- Email: [email protected]
Health care reform: Is the process the outcome?
Clinical Therapeutics
Editorial Health Care Reform: Is the Process the Outcome? The Pharmaceutical Economics & Health Policy section of this journal features empiric articles, editorials, and occasional commentaries to support evidence-based communications, all of them peer reviewed for relevance, technical accuracy, clarity, and objectivity. However, despite the availability of objective information both here and elsewhere, objectivity does not seem to figure in much of the media coverage of the current health care reform debate. It is clearly not the cumulative objective evidence that has generated the extreme passions surrounding health care reform. National health expenditures per capita increased 123% between 1990 and 2004,1 but it was not this that evoked such intensity. The numbers of the uninsured are substantial and have been increasing for years without arousing anything like the present turmoil. So, why is health care reform so contentious, and what is the role for evidence-based pharmaceutical economics and health policy? Rates of unemployment in the United States increased from 4.8% in February 20082 to 7.2% in December 20083 and 9.7% in August 2009,4 a 102% increase in 18 months. Under a system of employment-based health insurance, this magnitude of unemployment threatens or eliminates health insurance for millions. However, the fact of employment no longer guarantees health benefits: the percentage of firms offering health benefits declined from a high of 69% in 2000 to 63% in 2008.5 Americans’ domestic concerns are now dominated by the economy (33%), health care (25%), unemployment and jobs (14%), and the federal debt (7%).6 The Kaiser Family Foundation has estimated that each 1-point increase in the national unemployment rate produces an additional 1.1 million uninsured and an additional 1 million Medicaid and State Children’s Health Insurance Program enrollees.7 Trends in health care costs also pose a substantial threat to employers. From 16% of the gross domestic product in 2007, health care costs are projected to reach 25% by 2025, threatening the competitiveness of US businesses and the fiscal soundness of federal, state, and local governments.8 Financial crises, declines in employmentbased health insurance for those still employed, and the loss of health insurance by those in the growing ranks of the unemployed have converged to make the health care status quo unacceptable to many citizens. Public Opinion Strategies, LLC, the firm whose research contributed to the “Harry and Louise” campaign that helped defeat the Clinton Administration’s Health Security Act of 1993, reported that by June 2007, 36% of voters endorsed “the need for radical change in the U.S. health care system,” and about half supported reform.9 Support for radical change came from 45% of Democrats, 43% of Independents, and 20% of Republicans. In the 2008 presidential election, voters elected a candidate whose central campaign theme was change; however, the details of that change have been slower to emerge than the opposition to it. The clarity of the election results are in stark contrast to the melee that took place during the congressional recess, when McCarthy et al,10 writing in the Congressional Quarterly, observed that “as politicians and interest groups try to shape the outcome of the healthcare overhaul, they’ve offered interpretations that are so wildly different that truth sometimes seems to be taking a vacation.” Examining a dozen major talking points in the media coverage of health care reform, the authors concluded that 5 were demonstrably false, 6 were misleading, and 1 was true. An article in Newsweek magazine was more blunt, referring to “the five biggest lies in the health care debate.”11 When so much valid information is available from unbiased and peer-reviewed sources, why is the debate dominated by highamplitude but demonstrably false claims? Given the current approach to health policy and reform, the question posed by a 2004 editorial in this journal—“Evidence- or Opinion-Based Pharmaceutical Policy?”12—remains relevant today. Paul Grenier, writing in The Baltimore Sun, has asserted that “what we need…are not labels, but analysis.”13 Political theater is taking the place of the genuine work of crisis resolution. Only incomplete health care reform legislation had been drafted by the end of July 2009. Separate House committees had issued 3 marked-up bills, and only 1 Senate committee had completed its work.14 The remaining committee with jurisdiction, the Senate Finance Committee, was still negotiating as the August recess began. Plotted over time, health care costs form an 2014
