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On Health Reform, George F. Will Just Threw a Spitball

One could say of George Will what James Russell Lowell wrote of Emerson: "His eye for a fine, telling phrase that will carry true is like that of a backwoodsman for a rifle." Which is to say, the guy can write. But anyone who reads Will's latest screed on health reform with a critical eye might also be inclined to quote Lowell's observation about an Emerson lecture:

"It was as if, after vainly trying to get his paragraphs into sequence and order, he had at last tried the desperate expedient of shuffling them."

Indeed. Will's column is a mashup of disparate declamations. As is often his style, he offers quotes that are very enjoyable but only loosely related to the topic at hand. We also see the selective use of survey information and some standard-issue conservative lamentation that we have yet to unleash the power of the free market to fix health reform. (Will someone please provide some working examples of a "health care free market"?)

And baseball references, of course. If it's a George Will piece there has to be a baseball reference.

To the extent that the piece has a structure, it is built around a statement from Elizabeth (Betsy) McCaughey saying that the percentage of family income Americans spend on healthcare is essentially no greater now that it was in 1960. No supporting information or source material is offered for Ms. McCaughey's statement. Given her well-documented history of making false statements about health-related issues, it is sadly impossible to take this statement at face value. (See here for more information. Mickey Kaus, himself no liberal, wrote that "she completely distorted the debate on the biggest public policy issue of 1994.")

What's more, the point isn't all that relevant even if it's true. Medical conditions account for two-thirds of American bankruptcies today. Perhaps people died from lack of medical care at a greater rate in 1960, which limited their out-of-pocket expenditure. Or maybe people suffered just as much health-related bankruptcy back then as they do now.

Will goes on to say: "... (A)s societies become richer, they spend more on health care -- and symphonies, universities, museums, etc." This statement would be hard to substantiate, especially in the prosperous nations of Western Europe that spend far less on health care than we do. And Americans struggling to stay solvent while paying for needed care might rightfully take offense at the Marie Antoinette-ish undertone of the sentence. It's as if medical treatment were a whimsical indulgence of the prosperous, like attending the gala premiere of a new opera season.

"It is also because health care is increasingly competent," Will adds. But competent for whom? Isn't the ability to spend money on what works an essential aspect of competence? Yet conservatives continue to oppose studies that demonstrate what works and what doesn't. We spend far more on health care than other industrialized nations have poorer results, as measured by public health statistics. That does not meet any commonly-held definition of "competence."

And why compare us to the US circa 1960, anyway? In those pre-Medicare days older Americans and their families often went broke trying to meet basic medical needs. That could certainly account for the relative lack of change in those cost percentages over the past 50 years. It would make more sense to compare us to those countries that have a rational health system today - but that's not a comparison Mr. Will appears ready to make.

Ms. McCaughey, for her part, is now hard at work trying to undermine health reform by playing what can be described as a "six degrees of policy separation" game. In this piece, for example, she takes the Kennedy bill's "medical home" provision and suggests that it vaguely resembles "the unpopular controls HMOs imposed two decades ago" penalizing doctors for providing or authorizing care that was not approved by the plan. That provision is not present in the Kennedy bill nor, upon careful reading, does she claim that it is. But it looks like something that looks like something that looks like that provision ... or so she says, leading to guilt-by-inferential-association.

I don't mind a good healthy challenge in the marketplace of ideas. It would be valuable and even enjoyable to engage in a pickup game with our conservative colleagues over the merits of health reform. But George Will is throwing spitballs, layering extraneous matter - effluvia, you might say - onto his anti-reform pitch. Betsy McCaughey spits on the beanbag and George Will throws it.

Will and McCaughey have been guilty of this unsportsmanlike conduct before. As James Fallows documented so thoroughly, this is a routine they perfected in 1994 (see excerpt below).

To his credit, Will acknowledges that conservatives should stop arguing that reform will lead to health care "rationing," since - as he correctly observes - all goods and services (he uses the word "product," but I don't think that's applicable to healthcare) are already rationed "by price or by politics." Well said. As always, when Will stops throwing spitballs and gets to his real point he's well worth reading. He prefers rationing that is based on price because, he says, "prices produce a rational allocation of scarce resources."

Will should stick with that point and elaborate on it, since it's the crux of his (and other conservatives') argument against health reform. I think that's precisely the wrong way to allocate health care resources, but that's a debate worth having. In fact, it's the debate we should be having.

Instead, Will is too easily tempted to adopt a conservative strategy that appears to come from an old playbook: Toss out false statements or distracting statistics and hope that, as in 1994, the press starts repeating them as if they were either true or relevant.

The astute reader will observe that I've adopted some of Will's literary mannerisms in the writing of this piece. Consider it an homage to a master essayist who, should he so choose, could be a much better advocate for his own political philosophy. Instead he offers us, to use Russell's words, "a chaos full of shooting stars."

