Joseph White, a professor of politics at Case Western Reserve University, made this interesting observation in his weekend column in The Fiscal Times:

On most issues, there is no such thing as a stable "public opinion." People do have general attitudes, beliefs that they can use to evaluate a choice. But often voters hold different attitudes that would lead to different evaluations of the same choice. How they answer a question depends on which considerations have been raised in their minds most recently.

Therefore the analysts who predict Democratic defeats in November based on negative survey responses about health care reform now are making a fundamental error. The Republicans have shown great ability to raise considerations that push the evaluation in one direction. Yet some of that effort has been encouraged by the concerns conservative Democrats raised during the debate as they tried to make legislation better fit their preferences. They will not be making those arguments as they run for reelection. In the election campaign there would be far more spending on ads to defend the legislation. The press coverage may focus more on the actual provisions of the bill as opposed to the GOP charges. But focusing on the actual specifics will only be possible if there is a law that passed and can be defended. Democrats have to be able to point to something and say: "this is what we did, this is the truth about it, this is how it would help you."

The Democrats also have to remember that the "losers who can't deliver" consideration will be far more prominent in November if they pass nothing now. In short, the battle over interpretation of the health care reform effort has only begun. We do not know how it will turn out in November, but there are good reasons to believe the Democrats are better off fighting it with a new law in hand.

I was on a short break last week where I actually took time off. But here's the  column that appeared last Wednesday in The Fiscal Times:

The nation's health insurers held their annual policy forum Tuesday at Washington's Ritz-Carlton Hotel. I felt like I was attending chapel at the Alamo.

Several thousand people, many from labor unions, were demonstrating noisily outside. They called for a citizen's arrest of the industry's chief executives, who were safely ensconced in their executive suites hundreds if not thousands of miles away. Inside, a few hundred of the industry's leading policy wonks, lobbyists and communications officials heard multiple sermons on the benefits of health care reform.

Karen Ignagni, the chief executive officer of America's Health Insurance Plans (AHIP), sat impassively at the back of the ballroom ignoring the presentations. Her hands flew furiously over the tiny keyboard on her phone, while three security guards hovered nearby. . .

(To read more, click here.)

Rita Redberg, the University of California, San Francisco cardiologist and editor of the Archives of Internal Medicine, is raising some important questions about the quality of President Obama's annual physical. Since the journal made the editorial freely available, I'm reprinting it here (hat tip to Gary Schwitzer's HealthNewsReview blog):

Like most Americans, I was pleased to learn that our commander in chief is in excellent health and that he is exercising regularly, including working out 6 times a week and playing basketball and golf. The President has set a great example by responding to his increased cholesterol level by "walking to work." Active commuting is associated with better fitness and lower body mass index and blood pressure. Mr Obama's excellent fitness is reflected in the news accounts of his low resting pulse and low blood pressure. Commendably, the President and First Lady also have made healthy eating a priority and have planted the first White House vegetable garden since Eleanor Roosevelt's victory garden.

In the midst of these positive news stories, however, I was troubled to read that the President's physical examination included an electron beam computed tomographic (CT) scan for coronary calcium. This screening test likely exposed Mr Obama to significant radiation unnecessarily, increasing his risk of future cancer. A single electron beam CT scan is estimated to result in a lifetime excess cancer risk of 9 (range, 3-42) additional cancers per 100 000 persons for men. In light of this radiation risk, and the lack of proven benefit in low-risk persons, the US Preventive Services Task Force (USPSTF) recommends against this test in men such as Mr Obama. In addition, the leading professional cardiology societies do not recommend coronary calcium screening for such men. Indeed, the most powerful way for President Obama to reduce his cardiac risk is to stop smoking-a step that will reduce by 72% his chance of a cardiac event in the next 10 years. The relevance of Mr Obama's coronary calcium score, no matter how low, pales in comparison. According to news reports, Mr Obama also underwent colon cancer screening, even though this screening is not recommended in his age group. Moreover, even when he reaches age 50 next year, the recommended colon cancer screening tests are either fecal occult blood test or colonoscopy. The USPSTF does not recommend virtual colonoscopy for screening, as performed on Mr Obama, owing to the lack of supporting evidence. This CT colonography test, like the electron beam CT scan, increased his radiation exposure and subsequent cancer risk.