Volume 31 Number 9
Editorial upward-sloping cost curve; moderating them would, in the language of the current debate, “bend the cost curve.”15 The Administration’s acknowledged precondition for reform—that legislation bend the cost curve— implies that even if the result is not a zero sum, there will be winners and losers. According to Douglas W. Elmendorf, director of the nonpartisan Congressional Budget Office, the legislation introduced earlier in the summer lacked the “fundamental changes that would…reduce the trajectory of federal health spending by a significant amount.”16 The emotional milieu is not conducive to applying a rational process to bridging the gap between the goal of reducing long-term cost growth and the reality of legislation that falls short of that goal.17 Instead of bending the cost curve, politics is bending the facts. The experience of 5 previous endeavors at health care reform, 2 during Democratic administrations and 3 during Republican administrations, is instructive. These were the original Great Society programs that established the Medicare (Title XVIII) and Medicaid (Title XIX) programs under the Social Security Amendments of 1965; the 1972 expansion of Medicare coverage to include end-stage renal disease (ESRD); the Medicare Catastrophic Coverage Act (MCCA) of 1988; the Health Security Act of 1993 (President Clinton’s comprehensive health care reform initiative); and the Medicare Modernization Act of 2003. Each provides a partial lesson regarding the pursuit of health care reform. Passage of the original Medicare and Medicaid legislation has been attributed to President Johnson’s mastery of the legislative process and skill in wielding political power.18,19 Passing this legislation came at long-term political cost to the Democratic Party. The 7 years that followed saw unsuccessful attempts to include broader Medicare coverage, specifically for ESRD—a fatal condition for which a treatment existed. The inclusion of ESRD treatment under Medicare benefits was finally achieved through a late amendment to another bill and received only a half hour of debate. This peremptory action reflected the influence of Representative Wilbur Mills (D-AR), head of the House Ways and Means Committee, spurred by a 1971 session he had chaired at which an ESRD patient was dialyzed.20 The MCCA grew out of the work of the Bowen Commission, which was created by President Reagan to examine the costs of catastrophic medical conditions and the questions posed by these costs. The legislation that was eventually passed was guided by 2 main principles: that catastrophic coverage was the main benefit, and that intergenerational transfer was not an option—funding would be based on means testing and intragenerational premium differentiation. Of course, the first principle ensured that in any given year, a minority of beneficiaries would receive direct benefit, although many might be required to pay into the fund. In a nearly unprecedented action, the MCCA was rescinded on October 4, 1989, less than 2 years after being enacted by Congress. In fact, the fate of the MCCA was determined as much by how, when, and by whom information was presented as by what it contained.21 Two generally accepted lessons were derived from the failure of the Clinton Administration’s approach to health care reform, which was described as handing Congress “a 1300-page bill that had taken months to draft in the isolation of the White House office complex.”22 The first lesson is that the President should define and the Administration focus on broad principles, leaving the legislative details to Congress. The second is that there should be as many stakeholders at the table as feasible, even though some would be in opposition to particular provisions of a proposed bill.23–25 However, James Fallows, writing in the online edition of The Atlantic Monthly, sought to refute the notion that the Clinton plan was developed without extensive stakeholder input, citing a report in the Congressional Quarterly that 572 separate organizations had been consulted (even though the American Medical Association and the Pharmaceutical Research and Manufacturers of America were not represented).26 He noted that exclusion of the Washington press corps and an absence of details as planning progressed led to adverse coverage of the legislation during its formative stages. Furthermore, Fallows found that the Administration’s abandonment of its stated priority of controlling health care costs lost the plan additional support, citing an emphasis in the rollout on “health care that’s always there” and omission of the cost-control goal. The Medicare Modernization Act of 2003, which added the prescription drug benefit, was passed by a Republicanmajority legislature under a Republican president. Its success was described in the New England Journal of Medicine as “a pure power play.”27 The suggestion of overt political machinations in this instance, as well as in the September 2009