The problem with spitballs, as any baseball lover knows, is that the pitcher has a hard time controlling them. Will does neither his readers nor himself a service by continuing to throw them.

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(From Fallows)

The article's working premise was that McCaughey, with no ax to grind and no preconceptions about health care, sat down for a careful reading of the whole Clinton bill. Appalled at the hidden provisions she found, she felt it her duty to warn people about what the bill might mean. The title of her article was "No Exit," and the message was that Bill and Hillary Clinton had proposed a system that would lock people in to government-run care. "The law will prevent you from going outside the system to buy basic health coverage you think is better," McCaughey wrote in the first paragraph. "The doctor can be paid only by the plan, not by you."

George Will immediately picked up this warning, writing in Newsweek that "it would be illegal for doctors to accept money directly from patients, and there would be 15-year jail terms for people driven to bribery for care they feel they need but the government does not deem 'necessary.'" The "doctors in jail" concept soon turned up on talk shows and was echoed for the rest of the year.

These claims, McCaughey's and Will's, were simply false. McCaughey's pose of impartiality was undermined by her campaign as the Republican nominee for lieutenant governor of New York soon after her article was published. I was less impressed with her scholarly precision after I compared her article with the text of the Clinton bill ... In claiming that the bill would make it impossible to go outside the health plan or pay doctors on one's own, she had apparently skipped past practically the first provision of the bill (Sec. 1003), which said,

"Nothing in this Act shall be construed as prohibiting the following: (1) An individual from purchasing any health care services."

(cross-posted at The Huffington Post)

Could Doctors Go the Way of Record Companies?

Those of us who follow health care may be overlooking the big picture. Most of the profound (and sometimes disruptive) changes of the last half century -- computers, the Internet, social networks -- weren't initiated by the political process. They arose at the intersection of technology, economics, and mass social change. So here's something to think about:

Could the medical profession go the way of the record industry?

Consider the path that led to the current crisis in the music business:

1. An industry with a near-total monopoly experiences a minor disruption (in music's case, with the invention of cassette tape recording).

2. It 'relaxes' and assumes the crisis has past.

3. An even better technology comes along (the Internet) that includes lateral as well as vertical connections. (Individuals could only make tapes for themselves; sharing was possible but cumbersome, until the Net and mp3s made it instantaneous and worldwide.)

4. The industry fails to recognize the long-term significance and risks of this new tech.

5. Enterprising individuals use this new technology to distribute "information" of mutual interest - songs - through "P2P" (peer-to-peer) file sharing.

The result? A massive and ongoing implosion of the music biz. (David Byrne provided an excellent overview in Wired, with some corrections on his blog.)

Could the same thing happen to the medical profession? Many people's immediate reaction will be to say 'no.' They'll list the many barriers to what we might call a 'P2PMed' disruption of our medical economy (with 'P2P' here meaning either 'peer-to-peer' or 'patient to patient'.) Doctors are too respected. Regulations won't permit it. Doctors control access to medications. Medical information is walled off behind expensive, subscription-only medical journals. It's unthinkable.

That's pretty much how the record industry reacted in the 1990s. Let's look at those objections:

160 million people looked up medical information on the Internet circa 2007, according to Harris polling data. Yet they still go to doctors. That's true -- just as millions of people made tape copies of music for decades without seriously undermining musical economics.

Each of these searches was a solitary activity. The difference will come when a new technology allows lateral information-sharing in a way that people trust. It hasn't happened yet, but smart people are banking on the idea that it will soon. I agree with that assessment, although none of the many projects I've looked at so far struck me as a breakthrough. But a lot of folks are working on it.

Doctors monopolize access to medications through the power of the prescription pad. That monopoly's already eroding as online pharmacies provide low-cost 'doctor consults,' a legal work-around that allows -- to an sometimes disturbing extent -- easy access to meds. Where there is demand, there will be suppliers.

People won't spend money based on self-referral. The multi-billion dollar complementary medicine industry demonstrates this is untrue. Most "CAM" (complementary and alternative medicine) transactions are based on self-referral out of the traditional MD/patient relationship.

Medical information is walled off. True, but a backlash against the sequestering of research data is already underway. Case in point: A new publication called The Journal of Participatory Medicine hopes to provide peer-reviewed articles on self care for patients, as board member Kevin Kelly writes.

The Journal's Advisory Board reads like a Who's Who of Internet and medical business pioneers (and it's an open-source publication, meaning its content will be free to all). The Journal goal of helping patients take "responsibility for their own health and healing" (in Kevin Kelly's words) aligns with decades of movement toward a more patient-centric model championed by both the Left (as "patient's rights") and the Right (as with high-deductible "consumer-directed health plans").

Once again, the left/right paradigm is ill-suited for new developments... and don't blame initiatives like the Journal if medicine goes the way of record labels. They're symptoms of broader socio-informational change, not its cause.

