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 An archived version of the website can be found here.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.