In an article in the Australian Financial Review on Tuesday (August 17), my former colleague Silvana Anthony makes the case for the establishment of an independent Parliamentary Budget Office, modeled on the Congressional Budget Office in the U.S.

She makes the case that a PBO would model alternative budgets, provide economic advice to the Parliament, prepare 10-year pre-budget forecasts and cost policies for all political parties. She writes, “The CBO approach to fiscal and budget reform would strengthen this capacity [to provide independent budget estimates or macro forecasts] and open the door to robust fiscal and economic analysis within the Federal Parliament that is accessible by all parties and all people. It would render the Charter of Budget Honesty legislation unnecessary – and spare voters the mind-numbing accusations about costing inaccuracies and budget black holes.”

It seems Joe Hockey reads the AFR. Today he is quoted in The Australian as saying that the Coalition would establish a new parliamentary budget office “akin to the highly-regarded US Congressional Budget Office”.

Still, we can’t be sure that is really his intent, as he would allocate only $2 million a year in funding. Let’s see where this interesting idea goes after the election.

News Corp. says the money went to the GOP because the company’s political action committee felt Republicans would create a more favorable corporate landscape.

But there is one political outcome in the offing that the Republican Governors Association is particularly well-positioned to influence – redistricting of congressional districts, the line-drawing that can help make or break a congressional majority. Governors play a unique and powerful role in the process out in the states, and the primary driver for governors’ association contributions is the upcoming redistricting battle based on the 2010 census.

The Bloomberg article theorises that the RGA contribution may have been directly motivated by business interests, since News Corp. opposes proposed federal rule changes that could weaken Fox’s position in negotiations with cable companies. There are examples where governors have stepped in on such matters, such as when New York Governor, David Paterson, called for binding arbitration in a dispute over feeds between Cablevision and ABC.

“Looking at the quotes from News Corp, they seem pretty open and comfortable with what they are doing,” said Amy Mitchell, the deputy director of Pew Research Center’s Project for Excellence in Journalism. “I don’t think News Corp is trying to deny or step away from what these actions suggest. I think the most important thing is, we don’t know why they are doing it.”

His 13-year reign as Ways and Means chairman was a time of great power for the committee; at one point Rostenkowski boasted to a group of reporters and editors, “I am the House.” He played a key role in huge policy shifts like the 1983 rescue of the Social Security system, the 1990 budget deal and the 1986 overhaul of the federal tax code – which took two years of debate and negotiation.

He was also part of a remarkable chapter in health care policy-making, or, as it turned out, unmaking. The aptly named Medicare Catastrophic Coverage Act (a bill I worked on as a congressional staffer) was signed into law by President Ronald Reagan in July 1989 after bipartisan support in both the House and the Senate. The measure provided seniors on Medicare with protection against catastrophic medical expenses and coverage of prescription drug costs. The benefits were to be paid for exclusively by the elderly receiving them, with high-income seniors paying an extra premium surtax.

However after it was enacted, false stories circulated that implied every Medicare recipient would pay the full premium surtax. There is an iconic video clip  that shows a group of seniors chasing him down the hill and attacking him in his car. It has served ever since as a warning to lawmakers about the way seemingly good intentions in Washington can go very bad back home

Indeed, faced with a massive revolt that inspired a New Republic magazine cover story on "greedy geezers," Congress repealed the law three months later.

The woman who lay on Rostenkowski’s car with her protest sign decided later – too late - that the catastrophic health care bill was a good idea.

My own recent paper highlights that every dollar a state spends on Medicaid - whether from state or from federal sources - doesn’t just help keep people with Medicaid coverage healthy. It also brings additional economic benefits and new jobs to everyone in that state. The increased spending provided will deliver $17 billion in business activity, 171,000 new jobs and $6 billion in wages and salaries.

Last Thursday the Senate also voted to confirm President Obama’s nomination of Elena Kagan to the Supreme Court. Only five Republicans break ranks to vote for her.

Still, the one bright legislative spot that immediately after the Kagan vote the Senate finally voted – on the voices – to approved the reauthorization of national child nutrition programs that are set to expire in September. The legislation will expand the number of low-income children who are eligible for free or reduced-price school meals, largely by streamlining the paperwork required to receive the meals. And it will expand a program to provide after-school meals to at-risk children.

Food sold in schools will be required to meet new nutrition guidelines, whether sold in the school lunch lines or in vending machines. Schools still may be allowed to sell pizza and other favorites, though they may have to substitute healthier ingredients to qualify.

School vending machines and à la carte lines, however, may be prohibited from selling candy bars and high-sugar sodas that have long provided revenue for extracurricular programs.

To help schools cover the costs of healthier foods, the bill provides for the first non-inflationary increase in the reimbursement rate for federal-sponsored school meals - the amount local districts are repaid by the federal government - since 1973. The increase amounts to an additional 6 cents for every meal.

First Lady Michelle Obama, who has pushed for the bill’s passage as part of her “Let’s Move” agenda for children, applauded the Senate’s action.

“While childhood obesity cannot be solved overnight, with everyone working together, there’s no question that it can be solved — and today’s vote moves us one step closer to reaching that goal,” the first lady said in a statement released by the White House.

However on other issues, Senate Majority Leader Harry Reid has officially given up hope of passing legislation responding to the BP oil disaster and the looming threat of climate change. Everything that is enacted these days must be filibuster proof and so a super majority is needed.

On the House side, Republicans recently defeated a bill that would have provided up to $7.4 billion in aid to those sickened by toxins resulting from the 9/11 attacks. This set off a host of fiery speeches and denunciations from their Democratic colleagues and produced a YouTube moment from Rep. Anthony Weiner (D-N.Y), whose district includes many of those affected by the World Trade Centre disaster.

When George Washington turned 50 in February 1782, Philadelphia, then the capitol, awoke to the sound of bells ringing and artillery firing. Schools were out, servants were given the day off, and the militia paraded through the streets in their uniforms.

The Republicans, always party poopers, gave their supporters and array of electronic birthday cards to send to the President which take taking aim at his policies.

Visitors to the Republican birthday card website, redirected from the RNC official website, have a choice of 11 different electronic greetings cards featuring various administration officials and top Democrats, including Vice President Joe Biden, Treasury Secretary Timothy Geithner, Speaker of the House Nancy Pelosi, Senate Majority leader Harry Reid and even Florida Gov. Charlie Crist, who left the Republican party in May in order to avoid losing the Republican Senate primary to former Florida House Speaker Marco Rubio. “Just for you, I will officially become a Democrat until its (sic) no longer politically convenient. Now give me a hug,” the Crist card reads.

Despite Medicare’s success, there is still plenty of Republican opposition, and over the years, Republicans proposed numerous schemes to slash funding or privatise Medicare. Republican lawmakers are still regurgitating the claim that Medicare would create a “Soviet style model” of health care. In 1995, under the leadership of then House Speaker Newt Gingrich (R-GA), Republicans proposed major cuts in Medicare to ensure that Medicare was “going to whither on the vine” Gingrich explained.

But while Republicans have sought to undermine the program, seniors have benefited from it. Prior to Medicare, about one-half of America’s seniors did not have hospital insurance, More than one in four elderly were estimated to go without medical care due to cost concerns, and one in three seniors were living in poverty. Today nearly all seniors have access to affordable health care and only about 14 percent of seniors live below the poverty line.

In a speech last year Congressman Dingell said, “Medicare is built on a promise: If you work hard and pay your taxes, you will have an insurance program for your medical care that will free you from the threat of poverty in your retirement years. This promise must be kept, and we must guarantee that Medicare is able to adapt to the changing health needs of our seniors.”

But Arizona officials said they have been overrun by illegal immigrants who fueled a spike in the state's crime rate and put a strain on state resources. They said the measure was necessary only because of lax federal government enforcement of the southern US border.

During the hearing, Judge Bolton commented that the Arizona law was ambiguous and awkward in its wording and that she was doubtful it could be duly enforced.

A ruling is expected imminently, and much is at stake. If the law is struck down, it will help diminish state efforts to pass immigration laws. If it isn't, Judge Bolton's decision will unleash more copycat legislation. Twenty-one other states want to follow Arizona's footsteps.

Thousands are expected to march tomorrow in protest. The protest movement has come alive in Arizona, where one third of the 6.6 million population is foreign born and an estimated 460,000 are illegal immigrants. Demonstrators are set to descend on the Arizona state capital without their papers and will dare law enforcement in Phoenix, Arizona, to put the new law to the test. Arizona Sheriff Joe Arpaiohas prepared a tent city to house undocumented immigrants as local law enforcement gears up to enforce the law.

The eyes of the entire nation are fixed on this southwestern state, as the issue of immigration has grown in national scope both due to the recent economic downturn and the upcoming November legislative elections.

While most Americans support Arizona's immigration law, they also think its looming implementation increase discrimination against Hispanics while not necessarily making a dent in the immigration problem. Recent opinion polls found more than 60 percent of the US population supporting the Arizona immigration law, and 65 percent of people in Arizona favour the law.

Sixty-nine percent of voters in Arizona want President Obama to send more U.S. troops to their state in an effort to help secure the border. Only six percent believe there are already too many troops in the state. Forty percent believe that the immigration law has had a positive impact on the state’s image while 46 percent believe it’s had a negative impact. Forty-three percent believe the law is good for the state’s economy while 37 percent say it’s bad for the economy.

On Tuesday, a Gallup poll found that 45 percent of Americans believe immigration should decrease in the country, against 17 percent who said it should increase, and 34 percent that it should stay at current levels. This represents a narrowing of Americans' views on the subject since last year, when 50 percent wanted immigration to decrease and 14 percent favored an increase.

Arizona Governor Jan Brewer was struggling earlier this year but now holds a commanding lead in the campaign to keep her job. A new Rasmussen Reports statewide telephone survey now finds Brewer leading Democrat Terry Goddard by a 56% to 37% margin. However, Governor Brewer's star may not shine forever. Arizona public schools are experiencing a drop in enrollments which could account for a drop in millions of dollars of federal funding. Arizona's Office of Tourism is reporting a $12 million loss in canceled hotels and reservations. In the end, embracing the law also carries the risk of permanently alienating the critical Latino vote.

These hot days often culminate in ferocious summer thunderstorms, with lightning and torrential downpours. Such a storm last Sunday killed two people and has left thousands in the Washington area without electricity for days. People in affected Maryland suburbs, with no air conditioning and food rotting in freezers, have decamped to hotels. The lucky ones have a beach house in Delaware.

After the big snow falls earlier this year, it’s enough to make anyone (except a Republican member of Congress) believe in climate change.

Years with hottest June months since 1872.

"I think there's a good reason for a conservative to vote yes, and that's provided in the Constitution itself," Graham told his peers. He then read to them from Alexander Hamilton’s Federalist Papers; "The Senate should have a special and strong reason for the denial of confirmation," he read, such as "to prevent the appointment of unfit characters from family connection, from personal attachment and from a view to popularity."

Graham said Kagan had passed all the tests envisioned by the framers of the Constitution. Then he challenged his colleagues: "Are we taking the language of the Constitution that stood the test of time and basically putting a political standard in the place of a constitutional standard? That's for each senator to ask and answer themselves. Seventy-three of the 126 Supreme Court nominations were done without roll-call votes. The words haven't changed in the last 200 years, but certainly the voting patterns have."

He reminded his colleagues that President Obama had won the Presidential election, and he said that "the Constitution in my view puts a requirement on me as a senator to not replace my judgment for his.”

At least Senator in the room, Democrat Senator Richard Durbin, was given cause to rethink his own approach to judicial nominations. “I reflected on some of the things that I have said and how I have voted in the past, and thought that perhaps his statement suggested a better course,” he said.

It will be interesting to see how long it will be before the conservatives come after Lindsey, whose term expires in 2014. Earlier this year he was effectively nobbled by GOP Senate Leaders when he tried to work on a climate change bill with Democrats.

Meanwhile two other Senate Republicans also chose to cast their votes with the Democrats. The Senate voted on Tuesday to proceed to a final vote on an extension of unemployment benefits that had been stuck in the chamber for six weeks, and previously voted down three times by the Republicans.  The 60-33 vote came after Sen. Carte Goodwin was sworn in to replace the late Sen. Robert Byrd, and after GOP Senators Olympia Snow and Susan Collins gave the Democrats the 60 votes they needed to move to a final vote.

The legislation will provide retroactive benefits to more than 2.5 million people whose unemployment insurance expired. The House is expected to approve the measure later this week, but the timing of a vote will depend on when the Senate takes final action. It would then be sent to President Obama, who blasted Senate Republicans on Monday for holding up the legislation.

Republicans’ support for this legislation was contingent on it being fully funded, and on making permanent all the tax cuts enacted under President Bush, including cuts for the richest Americans (Obama has proposed extending the Bush tax cuts for all but the two percent of Americans with incomes of more than $250,000 a year). The jobs support bill would add $33 billion to the deficit; tax cuts for the richest Americans would add $678 billion.

• There are some 1,271 government organizations and 1,931 private companies working on programs related to counter-terrorism, homeland security and intelligence in the US.

• In Washington DC and the surrounding area, 33 building complexes for top-secret intelligence work have been built or are under construction since September 2001. Together they occupy about 17 million square feet of space.

• There is an enormous amount of waste and redundancy. For example there are 39 government organizations doing intelligence analysis, and 51 bodies, located in 25 government organizations, that are following the flow of money too and from terrorist networks.

• Some 50,000 intelligence reports are published each year – many of which are routinely ignored.

You can read these reports and more at topsecretamerica.com

• Allowing young adults to stay on their parents' coverage until they turn 26. In 2011, an estimated 650,000 young people who would otherwise have been uninsured will gain coverage. Another 600,000 will benefit by switching from individually purchased policies to less costly, more comprehensive employer plans. The number with coverage will grow in 2012 and 2013.

• A health plan for uninsured people with pre-existing health conditions. From 200,000 to 400,000 could benefit in 2011, according to the Congressional Budget Office. Beginning in 2014, insurers will be required to accept all applicants, regardless of medical history.

• Ending lifetime limits on coverage, and restricting annual limits. As many as 20,400 people a year hit lifetime limits. Many more — an estimated 102 million — are in plans that impose such limits and will no longer be able to do so.

• Requiring insurers to cover children with medical problems. An estimated 51,000 uninsured children are expected to gain coverage. Another 90,000 children who have been excluded for coverage for a particular condition - asthma, for example - will also benefit.

• Filling in the ‘donut hole’ – the gap in coverage for prescription drugs – for Medicare beneficiaries.

A new user-friendly website has been unveiled to help explain the provisions in the new law and how they will affect every American.

This website also provides access to the Hospital Compare tool which analyses and compares data about the quality of care at more than 4,700 hospitals across the country. This includes data on 44 quality measures such as how well hospitals handle conditions like heart attacks and diabetes, information about the quality of care patients with suspected heart attacks receive, and data about infection rates following outpatient surgeries.

The full impact of the health-care legislation will not be felt until 2014, when some of the most far-reaching (and controversial) elements take effect. Those include an end to discrimination by insurers based on preexisting conditions and a requirement that everyone carry health insurance.

As the various provisions come into effect, and as President Obama travels the country to highlight them, polls show that health care reform is gaining in popularity and support, despite continuing and concerted attacks from Republicans and the Tea Party Movement. A new Kaiser Family Foundation poll has support for the overhaul at 48 percent - up seven percentage points over the past month. Forty-one percent of people have unfavorable views, down from 44 percent in May.

Democrats and Republicans are now vying for advantage in the November mid-term elections and they have been fighting to shape how the public perceives the historic legislation. Roughly a third of voters say that a candidate who voted for the health reform law will be more likely to get their vote, a third say less likely, and a third say it doesn't really matter. These days the most pressing issues for voters are the economy and jobs.

