Silence - Not A Winning Strategy

Last week I spoke to lawyers, retired judges and others at a local bar association meeting about the "Patient Protection and Affordable Care Act" (the "ACA").  As I spoke about the availability of high risk insurance coverage, the Elder Justice Act, parents' health insurance for children up to age 26,  Long-Term Care insurance, the support for young families (including college students),  and the ultimate effect that supporting and encouraging young families to have children by removing financial and health insurance barriers through  providing health insurance and other benefits, it was clear that my audience was hearing this material for the first time.  WHY?

It wasn't their fault. Congress passed and President Obama signed a comprehensive health care reform act and the only thing the public heard were a few words from the administration about its benefits and a lot of words from the right about its high costs.  The administration spent a lot of time demonizing insurers, provider groups and our existing system but failed to support champions out in the field explaining to groups of citizens why the ACA was specifically in their interests.

In visiting with my Texas family this past week, I heard that a member who has a vital interest in maternity coverage, could not find an insurer who would provide it at a reasonable affordable cost.  Thus, her entire concept of health reform is that it has resulted in escalating costs and insurance unavailability. She was right in her observation that her interest in health insurance with maternity benefits is important for her and her family and for our country.  So it's time for the Administration to address her issue and at the same time champion provisions of the ACA which are good for American businesses and individuals.

Health care is not a game of golf- 18 holes and a visit to the clubhouse for lunch and drinks.  American lives and security  are at stake. Mr. Obama, treat health care as a continuing important subject. Commit the resources to champion the benefits that each American will - at some point in his or her life -  experience in the ACA.

Otherwise, Americans will face the bleak prospect of unaffordable health care while the lobbyists celebrate victory at their clubhouses.

Did I Miss Something

And  in his June 15th, 2010 TV talk, President Obama said what about the potential adverse health effects of benzene exposure on the men, women and children downwind from BP's crude oil disaster?  And who is to assume financial responsibility for dealing with those effects as they become real? And how will the victims and their families be made whole? And who is monitoring the environmental health risks and results?  How have Americans been notified of their exposures and the adverse consequences of those exposures?

Sorry, but a "I've got the situation in hand"  political talk just doesn't deal with the reality of a toxic exposure which may have consequences far worse than any terrorist attack our nation has yet experienced.

A Common Denominator: Questions For Obama's Administration

As a hematologist, I had many patients with severe, life-threatening blood malignancies, such as acute myeloid leukemia. I also consulted on patients with less advanced blood and bone marrow disorders of the type which predicted "there is a high likelihood that this person's bone marrow has been severely injured and will eventually develop leukemic changes".  There was a startlingly common denominator: even with extensive and repeated history-taking, most of the patients could not provide a history of toxic exposure which might have damaged their bone marrow.  Sometimes their occupations shed light on a petrochemical cause: commercial painters, workers (often undocumented immigrants working for construction contractors) who crawled under houses to spray for insects, farmers who worked land that had been contaminated by the dumping of insecticides years earlier), shoe-makers,  and artists using oil-based patients and solvents. But even homemakers with no commercial exposure to high levels of petrochemical based products came to my examining room with the story that they had "sprayed"  in a closed area (their homes' crawl-spaces) to rid their homes of destructive or annoying insect pests. Sometimes children who lived in residential communities not far from what we later learned was toxic industrial contamination of local water supplies presented with fatal acute leukemias. In each and every case, the person affected lacked information which would have aided him, her or parents to accept or avoid a life-threatening toxic exposure.

As I listen to the story of BP and the oceanic flood of raw oil contaminating the ocean, shore and coastal environment, I find it disturbing that there is no reliable information coming from the federal government about the level of highly toxic oil-based environmental contaminants to which adults and children are being exposed every day on the streets, at work,  in their homes and in their schools.  Why is this information not being obtained and distributed to the media for public knowledge?  How are people in the areas affected to know whether they and their families are being exposed to a high risk of bone marrow damage from raw oil and its airborne fumes?

