Quietly, this article has remained on the Top 10 Most Emailed list at NYTimes.com for 5 days since it was first posted on the 24th. It appeared in the print edition on the 25th. However, before it arrived on doorsteps, it had already run up the list of most emailed articles. Here is the opening paragraph, setting the context for the story.

A quiet revolution is transforming how medical care is delivered in this country, and it has very little to do with the sweeping health care legislation that President Obama just signed into law.

In short, new physicians coming out of medical school are far less interested in running their own practices than they used to be. The are choosing the route of working for larger, integrated multi-specialty groups, like the Everett Clinic, for HMO models like Group Health, or for hospital systems like Swedish Medical Center. (Worth noting is that in many states it is illegal for hospitals to employ physicians, but not in Washington State.)

“When I was young, you didn’t blink an eye at being on call all the time, going to the hospital, being up all night,” said Dr. Gordon Hughes, chairman of the board of trustees for the Indiana State Medical Association. “But the young people coming out of training now don’t want to do much call and don’t want the risk of buying into a practice, but they still want a good lifestyle and a big salary. You can’t have it both ways.”

Admittedly, that line reads a bit like “when I was your age… both ways uphill… young whippersnapper…” However, to the extent that is the case nationwide, it is even more pronounced in the Puget Sound area.

The American Medical Association states that about 70% of all physicians in the United States practice in groups of 9 physicians or fewer. In other words, the vast majority of care is provided in settings where physicians can take the time to develop strong patient-physician relationships.

In Western Washington, according to the Puget Sound Health Alliance, that number is far closer to 40%. Hospitals purchasing physician practices to build a referral base for tertiary services appears to be the primary driver for this decrease, but there is also the prevalence of multi-specialty groups like the Polyclinic. There are a number of reasons this is the case here, but those are a few.

So what does this mean for health care in the US?

For patients, the transformation in medicine is a mixed blessing. Ideally, bigger health care organizations can provide better, more coordinated care. But the intimacy of longstanding doctor-patient relationships may be going the way of the house call.

Again, to the extent that is occurring in the US is the extent to which Washington State is already well down this path. How is your relationship with your physician? Better hold on to it.

Well, from a legal perspective, it depends on who you ask. So, for questions like these, I turn to a mainstream constitutional society called the American Constitution Society for Law and Politics. This group bases their analysis on the Constitution, without frills or extrapolations, but also considers the more than 200 years of case law and Supreme Court decisions which clearly adapt the underlying document to the times in which we live. They describe themselves like this:

The American Constitution Society embraces the progress our nation has made toward full embodiment of the Constitution’s core values. ACS believes that law can and should be a force for improving the lives of all people. We are revitalizing and transforming legal and policy debates in classrooms, courtrooms, legislatures and the media, and we are building a diverse and dynamic network of progressives committed to justice. Through these efforts, ACS will ensure that the institutions of American law reflect the highest values of our nation and serve the needs of its people.

And, what they say is this.

The paper concludes that the mandate is lawful and clearly so – pursuant either to Congress’ authority to “regulate commerce among the several states,” or to its authority to “lay and collect taxes to provide for the General Welfare.” With respect to Congress‟ interstate commerce authority, the goals that drive this legislation – including achieving universal coverage, eliminating adverse selection, eliminating pre-existing conditions as a prerequisite for coverage, facilitating broad-scale pooling of individuals not covered by group health plans, and radically reducing costly emergency room visits by uninsured individuals – are eminently lawful objects for the exercise of that power. In the context of current health insurance market circumstances and the framework of the legislation, the use of an individual mandate, structured as it is to ensure affordability for all who are subject to it, is likewise an eminently rational and well-supported (“necessary and proper” in the words of Article I, §8) means for achieving these goals.

But, don’t take my word for it. They lay out an extensive explanation here. Have a look and see what you think.

What are the practical economic impacts of the Stupak amendment limiting coverage of abortions? There are some persuasive politics at play, but will this have a measurable “real world” impact on plans, providers or patients?

Let’s take a look. First, regarding the bigger picture, this amendment does not limit the current legal status of abortion. The amendment allows for elective abortions to be fully covered under private insurance plans and for individuals who receive affordability credits to purchase plans that cover elective abortions.

What the amendment does prohibit is public option funds from being used to perform abortions, with the usual exceptions of rape, incest, and the life of the mother.

However, pro-choice advocates argue that the amendment places an undue burden on women who seek to have legal abortions. The Washington Post summarizes it this way:

Under that language, abortion coverage would be unavailable not only to working-class women buying coverage with government subsidies, but probably also to women buying coverage on the new marketplace without federal assistance. The amendment suggests that women could buy separate “riders” covering abortions, but abortion-rights supporters say it is offensive to require a separate purchase for coverage of a medical procedure that for most women is unexpected.

Next, let’s look at the politics at play here. There was a lot of pressure from religious groups, especially the Catholic bishops, and conservative groups to not include abortion coverage in the healthcare bill. Now, some of these groups actively oppose healthcare reform in any form, regardless of abortion coverage – in other words, they are using abortion as a means to defeat healthcare reform. However other groups, like the Catholic bishops, support healthcare reform but oppose abortion. It is this group into which many moderate Democrats fall – and where politics come into play.

Will the Stupak amendment stand in the Senate (or in final passage)? It is hard to say. Sen. Claire McCaskill (D-MO), recently said that she can live with the amendment, while 40 House Democrats, led by Rep. Diana DeGette (D-CO), have vowed to vote against the final bill if the Stupak amendment is retained.