But health threats from the oil spill may linger unseen, perhaps for more than a generation. And we will not be fully prepared to address the public health problems that arise in the future unless there is an effective and coordinated handover of responsibilities for protecting public health from the emergency response agencies to agencies with the capability and capacity for long-term monitoring and management. Federal agencies have been pulled in as needed in the gulf spill response, but it’s not clear that the Health and Human Services response has been synchronized from the top to ensure effective delivery and coordination.

In short, the spill reiterates why we need to better manage the short- and longterm responses required to address the public health threats such disasters pose whether they are manmade or due to natural causes.

No systematic long-term monitoring and oversight was put in place with the Exxon Valdez spill in 1989, and now we wonder what we missed. Several studies following the Prestige oil spill off the coast of Spain in 2002 indicate that some respiratory problems in cleanup workers didn’t show up until years after the spill. Additionally, evidence suggests DNA damage occurred to these workers that could lead to cancers and alterations in hormone status.

The responsibility for both the immediate and long-term responses can only be led by the administration from the highest levels. This is not an appropriate role for corporations, which cannot be trusted to put the long-term interests and needs of the affected communities ahead of their business concerns. The BP oil spill is a clear example of why we cannot allow the very corporation that caused the problem in the first place to be trusted with monitoring its potential health effects. The protection of public health has always been a key responsibility of the federal government, and we have previously called for the federal government to takeover this responsibility with respect to the gulf oil spill.

The gulf oil crisis reminds us that it is essential to have a response plan that is activated early and can continue into the future for as long as needed.

This is not the first time the nation has faced such a crisis, and it won’t be the last. We have faced public health threats from the World Trade Center attack on 9/11, Hurricane Katrina, and the Exxon Valdez oil spill, and from infectious agents such as SARS, Avian flu, and H1N1 flu that fortunately did not reach crisis proportions but could have. The responses, while effective, have not been always been well coordinated. The Government Accountability Office in 2008 identified important lessons from the WTC response that could help develop responder health programs in the event of a future disaster, but the GAO recommendations have not been fully addressed.

The gulf oil crisis reminds us that it is essential to have a response plan that is activated early and can continue into the future for as long as needed. We need to establish an architecture complete with clear lines of responsibilities and acknowledged trigger points for action. It should facilitate the involvement of the appropriate federal health agencies in addressing a potential public health emergency— from watchful waiting to emergency response to long-term monitoring and management.

We do not need a new entity to put this system in place. Government has the expertise among the many HHS agencies to handle any given public health emergency, but different players may be called on at different times depending on the event. This transfer of responsibilities will occur mostly between HHS agencies, but it may also involve nonhealth agencies as well. Obviously this is now the case with the gulf oil crisis, but it could occur with other incidents as well. With a large-scale infectious agent attack, for example, medication may need to be delivered to the homes of many affected Americans, and it has been suggested that the U.S. Postal Service could fill this role since they know how to get parcels to nearly every U.S. home.

We propose that a single, high-ranking HHS official be designated to launch and oversee the coordinated response plan implemented whenever a situation arises that can threaten public health. We recommend this leadership role go to the assistant secretary for health, or ASH. The ASH should have responsibility for determining when and how the response to a public health threat moves into the initial emergency phase and when it transitions to a long-term monitoring and management phase. The ASH would have responsibility for ensuring—in conjunction with other federal, state, and local agencies, academics, and the private sector—that needed services are delivered and information is collected, and that data, information, and resources are transferred to the responsible HHS agency or agencies.

This approach does not require new agencies or significant new authorities. But it will require the following:

• Clarification of roles and responsibilities of all agencies and offices involved
• Robust surveillance systems with standardized data that can analyze information collected from a variety of sources
• Sufficient financial resources and the appropriate workforce to develop capacity and maintain long-term monitoring systems
• Mechanisms in place to address ongoing medical needs for individuals affected by the crisis
• A financial infrastructure to assure funding is available for immediate and longer-term health needs

This paper looks at the issues that must be addressed in the immediate (emergency) response situation to facilitate the eventual handover to a long-term monitoring and management system, what that system should incorporate, how to trigger the emergency response and the long-term monitoring phase, and how the different agencies should work together in a seamless fashion. But first, it examines how our current system lacks an overall plan to maximize the contribution of all available agencies and organize the strongest possible public health response.

You can also watch an "Ask the Experts" video on these issues here.

In a remarkable and touching coincidence, both John Adams and Thomas Jefferson, two founding fathers of the United States and the only two men who signed the Declaration of Independence to become President, died on the same day: July 4, 1826, the 50th anniversary of the nation they helped found.

Just in time for this year’s Fourth of July, the Library of Congress has this news: hyperspectral imaging of Thomas Jefferson’s rough draft of the Declaration of Independence has confirmed that he originally wrote the phrase “our fellow subjects,” but then scrawled over it the word “citizens.” The change occurs in that portion of the document that discusses the colonists’ grievances against King George III. This specific sentence was not in the final declaration but the word “citizens” was used elsewhere and reflected a progression of thinking by Jefferson as he tried to make clear that the people of the fledgling United States were no longer subjects of the British but citizens of their own democracy.

As Senator Harry Reid said in his eulogy on Byrd: “A dozen men called the Oval Office his own while Senator Byrd called the Capitol building his office – and he would be the first to remind you that those two branches are equal in the eyes of the Constitution.” http://reid.senate.gov/newsroom/pr_100628_remarksonsenbyrd.cfm

In fact Senator Byrd actually also got quite close to the presidency - as the President pro tempore he was third in the line of presidential succession, following the Vice President and the Speaker of the House.

"In 2003, Ms. Kagan wrote a tribute to Justice Marshall in which she said that, 'in his view, it was the role of the courts in interpreting the Constitution to protect the people who went unprotected by every other organ of government,' " Senator Jon Kyl  (Arizona) complained.

 As the Republicans delivered their anti-Marshall attacks, their staffers circulated details of the late justice's offenses to reporters: "Justice Marshall endorsed 'judicial activism,' supported abortion rights, and believed the death penalty was unconstitutional."

Only Senator Lindsey Graham ( South Carolina) broke the mould and was more thoughtful, saying that there were things about Kagan’s record both as Solicitor General and dean of Harvard Law School that he liked, such as her efforts to hire conservative law professors.  Senator Graham also echoed statements he made in supporting Sonia Sotomayor’s confirmation:  that the mere fact that Kagan appears liberal should not be a disqualifying factor.  “Elections have consequences,” he said, indicating that the president has a right to choose high court candidates in line with his views.  And “At end of day, if you think more like Justice Marshall than Justice Rehnquist, so be it,” he said.

Why did Republicans adopt this curious strategy, to go after an iconic civil rights lawyer who successfully argued Brown vs. Board of Education, a landmark case that that declared state laws establishing separate public schools for black and white students and denying black children equal educational opportunities unconstitutional?

As Dana Milbank points out:  

Did Republicans think it would help their cause to criticize the first African American on the Supreme Court, a revered figure who has been celebrated with an airport, a postage stamp and a Broadway show? The guy is a saint -- literally. Marshall this spring was added to the Episcopal Church's list of "Holy Women and Holy Men," which the Episcopal Diocese of New York says "is akin to being granted sainthood."

With Kagan's confirmation hearings expected to last most of the week, Republicans may still have time to make cases against Nelson Mandela, Mother Teresa and Gandhi.

I’m no expert on the law, but here’s what Justice Marshall himself had to say about the role of the judiciary:

 "Our central function is to act as neutral arbiters of disputes that arise under the law. To this end, we bind ourselves through our own code of ethics to avoid even the appearance of impropriety or partiality. We must handle the cases that come before us without regard for what result might meet with public approval. We must decide each case in accordance with the law. We must not reach for a result that we, in our arrogance, believe will further some goal not related to the concrete case before us. And we must treat the litigants in every case in an evenhanded manner. It would be as wrong to favor the prosecution in every criminal case as it would be to favor the plaintiff in every tort suit."

 With the mid-term elections looming, it seems that these confirmation hearings will be less about Elena Kagan and more about the dueling rhetoric of Democrats and Republicans over the size and scope of government and the proper role of judges in American society

Justice Marshall’s son summed it up when he said about the GOP diatribe against his father, "I was a little surprised. [My father] would've probably had the same reaction I did: It's time to talk about Elena."

Eventually the Democratic leadership will probably try again to attract GOP support for the measure, which Obama has called critical to avoiding the layoffs of hundreds of thousands of state workers and propping up the nation's still-fragile economic recovery. But after four months of talks, frustrated senior Democrats are likely to delay further action until after the July 4 recess.

Emergency jobless benefits, which provide up to 99 weeks of income support, expired June 2. Since then, more than 1.2 million people have had their checks cut off, according to estimates by the Labor Department. That number is expected to rise to more than 2 million people by the time Congress returns from its weeklong break. Unless Congress acts, the program would phase out entirely by the end of October, at a time when the unemployment rate is 9.7%.

In the real world, this means millions of jobless Americans will lose their already-modest benefits, and hundreds of thousands of state employees will be laid off over the next year, including teachers, police officers, and firefighters.

All of this will happen because it seems that Republicans are more concerned about the deficit - a deficit they created under Bush/Cheney - than the economy. The bill has become a political football.

The bill as presented yesterday would have increased budget deficits by $33 billion over the next decade - the cost of extending jobless benefits through the end of November. Obama's request for $24 billion in state aid was scaled back to $16 billion and its cost would have been covered by unspent funds from last year's economic stimulus package, much of it targeted at the food stamps program.

Other provisions would have been fully paid for, including plans to extend an array of expiring tax breaks that are hugely popular with many of the nation's largest business groups. Among the revenue-raising provisions in the measure are new taxes on investment fund managers and multinational corporations that move jobs overseas.

By ceasing work on the package, Democrats said they hope to prod business groups as well as Republican governors who need additional federal aid to balance their budgets.

However despite this impasse, elsewhere there has been legislative action to finally tackle the financial excesses and lack of oversight that contributed to the near collapse fot he U.S. financial system almost two years ago. Early this morning (Friday), after 20 hours of negotiations, a House-Senate conference committee reached agreement to reconcile competing versions of legislation that would transform financial regulation.

The patient bill of rights includes the phasing out of lifetime dollar limits on coverage, a particular problem for people dealing with cancer and other chronic illnesses. More than 100 million people are enrolled in plans that currently impose such limits. Starting this year, plans can set annual limits no lower than $750,000, rising to $2 million in 2012, and such limits will be completely prohibited in 2014.

Insurance companies are now prohibited from canceling the policies of people who get sick, and health plans will be required to provide consumers with simple and clear information about their choices and rights. Other safeguards to be put in place this year include allowing women to pick an ob-gyn specialist as their primary care doctor and forbidding insurers from denying coverage to children on account of a previous medical problem. Protection against such insurance denials will extend to adults in 2014, when most Americans would be required to have health insurance.

The announcement followed a private meeting between administration officials, several state insurance commissioners, and CEOs of major insurance companies, amid concerns over continued premium hikes. Consumers who buy their policies directly faced increases averaging 20 percent this year, according to a survey released Monday by the Kaiser Family Foundation. Although most Americans are covered on the job, about 14 million purchase insurance on the individual market and have the least bargaining power when it comes to costs.

The GOP marked the passage of 90 days since health care reform was signed into law with a glossy brochure full of the same tired old claims  - but no new ideas.  These days the Republicans can't even agree whether they are for 'repeal and replace' or just 'repeal'.

Meanwhile a Gallup poll released yesterday shows that health care reform is slowly gaining the support of the American people. Today 49% of Americans say passage of health care legislation was a good thing while 46% say it was a bad thing. In April 45% said it was good versus 49% who said it was bad.

Public reviews fall starkly on partisan lines. About three-quarters, 76%, of Democrats said passage was a good thing, compared with 17% of Republicans who said the same. Independent voters continue to lean against the overhaul, 51%-43%, largely unchanged from April.

U.S. ratings in Western Europe are overwhelmingly favourable (73% in France, up from 39% in 2007; 65% in the U.K., up from 51% in 2007) and have improved sharply in Russia (57%, up 16 points since 2007 and 13 points since 2009).  U.S. ratings have also risen in China (58%, up from 34% in 2007), Indonesia (66%, up from 29% in 2007); and South Korea (79%, up from 58% in 2007). They remain relatively constant but high in India (66%) and Japan (66%).

In countries with predominantly Muslim populations, the modest levels of confidence and approval observed in 2009 have slipped. U.S. favourability ratings have remained relatively constant but low in Pakistan. Ratings are very low in Turkey (17%) but that’s an improvement on 2007 (9%). Ratings in Egypt slipped to 17%, down from 21% in 2007 and 27% in 2009.

A special follow-up poll taken in Mexico after Arizona enacted a law which provided police with increased powers aimed at dealing with illegal immigrants saw the U.S. favourability rating tumble from 62% to 44%.

Reactions to U.S. policies

Despite signs of economic recovery in many parts of the world, the Pew Survey found that global publics – including Americans – but with the notable exceptions of China, India and Brazil, are depressed about the way things are. In 17 of 22 countries surveyed, less than half the population (240% in the U.S., 20% in the U.K., 13% in France, 33% in Russia) thinks that the national economy is in good shape. However 91% of Chinese, 57% of Indians, and 62% of Brazilians think that their economy is in good shape.

In fact a growing number of people around the globe (31% of those polled) see China’s economy as the most powerful in the world. The percentage naming the U.S. as the leading international economy has dropped from 50% in 2009 to 43%.

In contrast to the Bush years, there is substantial support for U.S. anti-terrorism efforts in a number of countries, including Britain, France, Spain, Germany, and India, and also in two countries that have been struggling with home-grown terrorism, Indonesia and Russia. Opposition to these policies is particularly strong in most Muslim countries and also, perhaps surprisingly, in Japan and South Korea.

There is more support for Obama’s anti-terrorism efforts than there is for keeping troops in Afghanistan. With regard to the way Obama is dealing with key trouble spots Afghanistan, Iraq and Iran, polling found that as many countries disapprove as approve. Even in NATO allies in Afghanistan, opinions are divided.

While overall 60% of the global populations polled have a favourable view of the U.S. (up 20 points form 2007) and 64% of people have confidence in President Obama (compared to 21% who had confidence in President Bush), the U.S. is still seen as unilateralst (only 32% thing that the U.S. considers their interests). However 14 of 22 countries think that the U.S. will ‘do the right thing in world affairs’. The list of those who don’t think the U.S. will do the right thing includes Russia, Turkey, Egypt, Pakistan and Mexico. In the Bush years only three countries (India, Nigeria and Kenya) believed that the U.S. will do the right thing – not even the U.S. was on this list.

On Monday the GOP killed a House bill that would increase funding for scientific research and math and science education by forcing Democrats to vote in favor of federal employees viewing pornography.

Rep. Ralph Hall (R-TX), the ranking member of the House science committee, introduced a motion to recommit, a last-ditch effort to change a bill by sending it back to the committee with mandatory instructions. In this case, Republicans included a provision that would bar the federal government from paying the salaries of employees who've been disciplined for viewing pornography at work.

To proceed with the bill and bring it to a final vote, Democrats would have had to vote against the motion to recommit, and against the porn ban. But they didn't have the stomach for it, and 121 Democrats voted with Republicans to kill the bill.

The bill had passed the committee last month with bipartisan support, in a vote of 29 to 8. At no point during the 48 hearings held on this bill were Minority concerns with isolated incidents of federal employees viewing pornography brought up, and no amendment was offered during any of the three Subcommittee markups, the Full Committee Markup, or the Floor Consideration.

2. Attempting to roll back Obamacare at the expense of small business tax relief.

 A Republican effort to repeal the individual mandate in the Democrats’ health care overhaul failed yesterday afternoon on a largely partisan vote. The procedural motion never really had a shot at passing, but that wasn't the Republicans' point. The vote was 187-230, with 21 Democrats voting to roll back the individual mandate and one Republican (the brave Rep Cao from New Orleans, who knows that the people he represents need these reforms). The votes were essentially the same as the final vote on the health care law.