2015
Clinical Therapeutics foregoing examples, leads to the question of whether an evidence-based approach can ever survive in such a politically charged environment. Uncertainty may represent an additional challenge to rational evaluation of the costs and benefits of new programs, as risk aversion assumes greater significance for more comprehensive changes. The development of the Medicare program—which was incremental—offers a useful contrast to present and past attempts to achieve near-universal health care coverage in a single piece of legislation. Martha Derthick, a historian of US social programs, has observed that health care reform advocates changed their tactics by substituting an “incremental approach…for a comprehensive one”28 after the failure of successive Wagner–Murray– Dingell proposals for universal health care during the Roosevelt and Truman administrations. Breaking with this incremental approach in April 1974, Representative Mills and the late Senator Edward Kennedy (D-MA) introduced legislation to expand the government’s role as the single payer beyond Medicare and Medicaid through universal coverage of health care expenses over $1000 per family—a middle ground between President Nixon’s proposal for mandatory employer-provided health insurance and the Kennedy–Griffiths Health Security Bill mandating a governmental health system.29 Failure of the Kennedy–Mills bill was attributed to organized labor’s insistence on a full governmental health system and its unwillingness to “take half.”30 A similar all-or-nothing approach may be ascribed to the Clinton Administration’s attempt at health care reform, which would have largely replaced the existing system rather than building on it. Given the range and intensity of preferences regarding health care reform, it is particularly crucial that the basis for discussion be as objective and valid as possible. However, the 24/7 news cycle and the sound bites that pass for commentary are not sufficient to clarify or present a nuanced view of the main issues in the debate on health care reform. For evidence-based policy to predominate, it will require more outreach from the community of applied researchers and accurate translation of the evidence for nontechnical audiences. Ed Gibson, PhD School of Public Affairs University of Baltimore Baltimore, Maryland Alan Lyles, ScD, MPH, RPh Section Co-Editor
REFERENCES 1. The Henry J. Kaiser Family Foundation. Trends and indicators in the changing health care marketplace. Exhibit 1.2: National health expenditures per capita, 1990–2004. http://www.kff.org/insurance/7031/ti2004-1-2.cfm. Accessed September 13, 2009. 2. Bureau of Labor Statistics, US Dept of Labor. The employment situation: April 2008. http://www.bls.gov/news.release/ archives/empsit_05022008.pdf. Accessed September 13, 2009. 3. Bureau of Labor Statistics, US Dept of Labor. The employment situation: December 2008. http://www.bls.gov/news.release/ archives/empsit_01092008.pdf. Accessed September 13, 2009. 4. Bureau of Labor Statistics, US Dept of Labor. The employment situation: August 2009. http://www.bls.gov/news.release/pdf/ empsit.pdf. Accessed September 13, 2009. 5. The Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Employer health benefits: 2008 Annual survey. Exhibit 2.1: Percentage of firms offering health benefits, 1999–2008. http://ehbs.kff.org/pdf/7790.pdf. Accessed September 13, 2009. 6. Morales L. Economy declines further as top problem; healthcare rises. August 14, 2009. http://www.gallup.com/poll/122339/ Economy-Declines-Further-Top-Problem-Healthcare-Rises.aspx. Accessed September 13, 2009. 7. The Henry J. Kaiser Family Foundation. Data spotlight: Unemployment’s impact on uninsured and Medicaid. http://www.kff. org/charts/042808.htm. Accessed September 13, 2009. 8. Congressional Budget Office. Budget options, volume 1: Health care. December 2008. http://www.cbo.gov/ftpdocs/99xx/ doc9925/12-18-HealthOptions.pdf. Accessed June 18, 2009. 9. McInturff WD, Weigel L. Déjà vu all over again: The similarities between political debates regarding health care in the early 1990s and today. Health Aff (Millwood). 2008;27:699–704. 10. McCarthy M, Armstrong D, Wayne A. Vetting the health care rhetoric. CQ HealthBeat News. August 24, 2009. http://www.
2016
Volume 31 Number 9
Editorial
11. 12. 13. 14. 15.
16. 17. 18. 19. 20. 21. 22. 23.