Not all doctors would go out of business after such a transition, of course. They're still selling some CDs, too. So who would be most likely to thrive after the transformation?

High-touch practitioners: Empathetic, comforting, and warm doctors.

"Mechanics": The most gifted and accomplished surgeons sometimes use this word to describe themselves. We will need talented neurosurgeons, cardiac surgeons, and other "fixers" for the foreseeable future (at least until the self-programmable nanobots take over).

Innovators: Doctors who are always exploring, changing, and trying new things, staying one step ahead of the curve.

Integrators: Doctors who can bring together seemingly unrelated ideas and solutions, whether in diagnosis or in treatment. Integration is the foundation of creativity, and creative doctors will always be valued.

Who'll fail? Doctors who function by rote, who make routine diagnoses, and who connect patients to other resources based on past relationships and not need. Anyone whose expertise and connections are easily replicated on the Internet (think "travel agents") will struggle to survive.

Watching the AMA defends its turf on issues like doctor reimbursement is like watching the RIAA file copyright lawsuits against teenagers, even as its business model collapses around it. You can't fight your own market and win, and you can't fight yesterday's battles. Doctor groups should look more like think tanks and less like a lobbying groups. (Come to think of it, so should the RIAA.)

Predicting this kind of change is not the same thing as endorsing it. But, like it or not, we should be talking about it now.

Because -- like it or not -- it's coming.

Health Reform: Ideas At Work vs. Self-Negating Arguments

The opposition to a public health plan option seems to be imploding, victimized by logic which looks something like this:

1. A public health plan will be a nightmare. You won't get the doctor you want. Waiting times will be horrendous. Government pencil-pushers will stand between you and your physician while political hacks decide what treatment you'll get. Everybody will hate it.

2. Public health care will have an "unfair advantage" on price. It will then drive private insurers out of business because it will be so popular that everybody will join it.

What's wrong with this picture?

These self-negating arguments¹ aren't displaying much faith - either in free markets, or in the imagination of people working within the current system. Speaking of which ...

There's a very interesting new proposal from "Health CEOs For Health Reform," a project of the Health Policy Program at the New America Foundation. The "Health CEOs" come from a diverse set of healthcare companies, and their proposal focuses heavily on - in their press release's words - " quality, efficiency, care coordination, and patient-centeredness." The proposal itself emphasizes a radical shift away from today's fee-for-service model, favoring total case care, accountability for outcomes, and new payment models for chronic care. Many of these ideas have been around for a long time, but the proposal seems to go further in some of its global recommendations.²

Yesterday Sen. Kent Conrad announced a new alternative to the public plan option: non-profit health cooperatives. I would argue with Sen. Conrad's timing. We don't need a milder alternative to the public option, since momentum for it seems to be building . And independent cooperatives would not have the research, development, or innovation capabilities that a public plan could muster. This is not the moment to undercut the public plan idea with another fragmented program. That said, Sen. Conrad's "chartered cooperative" alternative could enrich the set of choices reform can offer, even if it's not a substitute for the public plan.

We already have operational health plan cooperatives and other nonprofit groups throughout the country. Some of them incorporate elements that relate to the "Health CEO" proposal, and surveys usually show that their members are very satisfied with the care they provide. The presence of a public plan option doesn't preclude all sorts of imaginative initiatives from the private and nonprofit sectors. It should encourage them, in fact, germinating new financial and medical models that help them thrive.

It's particularly disappointing to see someone like Sen. Charles Grassley echo the opposition's self-contradicting arguments. Grassley's a Republican who's often been willing to reach across the aisle on health care. His hearings on corruption in medical research have been both courageous and profoundly important. It's time for Sen. Grassley and others to either frame a more defensible and coherent opposition to the public plan option, or step down and let it be enacted.

Why not create a health system that taps into all of our country's resources - government's tools, the private sector's energy, and the capabilities of our growing nonprofit/"social entrepreneurship" sector? After all, choice and competition are basic American principles.

Let's redesign our health system so that it encourages ideas that work. And how will we know what works? In our country's tried-and-true way: by letting the people decide.
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¹ I may be oversimplifying, but not by much. Opponents may say, for example, that their real concerns involve a long-term scenario where a public plan forces its opponents out of business and then turns dictatorial. But we don't make policy based on hypotheticals, especially extreme ones. Congress can always pass new laws if circumstances change. And private capital will always move in if there's a new marketing opportunity.

.²I should note that I need to study this just-released plan in greater detail, especially its recommendations for an overhaul of Medicare's reimbursement structure. And to be clear, the "CEO" plan is silent on the issue of a public plan option. I don't want to leave the impression that it took a position either way on that subject.

A Health Care Bailout For the Middle Class

It's on. The President's assuming direct ownership of the health debate. Draft bills are beginning to circulate on the Hill. Dozens of policy details are being debated. Universal coverage is one way to describe the objective, but here's one that might be better: We need a healthcare bailout for the middle class.