Rep. Dave Camp of Michigan, the top Republican on the Ways and Means Committee, called for the repeal under a motion to recommit.

It was rather shocking that the bill Camp is using for this manoeuver was a small business tax bill, but clearly the main point for the Republicans was that they wanted to get Democrats on the record once again saying they back a law that requires uninsured Americans to purchase health insurance.

There will be many more efforts like this. “This is a first step in Republicans’ efforts to repeal ObamaCare and replace it with common sense, step-by-step reforms to lower costs,” House Minority Leader John Boehner said.

The individual mandate was the foundation of the Democrats’ push for the health care overhaul, bringing more consumers into the marketplace, but it remains one of the most unpopular parts of the health reform law. Republicans have been unified in their opposition to the individual mandate, repeatedly claiming that the government does not have the authority to force Americans to buy health insurance. Some Republicans have said the mandate is unconstitutional.

However this idea was at the heart of Romneycare in Massachusetts and the GOP counter to Hillarycare in 1993, and it has worked. Analysts have predicted that the impact of the Republican move would be to raise premiums in the health insurance exchanges by nearly 40% and severely undermine employer sponsored health care.

The oil industry and its backers are trying every means to cover up the harsh evidence of oil's destruction. Alabama fire officials report that that BP is keeping trained local officials away from the spill response, and numerous press reports indicate that BP is blocking the media from reporting on the Gulf oil disaster. There is also evidence that BP is withholding water and air monitoring data and hindering public health monitoring.

BP has also consistently denied the existence of subsurface plumes of dispersed oil.

Last week my colleague Ellen-Marie Whelan and I released a paper calling for the federal government to have full responsibility, leadership, and oversight in monitoring and managing the disaster’s public health consequences. Our conclusion: “We cannot afford to leave something as important as Americans’ health to a corporation that has such a bad history of ignoring health and safety requirements, hiding information, and dissembling the extent of ongoing problems. This is already a disaster of unprecedented proportions; the government must act now to ensure that public health is protected so that the disaster does not linger through longstanding ill health effects long after the oil spill is cleaned up.”

This paper was cited in a hearing held on June 10 by the Energy and Environment Subcommittee of the House Energy and Commerce Committee.

This week the industry will be called to answer for its crimes. Rep. Ed Markey (D-MA) will hold a hearing with the CEOs of the top five oil companies on America’s energy future on June 15. The Obama administration has ordered top BP officials to come to the White House on June 16 to discuss how "to ensure that all individuals and communities impacted by the spill are made whole.” President Obama is off to the Gulf States today, and tomorrow night will deliver an address to the nation that is expected to lay out what is expected of BP, with timelines and possibly a requirement that cleanup funds are put in an escrow account.

And in the meantime, if it all seems too bleak, watch this and laugh – or cry!

But Berwick needs Senate confirmation before he can take over as administrator of CMS, and so it is no surprise that his nomination has been targeted by the Republicans and the right . He has become a GOP target because he dared to praise Britain's National Health Service (the conservatives' vision of health care hell) and the National Institute for Clinical Effectiveness (NICE). Indeed, he has been honored by the Queen for his work with NICE. However what Berwick’s critics consistently fail to note is that his praise for the NHS principles of universal coverage and a science-based approach to improving care are offset by criticisms about the NHS being under-staffed and under-performing. And he's not been an advocate of imposing such a system in the U.S.

But why let facts stand in the way of partisan politics and attempts to interfere with the implementation of Obama’s health care reforms? Here’s what Sen. John Barrasso (R-WY) said on National Public Radio this morning:   "Do I really want Dr. Berwick? Do I want somebody who is in love with the National Health Service of Britain - someone who says they have incredible respect for the way it works and thinks it's the right way to go? Why would an American citizen want that person to be in charge of Medicare and Medicaid for this country?"

But this is misdirection at its best. Berwick couldn’t ration health care, even if he wanted to. Lawmakers control Medicare's budget as well as most other aspects of the program. If there's going to be rationing, that will be their call, not Berwick's.

What Berwick can do, and what he's exceptionally well qualified to do, is help Medicare and Medicaid deliver more care for the money that's being spent on them. The new law is replete with efforts to eliminate waste, improve coordination among healthcare providers and align providers' financial incentives with patients' interests. Berwick is not only a top advocate for efficiency in health care, he's a world-class expert in ways to improve quality and safety. He's also known for a patients-first approach that emphasizes giving individuals more information and control - the kind of transparency that's needed for consumers to effectively manage their own healthcare spending.

There’s a particularly insightful recent interview with Berwick here.  In this interview he was asked about comparative effectiveness research and how critics have argued that it will lead to the rationing of health care. In response he said this: “The decision is not whether or not we will ration care - the decision is whether we will ration with our eyes open. And right now, we are doing it blindly.” He could have added that right now most of it is being done by health insurance companies with a focus on their bottom line.

By holding up Berwick's appointment and accusing him of having a hidden rationing agenda, the Republicans are trying to accomplish two goals: to scare voters about health care reform and to deprive the agency of its chief strategist at a time when he is most needed. 

Key findings from the Kaiser Family Foundation’s May Health Tracking Poll show that people are still confused about health care reform and what it will mean for them.

* Confusion over the new health reform law declined but remains widespread, with 44% of the public saying they were confused in May, compared to 55% in April. Moreover, more than a third of Americans (35%) say they do not understand what the impact of the law will be on themselves and their families.

* Americans continue to report getting information about health reform from a wide variety of sources, including the news media, friends and medical professionals. More than half report they got information from friends and family (68%), or from cable (63%) or broadcast news programs (55%).

* In fact, cable news still tops the list of the public’s “most important” sources of news about the new law, with 30% saying they rely on that source more than any other. Among this group, views of the health reform law differ dramatically between those who mostly watch FOX News (41% of whom are self-identified Republicans) and those who mostly watch CNN (45% of whom are self-identified Democrats). The FOX News viewers overwhelmingly oppose the law (78% feel unfavorable toward it versus 15% who are favorable), while the CNN viewers tend to support it (52% favorable, 40% unfavorable).

* Americans remain divided on health reform, with 41% holding favorable views of the law, 44 percent holding unfavorable views and 14% undecided or unsure. Most Democrats still approve of it and most Republicans still oppose it. The share with “very unfavorable” views is still around three in 10 people overall and seven in 10 among Republicans.

* Those with favorable views of health reform tend to cite the law’s potential for increasing Americans’ access to health insurance and health care (47%) and making both more affordable (12%) as the main reasons for their support. Those with unfavorable views had a wider range of reasons for their opposition, but topping the list were concerns about the cost of reform to the country and to individuals (27%) and opposition to the government’s perceived role in the changes (17%).

The Obama Administration is moving quickly to implement the new health care law so that people begin to see the benefits before the November mid-term elections.

Last Thursday the Obama Administration announced it is about to mail out the first rebate checks to help seniors on Medicare pay for their prescription drugs. The federal government will start on June 10 to send out the first $250 rebate checks to Medicare beneficiaries caught by the so-called “doughnut hole.” The term refers to a gap in coverage of prescription drugs for Medicare recipients. About 8 million seniors a year reach the “doughnut hole” threshold where they have to pay the full amount for their medications.

The new healthcare law closes that gap over time so that seniors only have to pay a fraction of the full cost of their drugs. A little more than 4 million Americans are expected to get rebate checks this year.

The announcement marks the latest example of ongoing efforts to persuade the public, and particularly seniors, of the new healthcare law’s benefits. Seniors disproportionately dislike the new law, and they’re also the group that’s most likely to vote in this year’s midterm elections.

For Democrats, the test here was whether they could hold on to a blue-collar district where they have a 2-to-1 registration advantage but that voted for Republican John McCain in 2008. The GOP used the race to gauge the effectiveness of portraying Obama's health care overhaul as a disaster and his energy-climate change bill as a jobs destroyer. The parties poured more than $1 million each into the campaign, most of it negative. The race was considered so close and so important that Democrats called on former President Bill Clinton to campaign for Critz, while Republicans turned to U.S. Sen. Scott Brown of Massachusetts to boost Burns.

This was the Democrats’ third consecutive victory in a highly competitive House special election since President Obama took office, with two other wins in upstate New York. And as 1994, 2006 and 2008 show, success in special election contests is a harbinger of success in the fall.

Now of course it’s true that the Democrats did not win the special election in Hawaii on Saturday. But what happened was that Charles Djou, a Republican, took most of urban Honolulu's 1st Congressional District because state Senate President Colleen Hanabusa and former Congressman Ed Case split the Democratic vote. Djou had 39.4 percent of the vote, followed by 30.8 percent for state Senate President Colleen Hanabusa and 27.6 percent for former congressman Ed Case. However with the combined vote for the Democrats considerably larger than that for Djou, he will have a difficult task to retain this seat in November.

Meanwhile, Republicans must figure out whether the “Randslide” in Kentucky is a plus or a minus for them. The GOP primary saw Rand Paul, son of former Presidential candidate Ron Paul, humiliate Trey Grayson, the protégé of the senior Kentucky Senator and Senate Leader Mitch McConnell in what was described by one commentator as a “pure, unalloyed victory for the Tea Party”.

Paul says he is anti-government and means it – he wants to end all agricultural subsidies in a state that relies on them, and shut down the Department of Education and the Federal Reserve Bank. But he does want to keep Medicare – presumably because as an ophthalmologist, it contributes substantially to his income.

Since winning the primary Paul has caused a ruckus by criticizing the Civil Rights Act and the federal role in desegregating private businesses. His comments have generated considerable discomfort for GOP leaders and highlighted the challenge for the national GOP of absorbing the Tea Party’s insurgent, anti-establishment candidates.

There are growing concerns among Republicans about the party’s get-out-the-vote operation and whether it can translate the Tea Party grass-roots enthusiasm into turnout on Election Day.

Republicans have been unified around opposition to the President’s agenda, trying to stop nearly every proposal. But that has allowed Democrats to brand their rivals as obstructionists who are unwilling to compromise. While Republicans have used health care reform as their case study that under Obama government has become too expansive and expensive, they are in a race against time on this score as previously cynical or skeptical voters are already getting to see some of the benefits of health care reform. The biggest threat the Democrats face is that the economic recovery remains tepid, with unemployment still high.

Representative Pete Sessions of Texas, chairman of the National Republican Congressional Committee, has said that anything short of taking back the House in November would be a failure.

As EJ Dionne has pointed out: of the 56 seats the Democrats picked up from Republicans in either 2006 or 2008, 23 of them were carried by McCain; in six more, Obama was held to 51 percent or less. These are at the heart of Republican hopes and the reason why it will be hard for Republicans not to gain in the House this fall. If Democrats can hang on to some of these McCain districts, they will not only keep control of the House but may be able to hold Republican gains to 25 seats or fewer.

After the enormous buildup of Republican expectations, such a result would be a shock – indeed, by their definition, a failure.

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More concerning is the ill effects that may come from the way that BP cleans up these oil disasters using dispersants. These chemicals, sprayed directly on the oil slick to break it up into much smaller particles, do not remove the oil, but make it less visible and the smaller droplets sink to the ocean floor.

BP has reportedly bought up more than a third of the world's supply of these dispersants. The issue is that we do not actually know what chemicals are in many of these dispersants, or what their long-term effects will be since their exact makeup is kept secret under competitive trade laws.

The House Energy and Commerce Committee has begun the process of overhauling the Toxic Substances and Control Act, an important step in protecting public health by setting government standards for safe chemical exposure in workplaces and the environment based on the most up-to-date science. This will require appropriate enforcement authorities and resources. But this important regulatory reform will come too late for those involved in the Gulf oil cleanup and those who live nearby.

As the President's Cancer Panel recently noted, exposure to chemicals in the air, food, and water pose a serious risk to Americans' health. The panel found that federal chemical laws are weak, funding for research and enforcement is inadequate, and regulatory responsibilities are split among too many agencies. The experts called for a new national strategy to focus on these threats.

Many agencies are ramping up monitoring particular effects of this disaster -including the Environmental Protection Agency and the Centers for Disease Control and Prevention - but none are ultimately responsible for the overall coordination of what could be a public health emergency. In the aftermath of the World Trade Center attack it became obvious that haphazard responses were not enough to adequately address health problems for the first responders and workers.

The good news is that there has recently been a major increase in federal investment in public health infrastructure and workforce. The recently enacted health care reform legislation provides additional tools to begin to ramp up the nation's public health infrastructure and workforce.

But there is much more that needs to be done to protect public health at times of natural and man-made disasters. The principal aim at this time must be for the federal government to act quickly and put monitoring and response systems in place in the threatened Gulf communities. These can be models of a system that could routinely be implemented at such times, regardless of where in the U.S. it occurs.

We can hope that these systems are not needed and that the cleanup work can be done quickly and safely with no adverse after effects. But as we learn more about this disaster, this does not seem to be the case, and action now must occur to ensure that there is no public health version of shutting the stable door after the horse has bolted.

The Task Force also addresses the multi-billion business of food marketing to children . The reports notes that the use of licensed characters to market foods to children is particularly effective and pervasive.. The Sesame Workshop has found that when preschoolers were asked if they would rather eat broccoli or a Hershey's chocolate bar, 78% of the children chose the chocolate bar and only 22% chose broccoli. But when an Elmo sticker was placed on the broccoli, 50% of the children chose broccoli. The report commends the industry for taking steps to reduce advertising of poor quality foods to children, but warns that voluntary industry efforts "had not substantially shifted advertising for children towards healthier products" and argues that "the FCC could consider revisiting and modernizing on commercial time during children's programming."

Those who might be tempted to respond with protestations about the nanny state should simply bear in mind that obesity imposes heavy costs on all Americans. Obesity is estimated to cause 112,000 deaths every year in the U.S., and one third of all children born in the year 2000 are expected to develop diabetes during their lifetime. Each year, obese adults incur an estimated $1,429 more in medical expenses than their normal-weight peers, and overall, the nation spent around $147 billion on obesity-related health costs in 2008.

Some of the recommendations are as down-to-earth as encouraging schools to swap out deep fryers for salad bars, limits on fees for participation in school sports and an increase in the number of playgrounds in low-income neighborhoods.

Simultaneously with the release of the White House Task Force report, the Center for American Progress released a report from me and two of my colleagues looking at the provisions within the new health care reform legislation that have the potential to address childhood obesity.

Some provisions in the Act specifically tackle obesity. These include

• Improved nutrition labeling in fast food restaurants, which will list calories and provide information on other nutrients;

• The Childhood Obesity Demonstration Project, which gives grants to communitybased obesity intervention programs; and

• Community Transformation Grants, which gives grants to community-based efforts to prevent chronic diseases.

Other parts of the new law take a broader approach and have the potential to address obesity because they are focused on prevention and because in their implementation they could make childhood obesity and its risk factors a focus for kids, their parents, and their caregivers. These provisions fall into the following general categories:

• Prevention and public health programs that invest in broader, population-level obesity intervention efforts;

• Primary care and coordination efforts that emphasize prevention, a team-based approach and paying for improved health;

• Community-based care that target communities that are disproportionately obese and overweight;

• Maternal and child health that promote breastfeeding and early-childhood nutrition;

• Provisions focusing on adult obesity that will likely impact the behaviour of children; and

• Better research and data collection to ensurethat what is being done to fight obesity is working.

This new store is certainly very American: there’s a climate-controlled wine cellar stocking 2,500 bottles, an open-flame hearth oven baking artisan breads, a personalized birthday and wedding-cake service, a sit-down sushi bar, a gourmet cheese department, a gelato stand, a carousel grinding fresh nuts, the freezer cases have fog-treated doors, and there are flat-screen televisions so you don’t miss the game while shopping.

In these situations, confronted with an aisle of breakfast cereals – all of them containing too much sugar – or a selection of orange juices with and without pulp, with calcium, ginko or extra vitamins, I’m rendered totally useless and unable to choose. That’s usually my excuse for not doing the food shopping.

