Wednesday, February 10, 2010

Obama looks for a way out of health care jam

Facing long odds and hardening public skepticism, President Obama is pushing forward with health care reform -- with a twist. In a speech to Democratic supporters, Obama laid out a new action plan for reform, calling on both parties in Congress work through existing legislation, then seek public input on what ideas work best. "It's important to have a methodical open process over the next several weeks, then let's go ahead and make a decision," Obama said.

But to a great extent, the public has already spoken on health care reform, with a range of polls showing a majority of Americans oppose the plan -- along with all Republican lawmakers.

Michael Cannon, a health policy expert at the Cato Institute, said Obama's new way forward is designed to fail. "They are not interested in public input because the public has opposed this since July, and they say they are open to Republican ideas but the Republicans' one idea is to kill the bill," Cannon said.

Instead, Obama's new way forward is better designed to appeal to his base -- Democratic Party loyalists disappointed over his handling of health care reform who still want to see it pass. Obama in his first year in office pinned much of his own political fortunes to passing health care reform. Appearing to give up the battle -- and handing Republicans a victory -- could be devastating to the Democratic Party in an election year.

Increasingly, Obama is challenging Republicans to put their ideas forward and be judged. "If Congress decides we're not going to do it, even after all the facts are laid out, all the options are clear, then the American people can make a judgment as to whether this Congress has done the right thing for them or not," Obama said.

But the risk in that for Obama is once again the polls. Having soured public opinion on health care reform, doubling back and winning converts is unlikely. Asking lawmakers to devote more time to an unpopular issue also is not likely to go over well.

Both Obama and Democratic leaders in Congress say they plan to focus on a jobs bill first. House Speaker Nancy Pelosi, who has never fully abandoned health care reform, nevertheless said moving forward will be tough. "I think that all of these things are a very heavy lift," Pelosi said. "Everything good that has been done, whether it is Social Security, Medicare, now health care reform, all have been difficult. It is never easy."

The reform effort was dealt a fatal setback when Scott Brown, a Massachusetts Republican, was elected to the late Sen. Edward M. Kennedy's seat. Brown, who ran against Obama's reform plan, effectively deprived Democrats of their filibuster-proof 60-vote majority in the Senate, which was their only hope for passing comprehensive reform. A subsequent plan to reform health care in smaller, bite-size increments has failed to generate much enthusiasm amid polls showing voters' top concerns are jobs and the economy.


Republicans may opt out of Obama's health-care summit

Leading House Republicans raised the prospect Monday night that they may decline to participate in President Obama's proposed health-care summit if the White House chooses not to scrap the existing reform bills and start over.

In a letter to White House Chief of Staff Rahm Emanuel, House Minority Leader John A. Boehner (Ohio) and Minority Whip Eric Cantor (Va.) expressed frustration about reports that Obama intends to put the Democratic bills on the table for discussion at the summit, which would be held Feb. 25. "If the starting point for this meeting is the job-killing bills the American people have already soundly rejected, Republicans would rightly be reluctant to participate," Boehner and Cantor wrote.

Obama proposed the half-day summit on national television Sunday, but in their letter, the two GOP leaders offer their suspicion that the president is not serious about opening bipartisan negotiations on health-care reform. " 'Bipartisanship' is not writing proposals of your own behind closed doors, then unveiling them and demanding Republican support," Boehner and Cantor wrote. "Bipartisan ends require bipartisan means."

White House press secretary Robert Gibbs responded by saying that Obama has sought Republican input since early last year, and that the president remains interested in hearing ideas that the GOP thinks will advance the reform cause.

But he appeared to give little ground on the idea that Obama might abandon the months of work that produced Democratic bills that passed the House and the Senate late last year. "He's been very clear about his support for the House and Senate bills because of what they achieve for the American people: putting a stop to insurance company abuses, extending coverage to millions of hardworking Americans, getting control of rising premiums and out-of-pocket costs, and reducing the deficit," Gibbs said in a statement.

He added: "The president looks forward to reviewing Republican proposals that meet the goals he laid out at the beginning of this process, and as recently as the State of the Union address. He's open to including any good ideas that stand up to objective scrutiny. What he will not do, however, is walk away from reform and the millions of American families and small businesses counting on it."


Clinton-era health aides push to save Obama's plan

Shock and awe. That's what survivors of the Clinton-era health care collapse are feeling as President Barack Obama's overhaul legislation wobbles in Congress. Aides who shaped Bill and Hillary Rodham Clinton's 1990s plan to cover all Americans, then labored in vain to pass it into law, are adamant that the Democrats can't afford another health care disaster. But they're divided on whether scaling down Obama's plan would be an acceptable solution.

The Clintonistas _ now in think tanks, universities, serving in the Obama administration or lobbying _ are a potent voice in the furious debate within the Democratic Party over how to salvage health care. Listened to because they're the veterans of the last health care policy war, they carry the scars of intense striving reduced to utter futility.

"If Bill Clinton couldn't get it done, and Barack Obama can't do it, no Democrat will ever try again," said economist Len Nichols, health policy director at the New America Foundation. A Clinton White House health budget aide, Nichols has been operating as an unofficial adviser to lawmakers and administration officials wrestling with details of the current legislation.

