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The Final Push

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Policy analysts are focusing now on the cost to the health care system and the nation of doing nothing (see the New York Times's Week in Review section, 2.28.10). But many of the 535 men and women whose votes will determine the outcome on health care reform -- especially those whose votes are uncertain as of now -- will concentrate on the political cost to them.

In that calculus, they will weigh 2 main dimensions: the politics in their districts or states and the persuasiveness of party leaders in the House and Senate. Freshmen elected from non-traditionally Democratic districts in the Obama landslide of 2008 are particularly vulnerable. So are Senators up for reelection in states that are not reliably blue. They face not only the presumed wishes of tax-averse, small-government constituents, but also the considerable force of the insurers, pharmaceutical companies and other economic interests most affected by the legislation. Arrayed against those powerful elements are the skills of Nancy Pelosi and Harry Reid. Although the outcome is uncertain, it would be wise not to count them out. Remember that, under their leadership, this Congress passed comprehensive health reform bills, which happened only once before in our history, when Lyndon Johnson's Congress passed Medicare and Medicaid in 1965.

The corollary is that if the House doesn't pass the Senate bill and then the 2 pass an adjustment using reconciliation, it will be many years before anyone will tackle comprehensive reform again. So, as the policy analysts quoted in the Times made clear, the stakes are high. If we do nothing, the system will continue to deteriorate and our ability to access it and benefit from it, whether or not we are insured, will decline.

A third force, if mobilized effectively, has the potential to turn the tide in favor of reform. That is the public's dissatisfaction with the current system. One problem is that the voters among them tend still to have good coverage. Not only are they afraid of losing it, but their ability to get exercised by a bill whose main goal is poorly understood health system reform is limited.

So, we need a concerted campaign. What will engage the public? Here are three ideas: first, emphasize the degree to which their present good coverage is at risk; second, detail the horrific behavior of private insurers under the current system; and third, show them that the delivery system itself is losing its ability to put patients first because of the degree to which it is dominated by the rules of private insurers.

All three points are captured dramatically in the heart-wrenching insurance nightmare of a retired New York Times reporter and editor. After saying it is "far easier to deal with my disease than with my insurers," Janet Battaile described in detail her encounters with United Healthcare, one of the nation's largest and most profitable. She had trouble even getting to talk with a person, and then was told by more than one that someone else was the person to help, transferring her to another who turned out to be even less helpful. United Healthcare has a bureaucracy as byzantine as any in the mythology of the federal government. Another astounding fact is the absolute ignorance of some of the people United Healthcare puts on the phone to deal with customers. Not only do they not know answers to questions and to whom to refer clients, they don't know terms that anyone in the health field should know, like what a clinical trial is. The story is so damning some might believe United Healthcare does it deliberately to make it impossible for patients to access services the company will need to pay for.

The author closes with a counterpoint: what happened when she and her husband encountered two other large bureaucracies. Signing up for Social Security took 15 minutes, and her checks come "like clockwork." He signed up for Medicare. "Same experience. No problems, no complaints. This is your government at work. Some bureaucrats know how to get it right."