I’m intrigued to see if the new Safeway can generate a bit of competition for price and quality with Whole Foods, just up the road. Over the past year most Social Safeway customers have been lured to Whole Foods – will they return? I laughed when I read that a Safeway company executive was quoted as saying "It won't be a problem to get them back. You can't buy Coca-Cola at Whole Foods.”

By the way, Washington DC Safeway supermarkets all have nicknames – there’s the Soviet Safeway, the Seniors Safeway, the Sandinista Safeway and the Secret Safeway.

Soooo inside the Beltway.

But despite this he has been the subject of harsh criticism from Tea Party activists, particularly for his vote for then-President Bush’s bank bailout in 2008, and more recently for working with Democrat Senator Ron Wyden on a health care bill that would have required individuals to purchase health insurance.

It wasn’t just the Tea Party who targeted him. In addition, the Club for Growth , which supports candidates espousing conservative economic policies, spent nearly $200,000 to defeat Bennett. And FreedomWorks, which has ties to the loosely organized tea party groups, dispatched staff to the state.

"The political atmosphere obviously has been toxic and it's very clear that some of the votes that I have cast have added to the toxic environment," said an emotional Bennett after his loss. "Looking back on them, with one or two very minor exceptions, I wouldn't have cast any of them any differently even if I had known at the time they were going to cost me my career."

Bennett finished third in the second round of balloting behind attorney Mike Lee and and businessman Tim Bridgewater. Lee and Bridgewater are now headed to a June 22 runoff to determine the GOP nominee, who will be a shoo-in to win the seat in November.

The dumping of Senator Bennett will give some other Republican Senators heartburn, including Utah’s other Senator, Orrin Hatch , whose term expires in 2012. The Tea Party could have a field day with Hatch’s much-vaunted collaboration over many years with Senator Kennedy on a range of health and education issues.

Hatch has appealed to the Tea Party movement to work with the GOP or see conservatives lose more ground. "If we fractionalize the Republican Party, we are going to see more liberals elected," Hatch warned a town meeting in Utah in February, amid jeers from Tea Party supporters.

• The need to “create a lawful way for foreign workers to come here and support our economy” (2008 State of the Union address).

• “Extending hope and opportunity in our country requires an immigration system worthy of America--with laws that are fair.” (2008 State of the Union address).

• “We cannot fully secure the border unless we take pressure off the border--and that requires a temporary worker program.” (2007 State of the Union address).

But earlier this year, the murder of a prominent Arizona border rancher put a spotlight on the violent smuggling syndicates operating along the border and poured petrol on the political firestorm raging in the state between John McCain and his Republican primary challenger, former Congressman J.D. Hayworth, a notorious anti-immigration hardliner who lost his seat in 2006 to Democrat immigration reformer Harry Mitchell. Hayworth, trying to rekindle his political career, is gunning for McCain by fomenting anti-immigrant fervor among their party’s conservative base.

McCain, who once championed comprehensive immigration reform, has abandoned his prior positions and is now trying to dethrone Hayworth as the state’s top immigration hardliner.

These ugly political skirmishes pale in comparison to the work of the Republican-controlled Arizona legislature, which has just passed draconian, anti-immigration legislation. It would, in effect, criminalize the undocumented population in Arizona and institutionalize racial or ethnic profiling on a stunning scale.

McCain has come out in favour of the legislation - which is likely unconstitutional. Even former Bush adviser Karl Rove said, "I wish they hadn’t passed it.” 

Republican members of Congress have largely remained silent - with a handful even offering support. Only two national Republican lawmakers - Rep. Lincoln Diaz-Balart (R-FL) and Sen. Lindsey Graham (R-SC) - have come out against the bill, while at least ten have either praised it, or remained noncommittal.

In addition to the civil rights toll, the new law could have a major economic impact on Arizona. There are calls for general boycotts of all Arizona goods and services and tourism. The Perryman Group estimates that if all unauthorized immigrants were removed from Arizona, the state would lose $26.4 billion in economic activity, , $11.7 billion in gross state product, and approximately 140,324 jobs.

But perhaps the worse thing Arizona has done is not to pick on people who look different / problematic but to discriminate against people who talk differently, to the extent of taking their jobs away.

There has been little focus on the fact that the Arizona Department of Education, having in the 1990s hired hundreds of teachers whose first language was Spanish as part of a broad bilingual education program (many of these teachers were recruited from Latin America; the bilingual program was abolished in 2000), has decided that teachers whose spoken English is heavily accented must be removed form classes for students who are still learning English.

Critics charge that the current political climate in Arizona has emboldened state education officials to target immigrant teachers at a time when the budget crisis has forced layoffs.

About 150,000 of Arizona’s 1.2 million public school students are classified as English Language Learners; this includes about 46% of children in kindergarten through grade 2. And in some Hispanic neighbourhood schools, nearly half the teachers are native Spanish speakers.

Some of my favourite parts if the U.S. (Sidona, the Grand Canyon) are in Arizona, but as an outraged, progressive alien (albeit legal) with an accent, I don’t intend to visit that state any time soon.

In an interesting sidebar to this latter issue – trying to turn an environmental and economic disaster into a political football - it turns out that workers from Halliburton, Dick Cheney’s old firm, had just finished cementing the well  when the rig blew. Halliburton was also responsible for cementing a well off the coast of Australia that blew last August, leaking oil for ten weeks before it was plugged. Though the Australian investigation continues, an official from the U.S. Minerals Management Service testified that a poor cement job probably caused the explosion.

Meantime I’ve spent this week in New York City (not too close to Times Square) at the 2010 meeting of the International Medical Workforce Collaborative, where representatives from the US, UK, Canada and Australia meet annually to address workforce issues. It’s surprising how these disparate health care systems have in common. The real surprise, given how eager many are to bag the NHS, is how well the UK is doing in terms of implementing national health reforms that are targeted where needed and meet measurable goals and outputs.

In contrast, Australia does virtually nothing about measuring the effectiveness and outcomes of health care dollars spent; all we can say is how many services are delivered, although sometimes we know to whom and by whom. The focus needs to move beyond quantity to quality and from volume to value.

And it’s not just about setting goals and targets and collecting data about progress towards tackling these – it’s about using this data to drive effective policies and programs.

Early next year the U.S. will get the official report on how the nation collectively fared in reaching the goals of Healthy People 2010, an every-decade governmental assessment of various health indicators. If preliminary results hold, the nation will scrape by with a low C.

Writing in the New England Journal of Medicine, Howard Koh, Assistant Secretary for Health, says that the nation has “progressed” toward 52% of the measurable goals and has met 19% of them. That’s about the same level of progress as from previous decades.

While there’s good news in heart disease, with the age-adjusted death rate from coronary heart disease surpassing its target, falling to 135 deaths for every 100,000 people from 203 per 100,000 in 1999, progress has lagged in other areas with implications for healthy lives and health care costs. The target for smoking, for example, was 12% prevalence; in 2008 it was 21%. And it will surprise no one who reads headlines that the goal of reducing the obesity rate to 15% was missed by a long shot; about a third of U.S. adults now fall into that category, defined as a BMI of 30 or more. Due in part to that increase in obesity, the age-adjusted prevalence of diabetes rose to 59 cases for every 1,000 people in 2008 from 40 cases per 1,000 in 1997 (the 2010 target was 25 cases per 1,000).

Things really need to improve.

Crist once looked like such a sure thing that he was endorsed by Senate Minority Leader Mitch McConnell, but he has now become a conservative scourge. They see his career as pockmarked with instances of consensus-seeking, deal-making and bipartisanship - three particularly vulgar notions to the Tea Party movement. Conservatives have tagged Crist as being part of that pariah breed of Republican today: a “moderate.” Or worse. There have been rumours about his sexuality, but to many Republicans, the governor’s biggest sin was literal embrace of President Barack Obama back in February and his support for the Obama Administration’s federal stimulus package.

"I was horrified," Rubio said. "This was more than just a courtesy greeting, this was an embrace and a support of $800 billion of deficit spending."

Cheney, in a statement  issued by the Rubio campaign, said Crist has shown "time and again that he cannot be trusted in Washington to take on the Obama agenda because on issue after issue he actually supports that agenda." "Lately it seems Charlie Crist cannot be trusted even to remain a Republican. I strongly urge him to either stay in the Republican primary or drop out of the race.”

Crist says he has no regrets about appearing with Obama. "I was happy and delighted to do so. I'm a civil guy. The president of the United States is the president of the United States," Crist said. "Especially when it's the first visit to Florida and I'm invited to be there. I have that kind of respect in my soul."

Things are much quieter in the Democratic primary race – or they were. Meek is has been a member of the U.S. House of Representatives since 2003, representing Florida’s 17th Congressional district (North Miami). He was elected to succeed his mother, who also held this seat. A former football star, Meeks made history  by becoming the first U.S. Senate candidate in Florida’s history to qualify for the ballot by petition. Most candidates take the easy option and write a check for $10,000.

Meek appears to have little to worry about from underfunded Democratic rivals, former Miami Mayor Maurice Ferre and former North Miami Mayor Kevin Burns. And indeed, it’s unlikely he will have anything to worry about as a result of Greene’s entrance into the race.

While it’s true that Green has the type of private wealth that could make him a headache for the Democrats, the baggage Greene brings to the race is so profound as to eclipse the "outsider" message on which he is running. It's reported that he got rich on the housing market's collapse; that he took investment advice from John Paulson, the hedge fund manager at the current center of the controversy surrounding Goldman Sachs; and that he once lived with the notorious madam Heidi Fleiss.

The latest Rasmussen Reports poll of Florida voters (taken before these recent announcements) finds that 37% would vote for Marco Rubio, 30% for Charlie Crist and 22% for Kendrick Meek. In a two-way race both Rubio and Crist currently hold solid leads over Meek. Rubio now leads among Republicans and unaffiliated voters with Crist in second. Among Democrats, Meek earns 46% support, while Crist picks up 33% of the Democratic vote.

However the prospect of a three-way race for a U.S. Senate seat in Florida has raised Democratic hopes of winning a nationally watched election that just a few months ago seemed beyond their reach. The Cook Political Report has changed their rating for the race from “likely Republican” to “toss-up”.

Fingers crossed!

Case in point: Senator John McCain, who was once an avid advocate for health care reform and immigration reform, voted against the Patient Protection and Affordable Care Act that contained many of the provisions he once embraced, and can somehow support Arizona’s dreadful new law on illegal aliens. And even then he’s likely to lose his Senate primary race – along with his political respectability and his maverick status.

And then there’s Senator Lindsey Graham. Having worked diligently with Democrat John Kerry and Independent Joseph Lieberman to produce a climate and energy bill that reconciled the needs of the business and environment communities, he pulled the plug last weekend, two days ahead of the formal release of their proposal. Why? Because Senate Leader Harry Reid has said that immigration reform (something that Senator Graham supports) should be a priority. That doesn’t mean that it will be – after all, there’s no legislation, no committee working on this – but it’s definitely on the to-do list.

Anyway, Senator Graham has taken his bat (and ball) and withdrawn from being a player. Personally, I think he was nobbled. These days the Republican leadership makes life pretty difficult for anyone who tries to be bipartisan – or even people who are just trying to be friendly. Ask Florida Governor Charlie Crist, who is paying the price for giving the President a hug.

Now Senate Republicans are apparently united in their opposition to legislation to tighten regulation of the financial system. Mostly this is just an effort to delay, obstruct and prevent the Democrats from doing anything else. And just possibly, the Republicans really do care more about Wall Street than Main Street. Anyway on Tuesday night they voted against allowing debate on the bill to begin. It was a cloture vote and therefore required 60 votes to pass, and the final vote was 57 – 41. So much for democracy you say! Republican Senator Richard Shelby, who has been working for weeks with the Chairman of the Banking Committee, Senator Chris Dodd, to produce a bipartisan bill, couldn’t bring himself to vote to allow debate on the bill to begin.

Senate Minority Leader Mitch McConnell declared his opposition to the financial reform bill, claiming that it "institutionalises…...taxpayer funded bailouts of Wall Street banks." Nobel Prize-winning economist Paul Krugman said McConnell's claim is "possibly the most dishonest argument ever made in the history of politics." Meanwhile a new Washington Post poll finds that nearly two-thirds of voters support "stricter regulations on the way banks and other financial institutions conduct their business."

Senator McConnell is using the issue to bolster his overarching political argument (the one he makes endlessly, tiresomely): that the Democrats’ one-party rule in Washington is detrimental. I find this fascinating for two reasons: (1) you can’t lose an election and expect to govern (even if that’s what happened with George Bush); (2) the U.S. system does allow for the losers to be players (and thus fully represent their electorates) if they want to be players, and assuming they have some policies and positions to put on the table, other than just saying “No”.

What the Republicans have done in fact is turn the Congress into a Westminster system, where there is no ability to do things in a bipartisan fashion and crossing the floor to vote with the other side is a major political sin. It’s not clear whether this has happened because the GOP has lost its way, because it’s bereft of policies, or because there is just some visceral antagonism to President Obama that would have him fail at any cost. The net result is the same – it puts party politics ahead of the needs of America.

No wonder my former colleague and I are saddened by this state of affairs. If we were on the Hill today, we would barely know each other and would definitely not both be claiming victories over the enactment of bills to improve nursing home regulation, to provide needed immunizations to children on Medicaid, and to establish programs for people with HIV/AIDS as we did 20 years ago.

It’s not just the rejected recruits who are in trouble. These days, soldiers can find fast food and subsidized fructose just as easily as civilians can. Even as the Army rejects the obese, those already in uniform are growing fatter. According to a 2009 Pentagon report at least 1 in 20 servicemen and women on active duty are “clinically overweight.”

Obesity is winning the war right up the supply chain to the front line. Now General McChrystal has ordered that by the end of April, U.S. bases in Afghanistan must shut down their Popeye’s, Burger King, and Pizza Hut franchises. The General’s staff justified the policy as a matter of logistics, insisting shipments of fries and milkshakes were filling shipping and storage space needed for reinforcements, ammunition and combat supplies, but military fitness may also benefit.

Military concerns about the fitness of our children are not new. It’s ironic that in 1946, General Lewis Hershey was instrumental in convincing Congress to pass the original National School Lunch Act as a way to improve the nutrition of America’s children and increase their height and weight, because then too many recruits were under-nourished.

However the shocker is that Australia’s military personnel are in even worse shape than their Americans counterparts. Last year it was revealed  that 7500 of 53,000 troops are now classified as obese and one in seven members of the defence force is overweight - more than three times the US ratio. The ADF has admitted obesity has become "an issue'' for personnel and has commissioned its specialist research centre, based at the University of Queensland, to investigate possible causes.

The first Kaiser Health Tracking Poll since the passage of health reform last month finds that while 8 in 10 Americans know that President Obama signed the legislation into law, 55 percent are confused about the law and 56 percent say they don’t yet have enough information to understand how it will affect them personally.

The poll finds 46 percent of people view health care reform favorably, 40 percent unfavorably and 14 percent undecided. Thirty one percent of Americans say they expect personally to be better off because of the law, while 32 percent say they will be worse off and 30 percent say they don’t expect to be affected.

Many reform provisions that take effect in 2010 are popular and have widespread support across the political spectrum, including among Republicans and independents

Nearly 9 in 10 Americans favor providing tax credits to small businesses that want to provide coverage for their workers, for instance. And roughly 8 in 10 have favorable views of provisions that would offer access to basic preventive care with no copayments, provide financial help to seniors who hit the gap in Medicare drug coverage known as the "doughnut hole," and end insurance companies’ practice of dropping coverage (recission) if a person has a major health problem.

In each of these cases, at least two-thirds of Republicans and independents join most Democrats in viewing the provisions favorably.

Clearly people are struggling to understand how the law will affect them and their families and to separate fact from political spin. Although anger grabs the headlines, the only emotion shared by more than half of the public when it comes to the health reform law is confusion. Overall, 55 percent say they are confused, an emotion more deeply rooted among those who feel unfavorably toward reform.