24. 25. 26. 27. 28. 29. 30.
cq.com/display.do?dockey=/cqonline/prod/data/docs/html/hbnews/111/hbnews111-000003193921.html@allnews& metapub=CQ-HBNEWS&searchIndex=3&seqNum=2&productId=5. Accessed September 13, 2009. Begley S. The five biggest lies in the health care debate. Newsweek. August 29, 2009. http://www.newsweek.com/id/214254. Accessed September 13, 2009. Lyles A. Evidence- or opinion-based pharmaceutical policy? Clin Ther. 2004;26:1922–1923. Grenier PR. Mob rule takes over the health debate. The Baltimore Sun. August 12, 2009. http://www.baltimoresun.com/news/ opinion/oped/bal-op.mob12aug12,0,6284701.story. Accessed September 13, 2009. Pear R, Herszenhorn DM. Health bill clears hurdle and hints at consensus. The New York Times. July 31, 2009. http://www. nytimes.com/2009/08/01/health/policy/01health.html. Accessed August 1, 2009. Antos J, Bertko J, Chernew M, for The Engelberg Center for Health Care Reform at Brookings. Bending the curve: Effective steps to address long-term health care spending growth. August 2009. http://www.brookings.edu/reports/2009/0901_btc.aspx. Accessed September 10, 2009. Pear R. House committee approves health care bill. The New York Times. July 16, 2009. http://www.nytimes.com/2009/07/17/ us/politics/17cbo.html. Accessed July 16, 2009. Harwood J. The Caucus: Tumultuous environment makes a health care compromise more unlikely. The New York Times. August 9, 2009. http://www.nytimes.com/2009/08/10/us/politics/10caucus.html. Accessed August 12, 2009. Caro RA. The Path to Power (The Years of Lyndon Johnson, Volume 1). New York, NY: Vintage; 1990. Caro RA. Master of the Senate: The Years of Lyndon Johnson. New York, NY: Vintage; 2003. Iglehart JK. The American health care system. The End Stage Renal Disease Program. N Engl J Med. 1993;328:366–371. Moon M. Medicare Now and in the Future. 2nd ed. Washington, DC: Urban Institute Press; 1996. Obama missteps confuse health overhaul: There’s no indication his strategy is working better than Clinton approach. Associated Press. July 22, 2009. http://www.msnbc.msn.com/id/32091708/ns/politics-white_house/. Accessed July 23, 2009. Hamburger T. Obama gives powerful drug lobby a seat at healthcare table: The pharmaceutical industry, once condemned by the president as a source of healthcare problems, has become a White House partner. Los Angeles Times. August 4, 2009. http:// www.latimes.com/news/nationworld/nation/la-na-healthcare-pharma4-2009aug04,0,3156176.story. Accessed August 4, 2009. Obama gets ally for health care plan: Wal-Mart. In a letter, retailer says it embraces employer coverage mandate proposal. Associated Press. June 30, 2009. http://www.msnbc.msn.com/id/31667110/ns/business-consumer_news/. Accessed July 1, 2009. Top senator, hospitals near health care deal. Under agreement, hospitals would accept lower-than-anticipated payments. Associated Press. July 6, 2009. http://www.msnbc.msn.com/id/31767218/ns/politics-capitol_hill/. Accessed July 7, 2009. Fallows J. A triumph of misinformation. The Atlantic Monthly Digital Edition. January 1995. http://www.theatlantic.com/politics/ healthca/hcfallow.htm. Accessed September 13, 2009. Iglehart JK. The new Medicare prescription-drug benefit—a pure power play. N Engl J Med. 2004;350:826–833. Derthick M. Policymaking for Social Security. Washington, DC: Brookings Institution; 1979. Rivlin AM. Agreed: Here comes national health insurance. The New York Times Magazine. July 21, 1974:8. Oral history collection. Robert M. Ball—interview #1. January 29, 2001. http://www.socialsecurity.gov/history/orals/ball1. html. Accessed September 13, 2009.
