Taking Note

Positive Signs for Health Care Reform

Health care reform, the biggest piece of social legislation passed since 1965, is now the law of the land. This historic achievement is getting some positive reactions from the public now that the painful congressional process has finally ended and there is an actual piece of legislation to consider. Of course, much of the public is still uncertain about what exactly is in the bill and how it will affect them, but these early reactions are nevertheless encouraging. At minimum, they suggest that conservative predictions of a massive public uprising against health care reform were decidedly overwrought.

Consider these findings from a Gallup poll taken right after the House passed the Senate reform bill. In that poll, 49 percent said they thought it was a good thing that Congress passed a bill restructuring the nation’s health care system, compared to 40 percent who thought that was a bad thing. This plurality possibly reflects some individuals moving toward supporting the bill who previously had opposed it because it didn’t go far enough (about 10 to 15 percent of the public). This group, whose opposition to health care bills in Congress has stemmed from progressive rather than conservative priorities, is a plausible candidate for early increases in support generated by the new legislation.

Reflecting this judgment, 50 percent in the Gallup poll were either enthusiastic (15 percent) or pleased (35 percent) the House passed the health care bill, compared to 42 percent who said they were disappointed (23 percent) or angry (19 percent).

Ann Arbor's Spring and the Digital Age

Early spring in Ann Arbor is especially welcome this year after what even diehards acknowledge is winter’s dreariness (and the University of Michigan’s miserable showing in football and basketball). At the western end of a time zone, it is still dark and cold at 7:00 a.m. But when sunshine hits the campus greens, you can feel spirits revive. With temperatures in the mid-50s, the first classes convene outdoors. Nearby is some sort of madcap student competition. Of all Michigan’s regions, Ann Arbor has the lowest unemployment rate, at 9.3 percent. By the standards of a state with the most devastated economy in the country, the city of about 115,000 is the best-off in Michigan. Ann Arbor is also a microcosm of the upheaval under way in how information is being distributed in the digital age, as I discovered on what is an annual visit with the Knight-Wallace Fellowship for Journalists and senior book sales executives at Borders, the nation’s second-largest chain, which was founded there. Here is some of what I learned.

Immigration, Jobs, and the American Economy, Re-visited

Although the contentious last steps toward passage of President Obama’s health care reform package dominated last week’s headlines, it was not the only important debate taking place. On Sunday, March 21st, thousands of protesters attended an immigration reform rally in Washington, D.C., calling on legislators to overhaul the nation’s immigration system. The rally came days after President Obama publicly pledged to support the Bipartisan Immigration Reform Framework, advanced by Senators Chuck Schumer (D-NY) and Lindsey Graham (R-SC). The framework consists of four main proposals: biometric Social Security cards, to eliminate document fraud by illegal immigrants; strengthened border enforcement; a temporary work program; and a legalization path for those undocumented workers already in the United States.

Public Warms to Afghanistan Effort

President Barack Obama’s decision to send 30,000 more troops to Afghanistan but start withdrawing forces in 2011 was controversial when announced late last year. But the public appears to be warming to this effort.

Prior to the announcement back in November, just 36 percent thought the military effort in Afghanistan was going very or fairly well and 57 percent thought the effort was not going too well or not at all well. This month, a new Pew poll shows these figures almost reversed: Fifty-two percent now think the effort is going very or fairly well, while those with a negative judgment are down to 35 percent.

Reflecting this more positive assessment, Obama’s approval rating on handling the Afghanistan situation has also improved over the time period. Before the decision to send troops was made, 36 percent approved of his handling of Afghanistan, compared to 49 percent who disapproved. In the new Pew poll, his approval ratings have flipped to 51 percent approval and 35 percent disapproval.

Who is Don Berwick and What Will This Mean for Health Care Reform

The rumors that I wrote about Friday are, in fact, true. President Obama will name Dr. Donald Berwick, president of the Institute for Health Care Improvement (IHI), to run Medicare and Medicaid. Berwick, who is a professor of pediatrics and health care policy at the Harvard Medical School and a professor of health policy and management at the Harvard School of Public Health, will have to be confirmed by the Senate Finance Committee.

Just how tough will the confirmation hearing be? I’m not worried. Berwick can handle himself.

Granted, yesterday the New York Times called Berwick “iconoclastic,” i.e., someone who “smashes sacred religious images” or “attacks cherished beliefs.”   But most who know him describe him a “visionary” and a “healer,” a man able to survey the fragments of a broken health care system and imagine how they could be made whole.  He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. health care.

Whither Maliki?

I have a new piece over at Foreign Policy's Middle East Channel discussing Friday's announcement of official election results in Baghdad. While Allawi's narrow victory represents a major political realignment, he is far from assured of being selected as the prime minister-designate, and I believe the process itself will largely be driven by attitudes toward al-Maliki:

Former Prime Minister Iyad Allawi's electoral list narrowly edged the incumbent Prime Minister Nuri Maliki's State of Law alliance in the official (but uncertified) results of the March 7 elections announced today. The horse-trading and deal-making which will produce a new government will now accelerate. But to a very large extent, a little-noticed Federal Supreme Court decision yesterday drained the drama from today's announcement. Despite Allawi's winning two more seats than his rival, he may not get the chance to form a government. Allawi's chances of becoming Iraq's Prime minister will hinge largely on the question of how much Maliki's Shiite rivals really hate him...and how loyal his political allies will be if their Shiite co-religionists make his exit a condition to forming a government.