Americans of all political leanings pointed to cable television news more than any other source when they were asked to choose their most important source of news and information about the law. More than a third (36%) cited cable TV news stations and their websites as their most important outlet, followed by network news (16%), newspapers (12%), friends and family (10%) and the radio (9%).

There were some differences along party lines, however. Republicans were more likely to name cable TV as their most important news source, with 45 percent saying so compared to 30 percent of Democrats. On the other hand, Democrats were twice as likely as Republicans and independents to say that they got most of their information from network news (23% of Democrats compared to 12% of the other two groups).

Given the level of misinformation and bias on cable TV news stations, that is a major concern and a major obstacle to be overcome as implementation proceeds.

Overall sentiment about the new law still breaks sharply along partisan lines. Nearly 8 in 10 Democrats (77%) favor the new law, while about as many Republicans (79%) view it unfavorably, a mix very similar to that seen before the bill’s passage in March. Political independents tilt against the law (46 percent opposed compared to 37 percent in favor), while self-described moderates favor the measure 55 percent to 31 percent.

And how do I know President Obama watches Treme? Because his deputy press secretary said so.

Nearly half of people polled say the government negatively affects their daily lives, a sentiment that's grown over the past dozen years. Currently, 43% see the federal government’s personal impact as negative, and only 38% see it as positive. But rising criticism about government’s personal impact is not limited to the federal government. Just 42% say their state government has a positive effect on their daily lives, and 51% now see the impact of their local government as positive.

While a majority of Americans say Washington is too big and too powerful, the public is split over whether the government should be responsible for dealing with critical problems or scaled back to reduce its power, presumably in favor of personal responsibility. About half say they want a smaller government with fewer services, compared with roughly 40% who want a bigger government providing more. Still, despite the distrust in government, more than 3 out of 5 Americans still think Washington should do more to rein in banks and exert control over the economy during the recession. Perhaps this is because the Pew poll shows that the people dislike banks, financial institutions and large corporations about as much as they like the federal government.

These findings fly in the face of claims from conservative critics that Americans continue to oppose governmental activism and prefer reliance on the free market to solve the country’s problems. And it is also supported by the best available evidence about Americans attitudes toward the role of government – the 2008 American National Election Study. In that study a majority of Americans came down on the side of governmental activism – 56% said that government had got bigger because the country’s problems had got bigger, 68% said that the country needs a strong government to handle complex economic problems, and 59% said that there were more things government should be doing.

The roots of government distrust stretch far back into America's past. In the opening line of the first of the Federalist Papers , Alexander Hamilton refers to "an unequivocal experience of the inefficiency of the subsisting federal government." This distrust has been reinvented regularly, as in the public philosophy of President Reagan, and now the Tea Party groups.

However, as Marc Hetherington points out in his book Why Trust Matters: Declining Political Trust and the Demise of American Liberalism there remains constant and widespread support for big government in areas where most Americans benefit. Hetherington writes: “Contemporary political rhetoric fuels this misunderstanding. By railing against ‘big government’ in general, conservative and moderate politicians imply that people want less government across the board. However, public opposition to government is focused entirely on programs that require political majorities to make sacrifices for political minorities, such as antipoverty and race-targeted initiatives. In short, Americans continue to support big government when they benefit from it, but they want limited government when they are asked to make sacrifices.”

Current political rhetoric and inconsistency also seem to go hand-in-hand. A recent Economist / YouGov poll found almost two-thirds (62%) of those responding said that they wanted to cut spending to reduce the budget deficit rather than raise taxes. But just three questions later, the only area of federal spending that a majority (71%) was willing to cut was foreign aid; only 7% would cut social security and Medicare; 11% would cut Medicaid; 13% would cut health research; 12% would cut education. But a surprising 22% would cut defence.

The programs that make up the largest share of the federal budget are typically the ones that the fewest people want to cut. Which suggests that whatever the problems with the political system, it does a decent job allocating public resources into programs that people like. Complaints about "big government" and excessive spending are more often based on who is getting the money - the poor and minorities often inspire the most ire - rather than the fact that spending is happening at all, despite the framing that conservatives would like to impose on the discussion.

And anyway, after reading this New York Times article , it seems to me that the US does not need to raise taxes to tackle the deficit, it should just get people (and corporations) to pay their taxes.

Although unemployment in the U.S. is at levels unknown since the Great Depression, 70% of Tea Party supporters say that their own economic situation is “fairly good” and only 14% have experienced “hardship.” Their rage about the economy is not directed not at Wall Street bankers, but at politicians like Barack Obama who might help the poor..

Their responses to the poll’s questions are like those of the general public in some ways. Most describe the amount they paid in taxes this year as “fair.” Most send their children to public schools. A majority do not think Sarah Palin is qualified to be president. They are surprisingly liberal on social issues; 57% favour gay marriage or civil unions, 65% favour access to abortion and 65% support some gun restrictions.

The Tea Partiers are overwhelmingly concerned with economic rather than social issues. They are far more pessimistic than Americans in general about the economy, but while most Americans blame the Bush administration or Wall Street for the current state of the American economy, the Tea Party supporters blame Congress and a majority remain supportive of George W Bush.

What primarily distinguishes them from other Americans is their animosity towards Washington, and the president in particular. This is rooted in deep pessimism about the direction of the country and the conviction that the policies of the Obama administration are disproportionately directed at helping the poor rather than the middle class or the rich – 92% believe Mr. Obama is moving the country toward socialism.

The overwhelming majority of supporters say Mr. Obama does not share the values most Americans live by and that he does not understand the problems of people like themselves. More than half say the policies of the administration favor the poor, and 25% think that the administration favors blacks over whites, compared with 11% of the general public who hold this opinion.

Asked what they are angry about, Tea Party supporters offered three main concerns: the recent health care overhaul, government spending and a feeling that their opinions are not represented in Washington. More than 90% of Tea Party supporters think the country is headed in the wrong direction and they strongly disapprove of the job Mr. Obama is doing over all, and particularly fault his handling of health care, the economy and the federal budget deficit.

When talking about the Tea Party movement, the largest number of respondents said that the movement’s goal should be reducing the size of government - more than cutting the budget deficit or lowering taxes. But they do not want to see cuts in Medicare or Social Security.

The New York Times quotes a retired woman in Jacksonville as saying this about Obama: “He’s a socialist. And to tell you the truth, I think he’s a Muslim and trying to head us in that direction, I don’t care what he says. He’s been in office over a year and can’t find a church to go to. That doesn’t say much for him.”

The only consolation is that the US has been through this eruption of conservative grass-roots anger before – and survived. For example, the affluent members of the Liberty League vilified President Roosevelt and attacked his New Deal in the 1930s, and the rallies of the National Indignation Convention , the 1960s version of the Tea Parties, which drew thousands of people, proclaimed JFK a communist of the caliber of Castro, and his administration was called “treasonous”.

Today is the 15th anniversary of the Oklahoma City bombing, and President Clinton came to the Center for American Progress to talk about what the lessons of that terrible tragedy are for today. He drew parallels between the antigovernment tone in the 1990s that preceded that devastating attack and the political tumult of today, saying government critics must be mindful that angry words can stir violent actions. Take the time to read or watch his speech and the words of others at this event  – they are important and very relevant in today’s world.

There are presumably several reasons for this.

1. The new Affordable Care Act offers lots of tax breaks to small businesses and individuals. So perhaps some Republicans have figured out that vowing to repeal the Act means they are effectively promising to raise taxes.

2. The Progressive States Network has released an analysis of the progress of state health care legislation which reveals the failure of conservative attempts to obstruct reform at the state level which reveals that legislation intended to nullify recently passed federal reforms has already been defeated or failed to pass in 14 states, with the count expected to rise. Despite the fact that the corporate-funded American Legislative Exchange Council which drafted the bills, has claimed success for their health care nullification legislation in 40 states, the analysis reveals that their bills, which have been called unconstitutional by experts across the ideological spectrum, have only succeeded in four.

3. Last weekend South Florida, in the first federal election since reform passed, voters elected, with a resounding margin of over 20 points, a Democratic state senator, Ted Deutch, to fill the vacancy in the US House of Representatives left by the retirement of Representative Robert Wexler (D). His Republican opponent tried and failed to run on a platform of opposition to health care reform, in a district in which more than one in every four resident are over 65 years old. There was little evidence of a fall-off in the Democratic vote among seniors, who are widely regarded as a critical voting bloc in the 2010 midterms.

Fox News and Republican lawmakers have been pushing a claim that the Internal Revenue Service (IRS) will need to hire more than 16,500 new agents to enforce the universal insurance mandates in the health care reform bill, and that the agency will impose harsh punishments on those who don't purchase insurance it deems worthy. Rep. Michele Bachmann (R-MN) warned Fox News host Sean Hannity that "the IRS will be tasked with breathing down the necks of 300 million Americans every month to determine whether we have purchased governmentally acceptable levels of health insurance."

The Republicans have attributed the 16,500 figure to the nonpartisan Congressional Budget Office, but in fact the figure comes from a report prepared by the Republican staff of the House Ways and Means Committee. IRS Commissioner Doug Shulman has made it clear that these claims are nothing but misconceptions. As for claims of draconian enforcement, including jail time, for those who do not buy insurance, the bill specifically prohibits the IRS from confiscating taxpayer assets, from using liens or levies, or imposing criminal penalties of any kind - including jail time - because of a lack of health care coverage.

New taxes will hurt big business

For months, Republicans and their allies like the U.S. Chamber of Commerce have been claiming that health care reform would create huge new taxes that would hurt businesses. Since the passage of the PPACA, AT&T, Caterpillar, John Deere and others have come out with a series of seemingly coordinated press releases announcing that the new bill will cost them billions of dollars.

The affected companies have already greatly profited from an inequitable provision in the 2003 Medicare prescription drug law. At the time, many employers were already providing drug coverage for their retirees. And to keep them from dropping that coverage, the new law provided doubly sweet subsidies to corporations.

For every $100 the company spends on retiree drug benefits, Medicare sends it a subsidy payment of $28. On top of that, the companies got a rare double tax break. The $28 subsidy is tax-free, and the company was allowed to deduct the entire $128 as a business expense.

The new health care reform law has left the 28 percent subsidy intact and continued to exempt it from taxation. But companies will no longer be allowed to deduct the subsidy as if it were an expenditure of their own; there will be no more double dipping.

Accounting rules require that the present value of the entire additional tax that companies will have to pay over the next several decades be put on the books now. Caterpillar Inc., Deere & Co., AT&T, Verizon Communications Inc. and Prudential Financial Inc. have said they will have to take first-quarter write-offs to reflect future higher costs due to the new tax provision. But this is an accounting change which will have a negligible impact on these companies’ valuation, or market capitalization.

It is really disingenuous for companies to suddenly complain about this provision, considering the change was a part of the draft bill that passed the Senate Finance Committee in September last year. At that time the chairman of Business Roundtable said about the change, "it's very closely aligned to [our] principles."

Wall Street certainly gave a collective yawn at these announcements. Stock prices for the companies that made announcements barely budged and some went up. Moreover, this change now treats all employers equally instead of favoring profit-making firms with a special deduction that is of no value to nonprofit organizations, state and local governments, or firms that lose money.

House Energy and Commerce Committee Chairman, Henry Waxman, has called a hearing for April 21 to examine whether retirees will be affected, and issued letters to Verizon, Deere and Caterpillar. The committee said in a statement that company statements “appear to conflict with independent analyses which show that the new law will expand coverage and bring down costs.” Secretary of Health and Human Services, Kathleen Sebelius said, “They have been actually taking tax deductions on money that the government has given them in the first place. That will cease under this bill.”

Analysis shows that some of the companies protesting this tax change managed to pay less than one-third of the 35 percent statutory federal corporate tax rate in at least one year from 2007 to 2009, despite being profitable in these years. Xerox, Navistar, Verizon, Boeing, Con-Way, and Deere all paid less than a third of the statutory rate on their profits in at least one of those years. Three of these companies - Boeing, Verizon and Xerox - actually got federal tax rebates in at least one profitable year during this period, meaning that their corporate income taxes were less than zero.

The Long War of Repealing Obamacare

The conservative Heritage Foundation has been emailing everyone, including me, with a missive entitled “The Long War of Repealing Obamacare” . It and the linked information that accompanies it are seductive materials that misstate the legislation and misuse the facts. Those who have actually read the legislation and the cost estimates from the Congressional Budget Office and the Joint Committee on Taxation know what the reality is, others are vulnerable to this sort of ideological analysis.

At first blush it also appears to offer some sort of alternative plan for health care reform, but then you get to the giveaway statement: “An effective reform program would begin to address the cost problem by making changes throughout federal health-care law. But the trick [emphasis added] is to do so in a way that allows for gradual change and decentralized decision-making.”

As anyone who has read Paul Ryan’s Road Map for America’s Future reform bill and the CBO analysis  of it knows, that ‘trick’ is to do away with both Medicare ( the very program Republicans argue they are fighting to save) and Medicaid.

What thoughtful conservatives are saying

Anyone who reads this blog knows that I’m no conservative, but I can respect a considered conservative opinion. I found this blog , on Frum Forum, interesting and thought-provoking. To quote selectively: “A radical reaction has erupted in response to the health care bill, and its motto is: “Repeal and Replace.” But this isn’t a principle; it is a talking point bordering along utopianism. True conservatives are not radicals; they respect tradition and work for stable reform to fix institutions.”

On Sunday and Monday Obama has individual meetings with heads of state from India, Kazakhstan, South Africa, Pakistan, Armenia, China, Jordan, Malaysia and Ukraine. before holding a working dinner with the leaders of the 46 delegations. Meanwhile, on the Sunday talk shows, Defense Secretary Robert Gates and Secretary of State Hillary Clinton gave interviews meant to reassert the nation's military strength – a somewhat surprising launch into the two-day nuclear summit, but clearly designed to reassure defense hawks that U.S. security will not be compromised. They indicated that the U.S. would spend $5 billion this year to modernize its existing nuclear weapons, which could be used if the country's security is in danger or in response to the threat of a biological attack.

The other major focus of the major weekend newspapers and the Sunday talk shows was the announcement that Justice John Paul Stevens will retire this summer, providing President Obama with the opportunity to make his second Supreme Court nomination in his first term of office – and providing the Republicans with yet another opportunity to block the President’s agenda. Senator Orrin Hatch has promised a “whale of a fight’  and the fact is that these days the GOP would put up a whale of a fight even if Obama nominated Senator Hatch himself.

Justice Stevens highlights precisely that a President can never really know what the legacy of his Supreme Court nominees will be. He was named to the Court in 1975 by President Gerald Ford, to replace Court’s longest serving justice, William O. Douglas. Although he was a Republican appointee, and for many years he was at the centre of the court, he came to side with the court's liberal bloc in the most contentious cases -- those involving abortion, criminal law, civil rights and church-state relations. He led the dissenters as well in the case of Bush v. Gore that sealed President George W. Bush's election in 2000. "I don't really think I've changed. I think there have been a lot of changes in the Court," said Justice Stevens in 2007.  "I see myself as a conservative, to tell you the truth, a judicial conservative."

The Senate confirmed Stevens in a 98-0 vote on December 17, 1975. We can be certain of one thing – that will not be the vote this time around.

Most Americans spent the weekend ignoring all this, more intent on watching Phil Mickelson win his third Masters title at Augusta, Georgia. This tournament also saw the return of Tiger Woods to the golf circuit – but he was let down by his putting and was never in contention.

And if golf was not your thing, then you could always watch Tina Fey doing her wonderful Sarah Palin imitation on Saturday Night Live . If you had a really strong stomach, you could watch Michele Bachmann and Sarah Palin together delivering their red meat, racist rhetoric, rah-rah rallying cries to adoring fans in Minneapolis . But you really need to be James Morrow to enjoy that!