"History is written by the victors, not the vanquished," said Chris Jennings, congressional liaison for then-first lady Hillary Clinton during the 1990s debate. "Failure would serve as the ultimate judgment as to whether this effort was worth doing." Jennings, now a lobbyist, replaced Ira Magaziner, principal architect of the Clinton plan, as White House health policy adviser.

The former first lady, now secretary of state, says "it's really hard" watching the travails of Obama's plan. Hillary Clinton has been giving advice, as requested, to lawmakers in Congress and administration officials, and says she's still hopeful. "I'm not sure that this last chapter has been written," she told CNN's "State of the Union" on Sunday.

For most of last year, the health care debate was among Democrats. Republicans were left heckling from the sidelines. That changed when Republican Scott Brown pulled off a Senate upset in Massachusetts, winning the seat held by the late Sen. Edward M. Kennedy and depriving Democrats of the 60-vote majority they were counting on in the final push. "Many of us thought we were really at the 1-inch line, then literally it was like being hit by a freight train with about 10 seconds' warning," said Ken Thorpe, a senior Health and Human Services official during the Clinton-era debate. Now a health policy professor at Emory University in Atlanta, Thorpe has proposed a scaled-back alternative in case Obama's plan can't get unstuck.

The mere mention of settling for less is causing consternation among former Clinton aides. Obama's health care plan _ denounced as a government power grab by critics _ is already scaled back from the ambition of the Clinton years.

Clinton would have changed how people covered by large employers got health insurance; Obama does not. Clinton required all employers to contribute significantly to the cost of coverage; Obama exempts small businesses. Clinton aimed at insuring all; Obama's plan reaches around 95 percent of eligible Americans. Today's Senate bill _ supported by Obama _ resembles a plan drafted by a moderate Republican senator in the Clinton years.

"It takes too much work to figure out what 'scaled back' means," said Judy Feder, a former colleague of Thorpe's at human services, now a health policy professor at Georgetown University in Washington. "You can't do insurance reforms alone without expanding coverage, and the expansion costs money. I don't see the politics coming together for scaling back."

The Obama plan focuses on those who have the most trouble getting and keeping health insurance, small businesses and people who buy their own coverage. They would be able to buy private coverage in a new kind of regulated marketplace, with government subsidies for many. Insurers would be prohibited from turning down people with medical problems. Most Americans would be required to carry health insurance. "We are using the private insurance market and private incentives, as opposed to command-and-control," said Nichols. "As a policy matter, we are in the middle."

Thorpe's proposal for scaling down Obama's plan would keep the new insurance marketplace and the ban on excluding people with health problems. It would chop the cost from $1 trillion to $500 billion over 10 years, covering about one-third fewer people than Obama. Thorpe said he hopes if the Democrats can't get Obama's bill, "we don't do like 1994 _ all or nothing."

Obama has sent mixed signals. Early after the Massachusetts defeat, he raised the possibility of scaling back. Then he insisted he still wants a comprehensive approach. Last Thursday, Obama publicly raised the prospect that Congress might not act at all. Sunday, he invited GOP and Democratic leaders to discuss possible compromises in a televised gathering later this month.

The Democrats' reversal "is like a big body blow," said Jennings. "You either stammer and fall down, or you stammer and regain your balance. What Americans respect are those people who can take a punch and come back."


British Leftist hatred of drug companies is very bad for Britons

By Jonathan Waxman, Professor of Oncology at Imperial College London

It wasn’t such a long time ago that we died from what are now considered to be trivial illnesses. Simple infections carried enormous numbers of people to ghastly deaths; cancer wasn’t treatable, and many suffered terribly from chronic diseases.

The advances that have been seen in the lifetime of today’s middle-aged are incredible. Antibiotics only became available during the Second World War, medicines for peptic ulcer appeared in the 1970s and treatment for cancer came into existence just 50 years ago. If Jane Austen had been around today she would have survived tuberculosis, and been up for the Booker, while Mozart would have got over cholera but would not be competing in The X Factor.

Today it is unusual to see people die in the industrialised world from diphtheria or pneumonia, and we are at the edge of developing effective therapies for Alzheimer’s, multiple sclerosis, rheumatoid arthritis and diabetes.

But where do these marvellous advances originate from? Not, as you might imagine, from the golden glades of the University of Arcadia. The universities have elaborated hypotheses and elucidated mechanisms, but it is the profit motive and the market that have been responsible for these life-improving changes. Big Pharma, that boggle-eyed devil in the undergrowth, has brought forward virtually all the drugs that make our lives liveable.

In cancer, for example, perhaps three agents have come from university laboratories — all the rest have been produced by drug companies. And drug development is big business. On average it takes 14 years and costs £1 billion to bring a drug to market. One successful blockbuster drug can make billions in profit and fuels the next generation of research for a new profit-making blockbuster.

The general view is that drug companies are populated by dodgy villains and squint-eyed knaves in sharkskin suits, out to deceive by falsifying clinical evidence, there just to make a buck. This prejudice has perhaps been reinforced by scandals such as the suppression of information about the adverse, possibly fatal, side-effects of Vioxx, which led Merck to fork out damages of $4.8 billion. But that is unusual.