High-income Americans will make out fine, and public programs will be strengthened for lower-income groups. But medical illness caused nearly two-thirds of all bankruptcies, and most of these bankrupt debtors had medical insurance. That raises two questions:

1. What's the value of "universal coverage" if "coverage" isn't providing the financial security people need?

2. If we can rescue troubled banks, what are we doing to rescue families whose "toxic assets" consist of unpaid medical bills for urgently needed care?

It's a mistake to assume that health reform will inevitably ease the financial burden for financially imperiled households. Medical problems caused 62.1% of all bankruptcies in 2007. Three quarters of these bankrupt debtors had health insurance. And 92% of them had medical bills of at least $5000, or 10% of pretax family income.

"10% of pretax family income" is also the figure many health policy analysts say families should be prepared to spend for health care under a mandate. But for many people that was a burdensome figure even before the financial crisis. We can't assume that a policy forcing them to spend that much will be either effective or politically popular. Nevertheless, AP reports House Dems are floating the idea of "slapping an unspecified financial penalty on anyone who refuses to purchase affordable health insurance." That's what is known as an "individual mandate."

Insurance was originally designed to eliminate financial ruin for individuals by distributing costs among many people. Does it make sense to insist that people buy coverage that won't necessarily protect them from disaster?

Feelings run high about this issue among us health policy wonks. Most Democratic/liberal analysts insist that reform can't succeed unless all individuals are first mandated to obtain coverage. The idea's based on sound economics: If some people can opt out, the healthiest are most likely to do so. Then the system will be burdened with sicker enrollees, driving up costs and making it harder to achieve universal coverage.

That's why smart and knowledgeable people like Jonathan Cohn can imply, as he does here, that individual mandates are indistiguishable from "good public policy."

I understand the economics, but here's the concern: The underlying concept of "shared responsibility" is sound, but in other countries - and in Medicare - that responsibility is mainly shared through the progressive mechanism of taxation. Unless carefully designed, individual mandates run the risk of being overly punitive and politically explosive among middle-income Americans.

Consider Sen. Kennedy's new draft proposal. It offers more generous subsidies than other proposals, with a sliding scale of assistance that goes up to $110,000 in income for a family of four. But a lot can happen beneath and near that $110,000 mark, especially in these perilous times. Yearly premiums for family coverage reached $12,680 in 2008 and continue to climb. That's one reason why families struggling to make ends meet sometimes 'bet' that they won't have catastrophic medical costs. That may be a bad bet, but using the levers of government to force them to pay $8,000 to $13,000 in premiums alone might not be the best solution.

And the assumption that mandates are more politically liberal is just that: an assumption. Mandates could, in fact, be economically regressive. They could also give the GOP a hot-button issue for 2010 and 2012. Proposals like Jacob Hacker's, which limit out-of-pocket premium costs to $2,500, go a long way toward addressing those concerns. But they're also costlier from the government side, so they don't seem to be on the table right now (even if those costs could ultimately be offset by improved compliance).

What's the solution? At least one proposal that has been anathema to Democrats might help. The Democrats campaigned against McCain's plan to tax health benefits. But a health tax, like any other, can be either progressive or regressive. (There's a good discussion of the topic here.)

It's true that a tax on all workers receiving health benefits could be disastrous. And nobody's receiving overly luxurious benefits, despite what some partisans claim. As Merrill Goozner observes, there are no "Cadillac health plans" for employees, though that phrase is has become a buzzword. (And Cadillacs are made by GM, where a little help was also needed.)

Here's one possibility: a health benefits tax that kicks in at high income levels. That could conceivably pay for some Hacker-like caps on premiums. It would also have the added benefit of sensitizing corporate decision-makers to the true cost of medical care in this country. It might even motivate more of them to take a proactive stand on health issues.

There are a number of other possible ways to "bail out" the American middle class in health care, too:

1. Phase mandates in slowly, as overall health costs are reduced through other measures. (This one's unpopular with a number of analysts, but I think unfairly so. It's do-able.)
2. Emphasize the public plan option. (If you're going to lay a heavy cost burden on the middle class, it's a good idea to give them every choice you can.)
3. Develop innovative ways of helping consumers pay their health debts through easy-to-use financing tools at favorable interest rates.
4. Ensure than health benefits include appropriate caps on out-of-pocket costs.

Universal coverage without universal financial security would be a Pyrrhic victory. The President and Congress can ensure successful health reform by making sure that American families can receive the care they need at a price they can afford.

The Meaning of Swine Flu, the Universe, and Everything

Wait a second. First we couldn’t get away from that swine flu story, although we were told that it had affected less than 100 people in Mexico and only a handful here in the US. It was getting round-the-clock high decibel coverage on all channels. Twitter, our new electronic central nervous system, was going ballistic. Andy Borowitz seemed to be on to something when he wrote, “CNN Warns Swine Flu Could Continue Through Sweeps.”