The weekend also saw the wind-up of the Southern Republican Leadership Conference in New Orleans. They were all there – beleagured RNC Chairman Michael Steele, promising no more money for forays into strip joints, Sara Palin proclaiming that this was the ‘party of no’, Michele Bachmann proclaiming that this was the ‘party of hell no’, and Newt Gingrich proclaiming that this must be the ‘party of yes’.

Perhaps because he wasn’t there, Mitt Romney secured a surprise victory over Sarah Palin in the convention’s straw poll on who should challenge Barack Obama in the 2012 presidential race. Romney won 24% (439 votes), one vote ahead of Ron Paul, with Gingrich and Palin both securing 18% (330 votes).

No wonder I’m more interested in what Congress is doing! Both the House and the Senate are back this week. They have a packed slate of issues, including energy reforms, and Senate Leader Harry Reid has promised to address immigration reform too. A recent CNN/OPC poll shows that of younger Americans, those 18 to 49 years old, just over half say that protecting the environment is most important and 47 percent say the economy is most important. Older and younger Americans apparently don't see eye to eye on the issue; 58 percent of people 50 years of age and older questioned in the poll say that the economy should be the top priority, with 37 percent saying that the environment is more important.

So, to cheer everyone up at the start of the week, here’s a nice looking graph that shows the economy is looking up.

Last summer, conservatives - led by Rep. Michelle Bachmann (R-MN) and Fox News' radical host Glenn Beck – began a fearmongering campaign designed to discourage Americans from filling out their census forms. Now that health care reform has passed, the right is setting its sights once again on the census, ratcheting up fiery rhetoric intended to scare Americans about some imaginary federal government overreach.

Many on the right argue that it is unconstitutional for the census to ask anything beyond the number of people in a household. While this year's questionnaire asks about race, gender, and age, the census has asked similar questions for decades. Beck has said that that he refuses to complete the census form because the government is "out of control” and the "the survey is an attempt to "increase slavery."

 Anti-immigrant groups have also relaunched their anti-census campaign, fearing "theft of representation from lawful Americans." A recent press release from Americans for Legal Immigration stated that: "We want Congress to take action now to authorize and require the use of census data collected to identify illegal aliens, exclude them from the census count for tax resources and Congressional redistricting, and to detain and deport those found in violation of our immigration laws."

However Republicans have belatedly realized that these campaigns to dissuade people from participating in the census could reduce the number of Republican seats in Congress and state legislatures for the next ten years. According to the Census Bureau figures, some of the most conservative states have among the lowest response rates so far,

The 14th amendment requires that elected representatives be apportioned according to an indiscriminate population count of "the whole number of persons in each State." Moreover, the census data is used to allocate federal funding. Thus, non-citizens, children, ex-felons, legal residents, and several other non-voters are included in census apportionment data in order to paint an accurate portrait of a state's demographic makeup and population density that is key to effective and adequate representation.

So an attempt to repair the damage inflicted by his right wing compatriots sees Karl Rove in a public service announcement on YouTube, pointing out that the questions on the Census forms are no more invasive than they were more than two centuries ago. "If you've not yet mailed back your 2010 Census form, please do," Rove says in the PSA. "Please, answer the 10 easy questions. They are almost the same ones Madison helped write for the first Census in 1790."

Love it!

The visit was important to local residents, who often feel they are forgotten by those who are elected to represent them. Forty percent of the residents live in poverty, the unemployment rate is 28.5 percent, and just last week four people were killed and five wounded in a drive-by shooting.

On Easter Monday the President and First Lady hosted the 2010 Easter Egg Roll on the South Lawn of the White House. The origins of this event reportedly date back to Easter Sunday in 1878, when the Congress enforced a ban on egg rolling at the Capitol, and President Rutherford B Hayes, seeing tearful children while riding by the Capitol Grounds in his carriage, invited them to play on the White House lawn.

This year 30,000 families from around the nation won tickets to attend the event, which consumed 14,500 hard-boiled and dyed eggs for the egg roll and the egg hunt, and an additional 4,500 hard-boiled eggs for the egg dying station.

And if this is spring then it must also be the start of the baseball season. On Monday morning the President also found time to throw out the first pitch at the Washington Nationals’ opening day. This marks the 100th anniversary of presidents throwing out Opening Day first pitches - Taft was the first to do so in 1910. Apparently the President has engaged in a little spring training in the Rose Garden to get his curve ball in Opening Day order, according to White House spokesman Robert Gibbs.

Clad in a red Washington Nationals jacket and a black Chicago White Sox cap that he pulled from his pocket to show his allegiance to his hometown team, the left-handed President threw his pitch high and a little outside the batter’s box.

But on Tuesday it’s back to work with a vengeance. Then the Obama administration is set to release its Nuclear Posture Review - a report that Congress requires of every president. Obama has said his plan is designed to "reduce the number and role of nuclear weapons in our national security strategy, even as we maintain a safe, secure and effective nuclear deterrent." On Wednesday, Obama flies back to Prague for the signing of the new Strategic Arms Reduction Treaty with Russia, one of the goals he outlined in his Prague speech a year ago. He will also meet with Russian President Dmitry Medvedev, in part to discuss one of the world’s biggest nuclear challenges: Iran. Next Saturday Medvedev will join 40 foreign leaders attending a nuclear security summit which Obama will host in Washington, DC.

The bill differs from the predicted Senate bill primarily by covering 8 million more people, albeit at a slightly higher cost.

What Pelosi didn't volunteer was that the bill now only funds the provisions for prevention and wellness and public health (originally funded at $89 billion / 10 years) at $34 billion / 5 years.  I assume the plan is to come back in later years to authorize further funds for this important refocusing of health care services.

The bill, which is up on the web, will be available for public scrutiny for 72 hours.  At that point, on Monday morning, the House managers expect to introduce an amended version, incorporating further changes, which will need to be available for a further 72 hours.  So the bill could be on the House floor for a vote as soon as Thursday next week.

Meanwhile the Republicans struggle on.  Yesterday, House Minority Leader John Boehner and House Republican Conference Chairman Mike Pence  held a press conference to explain why progressive health reform would hurt seniors and to highlight the GOP's "better solutions."  Boehner instructed readers to go to the GOP healthcare website "and you can see all of our proposals", but seniors are not addressed in any of the plans presented. In fact, there are no occurrences of the words "senior," "elderly," or "older Americans" at all. An archived version of the website can be found here.

Republicans have been insisting for months that Democrats are shoving a secret bill down the throats of the American public. The health reform legislation "should be posted online for 72 hours so members and the American people get a chance to see what's in these bills," Boehner told Fox News.   At a press conference this morning, a reporter turned the tables on Boehner and asked whether he'd post the GOP plan for 72 hours. Boehner declined to make such a pledge. Presumably the Republicans won't post the GOP plan because there isn't one. As Boehner said later in the press conference: "..... it's pretty difficult for us to have a solid plan".

There are currently just nine weeks left in which to get a health care bill to the President's desk for his signature before Christmas.  It should be a busy time for the Democrats.  I guess the Republicans can recycle their same old speeches and take it easy.

This is my last blog in this format. If you are keen to follow the rest of the story from Washington on health care reform, then you can read my Letters from Washington on the Menzies Centre for Health Policy website.

In most US states' insurance companies can retroactively cancel the entire policy if any condition was missed - even if the medical condition is unrelated, or if the person was not aware of the condition at the time. This practice is called rescission, and is often used to limit insurance payouts for expensive illnesses such as breast cancer.

In 45 states, when a person with a breast cancer tries to buy health insurance through the individual insurance market, insurance companies can charge higher premiums, exclude coverage for any recurrence of breast cancer or even deny coverage altogether. Because of this, breast cancer patients, even when in remission, are unlikely to find meaningful insurance coverage in the individual insurance market. A full 11% of individuals with cancer say they cannot obtain health insurance because of their illness.

The consequence of all this is that cancer patients stress about their disease and they stress about their bills. And there is growing evidence that stress is a key indicator as to whether cancer patients do well.

Many minority and low-income women are disproportionately affected by breast cancer, in large part because they are less likely to have adequate health insurance. While African American women have a lower risk of developing breast cancer than White women, once they develop the disease, they have a higher rate of dying from it. African American women experience five-year survival rates of 78% compared to 90% for White women.

Disparities also exist in treatment. Studies have demonstrated that African American and Hispanic women with early-stage breast cancer who undergo surgical treatment are less likely than White women to consult oncologists and receive recommended follow-up radiation and/or chemotherapies.

Health care reform offers real hope for women with breast cancer, their daughters and grand-daughters. Health care reforms will provide universal insurance cover, ban recission, treatment caps and discrimination on the basis of pre-existing conditions, make  preventive health care such as mammograms free, limit out-of-pocket costs in any year, and tackle quality and inequalities.

Hopefully it will help save some of the 40,170 women (and men) who will die of breast cancer this year from an early, untimely, and sometimes preventable, death.

A new whisper around Washington, now that passage of legislation looks increasingly likely, is that opponents of health care reform are laying the groundwork for lawsuits to stall and eventually kill any Democratic legislative victory. A broad group of conservatives has begun to explore how to file such lawsuits, who would file them, and what components of the legislation would be challenged, if not all of it.

As if to goad these conservatives into action, a new Washington Post - ABC News poll shows that support for a government-run health care plan to compete with private insurers has rebounded from its summer lows and wins clear majority support from the public (57% support; 40% oppose). There is also clear support for a mandate requiring all Americans to have health insurance. 

The poll does show that people are leery about the proposed changes to the health care system (45% support; 48% oppose), and there are some deep splits over whether the proposed changes go too far or not far enough. But since last month there has been a 9 points increase in the number who say that government should be more involved.

Two further polls out today from CNN / Opinion Research Corporation and USA Today Gallup have similar findings.

Some of this is change in support towards health care reform is because there has been a raft of hearings and reports highlighting the problems Americans face with health insurance every day. The Shriver Report, which Erin Riley blogged about earlier this week is just one example.

Sometimes the Republicans only open their mouths to change feet. A recent newspaper article that highlighted that maybe WHO data that ranked the US 37^th with respect to health care was less than accurate, was eagerly seized upon. But it seems no-one read all the article, which went on to state that new UN data shows that the US is seriously lagging in some of the key indicators of public health. For example, from 2000 to 2009 the US slipped from 18^th to 24^th rank in male life expectancy and 28^th to 35^th rank in female life expectancy. Rankings in preventing male and female mortality in children under 5 also slipped to the 30s.

Meanwhile, while the right watches Glenn Beck tear up at the good old days, the left, who watch MSNBC, have been contributing to a fund to support free health clinics around the nation. In all, about 4 million Americans are expected to visit the country's 1,200 free health clinics this year.

However the AHIP report has been seen as a cynical overplay by the very industry whose practices have driven the need for health care reform. It's been a strategic blunder for them, and ironically has increased Democrats' support for a public health insurance option. PricewaterhouseCoopers who did the report for AHIP are backpedalling frantically.

While House and Senate leaders work to get bills ready to take to the floor of each chamber within the next two weeks, recent data and analysis highlight the variations around the nation in who has health cover and the political dilemma faced by the politicians who represent these Americans.

If the states of America are divided into red (states that have two Republican Senators and voted for McCain in the last presidential election), blue (states that have 2 Democratic senators and voted for Obama) and purple (states that split their ballots in the presidential and senate elections), then residents of blue states are far more likely to have health insurance than residents of red states, with residents of purple states in the middle.

These data are based on both private and public cover, including Medicaid, but exclude Medicare which is available to virtually everyone over 65.

Of the 150 congressional districts with the most insurance, only three are in red states - one each in Alabama, Tennessee and Kansas. Another 25 are in purple states. The remaining 122 are in blue states.

However while the uninsured are more likely to be in red states, those with the least access to insurance are in minority blue districts in these states. Of the 10 congressional districts with the least insurance, seven are in Texas (red), two in California (blue) and one in Florida (purple).  However nine of these districts (which are largely black or Hispanic) are represented by Democrats.

Thoughtful Republicans keen on getting re-elected thus face an exquisite dilemma in the upcoming votes on health care reform legislation: will they represent the needs of the people of their electorate or their ideology of their party?

• Medicare spends on average $5,796 each year for the previously uninsured versus $4,773 for the previously insured.
• These differences are largely due to increased inpatient and home health agency spending and are concentrated among the 67% of adults with cardiovascular disease or diabetes.
• Previously uninsured adults have more hospital stays. Those with cardiovascular disease or diabetes are more likely to be hospitalised for complications like a heart attack, heart failure or stroke.
• Among adults with arthritis, those without coverage before enrolling in Medicare were more likely to be hospitalised for joint replacement that those with prior coverage.

This indicates that the cost of providing health coverage to uninsured adults aged 51 to 64, estimated at $197 billion a year, would reduce subsequent Medicare spending on adults aged 65 to 74 by about $98 billion - offsetting almost half the original costs.

These findings highlight the fallacy (and the cost to Medicare) of Republican proposals that would provide only catastrophic cover to people who are currently uninsured.

2. Medicaid expansion will generate revenue for the states

A study from the George Washington University School of Public Health and Health Services finds that the Medicaid expansions proposed in the health care reform bills will generate significant economic returns, between $2 and $6 for every dollar invested. These returns are as a consequence of new business activities, jobs, salaries and wages.  Medicaid represents essential revenue for community health centres, but it is also important to the economic health of medically underserved communities.

Expanding Medicaid is a cost-effective way to expand insurance coverage, but the costs are a significant impost on the budgets of the states, especially given the effects of the present economic downturn on their economies. While states fund a large portion of Medicaid costs (half or less, depending on the federal contribution rate to any particular state matching rate), the majority of funds come from the federal government.

Combined federal and state Medicaid payments for health care are directly translated into revenues to physicians, hospitals, clinics, nursing facilities, community drug stores, and other state and community providers of health care. In turn, these local health care providers pay staff, purchase goods and supply vendors, many of whom also are local. Workers and vendors use this income to pay their mortgages, car loans, grocery bills, state and local income and sales taxes, etc. The resulting cascade of funds raises household spending for consumer goods and eventually leads to increases in state government revenue through income, sales, and property taxes.

The conservative response to the health care crisis: 37 bills, no solutions

This week my analysis of the 37 bills which House Republicans have offered as their 'health care solutions'  is up on the website of the Center for American Progress. You can read it here.

On the House side, Speaker Pelosi has been working round the clock to structure a bill to take to the House floor before the end of the month. Whatever the outcome, based on her meeting schedule no-one can say that their point of view on the bill has not been heard.

But many Republicans are still raising the same stale objections; some are even inventing new reasons to oppose the legislation. For example, Senator Grassley, once a member of the Gang of Six, has developed a new-found opposition to the individual mandate - a policy that even health insurers support. Yet in June, in an appearance on Fox News Sunday, Grassley said, "there isn't anything wrong with it [an individual mandate], except some people look at it as an infringement upon individual freedom. But when it comes to states requiring it for automobile insurance, the principle then ought to lie the same way for health insurance. Because everybody has some health insurance costs, and if you aren't insured, there's no free lunch. Somebody else is paying for it....I believe that there is a bipartisan consensus to have individual mandates."

However there is growing bipartisan support for action on health care reform. Former Bush Administration Secretary of HHS Tommy Thompson has joined with Democratic former House Majority Leader Dick Gephardt to issue a statement in support of reform, saying that "Failure to reach an agreement on health reform this year is not an acceptable option".  Last week former Senate Republican Leader Bill Frist - a surgeon - said he would vote for health care reform. He said that even though he'd probably "take heat" from his party, "that's leadership". That's what California Governor Arnold Schwarzenegger and New York City Mayor Michael Bloomberg also think.

Meanwhile Louisiana Governor Bobby Jindal tried to edge his way into the debate but merely reprised his uncanny talent for clunkers. In a Washington Post opinion piece he added to the chorus of Republicans criticising their party's leadership and pressing them "to join the battle of ideas" on health reform. However he was apparently unaware that eight of the ten ideas he proposed for consideration are already incorporated into the House bill. It's time for Jindal to turn off Fox News and read the legislation - he might be pleasantly surprised.