doi: 10.1016/j.clinthera.2009.09.004
September 2009
2017
Editorial Health Care Reform: Is the Process the Outcome? The Pharmaceutical Economics & Health Policy section of this journal features empiric articles, editorials, and occasional commentaries to support evidence-based communications, all of them peer reviewed for relevance, technical accuracy, clarity, and objectivity. However, despite the availability of objective information both here and elsewhere, objectivity does not seem to figure in much of the media coverage of the current health care reform debate. It is clearly not the cumulative objective evidence that has generated the extreme passions surrounding health care reform. National health expenditures per capita increased 123% between 1990 and 2004,1 but it was not this that evoked such intensity. The numbers of the uninsured are substantial and have been increasing for years without arousing anything like the present turmoil. So, why is health care reform so contentious, and what is the role for evidence-based pharmaceutical economics and health policy? Rates of unemployment in the United States increased from 4.8% in February 20082 to 7.2% in December 20083 and 9.7% in August 2009,4 a 102% increase in 18 months. Under a system of employment-based health insurance, this magnitude of unemployment threatens or eliminates health insurance for millions. However, the fact of employment no longer guarantees health benefits: the percentage of firms offering health benefits declined from a high of 69% in 2000 to 63% in 2008.5 Americans’ domestic concerns are now dominated by the economy (33%), health care (25%), unemployment and jobs (14%), and the federal debt (7%).6 The Kaiser Family Foundation has estimated that each 1-point increase in the national unemployment rate produces an additional 1.1 million uninsured and an additional 1 million Medicaid and State Children’s Health Insurance Program enrollees.7 Trends in health care costs also pose a substantial threat to employers. From 16% of the gross domestic product in 2007, health care costs are projected to reach 25% by 2025, threatening the competitiveness of US businesses and the fiscal soundness of federal, state, and local governments.8 Financial crises, declines in employmentbased health insurance for those still employed, and the loss of health insurance by those in the growing ranks of the unemployed have converged to make the health care status quo unacceptable to many citizens. Public Opinion Strategies, LLC, the firm whose research contributed to the “Harry and Louise” campaign that helped defeat the Clinton Administration’s Health Security Act of 1993, reported that by June 2007, 36% of voters endorsed “the need for radical change in the U.S. health care system,” and about half supported reform.9 Support for radical change came from 45% of Democrats, 43% of Independents, and 20% of Republicans. In the 2008 presidential election, voters elected a candidate whose central campaign theme was change; however, the details of that change have been slower to emerge than the opposition to it. The clarity of the election results are in stark contrast to the melee that took place during the congressional recess, when McCarthy et al,10 writing in the Congressional Quarterly, observed that “as politicians and interest groups try to shape the outcome of the healthcare overhaul, they’ve offered interpretations that are so wildly different that truth sometimes seems to be taking a vacation.” Examining a dozen major talking points in the media coverage of health care reform, the authors concluded that 5 were demonstrably false, 6 were misleading, and 1 was true. An article in Newsweek magazine was more blunt, referring to “the five biggest lies in the health care debate.”11 When so much valid information is available from unbiased and peer-reviewed sources, why is the debate dominated by highamplitude but demonstrably false claims? Given the current approach to health policy and reform, the question posed by a 2004 editorial in this journal—“Evidence- or Opinion-Based Pharmaceutical Policy?”12—remains relevant today. Paul Grenier, writing in The Baltimore Sun, has asserted that “what we need…are not labels, but analysis.”13 Political theater is taking the place of the genuine work of crisis resolution. Only incomplete health care reform legislation had been drafted by the end of July 2009. Separate House committees had issued 3 marked-up bills, and only 1 Senate committee had completed its work.14 The remaining committee with jurisdiction, the Senate Finance Committee, was still negotiating as the August recess began. Plotted over time, health care costs form an 2014