This is serious business.  The Obama administration needs to treat its citizens as sensible adults and not dummies. The Obama administration should give the people facts about the very real and serious exposure to toxic materials spewing  from BP's disastrous oil well and let the people decide what is in their - and their families' - best interests. Should there be evacuation of entire shoreline communities? Should hospitals be gearing-up for an eventual flood of patients with petroleum-based bone marrow toxic effects, such as acute myeloid leukemia? Or is BP's calamity truly benign?

Have our public health authorities been gagged or do they just not know? And is finding out and disseminating information about toxic exposure a high priority or have the massive political contributions of the petroleum industry set the priorities to favor industry concerns over citizens' welfare?

Reform, Not Minimalism "Where's The Beef?"

I spent lots of time on National Health Lawyers Association activities in Washington, DC during Ronald Reagan's administration and remember the awesome power and control that President Reagan exercised through the House-Senate conference committee process. It would be hard for the current generation of Republicans to deny their Reagan heritage and cry foul should President Obama emulate Reagan's example with respect to reforming our health system.

But if Obama is going to use his presidential authority and legislative majorities to get the job done, it should be for major health care reform, not the minimalist program spelled-out in today's communique from the White House (Click Title for "Where's The Beef"):

"On Wed, Mar 3, 2010 at 11:45 AM, President Barack Obama wrote:

"Friend --

"Last Thursday's first-of-its-kind summit capped off a debate that has lasted nearly a year. Every idea has now been put on the table. Every argument has been made. Both parties agree that the status quo is unacceptable and gets more dire each day. Today, I want to state as clearly and forcefully as I know how: Now is the time to make a decision about the future of health care in America.

"The final proposal I've put forward draws on the best ideas from all sides, including several put forward by Republicans at last week's summit. It will put Americans in charge of their own health care, ensuring that neither government nor insurance company bureaucrats can ration, deny, or put out of financial reach the care our families need and deserve.

"I strongly believe that Congress now owes the American people a final vote on health care reform. Reform has already passed the House with bipartisan support and the Senate with a super-majority of sixty votes. Now it deserves the same kind of up-or-down vote that has been routinely used and has passed such landmark measures as welfare reform and both Bush tax cuts.

"Earlier today, I asked leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks. From now until then, I will do everything in my power to make the case for reform. And now, I'm asking you, the members of the Organizing for America community, to raise your voice and do the same.

"The final march for reform has begun, and your participation is crucial. Please commit to join with me to take reform across the finish line.

"Essentially, my proposal would change three things about the current health care system:

"First, it would protect all Americans from the worst practices of insurance companies. Never again will the mother with breast cancer have her coverage revoked, see her premiums arbitrarily raised, or be forced to live in fear that a pre-existing condition will bar her from future coverage.

"Second, my proposal would give individuals and small businesses the same choice of private health insurance that members of Congress get for themselves. And my proposal says that if you still can't afford the insurance in this new marketplace, we will offer you tax credits based on your income -- tax credits that add up to the largest middle class tax cut for health care in history.

"Finally, my proposal would bring down the cost of health care for everyone -- families, businesses, and the federal government -- and bring down our deficit by as much as $1 trillion over the next two decades. These savings mean businesses small and large will finally be freed up to create jobs and increase wages. With costs currently skyrocketing, reform is vital to remaining economically strong in the years and decades to come.

"In the few crucial weeks ahead, you can help make sure this proposal becomes law. Please sign up to join the Organizing for America campaign in the final march for reform:

http://my.barackobama.com/commit

"When I talked about change on the campaign, this is what I was talking about: coming together to solve a huge problem that has been troubling America for 100 years and standing up to the special interests to deliver a brighter, smarter future for generations to come.

"I look forward to signing this historic reform into law. And when I do, it will be because your organizing played an essential role in making change possible.