In Gaithersburg, when it comes to their health care, no-one is happy, everyone has a complaint. Nobody understands the way the current system works, only that it doesn't work very well, even for those people with expensive policies and expendable incomes. A working mother of three young children summed it up this way; "I don't know what everyone is so afraid of, I don't know what amazing coverage these people have that they're so afraid of losing."

These are the people President Obama must count on to give his health care reform effort the grass-roots push it needs to get through Congress. But it's only recently that the White House has realized the need to focus on this group which constitutes about 65% of the population.

With many middle-class families still facing huge financial burdens and uncertain employment prospects, the new selling language for health care reform is around providing more security and stability for those with insurance - and it's working.

One reason why this message appeals is that one out of three Americans under 65 were without health insurance at some point during 2007 and 2008, and 80% of these uninsured people were in working families. They lost cover because they lost their job, or were required to work reduced hours, or just simply could not afford the premiums which now average over $13,000 a year for coverage for a family of four.

Increasingly the polls show that the conservative members (of both parties) of the Senate Finance Committee who are still wrangling over amendments are out of touch with what the public wants. Yesterday saw two amendments to add a public health insurance option to the Senate Finance bill go down, despite the fact that over 60% of the population supports this approach to making health coverage more affordable.

Recent polls show that despite the summer town hall meetings, tea parties and tirades and the accompanying misinformation and hysteria, Obama's approval ratings are where Ronald Reagan's and Bill Clinton's were at this point in their presidencies. The President polls ahead of the Republicans in Congress on all the issues interrogated.

The latest Kaiser Health Tracking Poll, out today, finds that 57% of Americans now believe that tackling health care reform is more important than ever - up from 53% in August. The proportion of Americans who think their families would be better off if health reform passes is up six percentage points (42% versus 36% in August), and the percentage who think that the country would be better off is up eight points (to 53% from 45% in August).

Like me, the public continues to view the action in Washington with mixed feelings. The largest share (68%) said they were "hopeful" about reform, but 50% are "anxious" and 31% are "angry."

As always, these amendments run the gamut from far-reaching and thoughtful to provocative, predictable, and, dare we say it, simply out-of-touch (in most cases so out-of-touch that they will be ruled non-germane to the bill).

It's easy to tell where many of these members get their financial campaign support from on the basis of the amendments they are sponsoring. There are a depressing number of Senators simultaneously offering amendments to limit health insurance cover or help with out-of-pocket costs for low-income families and amendments that protect health insurance companies and pharmaceutical and device manufacturers.  At least 16 Republican amendments are about protecting doctors from medical liability costs.

The Center for Responsive Politics has looked at recent donations to the members of the Senate Finance Committee from health lobbyists. The three Democrats and three Republicans who make up the Gang of Six have each received an average of $74,600 in the first half of this year. This is about 25% more than the average of $59,600 in such donations that the other members of the Committee have received from the pharmaceutical, hospital, insurance and nursing home industries. However most of this is because of the high rate of donations to Senator Grassley, the Republican ranking member ($223,600) and the Chairman, Senator Baucus ($141,000). Senator Snowe received only received $9,000 and Senator Bingaman only $5,000. 

The White House has been really going to bat for health care reform. Yesterday, President Obama appeared on five Sunday morning talk shows fielding questions that predominantly focused on health care.  First Lady Michelle Obama is weighing in on the issue by focusing on how health care can affect families and women. This week the President is busy at the UN and the G20, but Vice President will wade deep into the debate, giving what is being billed as his first major health policy address on Tuesday to the National Association of Insurance Commissioners and visiting a retirement community to tell seniors that reform would not affect them adversely.

Biden will also be reaching out to lawmakers to press the case for health care reform. In addition to fellow Democrats, Biden plans to court Republicans in the hunt for health-care votes. His list of GOP targets will include the two senators from Maine, Olympia Snowe and Susan Collins, as well as Senators George Voinovich (OH) and Richard Lugar (IN).

The Senate Finance Chairman's Mark and the amendments can be read at http://finance.senate.gov/sitepages/legislation.htm

Still, it undoubtedly can be called 'health care reform' and as a starting point towards getting legislation reported out from the Finance Committee and on to the Senate floor, it's definitely workable material.

The Congressional Budget Office also released its preliminary analysis of the Chairman's Mark today, and it absolutely conforms to President Obama's vow that health care reform legislation should not add "one dime to the deficit, now or in the future." The CBO has gone beyond the normal 10-year time frame to look at the impact in 20 year's time and finds the proposal, if enacted, would increase the rate of cost savings and reduce the federal deficit in the second decade.

Doctors strong support for health care reform

A Robert Wood Johnson Foundation study published in this week's New England Journal of Medicine shows that a majority of doctors (63%) support a health reform proposal that includes both a public option and traditional private insurance. If the additional 10% of doctors who support an entirely public health system are included, then approximately three out of four physicians nationwide support inclusion of a public option. A minority (27%) support a private-only option that would provide subsidies for low-income individuals to purchase private insurance.

The majority of doctors surveyed found Medicare better or the same as private insurance in decision making autonomy (60%) and in ease of obtaining needed services (57%).

Meanwhile, health insurance costs continue to rise

The 2009 Employer Health Benefits Survey released today by the Kaiser Family Foundation and the Health Research & Educational Trust showed how unsustainable the status quo is. 

Premiums for employer-sponsored health insurance rose to $13,375 annually for family coverage this year - with employees on average paying $3,515 and employers paying $9,860. Since 1999, premiums have gone up a total of 131%, far more rapidly than workers' wages (up 38%) or inflation (up 28%).

The survey found that 60% of firms offered health benefits to any of their workers this year, but only 46% of the smallest businesses offered health benefits. Among those firms offering benefits, 21% report they reduced the scope of health benefits or increased cost sharing, and 15% report they increased the worker's share of the premium.

Recent work by the Center for American Progress shows that escalating health care costs threaten to erode the income of the more than 160 million people who depend on employer-sponsored coverage. Without real changes to the health care system, annual health care spending for families of four with employer-sponsored coverage will grow from nearly $17,000 today to over $39,000 by 2019, or from 19% of family income to 31%. 

He was smart to include some Republican initiatives such as John McCain's proposal for providing insurance cover for people who have lost it because of pre-existing conditions and the previous administration's idea for demonstration projects to address medical malpractice - and in fact both of these ideas will be implemented immediately, without the need for legislative action.

But when the President highlighted the previous efforts of McCain, Hatch and Grassley in health care, they sat sheepishly, clearly unwilling or unable to take up a leadership role from within a party that is fractured and fearful, that finds it easier to oppose than to propose.

The President also made it clear that the cost of these reforms, $900 billion over 10 years, is fully paid for, and will contain a 'failsafe trigger' to ensure that is the case. Meanwhile, the same party that had no concerns about the impact on the deficit of the $1.8 trillion Bush Administration tax cuts, or the fact that the true (and unfunded) cost of the Bush Medicare prescription drug bill was deliberately hidden, has been circulating analyses from a range of conservative think tanks about the cost of health care reform. 

What last night made excruciatingly clear that there is no possibility that health care reform will be a bipartisan effort. The Republicans have shown themselves to be bankrupt of ideas, comity and respect for a president who won office with a clear mandate to tackle health care reform. 

Their formal response to the speech was short on detail and bereft of savings and repeated the same old saws. But it was the behaviour of the Republicans in the House Chamber during the speech that was so shocking. 

I'm sure they were taken by surprise at being 'called out' by the President - his speech clearly aimed to make their intransigent opposition to reform look counter-productive and dishonest. However he could have saved his words; the Republicans made the case very effectively themselves with behaviour that was unforgiveable and extraordinarily disrespectful. Under normal circumstance, it would have seen several of them ejected from the House Chamber. 

The audio (Rep Joe Wilson shouting 'you lie') and the visual (Rep Eric Cantor checking his Blackberry) doesn't work in Republicans' favour. It does not encourage the public, 82% of whom still want major health reform, to think that Republicans have their health care concerns at heart.

Despite dire predictions, the chances were always good for a health care reform bill arriving on the President's desk before the end of the year. My assessment is that those chances have just improved substantially, thanks to a President who's prepared to lead and a Republican party that is actively working to make itself irrelevant in process.

By 2011, there will be 1.7 million prison inmates in the US, and this will cost taxpayers an additional $27.5 billion over the next five years. The majority of this money will go to the construction of new prisons to hold the ever-increasing number of inmates. Currently the states spend an average of $29,000 a year on every prisoner. The biggest operational cost is inmate health care. Every inmate is guaranteed access to health care when they need it, and last year prison health care services cost $3.3 billion, or almost $4,000 a person.

The prison population is rapidly ageing, and increasingly likely to suffer from chronic illnesses. Largely as a result of health care expenses, the average cost of housing an inmate aged over 60 is $70,000 a year. In 2007, cancer, coronary artery disease and end-stage liver disease primarily due to infectious hepatitis were responsible for almost 70% of inmate deaths.

Prisoners get a full range of health care services, including cancer treatments and dialysis. They are entitled to, and often receive organ transplants. This does not mean that health care services are ideal - far from it - and in relaying these facts there is no intimation on my part that health care should be withheld from prisoners in any way. But it does seem that American priorities around the big budget issues like the penal system and health care are too often back-to-front.

Take this example from California:  a man arrested for stealing a pair of socks worth $2.50 was found to have two previous convictions for abetting robbery (I don't know if a gun was involved), and so, under the "three strikes" law, received life imprisonment. His incarceration will cost the state $49,000 a year, maybe twice that as he gets older.

Opponents of universal health care say the US can't afford it. Granted, prison reform is difficult, won't come close to fully financing health care reform, and garners no votes. Still, to paraphrase Nicholas Kristoff in a recent opinion piece, isn't it better to use scarce resources to educate children and heal the sick rather than to imprison people for the rest of their life because they stole a pair of socks?

Ultra-conservatives claim that health reform violates the Tenth Amendment. Under the 'tenther' constitution, Medicare, Medicaid, Social Security, federal education funding, the Veterans Affairs health system and the G.I. Bill are  all illegal, beyond the power of the federal government to enact.

The opponents of healthcare reform fail to see the irony in their push for the government to stay away from government-funded Medicare and government-operated veterans' health programs, and presumably do not know that life expectancy is longer and infant mortality rates are lower in Canada and Britain, and Cuba too. 

They rail against rationing, treatment waiting times, and government intervention in doctor-patient relationships that will inevitably result if the US moves to a Canadian-style healthcare system or uses comparative effectiveness research to determine best practice in medicine as in the UK. 

Across the border and the Atlantic, Canadians and Britons are starting to hit back, tired of being typecast as countries with failing healthcare systems. Canadians, not unlike Australians, do not see their healthcare system as an unmitigated disaster, even while acknowledging that it is flawed.

A recent poll found that patients in Canada are more frustrated by waiting times to see medical specialists than patients in the US. But 65% of Canadians said they had access to all the healthcare services they needed at costs they could afford, a percentage that did not change with income; 49% of all Americans felt the same way, and that figure dropped to 37% for low-income Americans.  In the US, 59% of those with chronic conditions are satisfied with their access to care. In Canada, it's 69%.

Britons are also sick of ill-informed Americans latching on to a few bad experiences and skewed comments regarding healthcare in the UK. The stories have ranged from the benign to the outright asinine. They include claims that Ted Kennedy's brain cancer would have gone untreated and that Stephen Hawking would have been left to die under the NHS.   

Two British women who became the unwitting stars of a campaign to derail Obama's healthcare reforms have now publicly explained that they were misled about their televised interviews and that their views on the NHS had been misrepresented. They were told they were being interviewed for a documentary and were not aware that the footage was to be used for political advertisements.

In a final irony, it emerges that the woman who starred in the infamous Harry and Louise advertisements that are generally credited with killing off the Clinton health care reform effort was also conned into doing those television spots in 1994. Then she was a single mother whose time in Australia in the 1980s had left her a great fan of 'socialised' medicine. She had campaigned for Clinton and wanted health care reform, but she also needed to pay the bills, and when she initially baulked at her lines, she was literally seduced into continuing by the political consultant involved.

But in 2009 Louise has made a redemptive comeback, back with Harry in a new advertising campaign in support of the Obama plan.

Meanwhile, the conservative media failed to report that last month in California an estimated ten thousand people lined up for days to receive free medical, dental and optical treatment in a scene reminiscent of an aid expedition in the third world. 

Kennedy was instrumental in helping to create the Children's Health Insurance Program, the Americans with Disabilities Act, the Ryan White CARE Act to provide health care for HIV/AIDS patients, and legislation to require health insurers to provide mental health and substance abuse coverage equivalent to that for other health conditions.

During my seven years working on the Energy and Commerce Committee in the US House of Representatives, I was involved in some of these pieces of legislation and worked closely with Kennedy and his staff. It wasn't Kennedy's best era - he was between marriages and often drank too much. But he always attracted great staff, and the work always got done. It was from Ted Kennedy that I first came to appreciate the links between mental illness and substance abuse and the need to integrate these services better.

Today much is made of the fact that the push for health care reform is weakened because of Senator Kennedy's absence. Yes, his lion's roar and indefatigable energy would surely have galvanised Democrats, but in today's environment it's hard to see what Senator Kennedy might have done to get a bipartisan bill. Former Republican collaborators such as Senators Orrin Hatch and John McCain speak piously but show no signs of substantive action. It is likely that Senator Kennedy would be angered by those who use his absence to explain their failures on what he saw as a defining issue for society.

And to demonstrate that there are no depths to which right-wing media commentators won't sink, Rush Limbaugh and Glenn Beck have now accused Democrats of exploiting Kennedy's death to get health care reform passed.

Senator Kennedy's death may well become a rallying cry that helps to pass health reform legislation, but arguably he has already left his greatest legacy through his work on civil rights. This began as the first legislative challenge he took on in 1964, when he tried to abolish the poll tax, a $2 charge imposed on African-Americans to cast a vote. It culminated last January, when he saw hope translated into reality as Barack Obama was sworn in as the first African- American president.

The opponents of health care reform have made much of the provision in the legislation that would provide Medicare reimbursement to doctors who provide Advanced Care Consultations to patients. They claim this is euthanasia, akin to Hitler's final solution. But the Medicare End-of-Life Care Planning Act of 2007 had three Republican co-sponsors, Sen. Susan Collins (R-ME) Sen. John Isakson (R-GA) Sen. Richard Lugar (R- IN) . That bill has been reintroduced several times since, each time with Republican support. Why is this now seen as Obama's death panel?

In 2003, Republicans John Boehner, Charles Grassley and John Isakson were among over 200 Republicans who voted for a bill which provided coverage for "counseling the beneficiary with respect to end-of-life issues and care options, and advising the beneficiary regarding advanced care planning."

The only difference between the 2003 provision and the current one that's inspired euthanasia talk from these very members is that the earlier one applied only to terminally ill patients.

The unwillingness of the opponents of reform to use the facts was demonstrated in a recent News Hour interview. Dick Armey, chairman of FreedomWorks claimed the Congressional Budget Office had found that 100 million American would lose their employer-provided insurance under the House bill. In fact, the CBO figure is that 9 million people, many of them already unemployed, would seek health cover through the public plan.

Together with several colleagues at the Center for American Progress I have spent the past week pulling together a response to every one of the 120 charges that have been made about the bill. You can read them here.

However you don't need to take my word for what the truth is (or James Morrow's either). There are increasingly plenty of independent sites that will show you where the pointer lies on the truth-o-meter. See for example Politifact.com.

And if you want to make up your own mind about what's in the bill, you can read that, in non-legislative language, here.

On a population basis, Washington has twice as many hospital beds as the rest of the country and more than twice as many doctors.  Needless to say, these services are cheek-by jowl in the well-heeled northwest sector of the city.  When the poor residents of Anacostia need care, they head for the emergency rooms of Howard Hospital, which was initially set up to provide freed slaves with the medical care they were denied elsewhere.

