing. We can't throw more money at the problem only to be wasted in the friction of a dysfunctional health care non-system that is better at producing profits than health. First find savings. Then control costs. The low hanging fruit for savings is the insurance companies that add substantially to cost without adding to health. I can almost guarantee that we will have something that resembles single payer in 20 years. If all we do is more of the same, and THAT is what Congress keeps talking about, we will bankrupt our government (which might happen anyway), and out of the ashes of the implosion we will have either anarchy or single payer. The Industry, hopes to suckle at the breasts of the taxpayers for as long as possible.

BTW- This entire health care reform debate is less about health care than our political process that is broken (corrupt?) for the same reason. They are both mostly about money. Did you know that the AMA owns the proprietary rights to CPT codes, which every doctor must use to bill anybody? It earns them $70 Million in royalties every year. They are about as objective about health care reform as AARP, which has become extremely quiet since people have caught on to the fact that they are also the enemy of real reform since they, too, get indirect government subsidies by providing services to our seniors....for which they lobby.

Be well. Being otherwise is very expensive.

Paul Hochfeld, M.D.
Emergency Physician