Inadvertently, but perhaps fittingly, the reports of Mr Obama's physical examination reflect some of the key challenges facing health care reform today-Mr Obama appears to have been administered 2 cutting edge, expensive diagnostic tests that exposed him to a radiation risk while likely providing no benefit to his care. Some might defend these tests on the grounds that the President, of all people, deserves the very best our health care system can provide, but that would miss the point: more care is not necessarily better care. If the tests have no proven benefit for patients like Mr Obama, then they have no benefit for Mr Obama himself. Worse, evidence shows that the performance of unnecessary tests is not limited to Mr Obama or some select few patients. On the contrary, Mr Obama's case is multiplied many times over at extraordinary cumulative financial cost to society and personal cost to the individuals who receive tests with known adverse effects and potential harms but without benefits.

It is unlikely that Mr Obama will have a dispute with his insurance company over the costs of the tests performed at his physical examination, whether or not they were necessary, but it is a certainty that we all will have great disputes over the spiraling costs of health care for the rest of us.

(The following story links to The Fiscal Times, where it first appeared.)

Ever try shopping for a different hospital or physician network?

For most privately-insured Americans, choosing a different doctor or hospital requires changing insurers. Yet in the nation's most populous state, changing insurers doesn't make much difference-you're likely to be stuck with the same hospitals, doctors, and insurance cost coverage, according to a new study

Why? There's essentially no competition in most markets in California. The study by researchers at the Urban Institute and the Center for Studying Health System Change documented how physician and hospital networks in California have become concentrated in recent years. There are now just one or two networks in five of the six largest markets in the state, a level of concentration that in other industries would be seen as violating antitrust rules.

The lack of competition among doctors and hospitals-who are the primary providers of care in the U.S.-will have major implications for national efforts to control health care costs, the study warned. "Unchecked provider clout" by these networks will undermine many of the reforms that President Obama and the Democratic majority are banking on to hold down costs in the years to come.

(To read more, click here.)

(The following is reprinted from The Health Care blog, which reprinted it from the Wall Street Journal):

By EDWARD MILLER, MD

Dr. Miller is the Dean and CEO of The Johns Hopkins University Medical School.

Both the House and Senate health-care reform bills call for a large increase in Medicaid-about 18 million more people will begin enrolling in Medicaid under the House bill starting in 2013, Centers for Medicare and Medicaid Services (CMS) Actuary Richard Foster estimates.

We at Johns Hopkins Medicine (JHM) endorse efforts to improve the quality and reduce the cost of health care. But we also understand all too well the impact a dramatic expansion of Medicaid will have on us and our state-and likely the country as a whole.

A flood of new patients will be seeking health services, many of whom have never seen a doctor on more than a sporadic basis. Some will also have multiple and costly chronic conditions. And almost all of them will come from poor or disadvantaged backgrounds.

We know this because we've been caring for Medicaid patients in a managed-care setting for 14 years, as well as providing world-class care to people from all over the country and the world. Our experience provides a glimpse of the acute cost bubble that the health-care system will suffer with the reforms now being proposed.

Charles Krauthammer's columns in the Washington Post are like the Wall Street Journal editorial page, must-reading for anyone who wants to keep up with the illogical fulminations and small-minded cruelties of what passes for intellectual discourse on the right. The intellectual bankruptcy of today's offering shows not only why health care reform should pass, but why it will.

After scolding President Obama for continuing to push for reform despite "electoral rebukes" in Massachusetts, New Jersey and Virginia, Krauthammer complains that the cost-savings in the bill are "ridiculously insignificant." Dismissing the popular support of the insurance industry reforms that would protect most Americans from the worst predations of the health care insurance marketplace, he goes on to describe the 30 million Americans who would get health coverage as unworthy recipients of taxpayer largesse. The half trillion dollars in Medicare "cuts," he writes, are "not to keep Medicare solvent but to pay for the ice cream, steak and flowers."

He concludes by citing Warren Buffett as calling on the president to "start over and get it right" with a bill that focuses exclusively on cutting health care costs.

The man who ran as a post-partisan is determined to remake a sixth of the U.S. economy despite the absence of support from a single Republican in either house."