By May 7 the Associated Press and others were writing stories about the overhyped flu. It seemed resolved in a lot of people’s minds: Just another overplayed media story.

But wait. Now the World Health Organization is reporting nearly ten thousand cases of the virus worldwide, with more than half of those occurring in the United States. “We are not out of the woods,” a CDC director said (on CNN.) 16 schools have been shut down in New York after an assistant principal died of H1N1. Cases are “ballooning fast” in Japan and elsewhere, says Forbes. UN Secretary General Ban Ki Moon alled for international solidarity, which includes ensuring that “all have access to drugs and vaccines.”

We went from apocalypse to afterthought in about two weeks, and now we’re swinging back. It’s hard to know what to think. Here’s a way to reconcile some of the different and seemingly contradictory perspectives we’ve been hearing, which include:

It’s no big deal. The CDC estimates that 36,000 people die each year as the result of regular flu. Very few people have died from swine flu, but it’s all people can talk about. It’s an overhyped phenomenon, a distorted perspective caused by media sensationalism.

It’s an emergency. An assistant principal dies in New York. 103 students at nearby schools develop flu-like symptoms. Then a toddler dies in Queens. Forget the statistics: Death is a singular tragedy for the deceased and everyone who loved them. Why take chances?

It’s unlikely I’ll get it. 5,000 people have it in the US. Even if that number increases a hundredfold my chances of getting it are still only one in six hundred. And it probably won’t be worse than any other flu.

I should take serious precautions. I should carry disinfectant and wash my hands regularly. I should stay home if I’m not feeling well, and should look for instructions from my local health authorities.

Let’s take the last two statements first. Which is correct? The answer, based on what we know now, is: Both. It’s unlikely you’ll get it, but you should take precautions anyway. You should be taking some precautions already to avoiding getting routine illnesses. But you should be even more careful with swine flu.

Why? To use Homeland Security symbolism, our individual threat level is “yellow” but our collective risk is “orange.” Your chance of getting it is low, and you don’t need to be too concerned about your own health right now unless you have other complicating conditions. But you should be concerned about all of us. As more people get it, the chance of pandemic increases. And a pandemic is a catastrophe. So even though your individual risk is low, our collective risk level is high enough that you should take precautions – for humanity’s sake, if not your own.

Concepts from risk management should help. Your risk of contracting it is low, and the outcome if you got it probably wouldn’t be severe. The chance this could become a pandemic is also low – but the outcome would be catastrophic. So we need to treat the possibility of pandemic very seriously.

Tyler Cowen does a good job of summarizing the way this kind of risk analysis should be conducted:

A one percent chance of one hundred million deaths is, in expected value terms, one million deaths and that is a big deal. Probably the United States is less vulnerable than it was in 1918, but how many people would die in China, India and many other locales? How much disruption to trade, travel, and the world economy would take place? Even in the United States, our public health systems would break down quickly and render many modern medical advances useless (e.g., when would the Tamiflu run out?)”

Expected value calculations are a good way to look at problems of this kind. The fact that the United States is less vulnerable than it was one hundred years ago does not mean it isn’t vulnerable at all. What’s more, the deaths of millions abroad should concern us for both selfish (e.g. economic) and altruistic reasons.

This kind of risk analysis should be standard operating procedure in the business community. That’s why it’s still surprising when business-friendly politicians strip money from the budget because they think bad events aren’t likely to happen (e.g. Bobby Jindal’s mockery of volcano monitoring, or Susan Collins’ removal of flu pandemic money from the stimulus budget). Remember: A low-probability event plus a high-loss outcome = cause for concern.

To sum up, based on what we know today: Swine flu is not that grave a threat to us as individuals, but it’s a serious danger for all of us – collectively. Think of it as an exercise in interconnectedness, a real-world and scientific example of that “one world” talk we’re always getting from pop stars and movie actors.

Because we are interconnected: A farmer coughs while tending livestock in Mexico. At lunch he shakes hands with his cousin the policeman, who writes a ticket for a visiting tourist later that day. The tourist goes home to Belgium, where his colleague leaves the next day to visit his cousin the day-care worker in New York. A week later a 16-month-old child dies in Queens.

It could have happened that way. We don’t know. And washing your hands today might save thousands of lives in Bangladesh or West Africa next month. We don’t know. But we do know that, in a a very literal sense, that “one world” business is real. It’s a good reason to take health precautions. It’s a good reason to support flu management and other risk management funds in the Federal budget. And it’s a good reason to care what happens anywhere and everywhere in this interconnected world.