The performance of Allawi and his Iraqiyya list's performance represent a major, even stunning political realignment. But the Iraqi Supreme Court's ruling yesterday means that contrary to general belief, he is not guaranteed the first opportunity to form a government. The ruling hinges on the interpretation of Article 76 of the Iraqi constitution, which mandates that the new president authorize a prime minister-designate representing the largest parliamentary bloc to attempt to form a government. There has been some controversy over what this meant in practice. The Federal Supreme Court interpreted the clause broadly and decided that "largest parliamentary bloc" referred to any parliamentary bloc in existence at the time when the president makes his designation -- not to the lists which contested the election. If the court had ruled narrowly, then the razor-thin difference in seats would have had profound effects. As it stands,Maliki and Allawi now enter this next phase of horse-trading basically even.

You can read the whole thing here.

Dr. Don Berwick to Become Medicare Director?

Within the past hour  both New America Foundation’s Joanne Kenen and Wall Street Journal blog “Washington Wire” have reported the rumor—not yet confirmed—that President Obama has chosen Dr. Donald Berwick, the president and founder of the Institute for HealthCare Improvement (IHI) to become the new director of the Centers for Medicare and Medicaid (CMS).  Readers who have seen Money-Driven Medicine, the documentary based on my book will recognize Berwick’s name: he is one of the stars of the film.  (See clips of Berwick from the film, which is being distributed by California Newsreel here. )For more information on the film, go to www.moneydrivenmedicine.org.

Thursday, Inside Health Policy’s Brett Coughlin and Amy Lotven were the first to report the rumor : “According to several Washington sources . . . the White House has picked Harvard professor and pediatrician Donald Berwick to serve as CMS Administrator. A K Street source said that Berwick agreed to take the job ‘some time ago’ but only on the condition that health reform pass first. Although administration officials did not confirm the chatter, sources said that the announcement could come as soon as next week.” (via Politico Pulse)

Over-treating Birth? C-section Rates Hit an All-time High of 32%

The figures are alarming: The cesarean rate in this country has increased 50% since 1996; hitting an all-time high of 32% of all deliveries. What could possibly be fueling this dramatic rise in surgery?

The latest figures come from a report released yesterday by the National Center for Health Statistics
and have added more fire to an already simmering debate over the increased use of cesarean sections. Cesarean deliveries carry greater risks for mothers and newborns; require longer recovery times and incur hospital costs that are almost double those for a vaginal delivery, according to the report.

In the past, some medical groups have attributed the rise in c-sections to factors like older mothers and an increase in multiple births. But the NCHS report found that the rate of c-sections rose in all age groups between 1996 and 2007; with women under age 25 experiencing a 57% increase in cesarean deliveries, the largest increase of all. Increases were found across the board in all racial and ethnic groups and at all gestational ages. And surprisingly, the rate of c-sections for single births increased substantially more than cesarean rates for multiple births.

What the Health Care Reform Bill Will Mean for You and Your Family

Appearing on CNN yesterday morning, Senator Orrin Hatch (R, Utah) groused about what he called the “Europeanization” of health care. Translated, that means that we have decided to take a more collective approach to survival. If you cannot afford health insurance, your fellow citizens will help you pay for it.

Hatch is correct: in 2014, a family of four earning $88,200 (or four times the federal poverty level) will get a subsidy to help buy insurance in the new Exchanges. $88,200 may sound like a fortune if you live in Idaho (where median income for a family of four is $58,000), but in Maryland, Massachusetts, Connecticut, and New Jersey, $88,200 is actually less than median income for a family of four. Even in New Hampshire, median income for a family of four is $87,396. (Half of all families of four earn less; half earn more. In other words, a family that size bringing home $88,200 in New Hampshire is smack dab in the middle of the pack.)  See this fascinating table that shows median income for individuals as well as families including of two to six people in all fifty states. It’s startling to see how widely incomes vary in different parts of the country.

Glory Days and the Pentagon Papers

On June 13, 1971, the New York Times published the first explosive stories based on Pentagon studies of the decision-making that led the United States to war in Vietnam. After the Times was enjoined from publishing further, the Washington Post obtained much of the same material and produced its own stories. The Nixon administration, claiming a massive breach of national security, fought for restraint all the way to the Supreme Court, which on June 30, in the last opinion by Justice Hugo Black, decided 6–3 in favor of the newspapers. The outcome was a glorious victory for a robust press and launched an era of aggressive reporting about Washington. What a time it was.

While the excitement of what became known as the Pentagon Papers case was unfolding, I was on the other side of the world as a correspondent for the Washington Post based in Saigon. The high drama on the home front did not, as I recall, resonate on the fighting itself. Like so much about the conflict, the political and social turmoil in the United States operated on rhythms that meant little to the Vietnamese combatants and not a lot more to the GIs risking their lives on the battlefield. By 1971, the war in Vietnam had become so discredited in the minds of Americans that the country’s leaders were determined to get out, recognizing that in all likelihood a “decent interval” was the best that could be achieved before the Communists prevailed.