The infant mortality rate for black babies in Washington (13.6 per 1000 live births) is similar to that for Indigenous babies in remote Australia, and more than twice as high as the national rate (6.3).  In comparison, the infant mortality rate is 5.1 for Cuba and 4.2 for Australia.  The life expectancy of an American male is 72 years - the same as for someone living in Cuba and 10 years less than the average Australian - but for a black male living in Washington it is 58 years. 

Perhaps the most appalling statistics are those for HIV/AIDS and related diseases. Recent estimates are that 3 percent of Washington residents have HIV/AIDS, and the rate is 7 percent for black men.  Rates of infection with sexually transmitted diseases such as chlamydia, gonorrhea and syphilis are three to five times higher than the national average and infections with tuberculosis are increasing.  The age adjusted death rate from AIDS in Washington is almost 10 times that for the nation as a whole.

Such high HIV infection rates have not been seen since the height of the epidemic in San Francisco in the 1990s.  When these findings were released earlier this year, the director of the District of Columbia's HIV/AIDS Administration, who previously worked in Africa, stated that these rates were higher than West Africa, and on a par with Uganda and some parts of Kenya.

Many of the health problems of black residents of Washington DC are due to poverty, poor education, violence and discrimination.  But they are also due to a system that is focused on delivering expensive treatments to people once they are sick rather than keeping those people healthy through prevention and primary care services.

The consequences are inevitable: even in a city overloaded with the trappings of wealth and with excellent health care facilities, there are large pockets of people whose health status is no better than that of people in the third world.  It's a salutary call for reform.

The President and Democrats must now begin the process of inoculating their constituents against the false messages that abound. 

These include:

The bill is really about socialized medicine and the government takeover of health care, so the US will end up with a health care system like the UK or Canada. It seems that Americans believe every bad story they hear about health care systems elsewhere around the world, and you often hear Medicare recipients, oblivious to the irony, argue that they don't want the Government running their health care program.

The provisions in the bill that relate to comparative effectiveness (considered a nicer term than cost effectiveness, but still red rag to a bull) are attempts to ration care, intervene in the relationship between doctor and patient and deprive patients of treatments that would keep them alive. Every Republican has a story about how someone died in the UK because the National Institute for Clinical Excellence denied them treatment.  Presumably if they knew more about Australia there would be stories about the PBAC and MSAC too. In both the House and the Senate there have been multiple attempts to excise these provisions from the bill. They failed, but the Secretary of HHS is now constrained by language which says none of the data generated by the new Center for Comparative Effectiveness Research can be used to limit health cover or ration care. It's ironic that people who are most opposed to comparative effectiveness are generally most supportive of the for-profit health insurance industry, medical liability reform, and cutting the cost of federally-funded health care services.

The bill will mandate abortions and euthanasia. Despite the fact that the bill does nothing to change the current provisions that preclude the use of federal funds for abortion, and do not require health insurance funds to provide abortions, this has been an over-riding concern for conservatives. The issue about euthanasia arises because the bill provides Medicare reimbursement for a doctor or nurse practitioner to consult with a patient about 'advance care planning' which can help patients make their own decisions about end-of-life treatments. Such consultations can only be reimbursed in those states which medical directives are legal. Patients are not required to take advantage of the benefit or to sign a directive or living will at the end of the consultation.

The bill will use federal money to pay for the health care of illegal immigrants. Regrettably, this is not the case. All federally funded programs already require proof of citizenship for participation, and the bill has some tough language that says that financial assistance to help people purchase health cover is not available to individuals who are not lawfully present in the country.  

The bill will bankrupt the federal budget. This is probably the biggest myth of all. The US currently spends $2.5 trillion / year on health care, and the bill costs $1 trillion / 10 years. Provisions in the bill ensure that it is fully paid for - even the Congressional Budget Office agrees on that now.

Enormous progress has been made against some tough odds.  But health care reform is a long way from reality, and there is still plenty of room for things to go wrong. Stay tuned.

National Public Radio interviewed one man who had come with his family seeking medical care and he described how he had earned a six-figure income working for an international industrial supply firm until an accident five years ago left him disabled.

In America in 2009 that's an increasingly common story. 

A recent Harvard study showed that 62% of all bankruptcies in 2007 were medical; 92% of these involved medical debts over $5000 or 10% of pre-tax income. The rest met the criteria for medical bankruptcy because people had lost significant income due to illness or had mortgaged a home to pay medical bills.  Most medical debtors were well educated, owned homes and had middle-class occupations. Three-quarters had health insurance. There was a 49 % increase in medical bankruptcies as a proportion of all bankruptcy filings between 2001 and 2007. The total number of medical-related bankruptcies is likely higher as the data were compiled before the recession began last year.

However bankruptcy is only the tip of a medical-debt iceberg. In 2005 medical debt affected about 29 million non-elderly adult Americans, with and without health insurance.

The risk of medical debt is greater for people without health insurance, but even those who are insured are not immune; 15 % of those who had insurance for all of the past twelve months reported having medical debt, and 70 % of all those with debt said that they were insured at the time the debt was incurred.

The presence of medical debt, even for the insured, appears to create health access barriers akin to those faced by the uninsured as health providers often refuse to provide services without at least partial payment and debtors may be too embarrassed or ashamed to return to providers knowing they owe money.

[1] The Congressman for this area is Representative Rick Boucher, a Blue Dog Democrat who, to date, has not been a supporter of the House tri-committee health care reform bill.

Legislators in Massachusetts and on Capital Hill must now wrestle with how to keep costs down so that reforms are sustainable in the long-term, ensure that patients have choice and quality care, and keep everyone reassured that the government is not taking over the management of health care. Despite the nay-sayers, this is not an impossible task. 

As Atul Gawande pointed out in a recent essay in The New Yorker, good health care is not necessarily expensive care, and indeed, there seems to be an inverse relationship between overall cost and improved health outcomes. Studies have shown that the care for patients in the highest-cost regions of the US tends to be very fragmented, with considerably more diagnostic tests, hospital admissions, operations, and specialist visits, but less low-cost preventive services and primary care, and equal or worse survival, functional ability, and satisfaction with care.

Nearly thirty per cent of the costs of the US Medicare system could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the levels in areas like Rochester, Minnesota, or Seattle, Washington, or Durham, North Carolina - all of which have world-class hospitals and costs that fall below the national average.

While the funders of health insurance - the federal and state governments and the private companies - will all have to do more to reign in costs, the primary lesson from these studies is that there must be a dramatic change in culture among both health care providers and patients if the whole of the US is to experience the same quality of care. That will certainly require carrots and probably a few sticks too.

Massachusetts is now weighing changes in the way doctors are reimbursed to reward them for keeping patients healthy, not for performing more tests. In a report released this month, the state's Special Commission on the Health Payment System found that fee-for-service rewards service volume rather than outcomes and efficiency and recommended a risk-adjusted global payment system that will prospectively compensate providers for all or most of the care that their patients require over a contract period. 

It is proposed that this change is done in conjunction with mechanisms to ensure better integration and continuity of care, provider incentives such as common performance measures and pay-for-performance programs, appropriate consumer incentives to manage their health and to seek and use care efficiently, and a mechanism to protect providers from catastrophic financial loss.

Many of these approaches are already incorporated into the health reform bill currently under consideration in the House of Representatives, albeit as pilot and demonstration programs. 

Meanwhile, Republicans are trying to slow down the legislative effort and trying to mischaracterize it as a costly and ineffective endeavor that would expand government control, take away Americans' existing coverage, ration care, and contribute to run-away government spending.  

The Republicans have indicated that they do not plan to counter the Democrat bills with their own alternative, although in the past they have introduced alternative proposals.  A close examination of these nearly identical proposals, all based on John McCain's election policy, indicates that Republicans would effectively dismantle the employer-based system by giving all Americans a tax credit to purchase their own health insurance, and that their idea of controlling health care spending is to cap awards for malpractice claims.

So far, issue advertising around health-care reform hasn't erupted into a major spending spree and it has trailed behind lobbying and grassroots efforts.  Most of the $19.7 million advertising outlay to date is by groups such as the American Association of Retired Persons and the pharmaceutical industry which are in favour of reform.  This is a minute spend in contrast to the $127 million spent on lobbying on health in the first three months of 2009.

Between now and the beginning of August, when the Congress leaves for the summer recess, it seems likely that the Energy and Commerce Committee will finally get agreement on a bill.  However it is not clear if the bill will then go to the House floor, even though Speaker Nancy Pelosi says the Democrats have the votes.  But Senate Majority Leader Harry Reid has already declared that the Senate will not attempt to pass health reform legislation before the recess.

So Congressional members must return home until after Labor Day (September 7) to face the concerns of their constituents and make the case about why they are supporting or opposing health care reform. 

Many are nervous about what awaits them and rightly so, because while delay may create opportunities for the opponents of reform, doing nothing about the current health care crisis is increasingly not an option.  Between the first of August and Labor Day almost half a million Americans are going to lose their health insurance coverage.

Yesterday the Director of the Congressional Budget Office (CBO), Douglas Elmendorf threw a spanner in the works by suggesting that the health care legislation before Congress does not achieve "the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount." That got the salivary juices of the conservatives flowing.

Part of Elmendorf's message is painfully obvious: investing in health care reform by providing all Americans with health cover will cost the federal government a good deal of money - around $1 trillion over the next decade. This is a relatively small increment for a health care system that current costs $2.5 trillion a year.

Moreover, the budget outline that passed the Senate Budget Committee requires a fully funded health reform bill, and both the Senate Finance Committee and the House Ways and Means Committee are proposing different options to pay for reform and ensure that the bill does not add to the deficit.

However CBO does not consider those savings from reforms that come from modernizing the health care system (implementing electronic medical records, health information technology) and reforming the way Medicare and Medicaid reimburse providers.  Independent analysts have estimated these savings to be as high as $2 trillion / 10 years.  In addition, the health industry is on record as saying that the growth rate in annual health spending could be reduced by 1.5% a year, lowering overall spending by $2 trillion.  Arguably Elmendorf is looking at the trunk of the elephant and not the whole.

The White House and Congressional leaders will spend the weekend in negotiations. The bright news is that the current bills have garnered some important and very public support - from big employers WalMart and Target, from the American Medical Association, the pharmaceutical industry, and Harry and Louise.

Harry and Louise, a fictional suburban couple featured in a series of national television spots sponsored by the health insurance industry in 1993 and 1994, stoked fears that helped doom a government-created health plan promoted by a Democratic president, Bill Clinton. Now, the same actors are back in a new campaign, this time to support a government overhaul of the medical system promoted by a Democratic president, Barack Obama.

Miracles do happen!

It is insightful to look at what the Republicans are trying to do with this legislation and compare that to their rhetoric on health care reform.  They claim they have ideas to put on the table for consideration but reject a bipartisan approach; they have alternatively stated the urgent need for health reform and then were deliberately obstructionist in HELP Committee mark-up, arguing and debating endlessly as part of a delaying strategy that they and their pollsters publicly acknowledged.

Republican amendments offered in the HELP Committee would undermine current employer-based health cover and Medicaid, ensure that middle-class Americans get no subsidies to help with the cost of insurance cover, and do nothing to tackle increasing costs of both insurance and health care.

This culminated in Senator Coburn's offer of the Patients' Choice Act (PCA) as a substitute for real health care reform.  In a true indication that the Republicans are bereft of new ideas, this fatally flawed bill is a recycled version of Senator McCain's election commitment.  Moreover, the Republicans have yet to release CBO costings on this bill. 

It is no surprise that the American public have rejected this approach, which eliminates the tax break that employers receive for providing health insurance benefits to their workers.  This bill would undermine employer-provided insurance, which most Americans who have it are anxious to continue, and instead provide an annual tax credit that would not cover even half the cost of the average family's health insurance premiums.

Republicans on the HELP Committee have boosted this plan and personalized it in multiple hypothetical situations.  But this denies reality: their proposal ignores the higher premiums faced by people with existing illnesses, who are older or who live in states with higher medical costs and are likely to find premiums still out of reach.

For example, unlike employer-provided insurance cover, individual insurers in most states can exclude people with pre-existing conditions directly by denying them coverage or indirectly by charging them exorbitant premiums. Currently employers insure 62 percent of all adults with chronic illness, some 56 million Americans.  Even if these people could find health insurance in the market, data suggest that their premiums would be as much as 50 percent higher. 

At the same time, the Republicans are implacably opposed to the public insurance option, which will help keep insurance premiums affordable, and the expansion of Medicaid to enable sick and low-income adults access to affordable cover. Two-thirds of the 45 million uninsured are low-income individuals (below 200% of the poverty level) who do not have access to employer-provided cover and cannot afford or access private cover through the individual market.

They have rejected the idea of community rating and a raft of other measures which will begin to tackle the high costs of health care and address discrimination on the basis of chronic illness and pre-existing conditions and limitations on treatment imposed arbitrarily.

The Republican opponents of reform are not just sitting idly by as our current system continues to unravel - they are speeding up the process!  We can expect more of the same in the House of Representatives and the Senate Finance Committee, where mark-up of health reform legislation begins today.

The Community Health Insurance Option would be run by the Department of Health and Human Services. The government would pay for the first three months of claims as a way to capitalize it; this would be a loan to be repaid over time. For the first two years and longer if necessary, this public option would also qualify for "risk corridor protections"
which offset or reclaim excessive losses and gains which could result during the start-up period. Subsequently, its premiums would be set to make it self sufficient.

The public option would be one of the choices available to purchasers of health insurance. It would follow the same rules as private plans for defining benefits, protecting consumers, and setting premiums that are fair and based on local costs.

It will make health care more affordable by nationally pooled purchasing power, the ability to have payment policies that promote quality and best practice, and lower
administrative overheads.

This proposal, considered an essential element of health reform by the President and leading Democrats, has become the focus of the conservatives' attack on the current Bills.

The health insurance industry has supported health care reform, but is implacably opposed to the community health insurance option, claiming they will be unable to compete and it will destroy them. For all but a few Republicans, the issue is seen as a deal breaker.

Earlier this week I was at a breakfast meeting with a large number of patient groups, and someone from one of those groups described how their plea for letters to Congressmen in support of health care reform had engendered a surprising backlash from some members. One constituent, a veteran who presumably receives his care from the federally-funded Department of Veterans' Affairs, wrote that he "lost his legs fighting against communism and he wasn't going to support communism now, here in the US."

This type of approach, based largely on fear of the unknown and concerns about losing current benefits, fails to acknowledge that in many areas of American commerce, private and government programs comfortably co-exist. Public and private schools and universities, FHA insured loans and non-FHA loans, Social Security and private pensions - all have long thrived side by side.

Arguably the most contentious issue is whether to create a new government-run health insurance program to compete with private insurers (this is part of the House and Dodd bills). Proponents say it would drive competition, improve quality and lower costs, while opponents say it would put private plans at a competitive disadvantage and lead to a single-payer system.

It is not surprising that Washington's health lobbying organisations are moving into full gear.
According to a recent report from Common Cause,the major health interests have spent an average of $1.4 million per day to lobby Congress so far this year and are on track to spend more than half a billion dollars by the end 2009. That's about $2,600 per day per member of the House and Senate.

The pharmaceutical lobby is far and away the largest in the health industry, accounting for nearly half of the total lobbying expenditures. The pharmaceutical industry has spent $733,000 per day in the first quarter of 2009.
Between 1998 and 2008, the number of registered lobbyists on health care more than doubled, to 3,627, according to the Center for Responsive Politics. This doesn't include those who don't engage in lobbying as defined by federal law - among them, grass-roots organizers, producers of TV campaigns and former members of Congress who remain in Washington as senior advisers to corporate clients.

Spending on lobbying has climbed over the past decade. Organizations lobbying on health care spent $484.4 million in 2008, more than two and a half times the spending in 1998. This year's spending will easily surpass half a billion dollars.