(originally written for The Huffington Post; also cross-posted at The Sentinel Effect, my health blog)

Health Noir: $10 Million Ransom Demand for Data - and Stranger Crimes Are Coming

(originally written for The Huffington Post)

“Attention, Virginia!” the ransom note begins. “I have your shit! In *my* possession, right now, are 8,257,378 patient records and a total of 35,548,087 prescriptions. Also, I made an encrypted backup and deleted the original. Unfortunately for Virginia, their backups seem to have gone missing, too. Uhoh “

“For $10 million, I will gladly send along the password. You have 7 days to decide.”

Someone says they’ve stolen 8.3 million patient records, and now the FBI is on the case. However strange this crime may sound, it was a predictable event. Stranger and more severe crimes are coming, if they’re not here already. I’ve been tracking health data breaches for a while, and it’s one of six scenarios I sketched out (but chose not to publish). It’s important now to ensure that these concerns are given a high enough priority – and proper funding – in future health IT initiatives.

Whatever your position on health reform, nobody wants health data to be the topic of the next private eye novel or film noir. Philip Marlowe wouldn’t be happy working at HHS.

Since they’re now playing out in public, I’ll briefly mention those other five scenarios. They are:

1. Individuals are blackmailed using information obtained from stolen medical records.
2. “Medical identity theft” – using stolen information to fraudulently obtain medical care
3. Stolen information is used to submit fraudulent bills to Medicare, Medicaid, and insurance
4. Electronic funds transfers are intercepted using stolen data
5. Medical data is used to obtain controlled substances and sell pharmaceuticals online

There are no doubt other ideas out there, and inventive minds will find them. Authorities say the Virginia hackers breached the system’s security, but it’s less clear whether they can do what they’ve threatened. Either way, the language in their ransom threat seems to fit the hacker profile of young American kids with time on their hands. We don’t know whether that’s real or a ruse, but it raises a couple of disturbing questions:

- What happens when organized crime gets into the stolen health data business?
- Who says they haven’t already?

Crime syndicates could become brokerages for acquiring and selling health information, which can be traded online.

It would be a mistake to use the threat of these crimes to oppose health IT initiatives, however. These crimes will continue, no matter what, because the exchange of data is embedded in every aspect of our insurance-based health system. Doing nothing will not protect us. It makes more sense to use this historical moment to take bold preventive steps.

If stolen health data fits the pattern of other cybercrimes, publicly reported breaches don’t reflect the full scope of the problem. So what should the Administration and private industry do next?

1. Acknowledge the problem. Don’t lose control of the debate by letting health reform opponents raise the topic first.
2. Provide funding for security software and solutions.
3. Clarify the security levels and procedures expected of all health IT users. (You’d be surprised how many of these breaches occurred because someone left a laptop in an airport or a computer disk on their front seat.)

What should private industry do? Those industries that will benefit from reform and IT initiatives could establish a reward – something like the “X Prize” – for innovative security solutions in healthcare.

Organized crime – or even disorganized crime – has no place in the world of healthcare.

ObamaHealth: The Prognosis at 100 Days

We can find out which medical treatments work best with "clinical effectiveness research" (CER). Newt and Hillary both love it - but some people are against it just because the President supports it. They say these measurements would be too "arbitrary." Well, speaking of arbitrary measurements ...

It's Day 100. That's early to draw any conclusions, but people will anyway (bringing to mind Henny Youngman's opening line, delivered as he walked out on stage: "How do you like me so far?") A fairer measurement might be: How have these 100 days measured up against expectations? Giving a single grade would be too arbitrary, so we'll give several instead, like doctors do when they check your vital signs:

Building Public Support

So, has the President been effective at articulating the need for health care reform? Has he been building a broad base of support for the idea that we need to change the system? What, are you kidding? This is Obama we're talking about. When we talk about communications we're in his house - and it shows in the polling numbers.

You'd think that the economic crisis might lead people to conclude "we can't afford health reform right now." While that's a familiar refrain in Congress, the public's singing another tune. An April poll by the Kaiser Foundation shows that "59% of U.S. residents believe health care reform is now more important than ever," while only 37% say that "reform would be too costly to attempt during the current economic climate."

That's a home run for the President.

How did he achieve these numbers? First, by adopting a position forcefully supported by Peter Orszag (according to Ryan Lizza's New Yorker profile): that health reform, if done correctly, is deficit reduction. The New Yorker piece describes Orszag's "obsession" with "the findings of a research team at Dartmouth showing that some regions of the country spend far more money on health care than others but that patients in those high-spending areas don't have better outcomes than those in regions that spend less money." That would be the Dartmouth Atlas of Health Care, designed by Dr. John Wennberg. It's a critical tool for understanding how healthcare works in this country.

Orszag's fascination with this kind of research has pushed ideas like CER and results-based doctor reimbursement to the forefront, and Obama's been able to communicate the notion that reform can be cost-effective, despite scare-mongering on the topic from his opponents. That's a big win.

Grade: A+.