"Thank you,

President Barack Obama"

MY OPINION

America needs reform which will provide: (1) efficient basic accessible, ethical, scientifically appropriate, health care, pharmaceutical product and health insurance coverage for every citizen in America; (2) a health care work force including physicians, nurses and other personnel, which is adequate in number, well-educated, highly competent, and incentivized to provide appropriate high quality health services; (3) a system, including but not limited to, a federal independent agency provider, which provides economically sound medically necessary, scientifically well-founded, and appropriate health services 24 hours a day, 7 days a week, 365 days per year; (4) appropriate incentives for high level mathematical and scientific student and post-graduate training; (5) a respected and appropriately supported system of national public health services which will coordinate and manage health care emergencies including epidemics, national disasters, bio-terrorism episodes, nuclear disasters and other events; (6) national licensing of health care providers; (7) support for local, national and internationally based health care fraud detection, prosecution and punishment; (7) continued support for scientific research; (8) appropriate quality, professional and financial standards for all institutional providers of health services including hospitals, outpatient facilities, research institutions dealing directly with patients; (9) independent objective public health education; and (10) encouragement and support of the development of enforceable ethical standards related to health care, health-related information, and products which purport to effect health care.

Fodder For Psychoanalysts

A number of years ago, through a connection I made at a Rotary International meeting at the YMCA in Jerusalem, I spent hours interviewing the medical directors of three of Israel's largest health systems.  When I finished these meetings, I felt as if I had delivered hours of psychotherapy to these individuals who were beseiged by the need to deliver life-saving health care through an irrational system, bounded and constrained by politics and religion rather than by scientific medicine.

 In listening to President Obama's meeting today, I had that feeling again.  It was clear that the parties on both side of the aisle understand the desperate straits that our health care system is in, but prefer to give precedence to irrational political (and personal) considerations in the guise of putting their constituents' needs first, rather than deal honestly with the issues.  My bottom line is that all sides at the meeting were adequately informed as to our health system's prospects for a disasterous future, but that none is willing to abandon political strategy, and personal interest, to meet our country's and its citizens needs.

A good conference, Mr. President.  But perhaps the next one should be led by an experienced psychoanalyst. Call me and I'll give you some names.

Executive Authority - An Exquisite Tool for Health System Reform

In light of Congressional leadership mismanagement of proposals for health reform, the burden of setting healthcare "right" will move to President Obama. Perhaps his advisors should be thinking about those features of serious health system  reform which could be implemented under the the President's executive powers (could Republicans deny such authority with straight faces?). For instance, how could executive powers support   education in the sciences, including graduate and postgraduate training in the various medical skills our health care system will need as our population grows and ages?  How could federal responsibility for veterans' and public health services evolve into a model system for delivering health services?  How should federal support for Medicaid be administered to achieve significant societal good? How should we structure our priorities and ethical principles?

The President is not without tools.

Critical Political Effectiveness

A few days ago, my wife and I visited the Lyndon B. Johnson museum and Library at Austin'sUniversity of Texas campus. We saw a detailed history of Johnson's  life and political activities from childhood to death. What struck us was the thoroughness of his apprenticeship and life's training as a political figure and campaigner, his long-hours of work (often from 4 A.M. to midnight),  his extraordinary Congressional career which earned him respect, and political chips, from Representatives and Senators on both sides of the aisles, and his principles concerning civil rights which dated to his early career as a teacher in a Texas Mexican-American primary school.

When Lee Harvey Oswald murdered President Kennedy,  Vice President Johnson had the energy, talent, politcal experience, credibility, focus, commitment and contacts  to become an extraordinary President, actively involved in passage of  revolutionary civil rights  and health care reforms, including the establishment of Medicare.  However, his commitment to continuing the Vietnamese war eroded  public support and led to his decision not to seek reelection.

In my opinion, President Obama lacks a number of the presidential  qualities of President Johnson. Obama's decision to flee Washington to pursue the illusion of a Chicago Olympics, rather than to provide needed leadership to ineffective Harry Reid in the Senate battle over health care reform, demonstrates a lack of  focus and a failure of staff  to work with him to set an appropriate agenda. Obama abandoned the appearance of serious comitment to health care reform to chase after international games. Like the Olympics, his actions suggest amateurism.

A Sort-Of Historical Speech

It was a textbook, "let's make a deal" speech, aimed at obtaining concensus on the principles which President Obama laid out, so  that later, the principles could be expanded to provide the real muscle and meaning behind the vague wording. For its purpose, it was well done. I found myself asking for more specifics, but having watched/listened to several of Obama's internet-based presentations, knew that I and other Americans stood no chance of getting specifics  tonight. It was not what I had hoped for in my blog of September 6, 2009.