Actually, one Louisiana Republican did vote for the bill. But that little untruth isn't the real problem with his formulation. How can a bill whose cost-cutting is insigificant "remake a sixth of the U.S. economy"?

It can't, and it doesn't. Whether the bill will actually bend the upward trajectory of health care costs by a trillion dollars in its second decade, as administration officials Peter Orszag and Nancy-Ann DeParle argue in a separate op-ed in today's Post, will be determined in large part by the success of the payment reforms that are contained in the legislation. There is a serious likelihood that the bundled payments and accountable care organizations cited by Orszag and DeParle will fail because of the monopolistic powers that hospitals and physicians have in the health care economy, and the powerful hold they have as special interests over majorities in both political parties on Capitol Hill to keep it that way (for more on that, see "Unchecked Provider Clout in California Foreshadows Challenges to Health Care Reform" by Robert Berenson of the Urban Institute and Paul Ginsburg and Nicole Kemper of the Center for Studying Health System Change on the Health Affairs website).

But challenging "Obamacare" on those serious concerns -- a worthy exercise -- is something that Krauthammer can't be bothered with. That would require knowing something about or at least thinking logically about the nation's complex health care system and how its powerful special interests interact. Instead, what we get from the troglodytes on the right are ad hominem attacks mixed with slapdash cruelty for the less fortunate (health insurance as steak and ice cream, indeed).

The Post op-ed page is badly in need of a house-cleaning.

Princeton sociologist Paul Starr in today's New York Times recommends the Democrats add an opt-out provision to the requirement that everyone buy health insurance, which is included in both reform bills. This is a timely reworking of his column in the American Prospect that made the same proposal last December, which I endorsed here.

Why is the individual mandate required in the first place? To force insurers to take all comers despite existing health conditions, which is part of reform, the companies have to be assured that people won't simply wait until they get sick before buying coverage. Starr's proposal would allow Americans who don't want to  buy insurance and don't want to pay penalties to avoid those obligations to simply sign a waiver of their right to buy subsidized coverage through the national exchange -- which must be open to all comers no matter what their previous health status -- for at least five years. In other words, Starr writes, they could opt-out and face the same market the uninsured face today when they get very sick -- a market that will not sell them policies because they have a pre-existing condition.

The legislation isn't slated to go into effect until 2014. Should the Democrats push ahead and pass the bill without Republican support, there will be a huge "debate" this election year over its implications for the insurance market. Reformers already have a few arrows in their quiver to argue its benefits: the law will immediately ban some of the worst excesses of the private insurance market like rescissions (claiming policies don't cover major conditions after a person gets sick) and discrimination based on pre-existing conditions.

Being able to point to an opt-out clause on the individual mandate would be another major talking point in favor of the bill. It could be used to refute claims the bill forces people to buy a product they don't want or need.

The Food and Drug Administration announced earlier this week it will ask the Orthopaedic and Rehabilitation Devices Advisory Committee to evaluate New Jersey-based Regen's Menaflex collagen scaffold device, an artificial tissue used during joint repair operations. The meeting will take place in Gaithersburg, MD on March 23rd.

The political machinations behind its approval in late 2008 were first revealed by the Wall Street Journal a year ago. This blog discussed the case's implications for health care reform here. The Regen affair has triggered an Institute of Medicine reevaluation of the entire device approval process, which held a public session earlier this week (reported on here).

There's two reasons why the FDA calls advisory committees into session. Either the agency is genuinely puzzled by the conflicting evidence surrounding a new drug or device application and wants outside guidance. Or, it wants outside confirmation and support for a controversial decision that may not go down well in sections of the business community.

This would appear to fall into the latter category. The scientific case against approval of Regen's Menaflex was laid out last September in this public protest letter from Public Citizen, which was co-signed by Peter Lurie. Dr. Lurie now works at the FDA.

President Obama sent a concessionary letter yesterday to legislative leaders from both parties in a last-ditch effort to generate bi-partisan support for the bill. His overture was immediately rejected by the Republican Party.