Staffing

It wasn't supposed to be this way. By now Health Czar Tom Daschle was supposed to have used his DC experience, his insight into the healthcare system, and the power vested in him by the President to launch health reform in a broad and dramatic way. But the Daschle nomination was derailed and the HHS spot stayed open. Things should start to pick up with today's news that Kathleen Sebelius' nomination is moving forward.

Progress in filling top health positions has been slow, as the Washington Post points out. This was inevitable, given the delay in filling the top slot, and it should change now. And while there was some grumbling in the press about empty seats during a potential epidemic, there's nothing to suggest that the interim players haven't been covering things just fine.

Power is always decentralized in Washington, and even more so when the President is a consensus-builder by nature and by choice. In the absence of a 'czar,' influence has coalesced around players like Peter Orszag and Sen. Max Baucus. Orszag has been exploring some of the more interesting corners of health policy research, while Baucus has defined core principles for the Democratic leadership.

Then there's Ezekiel Emanuel, the physician who's also a martial arts black belt (thus capable of controlling both supply and demand for his services). Dr. Emanuel (yes, he's Rahm's brother) is on Orzsag's staff. He's a contrarian and innovator by nature. He'll probably serve as an idea generator and internal gadfly.

The President also appointed David Blumenthal, M.D., as his Health IT Coordinator. Dr. Blumenthal's a health policy expert, not a techie, so he'll probably focus on building an information base for policy objectives. With them all, Obama seems to be building a healthcare team that's strong on imagination and execution.

Grade: B (but expected to rise soon).

Policy Development

We're not much closer to a health policy blueprint than we were on Inauguration Day. Is that a flaw? Not necessarily. Health analysts used to speak of the three qualities of medical care delivery as structure, process, and outcome. Most people focus on structure and outcome, but the President is very much a "process" leader.

We're still in the "process" stage. It began when the President indicated that he'd like to have a consensus bill that includes significant Republican support. While he hasn't withdrawn that statement, he has indicated that he's willing to pass a health bill through the reconciliation process if necessary. That suggests he has basic policy goals he won't compromise, and that he'll override the GOP if necessary to enact them.

What are they? He's not giving specifics yet. He's sketched out broad objectives - rewarding cost-effective medicine, health IT, universal access, and choice - but that's about it. He stood apart from candidates Clinton and Edwards last year in his opposition to health mandates, saying they hadn't been proven necessary to achieve universal coverage. He's not saying that now, and he may have signalled a walk back from that position when he indicated that key reform provisions will be designed in Congress. (Max Baucus supports mandates.)

He's also staying flexible on the "public plan option," which would allow people to buy into a Medicare-like program that would compete with private insurers. As we discussed earlier (in The Sentinel Effect and a radio interview with Bill Scher), these two issues are the defining areas in the struggle to define health reform - both practically and politically. A plan that requires people to buy coverage, but only from private insurers, would be a difficult sell.

Is he behind schedule on defining his health policy? That's the wrong question. He's on a different schedule, one that favors process over policy. He's using the first half of 2009 (or so) to build consensus. If that means leaving critical questions unanswered for now, he's prepared to do that.

Grade: If you want to grade him on outcome already, you don't understand the President.
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So where does this leave us? President Obama has not backed down from his commitment to health reform. That means something will be proposed this year, and something will be enacted into law. "Don't talk too soon," said Bob Dylan, "the wheel's still in spin." Turning this process into a meaningful outcome will probably be even harder than the President and his team expect. But it's not impossible - and, as we keep getting reminded, it's needed even more when times are hard.

(crossposted at The Sentinel Effect and chez Arianna)

How to Follow the Health Reform Debate

In what may become a new Opening Day tradition, John McCain threw out the first cranky¹ when debate on Kathleen Sebelius' nomination began this week . That means the topic of health reform is about to heat up even more, and it's getting hard to tell the players without a scorecard.

Here's a handy guide to the action: The debate now centers on two key proposals - the 'public plan option,' and mandates that require individuals and businesses to obtain health coverage. While you'll hear about other issues (including fearmongering about health IT), they represent the real fight. And the ground may be shifting as some Democrats draw what may be the wrong conclusions from reform efforts in Massachusetts.

The public plan option offers people under 65 the ability to bypass private insurance and enroll in a government-run plan, similar to (but separate from) Medicare. "Mandates" come in two forms - one that requires employers to offer health coverage, and one that requires individuals to obtain coverage (either from their employer or privately) or face penalties.

The public plan option would act as a restraint on private insurers and generate innovative cost-cutting measures. But some object because they believe it would become a virtual monopsony (like a monopoly, but where one buyer dominates a market), giving it "unfair advantage" over the private sector. That position may have some inherent logical flaws (e.g. if the free market does a better job why does it need protecting?), but the President has shown a certain amount of sympathy for it.

Mandates help manage costs by ensuring that healthy people, as well as those more likely to need care, join the plan. But forcing individuals to pay costly premiums to profit-making ventures could become an onerous burden and an politically unpopular move.