Having spent a long afternoon today at a biomedical ethics meeting dealing with serious issues of life and death, I resented the failure of Obama to discuss anything other than the business of health reform.   I also found myself resentful of the Republicans, massed and unsmiling in their dark blue suits, unwilling to let their politics yield to human and national needs, and almost expecting someone among them to stand up to demand that Social Security be repealed.

In all,  it was  not a memorable night.  Perhaps there will be substance soon to come.

And don't forget  ethics.

Ethics, Quality, Compassion

I listened carefully to President Obama's AARP televised and internet-carried conference On July 29, 2009. I heard nothing about the ethical construct for health reform. I heard nothing about health care quality. I heard nothing about assuring Americans that there would be competent qualified physicians available to provide the care that is being promised to them. I find myself more and more concerned that the only subject for Obama and Congress seems to be cutting health care cost inflation and saving money.

I have proposed changes to the health system in earlier blogs. Others have proposed different changes. But the only change that seems to be in the wind is that insurers and pharmaceutical companies' revenues and profits will be protected, with no apparent concern for the quality and ethics for the services they provide.

Years ago, one of my patients with advanced metastatic breast cancer was in the Oncology Unit of a local hospital with a fractured hip. She was in agony and her quality of life was poor, but could have been helped by appropriate orthopedic surgery. MediCal (California's Medicaid) refused, saying that the expense was not justified by the patient's poor prognosis. I called the MediCal authorization number and asked Medical's "authorizer" for the address of MediCal's office. She asked why I wanted to know. I told her that it was because I was going to put the patient in an ambulance and send her to their office for care, because I couldn't take care of her under the circumstances they dictated. After a few moments of silence, I received the authorization. The patient had surgery by a competent and compassionate orthopedic surgeon, went home without devastating hip pain and died several months later appreciative that her pain had been treated, her ability to walk restored, and she could be at home with her family.

I have seen the value of ethical commitment, concern about the quality of care that patients receive and compassion. It is unfortunate that Congress does not address these issues. The Administration and Congress just don't have the words to discuss ethics, quality of medical care, and compassion.

The Walter Reed Experience Reduplicated

The recent murderous attack by a 3rd Iraq deployment Sergeant prompted me to think back two years to the Walter Reed Hospital scandal, in which brain injured, severely wounded and post-traumatic stress disordered personnel were lodged in horrible facilities and provided with back-ward care (click on title for Soldiers Face Neglect, Frustration At Army's Top Medical Facility by Dana Priest and Anne Hull,
Washington Post Staff Writers, Sunday, February 18, 2007; Page A01). If this was the care that an arrogant neglectful Congress and our politician-led armed forces provided to men and women who were willing to give their lives and limbs on behalf of their country, should we stop a consider whether we should have a universal health system, controlled at the top by our federal government and its bureaucracy?

Unless we have a moral and ethical framework, upon which our proposed federal health reform is built and contained, we will be duplicating and expanding the philosophy and conditions which led to the uncaring and inhumane Walter Reed Hospital experience. If health care is the domain of hospital administrators, insurance company executives, nursing home operatives, pharmaceutical manufacturers and sales people, we will not have a humane, appropriate and ethical health care system.

Mr. Obama, I would rather hear that you were meeting with persons on the front lines of patient care, and ethicists, than with health industry related major political donors. Those who have the daily responsibility for patients' well being, and ethicists, can tell us what we need to do to build a great health system. The industry people will tell us to build a system that will be good for them.

Obama's Quest For $634 Billion

WASHINGTON (Reuters) Feb 24 - Health spending will hit $2.5 trillion this year, devouring 17.6% of the economy, as the White House and Congress consider major changes to the health care system, U.S. government economists said on Tuesday.

Reuters reported a forecast by The Centers for Medicare and Medicaid Services predicting an increase in health care's percentage of the gross domestic product by one percentage point (to 17.6% of the gross domestic product) in 2009 as compared with 2008.

For my earlier discussion of this issue see the "Avalanche" blog: http://www.blogger.com/posts.g?blogID=1547787506785837911&searchType=ALL&txtKeywords=&label=Health+Care+Inflation.