Here's what could end up in the final bill:

• Expanded tax-advantaged health savings accounts coupled with high-deductible plans, sold through the national or state exchanges (still unclear which route the final legislation will take);
• Increased physician payments in Medicaid to encourage doctors to take the 15 million near-poor people expected to join that program under reform;
• Putting undercover cops on the Medicaid/Medicare fraud beat; and
• Giving small grants to states to experiment with setting up alternate resolution mechanisms for medical malpractice claims.

Let me address just one: the increased physician payments for Medicaid. There appears to be consensus that Medicaid underpays. But so does Medicare. And so do the uninsured (who get uncompensated care in the nation's emergency rooms and other settings). The net result is a transfer of costs from public programs to the privately-insured.

The health care industry isn't alone in using variable pricing. It is standard in the airline and other travel-related industries. It's increasingly popular in consumer goods like cell phones and books. And its endemic in the drug industry, which charges different countries and different classes of consumers in this country different prices depending on their negotiating power and ability to pay.

What marks them all is the very low marginal costs of production. The billionth pill costs pennies to make. The cost of filling an empty airline seat is the exra fuel needed to carry an additional 250 pounds or so (that includes luggage and/or the average weight of the guy who always seems to end up sitting next to me).

The outcry against low payments for Medicaid and Medicare is based on the notion that the nation's physician offices and hospitals do not have low marginal costs or unused capacity. The doctors and hospitals are telling us that they lose money on those patients and/or each additional visit paid for by government could just as easily go to a privately-insured patients who would pay more.

Maybe that's true. In this economy, I doubt it. Still, to the extent it is true, it suggests a misallocation of scarce resources driven by physician choice. Higher paying patients are probably consuming too much health care while lower paying patients are probably under consuming. 

The solution to this misallocation is a government regulatory scheme that dictates all-payer rates where every patient pays the same for the same visit, test or procedure. While this would increase government costs and decrease private costs in the short run, it would generate better information about the true costs of health care. That would be very useful for controlling total costs down the road.

Of course, moving to such a scheme is impossible unless taxes were raised precipitously or regulators made the Medicare/Medicaid rates the all-payer rates. The president ought to put that on the table and see how Congress and the lobbyists respond.

Rep. Rosa DeLauro (D-CT), who controls the purse strings for the Food and Drug Administration from her perch on the House Appropriations committee, took another swipe at the agency's process for approving devices, this time with commissioner Margaret Hamburg in the audience.

"Pretty much every (device) now is trying to fast track approvals, to the point where public safety becomes endangered," she told an Institute of Medicine meeting yesterday. Her comments were reported on FDAWebview (subscription required). "What was a sensible approach to approving new products that are substantially equivalent to existing low-risk devices is now a process that includes even potentially life-saving and life-threatening devices.

"The expedited process should be restricted only to low risk devices and even then we need more independent scientific review of devices for approval," she said.

Will Hamburg's FDA and the Center for Devices and Radiologic Health, headed by Jeffrey Shuren, push for major changes in the laws governing device approvals, which would surely anger Advamed, the industry lobbying group? Yesterday, Shuren presented the IOM committee studying the question a broad outline of possible changes without offering an agency position, according to a separate story on FDAWebview.

Though little noticed by the general public when they go in for operations, devices, whether artificial joints or simple sutures, have become a major driver of rising health care costs in the hospital setting. You don't have to be a rocket scientist to figure out who benefits from that.

Yet hospital administrators have very little information about medical value of devices. Physicians -- often on the payroll of the device manufacturers (see this GoozNews post, for instance) -- tell them the latest gizmos offer major advances in quality of care. So the hospital orders them, and writes a check.

It would be nice if the FDA generated good clinical trial data on the effectiveness of devices before they entered the market. At least then the hospital would have information that could be used to put a brake on spending for these "physician preference" items. However, that will require major reforms of the 510(k) process, under which new devices can enter the market without efficacy trials as long as they are somewhat like the older devices they seek to replace.

That's unacceptable as a regulatory regime. The new leadership at FDA should get out front on this issue. Now that CDRH's old leadership is out of the way (Donna Bea-Tillman, the last of the ancien regime announced her resignation yesterday to join Microsoft), Shuren should develop agency recommendations for the IOM committee. Laundry lists of possibilities of will not suffice. Only a strong IOM report will create momentum on Capitol Hill for changing the rules by which new devices come to market.