Volume 31 Number 9
Editorial upward-sloping cost curve; moderating them would, in the language of the current debate, “bend the cost curve.”15 The Administration’s acknowledged precondition for reform—that legislation bend the cost curve— implies that even if the result is not a zero sum, there will be winners and losers. According to Douglas W. Elmendorf, director of the nonpartisan Congressional Budget Office, the legislation introduced earlier in the summer lacked the “fundamental changes that would…reduce the trajectory of federal health spending by a significant amount.”16 The emotional milieu is not conducive to applying a rational process to bridging the gap between the goal of reducing long-term cost growth and the reality of legislation that falls short of that goal.17 Instead of bending the cost curve, politics is bending the facts. The experience of 5 previous endeavors at health care reform, 2 during Democratic administrations and 3 during Republican administrations, is instructive. These were the original Great Society programs that established the Medicare (Title XVIII) and Medicaid (Title XIX) programs under the Social Security Amendments of 1965; the 1972 expansion of Medicare coverage to include end-stage renal disease (ESRD); the Medicare Catastrophic Coverage Act (MCCA) of 1988; the Health Security Act of 1993 (President Clinton’s comprehensive health care reform initiative); and the Medicare Modernization Act of 2003. Each provides a partial lesson regarding the pursuit of health care reform. Passage of the original Medicare and Medicaid legislation has been attributed to President Johnson’s mastery of the legislative process and skill in wielding political power.18,19 Passing this legislation came at long-term political cost to the Democratic Party. The 7 years that followed saw unsuccessful attempts to include broader Medicare coverage, specifically for ESRD—a fatal condition for which a treatment existed. The inclusion of ESRD treatment under Medicare benefits was finally achieved through a late amendment to another bill and received only a half hour of debate. This peremptory action reflected the influence of Representative Wilbur Mills (D-AR), head of the House Ways and Means Committee, spurred by a 1971 session he had chaired at which an ESRD patient was dialyzed.20 The MCCA grew out of the work of the Bowen Commission, which was created by President Reagan to examine the costs of catastrophic medical conditions and the questions posed by these costs. The legislation that was eventually passed was guided by 2 main principles: that catastrophic coverage was the main benefit, and that intergenerational transfer was not an option—funding would be based on means testing and intragenerational premium differentiation. Of course, the first principle ensured that in any given year, a minority of beneficiaries would receive direct benefit, although many might be required to pay into the fund. In a nearly unprecedented action, the MCCA was rescinded on October 4, 1989, less than 2 years after being enacted by Congress. In fact, the fate of the MCCA was determined as much by how, when, and by whom information was presented as by what it contained.21 Two generally accepted lessons were derived from the failure of the Clinton Administration’s approach to health care reform, which was described as handing Congress “a 1300-page bill that had taken months to draft in the isolation of the White House office complex.”22 The first lesson is that the President should define and the Administration focus on broad principles, leaving the legislative details to Congress. The second is that there should be as many stakeholders at the table as feasible, even though some would be in opposition to particular provisions of a proposed bill.23–25 However, James Fallows, writing in the online edition of The Atlantic Monthly, sought to refute the notion that the Clinton plan was developed without extensive stakeholder input, citing a report in the Congressional Quarterly that 572 separate organizations had been consulted (even though the American Medical Association and the Pharmaceutical Research and Manufacturers of America were not represented).26 He noted that exclusion of the Washington press corps and an absence of details as planning progressed led to adverse coverage of the legislation during its formative stages. Furthermore, Fallows found that the Administration’s abandonment of its stated priority of controlling health care costs lost the plan additional support, citing an emphasis in the rollout on “health care that’s always there” and omission of the cost-control goal. The Medicare Modernization Act of 2003, which added the prescription drug benefit, was passed by a Republicanmajority legislature under a Republican president. Its success was described in the New England Journal of Medicine as “a pure power play.”27 The suggestion of overt political machinations in this instance, as well as in the September 2009