Reuters quoted CMS economist Christopher Truffer: "We project that the health share of the economy will increase steadily through 2018." The increase in health care percent of the gross domestic product not only reflects the subject of my earlier analysis, but also increased costs of technology, population growth, an aging population, pent-up unmet demand (i.e., from those receiving insurance for the first time (i.e., through Medicaid) and immigrants who may not have had access to advanced health care before arriving in the U.S.), time spent with patients, prescription drug costs, and the failure of providers to provide efficient systems of care (as patients move into hospital emergency departments where extensive testing and high costs of care waste enormous financial resources.

If Obama's rationalization of health care reflects the excesses and lack of corporate responsibility that we have already seen in the financial industry, we will have a big, expensive, inefficient health care system which increasingly fails to provide care as predatory unethical and wasteful behavior flourishes. Even if Obama gets the $634B over 10 years for health care that he seeks, without a program grounded on an ethical framework which reflects American consensus, health care will not improve. We will move to a 20% of gross domestic product health care system with lots of money for corporate entities and no significant benefit for our citizens.

A New SAT Question

What is the similarity between between Ariel money manager J. Ezra Merkin (who The NY Times 2/14/2009 p. B3)invested $2 billion of his clients' money with Madoff) and a subsidiary of Compushare which sells high-end software in the health care field (p. A13)?

Merkin received some of his telephone advice directly from an "Imprisoned Felon," Victor Teicher, whose federal securities fraud felony landed him in a New Jersey prison.

Covisint, the Compushare subsidiary, is paying $100,000 a year plus commissions, to felon and ". . . former Detroit mayor Kwame M. Kilpatrick . . ." because he is "uniquely qualified" to sell high-tech services in the health care field.

Have you any unease about the safety and integrity of your personal medical information? Or about the types of operators who - attracted to electronic medical records services, as vultures are to decaying carcasses - look upon the federal governments' willingness to pour resources into electronic medical records as an invitation to feast?

Is the Obama administration oversight of electronic medical records to be like the Bush administration oversight of Halliburton in Iraq?

Dear President-Elect Obama

You have staked your political and personal reputation on your promise to reform health care, make it more effective and more cost efficient. My guess is that you have surrounded yourself with experts who tell you that the federal government can save enormous amounts by managing and coordinating disease care for high risk people. These high-cost patients, many of them poor, elderly and not well educated, with multiple diseases, use enormous amounts of government funds for their care. Obviously, your experts will say, spending money on managing disease care through insurers or other plans, telephonically or by personal contact (with such interventions as providing transportation, medication or social service support), makes sense.

As a lawyer and former President of the Harvard Law Review, you know very well that all that is in print is not true, that experts can honestly hold to strong but incorrect opinions, and that one should be skeptical of claims by anyone that he or she has "the" solution. Please use those skills in evaluating the hype about disease management.

The managed disease care solution falls apart under close scrutiny. The Fall, 2008 Health Care Financing Review, in an interesting series of papers growing out of disease management studies conducted by Medicare and Medicaid, shows that savings, if any are negligible. Brown and Peikes (15-Site RAndomized Trial of Coordinated Care in Medicare FFS") found that after two years, the treatment group experienced no gross or net expenditures savings when compared to the control. Esposito and Brown reported that a primarily telephonic patient monitoring and education service "show virtually no overall impacts on hospital or emergency room . . . .use" although for a subset of patients with congestive heart failure program reduced Medicare expenditures by 9.6 percent. In the paper "Evaluation of Medicare Health Support Chronic Disease Pilot Program," Cromwell and McCall's conclusions were consistent with the cited authors' interpretation of their data. Goldfield and McCullough's paper, "Identifying Potentially Preventable Readmissions" unsurprisingly showed that "readmission rates increase with increasing severity of illness and increaasing time between admission and readmission, vary by the type of prior admission, and are stable within hospitals over time."

Treating elderly individuals with near end-stage severe chronic disease and mental health illness, will absorb enormous resources with very limited benefits. Providing a significant portion of those resources to young Americans, and using less expensive culture-changing methodologies, may yield better long-term results. America needs to resolve its ambivalence over tobacco, alcohol, addicting substances, unhealthy food intake, exercise and work habits. It should facilitate education for all of our young people and devote adequate resources to building a healthy life foundation for our country.