We know that “pro-choice” Senators outnumber “pro-life” Senators – but will both sides stand uncompromising and potentially block the passage of the bill? The political reality is that the passage of healthcare reform could come down to the issue of abortion.

This leads me to pose a few questions:

–Can healthcare reform take place as long as there are divisive issues like abortion or immigration involved in the debate?

–What precedent does this abortion debate set for future healthcare debates?

–To repeat DJ’s question, “will this have a measurable ‘real world’ impact on plans, providers or patients?”

On a final note, it will be interesting to see how President Obama responds, keeping in mind his words from his Notre Dame speech:

So let’s work together to reduce the number of women seeking abortions by reducing unintended pregnancies, and making adoption more available, and providing care and support for women who do carry their child to term. Let’s honor the conscience of those who disagree with abortion, and draft a sensible conscience clause, and make sure that all of our health care policies are grounded in clear ethics and sound science, as well as respect for the equality of women.

Here are the statements released by NARAL and National Right to Life concerning the Stupak amendment:

NARAL Press Release
NRLC Press Release

- What was Brian Baird’s rationale for voting against this bill? Not just what he says in the press statement, but what are the real politics at play there?

- What are the practical economic impacts of the Stupak amendment limiting coverage of abortions? There are some persuasive politics at play, but will this have a measurable “real world” impact on plans, providers or patients?

- What will it take to get the Senate to bring their bill to the floor?

- What are the consequences of Lieberman standing athwart this effort to his future with the Senate Dems?

- Perhaps the most intriguing thing we’re thinking about: what are the impacts of this reform package on Washington State’s efforts at reform? This sets the stage for a real effort at reform in 2011. What will this mean for that?

When the dust settles from reform at the end of the day, I have the sneaking suspicion we will have just as many questions then as there are today. More from us as our brains wake up to the week.

More later. Rules are getting finalized at 10:00 pst. Looks like the final floor vote is has been pushed back to 7:30 pst.

“The House legislation includes critical reforms to the insurance industry, so that Americans will no longer have to worry that they will be denied coverage, or that their coverage will be dropped or watered down when they need it most. It covers virtually all Americans and ensures that all Americans with health insurance are protected against high out-of-pocket spending.

The House bill also includes a public option, or a government run insurance plan meant to compete with private plans. “The Administration is pleased that the bill includes a public health insurance option offered in an exchange. As the President has said throughout this process, a public option that competes with private insurers is one of the best ways to ensure the choice and competition that are so badly needed in today’s market.”


There has been a battle over a public option both between Democrats and Republicans, as well as within the Democratic Party.

This House bill was sponsored by Congressman John Dingell (D-MI), the longest serving current member of the House of Representatives.

There are three other related bills, all of which will eventually be crafted into one bill. The House bills will be combined while the Senate bills are combined, and then those bills will be crafted into one bill in the House and Senate Conference Committee.

Here are the related bills:

H.R. 3200: America’s Affordable Health Choices Act
H.R. 3962: Affordable Health Care for America Act
S. 1679: Affordable Health Choices Act
S. 1796: America’s Healthy Future Act

After reading the section of the bill containing the public option, Rep. Larsen has come to the conclusion that he supports the public option in this bill. This new public option will work for Washington state. In the original bill (H.R. 3200) payment rates in the public option would have been based on Medicare, which would have shortchanged Washington state. But the payment rates in this new public option (H.R. 3962) will be negotiated between doctors and the Secretary of Health and Human Services. This will ensure that doctors and hospitals are paid closer to market rates. Paying doctors fair market rates will ensure that they are able to accept patients covered by the public plan.

Rep. Larsen has also said that he believes any public option must compete under a “level playing field” with the private health insurance market. The public option in this bill will do just that: it will be subject to the same rules that private insurance plans are subject to, and it will not be subsidized by the government.

Representative Larsen previously stated he was likely to support the bill, but wanted to read it before making further comments.

The health care reform bills currently being considered by Congress do not fully address costs; more importantly, they do not address the annual increases in costs. They are focused more on the issue of expanding coverage. This is an admirable goal, but unless we find a way to control costs, expanding coverage will only make our situation worse.

Read the entire article here.

There are lots of legitimate reasons to dislike the current bills being considered as health care reform. For instance, the best of them considers universal coverage to mean that more than 12 million people are still left without health insurance. None of the bills do much to contain costs, meaning that health care costs may still rise faster than inflation and consume even more of our GDP. Too few people are likely to be able to access many of the benefits of reform, such as the insurance exchange.

Reform as currently prescribed does not fully decouple insurance from employment. Out of pocket costs are still too high for many Americans. And it’s unclear whether even the regulations contained within will be able to curb the worst practices of the private insurance industry.

However, he also points out that the current talking points for the Republican opposition to healthcare reform are out of touch with reality and lack perspective. House Minority Leader John Boehner (R-OH) said of the current House bill, “This is not affordable… what this is going to do is bankrupt America.” Carroll responds to this by pointing out the current proposal is deficit reducing.

He also compares numbers – showing that current proposals put the cost of healthcare reform at $900 billion over 10 years ($90 billion per year) – this compared to $470 billion a year for Medicare, $515 billion for Social Security, and $680 billion in defense (not including the two wars). Additionally, about $1.5 trillion in tax money went to healthcare costs last year.

Carrol concludes:

People are saying that of all of these things, health care reform is going to break the bank. No. Health care costs are what might bankrupt us, and I am all in favor of reducing those, but railing against the cost of reform while ignoring all the rest is willful ignorance.

And, in my humble opinion, this is (or at least should be) the aim of healthcare reform – making healthcare affordable to everyone, including taxpayers. There are many good reasons to oppose the current reform push, but there are also many uninformed ones.