The bottom line does matter to the drug industry — and Britain has created a regulatory environment that makes it harder for them to make money and produce the drugs that we depend upon.

The process for approving drugs in the UK is slow, costly and bureaucratic. A new drug will first be licensed by the EMEA, the European drugs agency. Then, the Department of Health will set a time course for the National Institute for Health and Clinical Excellence to evaluate that new drug. NICE’s evaluation standard is a matter of great despair to patients and clinicians. Why do we despair? Not because we think that there is an unlimited public purse, and not because we think that Pharma profit should be unregulated. Our despair takes its origin from the unscientific and subjective basis for NICE judgments.

NICE evaluations are based on a complex, pseudoscientific formula that attempts to calculate the benefit of a year’s treatment or therapeutic intervention in terms of a year of a patient’s quality-adjusted life or, to use the acronym, QALY. The term QALY casts an illusion of apparent objectivity to NICE’s conclusions.

Here is one of the ways that the QALY is calculated. Imagine that you have ten years left to live. You can choose to live it in your current state or give up some years to live in full health. Mark on the line the number of years in full health that you think is of value to ten years in your current state. If the patient puts that mark at eight years the QALY is 0.8. The formula then takes into account the cost of a whole year of treatment.

But doctors have trouble with this idea of a year’s worth of treatment. For many patients, treatment under a particular drug regime might be just for a couple of months. This is because the drugs might only benefit a third of patients treated; so for unresponsive patients treatment is stopped. That is part of the reason why the QALY calculation is a joke.

At present only 40 per cent of new drugs are considered within the timeframe set as a standard by the Government. During this timeframe, the countdown ticks inexorably towards the expiry of the drug companies’ patent. The UK market is a small fraction of the total market for drug sales — currently about 3.5-4 per cent of global drug sales. Pharma is losing patience with “process”. Many new drugs are not being put up to NICE, and we are in the position now where the UK will be excluded from using new drugs simply because Pharma doesn’t consider us a financially worthwhile market.

This particularly matters at the moment because drug companies are feeling the pinch and having to cut costs. AstraZeneca, which is losing 8,000 jobs worldwide, and GlaxoSmithKline, which is cutting its workforce by 4,000, are both looking at waste-of-time investments.

We mustn’t be a waste-of-time country for the drug company market analysts. That’s why we need to overhaul NICE before the regulator ensures that the British people don’t receive the best medicine on the market.


"High" standards at an Australian public hospital

And a government that refuses to do anything about it

A SENIOR nurse was undergoing emergency surgery last night after slipping in a puddle caused by a leaking vent at the decaying Hornsby hospital. Her fall came two months after orders were given to hide the crumbling, water-damaged ceiling by painting over it.

Last year angry doctors called the rundown hospital "offensive and mediaeval", and complained of possum urine on the walls, dangerous cables across floors, and ceilings collapsing from rain damage. They have run a campaign to have the hospital rebuilt and say they were stunned to see a tradesman painting over the water damage in December.

In the latest incident, Andrea Walters, 54, who said staff had been mopping up water from leaking ceilings in her ward for 16 years, was finishing her shift in the operating theatres on Sunday night when she slid in the puddle. She landed heavily on her side, shattering her right arm. Doctors fear she will need a partial joint reconstruction and a nerve graft. She is expected to be off work for at least three months.

The head of the hospital's medical staff council, Richard Harris, said yesterday: "We are very cranky and upset about this, particularly as the rain marks were painted over … We haven't seen any evidence the state government is taking this issue seriously, and we now demand action."

Dr Harris said the Health Minister, Carmel Tebbutt, was shown several buckets under the vent during a visit in October. They were put in place after Sydney received 27 millimetres of rain in two days. She had asked how staff managed to move patients from the operating theatres to wards through open corridors in bad weather. "She was told it was a nightmare," Dr Harris said, "but nothing was done."

On Sunday two garbage bins and eight towels were put under the vent to catch the rain. They were removed when the leaking subsided, but another downpour about 9pm flooded the floor and caught Ms Walters unaware. "This was totally avoidable," she said. "The [leak] has been placed in the too-hard basket, and it should have been fixed. I haven't got a little bruise, I've got a life-changing injury."

A clinical nurse specialist who has worked at the hospital for 23 years, Ms Walters said she now feared she could lose her house because nurses do not receive penalty rates - which make up a large portion of their income - while on worker's compensation.

A spokesman for the Northern Sydney Central Coast Area Health Service said theatre staff reported the leak on October 26 and the ceiling was repaired two days later. Aesthetic repairs, including painting, were done on December 17. Maintenance staff were working to fix the leak, but there were no plans to replace the roof, she said.

An independent review, the sixth in 30 years, this week found the hospital to be unsafe. The review, part of a redevelopment master plan, found the theatres were a fire risk, surgical and medical wards were cramped and did not allow for effective clinical supervision; and bathrooms, nursing stations and storage areas were too small. It said the hospital needed painting, asbestos removed and its roofs repaired.


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