Good luck, Mr. President-elect. My grandchildren's well-being will depend on the decisions you make.

What Is The Lesson of Obama?

The election of Obama teaches us, not only that a well-organized, dedicated and competent electorate will respond to an articulate smart and sensible leader, but that it will recognize its legitimate self-interest and take forceful action.

That lesson is applicable to our health care system. The Clintons tried to design a hierarchical system from the top down: it didn't work. Let our united voices help build a system, from the bottom up, which provides affordable appropriate necessary health care to all Americans. See my blog dated November 6, 2008,write your letters, and make your voices heard.

Voters: Set The Health Care Agenda

When Congressman Norman Mineta and I had a discussion about health care reform at his annual barbecue in the mid-90s, Norm, a very smart, seasoned and common-sensed San Jose Democrat, felt that neither Congress nor the Administration at the time was ready to act. As usual, he was right

Although health care has even greater public importance today, unless it's a high profile item on the national political agenda, nothing substantive will happen. Partisan politics, budgetary priorities and shortfalls, and our economic woes will block reform of our health systems. Major donors (i.e., insurers, hospitals, pharmaceutical manufacturers, chiropractors organizations, nursing homes, nursing associations and unions, physicians' lobbies, various unions and many others) will preserve their privileged positions. The public, patients and their families, will once again be ignored or stalled.

It's time for voters to use some of their chips - to write brief clear letters (especially the kind that go in the Post Office mail) to our Representatives, Senators, the Administration, and national political parties, making it very clear what we expect them to accomplish for health care. (If you can't write a letter, send an email, but note that email is not as effective at influencing political judgment.)

If you choose not to use your political chips, those major donors to the Republican and Democratic parties, candidates and functionaries, will be at the health policy table in a no limit to the stakes game. Setting an agenda in which health care needs are trivialized, they will divvy up the health care pot, and the public will once again be screwed. You can make a difference by writing a one page letter to your Congresspeople, the Republican and Democratic national parties, the Obama Administration, and your local newspaper:

!. First short paragraph: tell the recipients who you are, where you live, and that you are a voter in their districts (use your zip code); briefly describe the single most serious health system problem you have found.
2. Second short paragraph: describe a solution to the problem you have identified and describe the single most important thing that you want them to do.
3. Third paragraph: picture for them how your proposed solution will help.
4. Fourth paragraph: tell them why their advocacy for your solution to the problem you have identified will be in their best interests.

Politicians count numbers. If enough of us write to our politicians they will notice and respond. If we set their agenda, they will follow. After all, they work for us.

Obama Really Didn't Talk About Health Care Did He?

Obama's speech accepting the Democratic party nomination was short on plans for health care. He described his cancer-ridden mother's battles with insurers over benefits. He mentioned a plan for Americans which would give them Congress-like benefits. He spent a lot of time embracing, holding, and beaming at his family. But there was nothing of substance which could help 250+ million Americans understand whether he really has any health plan at all. We were entitled to more.

He could have said that he favored a single payer system with a available supplmentary coverage similar to the Medigap insurance that seniors on Medicare can purchase. He could have said a few words about setting up a truly competitive healthcare insurance environment in which qualiy and efficiency of health care can be measured to maximize benefit. He could have said a lot of informative things about his plans for health care. But he didn't.

How much money was spent by corporate health care interests to fund the Democratic Party convention? Will the big spenders be at the table designing the health care system that meets their organizational and financial/profit requirements without serious regard for public benefit? Will it be a glossed-over "business as usual" fix to our bloated, expensive and inefficient system? Or will Obama, if elected, and the Congress to be elected, get serious about fixing our ailing health system?

A number of years ago, at a meeting in Sacramento, the Senate President Pro-tem told me (and a few others from a powerful health trade association) that money did not buy his vote. He followed that statement by making it clear that money buys access to him and subsequent comments inferred that it might favorably dispose him to vote, some of the time. The rules haven't changed. Pay attention to who is funding the political parties, and their members, to gain access and influence opinion. If you do, you will be able to predict what our health system will look like in two years.

Obama: Does "Americans" Mean No Health Care For Uninsured Immigrants?

On August 5, 2008, discussing Barack Obama's health plan, I quoted his web site's language ("Obama will make available a new national health plan to all Americans") and commented "This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally".

A recent publication, The Impact of Immigration on Health Insurance Coverage in the United States, 1994-2006 clarifies the significance of Obama's omission. This August, 2008 report by Paul Fronstin of EBRI (Employee Benefit Research Institute) describes and analyzes the 1994-2006 impact of immigration on health insurance coverage. (ebri.org/pdf/notespdf/EBRI_Notes_08b-20081.pdf).

In 1994 36.5 million persons in the U.S. were uninsured and that number climbed to 45.4 million under age 65 in 2006. While most uninsured in the U.S. are native-born Americans, Fronstin reports that in excess of 46 percent (more than 12 million) of foreign-born noncitizens were uninsured in 2006 (as compared to almost 20 percent among American citizens who were foreign-born and 15 percent among native-born individuals.

The report notes that California, Texas, Florida and New York are the states where the greatest numbers of the uninsured immigrants live.

Fronstin has helped to clarify the dimensions of the impact of immigration on uninsured health care in the U.S.

Obama's health plan will still leave states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally. His plan perpetuates an expensive cost-shift to cities, counties, states and their taxpayers and employers.

As a Harvard Law School Law Review editor, graduate and lawyer, Obama's choice of words and particularly his ambiguities, are significant. Words do count.

Obama: A Health Plan or Weasel Words?

Barack Obama's web site (http://www.barackobama.com/issues/healthcare/) neatly encapsulates his health plan. I have taken the liberty of interlineating comments (in bold).

Barack Obama's Plan
Quality, Affordable and Portable Coverage for All

* Obama's Plan to Cover Uninsured Americans: Obama will make available a new national health plan to all Americans This still leaves states, counties and cities with the staggering financial burden of providing health care services for individuals who are in the United States illegally, including the self-employed and small businesses, to buy affordable health coverage that is similar What does "similar" mean?to the plan available to members of Congress. The Obama plan will have the following features:
1. Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions Will full benefits apply immediately upon enrollment or will there be a waiting period?.
2. Comprehensive benefits. The benefit package will be similar That word again. to that offered through Federal Employees Health Benefits Program (FEHBP), the plan members of Congress have. The plan will cover all essential Who defines "essential"? Right now, it may be a clerk in an insurance company's office who is not a physician or otherwise qualified to make decisions about essential care. Sometimes, it is patients' families whose expectations may not be consistent with standards of reasonable medical judgment. And as we saw a few years ago, sometimes Congress jumps in to make decisions concerning "essential" care. medical services, including preventive, maternity and mental health care.
3. Affordable How is "affordable" defined? premiums, co-pays and deductibles.
4. Subsidies. Individuals and families who do not qualify for Medicaid or SCHIP but still need financial assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan. Will they be able to purchase a plan which has a comparable network of providers and pays its network of providers the same amount as other plans?
5. Simplified paperwork This was the promise of HMOs, too. The paperwork was replaced by the requirement that physicians, other health care providers and hospitals spend hours on the telephone trying to get authorizations. and reined in health costs. What does "reined in health costs" mean? Does it signify that services will be cut in order to control costs?
6. Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage. If experience is of any value, such plans have neither been simply to enroll in and financial constraints have made access problematic.
7. Portability and choice. Participants in the new public plan and the National Health Insurance Exchange (see below) will be able to move from job to job without changing or jeopardizing their health care coverage. This may be a major benefit. However, some employers may find that portability means that some talented individuals leave their employ because they are no longer constrained by a family member's uninsurability.
8. Quality and efficiency. Participating insurance companies in the new public program will be required to report data to ensure that standards Such standards are not described. Where will the bar be set? for quality, health information technology and administration are being met.

Words Do Count - As Obama Should Know

Senator Obama's web site (http://www.barackobama.com/issues/healthcare/)speaks of his health care plan on several levels of complexity. The "At a Glance" section talks of "Quality, Affordable and Portable Coverage For All", "Lower Costs by Modernizing The U.S. Health Care System", and "Fight for New Initiatives". The next level of complexity describes. in vague terms, such items as guaranteed eligibility, comprehensive benefits, affordable premiums, co-pays and deductibles, subsidies, simplified paperwork, easy enrollment, portability and choice and quality and efficiency. It goes on to describe a "National Health Insurance Exchange," employer contributions, children's mandatory coverage, expansion of Medicaid and SCHIP, and flexibility for state plans. It proposes to lower costs by modernizing the US Health Care System, ensure that providers deliver "Quality" care, lower costs through investment in electronic health information technology systems, lower costs by increasing competition in the insurance and drug markets, and fight for initiatives which appears to be a mix of politically appealing verbage.

Skip to "Background Questions and Answers On Health Care Plan" and discover that all of this will cost "us" taxpayers a mere $50-65 billion a year when fully phased-in. The basis for this number is not made clear: is it conjecture? Is Obama proposing an adjective laden piecemeal patch to the current system?

Not long ago we were told that $70 billion dollars (if my recollection serves me correctly) would cover our costs for the war in Iraq. It didn't, it won't and neither will Obama's health care proposal cost what it says in print on his site. He should provide a realistic tabulation of costs versus savings.

Obama's site does not explore the impact of his proposal on the economy, especially on the small businesses which are the lifeblood of American industry. It does not explain the impact of globalization on the offshoring of employment which allows major companies to get out from under health care insurance costs (and their pension costs) and shift them to others. It does not explain the risks of tinkering with a $2 trillion plus economic sector which, if it implodes, will make the current housing recession look like childs' play (health care is a major employer) as well as destroying the function we now have in our dysfunctional health system. Obama offers a simplistic fix.

In my opinion, Clinton and Obama suffer from a common defect. Each believes that she/he knows precisely what is wrong and exactly how the American people want their health care system to deliver services. My analysis is that they are wrong on both counts and that it would be better to start by having national bipartisan hearings to find out what is wrong and what the people want in the way of a health care system. Enough with the patriarchal approach - let's really have a sensible program for improvement founded in reality and the compromises which the American people will accept.

Words Do Count - As Lawyers Should Know

Senator Clinton is a Yale Law School graduate; Senator Obama is a Harvard Law School graduate. (I must acknowledge a bias towards HLS - my class was 1959.) Both of these respected institutions teach their students that words do count and lawyers must be experts at using words.

Clinton's web site (Obama will be discussed in a separate blog( has a summary of her health plan proposal: http://www.hillaryclinton.com/issues/healthcare/summary.aspx. As I read through it (fully recognizing that it is a "summary"), I noted the use of vague terms, weasel words, and few concrete definitions. The summary calls for ". . . affordable, quality health insurance" and reigning "in costs and to insist on value and quality." Clinton calls for a plan which "will secure, simplify and ensure choice in health coverage for all Americans. . . finally addressing the needs of the 47 million uninsured and the tens of millions of workers with coverage who fear they could be one pink slip away from losing their health coverage - with no overall increase in health spending or taxes." Magically, "For those with health insurance, the plan builds on the current system to give businesses and their employees greater choice of health plans - including keeping the one they have - while lowering cost and improving quality".

When I turn to Clinton's "americanhealthchoices.pdf" site, where the resources (savings related to existing spending) to pay for this utopian health care system are described, I find projected savings related to "Reducing Overpayments and New Efficiencies": $10 billion from Phase-outs of Excessive Medicare Overpayments to HMOs and Other Managed Care Plans; $7 billion in savings related to Unnecessary Medicare and Medicaid Spending; $4 billion in savings related to Constraints on Prescription Drug Costs; $35 billion in savings from Modernizing the Health System. I also find a projected $54 billion savings through "Limits on High-Income Tax Breaks". Add these together to get $110 billion which is a relatively small percentage of our $2 trillion plus current expenditure.

The words do not adequately describe the means for accomplishing the needed savings and new revenue sources Clinton's plan requires, nor do they address the practical means of accomplishing her proposed enormous task. Clinton has not just left herself wiggle room, her use of words belies her own belief in her ability to accomplish the health reform which America needs.