2015
Clinical Therapeutics foregoing examples, leads to the question of whether an evidence-based approach can ever survive in such a politically charged environment. Uncertainty may represent an additional challenge to rational evaluation of the costs and benefits of new programs, as risk aversion assumes greater significance for more comprehensive changes. The development of the Medicare program—which was incremental—offers a useful contrast to present and past attempts to achieve near-universal health care coverage in a single piece of legislation. Martha Derthick, a historian of US social programs, has observed that health care reform advocates changed their tactics by substituting an “incremental approach…for a comprehensive one”28 after the failure of successive Wagner–Murray– Dingell proposals for universal health care during the Roosevelt and Truman administrations. Breaking with this incremental approach in April 1974, Representative Mills and the late Senator Edward Kennedy (D-MA) introduced legislation to expand the government’s role as the single payer beyond Medicare and Medicaid through universal coverage of health care expenses over $1000 per family—a middle ground between President Nixon’s proposal for mandatory employer-provided health insurance and the Kennedy–Griffiths Health Security Bill mandating a governmental health system.29 Failure of the Kennedy–Mills bill was attributed to organized labor’s insistence on a full governmental health system and its unwillingness to “take half.”30 A similar all-or-nothing approach may be ascribed to the Clinton Administration’s attempt at health care reform, which would have largely replaced the existing system rather than building on it. Given the range and intensity of preferences regarding health care reform, it is particularly crucial that the basis for discussion be as objective and valid as possible. However, the 24/7 news cycle and the sound bites that pass for commentary are not sufficient to clarify or present a nuanced view of the main issues in the debate on health care reform. For evidence-based policy to predominate, it will require more outreach from the community of applied researchers and accurate translation of the evidence for nontechnical audiences. Ed Gibson, PhD School of Public Affairs University of Baltimore Baltimore, Maryland Alan Lyles, ScD, MPH, RPh Section Co-Editor
REFERENCES 1. The Henry J. Kaiser Family Foundation. Trends and indicators in the changing health care marketplace. Exhibit 1.2: National health expenditures per capita, 1990–2004. http://www.kff.org/insurance/7031/ti2004-1-2.cfm. Accessed September 13, 2009. 2. Bureau of Labor Statistics, US Dept of Labor. The employment situation: April 2008. http://www.bls.gov/news.release/ archives/empsit_05022008.pdf. Accessed September 13, 2009. 3. Bureau of Labor Statistics, US Dept of Labor. The employment situation: December 2008. http://www.bls.gov/news.release/ archives/empsit_01092008.pdf. Accessed September 13, 2009. 4. Bureau of Labor Statistics, US Dept of Labor. The employment situation: August 2009. http://www.bls.gov/news.release/pdf/ empsit.pdf. Accessed September 13, 2009. 5. The Henry J. Kaiser Family Foundation and Health Research & Educational Trust. Employer health benefits: 2008 Annual survey. Exhibit 2.1: Percentage of firms offering health benefits, 1999–2008. http://ehbs.kff.org/pdf/7790.pdf. Accessed September 13, 2009. 6. Morales L. Economy declines further as top problem; healthcare rises. August 14, 2009. http://www.gallup.com/poll/122339/ Economy-Declines-Further-Top-Problem-Healthcare-Rises.aspx. Accessed September 13, 2009. 7. The Henry J. Kaiser Family Foundation. Data spotlight: Unemployment’s impact on uninsured and Medicaid. http://www.kff. org/charts/042808.htm. Accessed September 13, 2009. 8. Congressional Budget Office. Budget options, volume 1: Health care. December 2008. http://www.cbo.gov/ftpdocs/99xx/ doc9925/12-18-HealthOptions.pdf. Accessed June 18, 2009. 9. McInturff WD, Weigel L. Déjà vu all over again: The similarities between political debates regarding health care in the early 1990s and today. Health Aff (Millwood). 2008;27:699–704. 10. McCarthy M, Armstrong D, Wayne A. Vetting the health care rhetoric. CQ HealthBeat News. August 24, 2009. http://www.
2016
Volume 31 Number 9
Editorial
11. 12. 13. 14. 15.
16. 17. 18. 19. 20. 21. 22. 23.
24. 25. 26. 27. 28. 29. 30.
cq.com/display.do?dockey=/cqonline/prod/data/docs/html/hbnews/111/hbnews111-000003193921.html@allnews& metapub=CQ-HBNEWS&searchIndex=3&seqNum=2&productId=5. Accessed September 13, 2009. Begley S. The five biggest lies in the health care debate. Newsweek. August 29, 2009. http://www.newsweek.com/id/214254. Accessed September 13, 2009. Lyles A. Evidence- or opinion-based pharmaceutical policy? Clin Ther. 2004;26:1922–1923. Grenier PR. Mob rule takes over the health debate. The Baltimore Sun. August 12, 2009. http://www.baltimoresun.com/news/ opinion/oped/bal-op.mob12aug12,0,6284701.story. Accessed September 13, 2009. Pear R, Herszenhorn DM. Health bill clears hurdle and hints at consensus. The New York Times. July 31, 2009. http://www. nytimes.com/2009/08/01/health/policy/01health.html. Accessed August 1, 2009. Antos J, Bertko J, Chernew M, for The Engelberg Center for Health Care Reform at Brookings. Bending the curve: Effective steps to address long-term health care spending growth. August 2009. http://www.brookings.edu/reports/2009/0901_btc.aspx. Accessed September 10, 2009. Pear R. House committee approves health care bill. The New York Times. July 16, 2009. http://www.nytimes.com/2009/07/17/ us/politics/17cbo.html. Accessed July 16, 2009. Harwood J. The Caucus: Tumultuous environment makes a health care compromise more unlikely. The New York Times. August 9, 2009. http://www.nytimes.com/2009/08/10/us/politics/10caucus.html. Accessed August 12, 2009. Caro RA. The Path to Power (The Years of Lyndon Johnson, Volume 1). New York, NY: Vintage; 1990. Caro RA. Master of the Senate: The Years of Lyndon Johnson. New York, NY: Vintage; 2003. Iglehart JK. The American health care system. The End Stage Renal Disease Program. N Engl J Med. 1993;328:366–371. Moon M. Medicare Now and in the Future. 2nd ed. Washington, DC: Urban Institute Press; 1996. Obama missteps confuse health overhaul: There’s no indication his strategy is working better than Clinton approach. Associated Press. July 22, 2009. http://www.msnbc.msn.com/id/32091708/ns/politics-white_house/. Accessed July 23, 2009. Hamburger T. Obama gives powerful drug lobby a seat at healthcare table: The pharmaceutical industry, once condemned by the president as a source of healthcare problems, has become a White House partner. Los Angeles Times. August 4, 2009. http:// www.latimes.com/news/nationworld/nation/la-na-healthcare-pharma4-2009aug04,0,3156176.story. Accessed August 4, 2009. Obama gets ally for health care plan: Wal-Mart. In a letter, retailer says it embraces employer coverage mandate proposal. Associated Press. June 30, 2009. http://www.msnbc.msn.com/id/31667110/ns/business-consumer_news/. Accessed July 1, 2009. Top senator, hospitals near health care deal. Under agreement, hospitals would accept lower-than-anticipated payments. Associated Press. July 6, 2009. http://www.msnbc.msn.com/id/31767218/ns/politics-capitol_hill/. Accessed July 7, 2009. Fallows J. A triumph of misinformation. The Atlantic Monthly Digital Edition. January 1995. http://www.theatlantic.com/politics/ healthca/hcfallow.htm. Accessed September 13, 2009. Iglehart JK. The new Medicare prescription-drug benefit—a pure power play. N Engl J Med. 2004;350:826–833. Derthick M. Policymaking for Social Security. Washington, DC: Brookings Institution; 1979. Rivlin AM. Agreed: Here comes national health insurance. The New York Times Magazine. July 21, 1974:8. Oral history collection. Robert M. Ball—interview #1. January 29, 2001. http://www.socialsecurity.gov/history/orals/ball1. html. Accessed September 13, 2009.
doi: 10.1016/j.clinthera.2009.09.004
September 2009
2017