Health policy experts support mandates for sound economic reasons, but they bring significant practical and political problems -- unless they are combined with a public plan option, as in the proposal put forward by Prof. Jacob Hacker. (I interviewed Hacker about it here.) Combining the two programs should help limit premiums to an affordable level, expecially with government support at higher income levels. That's important.

Revolt 2009! Computers Rise Up, Force Improved Health Care Upon Anxious Population

We see Freder descend into the underground city.   There he watches workers frantically push dial hands back and forth.  A valve shows the great machine building up steam. Finally it explodes.  Freder sees the machine transformed into a giant demon, spewing fire and devouring workers.

"Moloch!" he exclaims as columns of workers march into its gaping, fiery mouth.

- Fritz Lang's "Metropolis," 1927

From Ezra Klein we learn of the continued use of a discredited story: that Obama created the post of "National Coordinator of Health Information Technology," presumably for sinister reasons. Improved health IT is actually one of the few issues where left and right - at least the reasonably informed left and right - agree. The position was actually created by President Bush in 2004. Its Republican-appointed prior occupant and his Republican-appointed boss (HHS Secretary Mike Levitt) both did some good work. Better health information is not a partisan issue - or at least it wasn't until now.

The latest appearance of this folktale - call it "Obama's Health Big Brother" - comes in a Bloomberg News editorial by Amity Shlaes that compares the current Administration to the best-known works of the Wachowski Brothers. "Barack Obama has dropped us all into The Matrix," writes Ms. Shlaes. She continues:

In the Obama Era, it seems, we all pick our way through anxious lives that have something to do with software. Like Keanu Reeves' Neo, we realize hour-to-hour that we are being manipulated by a system that has its own larger plan.

If only we keep a cool head, we tell ourselves, our powers of logic will help us escape the web. But each move we make, even the one that feels independent, takes us deeper into the Matrix ...

President Obama's $634 billion, 10-year health-care plan undoubtedly appeals to would-be Neos out there ... As in "The Matrix," freedom is a mirage ... and there's no escape.

If I tell you that before she's done she compares Peter Orszag to Agent Smith, you'll get the general idea. America reads this and wonders: Do I take the blue pill or the red pill?

(Think I'll take a Tylenol capsule. It's blue and red.)

Ms. Shlaes has more, like this line: "There was discussion during the campaign of tax breaks for employers for providing health care." (Actually, employers already have a tax break for providing health care. But let's not dwell on the details ...)

There's a pattern developing. It's the outline of a new politically-motivated mythmaking that's about finding spooky sounds on the organ, then playing them over and over until (they hope) the audience runs screaming from the theater. Why pick on the "national coordinator for health information technology"? Because that pedal might sound scary if it brings up memories of all those computers-are-taking-over movies from the seventies. Because some partisans believe that we all share a general anxiety about everything digital, that we all "pick our way through anxious lives that have something to do with software.'

Picture Julie Christie, cowering from a giant mainframe like she did in "Demon Seed." Except, instead of impregnating her with a human/machine hybrid, this computer wants to provide information about methodologies for the treatment of orthopedic injuries ...

Frightening, isn't it?

The problem is that, judging from the poll numbers, they're grinding away at the old pipe organ but nobody's listening. All of which gives me an idea ... how about a piece comparing criticism of health reform to 'Phantom of the Opera'? I could wring 1,000 words out of that one, easy. Think I'll pitch it to Bloomberg News.

In the meantime, I look forward to Amity Shlaes' next piece, in which she warns of the enslavement of humanity that's sure to come if people don't stop forwarding that cute video of a dog cleaning your computer screen from the inside.

"Dr. Madoff" and "Dr. Countrywide": Barriers to Health Reform, Threats to Economic Recovery

(cross-posted at Huffington Post)

"Doctors are not the problem," said Michael Moore while publicizing Sicko. But some doctors are part of "the problem." Their behavior is threatening the entire $2 trillion health economy, which in turn threatens to become 20% of our entire GDP. Their actions have affected our health and have altered the way we spend tens of billions - or hundreds of billions - of medical dollars.

When most Americans talk about health reform, they're talking about reforming the way we pay for health care. That's critical, and Michael Moore and others have succeeded in making this a high-visibility issue. But health financing reform can't succeed unless there is also an effort to create health care reform- with our country's physicians leading the way.

Attacking drug companies for their greed has become almost commonplace in the last few years. But the problem created by drug company money runs wider and deeper than just pharmaceutical costs, as staggering as those are. An interlocking web of drug manufacturers, physicians, and universities is altering all of our medical care - and everyone's personal health - by influencing the clinical research that often determines how doctors treat patients.

Dr. Marcia Angell, a former editor of The New England Journal of Medicine, wrote this in a recent must-read piece for the New York Review of Books:

"It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine."