by Thomas R. McCormick, D Min, University of Washington
The place of principles in bioethics
In the realm of health care it is difficult to hold rules or principles that are absolute. This is due to the many variables that exist in the context of clinical cases as well as the fact that in health care there are several principles that seem to be applicable in many situations. Even though they are not considered absolute, these rules and principles serve as powerful action guides in clinical medicine. Over the years, these moral principles have won a general acceptance as applicable in the moral analysis of ethical issues in medicine.
How do principles "apply" to a certain case?
Principles in current usage in health care ethics seem to be of self-evident value. For example, the notion that the physician "ought not to harm" any patient appears to be convincing to rational persons. Or, the idea that the physician should develop a care plan designed to provide the most "benefit" to the patient in terms of other competing alternatives, seems self-evident. Further, before implementing the medical care plan, it is now commonly accepted that the patient must indicate a willingness to accept the proposed treatment, if the patient is cognitively capable of doing so. Finally, medical benefits should be dispensed fairly, so that people with similar needs and in similar circumstances will be treated with fairness.
One might argue that we are required to take all of the above principles into account when they are applicable to the clinical case under consideration. Yet, when two or more principles apply, we may find that they are in conflict. For example, consider a patient diagnosed with an acutely infected appendix. Our medical goal should be to provide the greatest benefit to the patient, an indication for immediate surgery. On the other hand, surgery and general anesthesia carry some small degree of risk to an otherwise healthy patient, and we are under an obligation "not to harm" the patient. Our rational calculus holds that the patient is in far greater danger from harm from a ruptured appendix if we do not act, than from the surgical procedure and anesthesia if we proceed quickly to surgery.
In other words, we have a "prima facie" duty to both benefit the patient and to "avoid harming" the patient. However, in the actual situation, we must balance the demands of these principles by determining which carries more weight in the particular case. Moral philosopher W.D. Ross claims that prima facie duties are always binding unless they are in conflict with stronger or more stringent duties. A moral person's actual duty is determined by weighing and balancing all competing prima facie duties in any particular case.
What are the major principles of medical ethics?
The commonly accepted principles of health care ethics include:
the principle of respect for autonomy,
the principle of nonmaleficence,
the principle of beneficence, and
the principle of justice.
1. Respect for Autonomy
Any notion of moral decision making assumes that rational agents are involved in making informed and voluntary decisions. In health care decisions, our respect for the autonomy of the patient would, in common parlance, mean that the patient has the capacity to act intentionally, with understanding, and without controlling influences that would mitigate against a free and voluntary act. This principle is the basis for the practice of "informed consent" in the physician/patient transaction regarding health care. (See also Informed Consent.)
2. The Principle of Nonmaleficence
The principle of nonmaleficence requires of us that we not intentionally create a needless harm or injury to the patient, either through acts of commission or omission. In common language, we consider it negligence if one imposes a careless or unreasonable risk of harm upon another. Providing a proper standard of care that avoids or minimizes the risk of harm is supported not only by our commonly held moral convictions, but by the laws of society as well. In a professional model of care one may be morally and legally blameworthy if one fails to meet the standards of due care. The legal criteria for determining negligence are as follows:
the professional must have a duty to the affected party
the professional must breach that duty
the affected party must experience a harm; and
the harm must be caused by the breach of duty.
This principle affirms the need for medical competence. It is clear that medical mistakes occur, however, this principle articulates a fundamental commitment on the part of health care professionals to protect their patients from harm.
3. The Principle of Beneficence
The ordinary meaning of this principle is the duty of health care providers to be of a benefit to the patient, as well as to take positive steps to prevent and to remove harm from the patient. These duties are viewed as self-evident and are widely accepted as the proper goals of medicine. These goals are applied both to individual patients, and to the good of society as a whole. For example, the good health of a particular patient is an appropriate goal of medicine, and the prevention of disease through research and the employment of vaccines is the same goal expanded to the population at large.
It is sometimes held that nonmaleficence is a constant duty, that is, one ought never to harm another individual. Whereas, beneficence is a limited duty. A physician has a duty to seek the benefit of any or all of her patients, however, the physician may also choose whom to admit into his or her practice, and does not have a strict duty to benefit patients not acknowledged in the panel. This duty becomes complex if two patients appeal for treatment at the same moment. Some criteria of urgency of need might be used, or some principle of first come first served, to decide who should be helped at the moment.
4. The Principle of Justice
Justice in health care is usually defined as a form of fairness, or as Aristotle once said, "giving to each that which is his due." This implies the fair distribution of goods in society and requires that we look at the role of entitlement. The question of distributive justice also seems to hinge on the fact that some goods and services are in short supply, there is not enough to go around, thus some fair means of allocating scarce resources must be determined.
It is generally held that persons who are equals should qualify for equal treatment. This is borne out in the application of Medicare, which is available to all persons over the age of 65 years. This category of persons is equal with respect to this one factor, their age, but the criteria chosen says nothing about need or other noteworthy factors about the persons in this category. In fact, our society uses a variety of factors as a criteria for distributive justice, including the following:
to each person an equal share
to each person according to need
to each person according to effort
to each person according to contribution
to each person according to merit
to each person according to free-market exchanges
John Rawls and others claim that many of the inequalities we experience are a result of a "natural lottery" or a "social lottery" for which the affected individual is not to blame, therefore, society ought to help even the playing field by providing resources to help overcome the disadvantaged situation. One of the most controversial issues in modern health care is the question pertaining to "who has the right to health care?" Or, stated another way, perhaps as a society we want to be beneficent and fair and provide some decent minimum level of health care for all citizens, regardless of ability to pay.
Additional Reading: Tom Beauchamp and James Childress, Principles of Biomedical Ethics (4th edition) (New York: Oxford University Press, 1994).
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©1998, University of Washington. All Rights Reserved.
Saturday, September 26, 2009
Thursday, September 24, 2009
Doctors as the Key to Health Care Reform
Arnold S. Relman, M.D.
New England J of Medicine, Sept 23, 2009
(Ed Note; Dr. Relman has long believed that the solution to much of the high cost of health care is to remove "perverse incentives", whicn means doing away with fee-for-service Medicine. He presents his idea in this piece from the current NEJM).
Experts agree that sustainable health care reform requires reining in rising costs, but few people understand that the control of medical expenditures is largely in the hands of the medical profession. Doctors, in consultation with their patients — not insurance companies, legislators, or government officials — make most of the decisions to use medical resources, thereby deermining what the United States spends on medical care.
Most doctors are paid on a fee-for-service basis, which is a strong financial incentive for them to maximize the elective services they provide. This incentive, combined with the continued introduction of new and more expensive technology, is a major factor in driving up medical expenditures. The same incentive is attracting more and more young doctors into specialties that command much higher fees — and therefore guarantee much greater income — than those earned by primary care practitioners. Primary care is rapidly becoming an endangered specialty; an important, but not the only, reason is its relatively low economic rewards.
A system like ours, which is grossly deficient in primary care physicians and dominated by specialists who are trained to use expensive tests and procedures, is inevitably costly, particularly when most specialists practice as independent small businesses, competing for patient referrals and for income. Adjusting the fees paid by insurers, with increases for primary care and decreases for specialized procedures, or basing fees on the quality or outcome of care won’t solve this problem, because specialists can easily control the volume and kinds of services they provide. Furthermore, competition doesn’t lower prices in medical care as it does in other markets, because physicians usually choose the services to be provided and are paid largely by insurance — not by the consumers for whose business they would compete if this were an ordinary market.
To judge from the health care reform proposals getting serious attention in Washington, there is little evidence that lawmakers are aware of, or understand the significance of, these facts — or that, even if they did, they would have the stomach for the major reforms needed to solve this problem.1 Having surveyed all the current legislative proposals for slowing the continued inflation of costs, the Congressional Budget Office is not optimistic. Why should it be? We are not likely to control medical inflation unless the incentives in the traditional fee-for-service payment of doctors are eliminated, but nothing on the table in the health care reform debate even comes close to eliminating them. This fact explains why the private insurance and drug industries have so far been willing to support the Obama administration’s reform proposals. These proposals would expand coverage and increase total health care expenditures, which means more income for insurers and drug manufacturers. Even after their promised help in reducing the increase in costs, these industries will make more money in the reformed system than they do now.
Massachusetts, often mentioned as a model for the nation, enacted legislation more than 3 years ago that achieved nearly universal insurance coverage but from the outset found itself struggling to keep up with rising costs. To control expenditures, a special state commission on health care payment has recommended the elimination of traditional fee-for-service payment.2,3 The commission envisions the creation of new, as-yet-undefined medical management entities that it calls “accountable care organizations” (ACOs), which would organize physicians into multispecialty teams with strong primary care staffing. ACOs could include hospitals, could be for-profit or not-for-profit, and would be expected to take risks only for their performance. Insurance carriers would continue to hold the insurance risk for their contracts with ACOs, and they would pay the latter on a per capita, risk-adjusted basis for comprehensive care. They would also use “pay for performance” as an incentive to promote quality and efficiency. The commission does not specify how physicians in ACOs would be paid, but a salary system is implied by the report’s emphasis on the argument that Massachusetts cannot afford fee-for-service payment of its doctors if it wants to provide near-universal health insurance. Whether the commission’s proposals will prove acceptable to stakeholders and, if so, whether they will ever be implemented remain to be seen.
As it moves to expand insurance coverage, the federal government will soon face the financial difficulty now confronting Massachusetts. However, I believe there is a much simpler national solution that would control costs by eliminating profit incentives and traditional fee-for-service payment while achieving all the advantages of integrated practice. It would allow physicians and their patients to control medical care with less interference by insurers or government than the recommendations of the Massachusetts commission would probably require.
I have proposed a reformed health care system based on tax-supported, universal insurance, with medical care provided by a national network of community-based, private, not-for-profit, multispecialty, doctor-managed group practices.4 The insurance would pay for comprehensive care by the groups. Successful examples of multispecialty group practices already exist in our current health care system: the Mayo Clinic, the Cleveland Clinic, the Permanente Medical Group, the Geisinger Health System, the Marshfield Clinic, the Scott and White Clinic, the Billings Clinic, Denver Health, and many others. However, most of these groups are not prepaid for comprehensive care, and they bill many different payers for their services.
Groups in the system that I propose would pay their staff physicians a salary for doing what doctors ought to be doing: providing patients with the best, most cost-effective care, within the limits of a publicly determined budget. Physicians would not be influenced by the effects of each medical decision on their own income. The groups would enable primary care physicians and specialists to work together, without competition or turf warfare, but with compensation that would be acceptable to specialists and generalists alike.
Groups would compete for patients and for published ratings of their quality — but not for income, because they would not be allowed to keep any net income. In addition, capital improvements would require approval, and groups would be held harmless for any losses due to adverse selection by patients with, or at high risk for, expensive conditions. Capitated prepayment of the groups would allow a central public agency to control the country’s total medical expenditures. This agency would establish standards for group organization, administrative operations, and accountability but would leave individual medical care decisions where they belong — in the hands of physicians and patients. Private insurance plans and employers would have no role in this system.
Achieving reform of this kind would be a major task that would probably have to be carried out in stages. The opposition by vested interests and conservative ideologues would be fierce. To persuade lawmakers to act, the majority of the public, the medical profession, and the business community would have to unite in advocating this change. But without such a political awakening, I believe that the economic incentives and organization of medical care cannot be changed, and the current slide of the system toward bankruptcy will continue. That decline, however, might ultimately cause a disaster that would generate popular demand for real reform.
From Harvard Medical School, Boston.
References
Relman AS. The health reform we need and are not getting. New York Rev Books 2009;56:38-40.
Recommendations of the Special Commission on the Health Care Payment System. Boston: Commonwealth of Massachusetts, July 16, 2009.
Steinbrook R. The end of fee-for-service medicine? Proposals for payment reform in Massachusetts. N Engl J Med 2009;361:1036-1038. [Free Full Text]
Relman AS. A second opinion: rescuing America’s health care. New York: Public Affairs, 2007.
New England J of Medicine, Sept 23, 2009
(Ed Note; Dr. Relman has long believed that the solution to much of the high cost of health care is to remove "perverse incentives", whicn means doing away with fee-for-service Medicine. He presents his idea in this piece from the current NEJM).
Experts agree that sustainable health care reform requires reining in rising costs, but few people understand that the control of medical expenditures is largely in the hands of the medical profession. Doctors, in consultation with their patients — not insurance companies, legislators, or government officials — make most of the decisions to use medical resources, thereby deermining what the United States spends on medical care.
Most doctors are paid on a fee-for-service basis, which is a strong financial incentive for them to maximize the elective services they provide. This incentive, combined with the continued introduction of new and more expensive technology, is a major factor in driving up medical expenditures. The same incentive is attracting more and more young doctors into specialties that command much higher fees — and therefore guarantee much greater income — than those earned by primary care practitioners. Primary care is rapidly becoming an endangered specialty; an important, but not the only, reason is its relatively low economic rewards.
A system like ours, which is grossly deficient in primary care physicians and dominated by specialists who are trained to use expensive tests and procedures, is inevitably costly, particularly when most specialists practice as independent small businesses, competing for patient referrals and for income. Adjusting the fees paid by insurers, with increases for primary care and decreases for specialized procedures, or basing fees on the quality or outcome of care won’t solve this problem, because specialists can easily control the volume and kinds of services they provide. Furthermore, competition doesn’t lower prices in medical care as it does in other markets, because physicians usually choose the services to be provided and are paid largely by insurance — not by the consumers for whose business they would compete if this were an ordinary market.
To judge from the health care reform proposals getting serious attention in Washington, there is little evidence that lawmakers are aware of, or understand the significance of, these facts — or that, even if they did, they would have the stomach for the major reforms needed to solve this problem.1 Having surveyed all the current legislative proposals for slowing the continued inflation of costs, the Congressional Budget Office is not optimistic. Why should it be? We are not likely to control medical inflation unless the incentives in the traditional fee-for-service payment of doctors are eliminated, but nothing on the table in the health care reform debate even comes close to eliminating them. This fact explains why the private insurance and drug industries have so far been willing to support the Obama administration’s reform proposals. These proposals would expand coverage and increase total health care expenditures, which means more income for insurers and drug manufacturers. Even after their promised help in reducing the increase in costs, these industries will make more money in the reformed system than they do now.
Massachusetts, often mentioned as a model for the nation, enacted legislation more than 3 years ago that achieved nearly universal insurance coverage but from the outset found itself struggling to keep up with rising costs. To control expenditures, a special state commission on health care payment has recommended the elimination of traditional fee-for-service payment.2,3 The commission envisions the creation of new, as-yet-undefined medical management entities that it calls “accountable care organizations” (ACOs), which would organize physicians into multispecialty teams with strong primary care staffing. ACOs could include hospitals, could be for-profit or not-for-profit, and would be expected to take risks only for their performance. Insurance carriers would continue to hold the insurance risk for their contracts with ACOs, and they would pay the latter on a per capita, risk-adjusted basis for comprehensive care. They would also use “pay for performance” as an incentive to promote quality and efficiency. The commission does not specify how physicians in ACOs would be paid, but a salary system is implied by the report’s emphasis on the argument that Massachusetts cannot afford fee-for-service payment of its doctors if it wants to provide near-universal health insurance. Whether the commission’s proposals will prove acceptable to stakeholders and, if so, whether they will ever be implemented remain to be seen.
As it moves to expand insurance coverage, the federal government will soon face the financial difficulty now confronting Massachusetts. However, I believe there is a much simpler national solution that would control costs by eliminating profit incentives and traditional fee-for-service payment while achieving all the advantages of integrated practice. It would allow physicians and their patients to control medical care with less interference by insurers or government than the recommendations of the Massachusetts commission would probably require.
I have proposed a reformed health care system based on tax-supported, universal insurance, with medical care provided by a national network of community-based, private, not-for-profit, multispecialty, doctor-managed group practices.4 The insurance would pay for comprehensive care by the groups. Successful examples of multispecialty group practices already exist in our current health care system: the Mayo Clinic, the Cleveland Clinic, the Permanente Medical Group, the Geisinger Health System, the Marshfield Clinic, the Scott and White Clinic, the Billings Clinic, Denver Health, and many others. However, most of these groups are not prepaid for comprehensive care, and they bill many different payers for their services.
Groups in the system that I propose would pay their staff physicians a salary for doing what doctors ought to be doing: providing patients with the best, most cost-effective care, within the limits of a publicly determined budget. Physicians would not be influenced by the effects of each medical decision on their own income. The groups would enable primary care physicians and specialists to work together, without competition or turf warfare, but with compensation that would be acceptable to specialists and generalists alike.
Groups would compete for patients and for published ratings of their quality — but not for income, because they would not be allowed to keep any net income. In addition, capital improvements would require approval, and groups would be held harmless for any losses due to adverse selection by patients with, or at high risk for, expensive conditions. Capitated prepayment of the groups would allow a central public agency to control the country’s total medical expenditures. This agency would establish standards for group organization, administrative operations, and accountability but would leave individual medical care decisions where they belong — in the hands of physicians and patients. Private insurance plans and employers would have no role in this system.
Achieving reform of this kind would be a major task that would probably have to be carried out in stages. The opposition by vested interests and conservative ideologues would be fierce. To persuade lawmakers to act, the majority of the public, the medical profession, and the business community would have to unite in advocating this change. But without such a political awakening, I believe that the economic incentives and organization of medical care cannot be changed, and the current slide of the system toward bankruptcy will continue. That decline, however, might ultimately cause a disaster that would generate popular demand for real reform.
From Harvard Medical School, Boston.
References
Relman AS. The health reform we need and are not getting. New York Rev Books 2009;56:38-40.
Recommendations of the Special Commission on the Health Care Payment System. Boston: Commonwealth of Massachusetts, July 16, 2009.
Steinbrook R. The end of fee-for-service medicine? Proposals for payment reform in Massachusetts. N Engl J Med 2009;361:1036-1038. [Free Full Text]
Relman AS. A second opinion: rescuing America’s health care. New York: Public Affairs, 2007.
Monday, September 14, 2009
Physicians’ Beliefs and U.S. Health Care Reform — A National Survey
Posted by NEJM • September 14th, 2009 •
Ryan M. Antiel, M.A., Farr A. Curlin, M.D., Katherine M. James, M.P.H., and Jon C. Tilburt, M.D., M.P.H.
In an address to the American Medical Association on June 15, 2009, President Barack Obama acknowledged that he needed physicians’ support on health care reform and offered to work with physicians to achieve the reform he believes is essential. In recent months, commentators have called on physicians to be “our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care” and to “find a brave voice” for changing health care’s funding structures in a way that “puts quality of care before financial gain.”1 Are U.S. physicians prepared to play such a part?2
Previous research suggests that physicians endorse a public role for the profession and believe they have an obligation to care for people with limited resources. But it remains unclear whether physicians in 2009 see participation in the formation of health policy as part of their professional responsibility or accept the potential consequences of reform. Furthermore, individual physicians may have strong financial incentives to downplay their responsibility for caring for the uninsured and underinsured. Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.
In May 2009, we mailed a confidential questionnaire to 2000 practicing U.S. physicians, 65 years of age or younger, from all specialties in order to explore these issues. (Detailed information about our methods appears in the Supplementary Appendix, available with the full text of this article at NEJM.org.) As part of an eight-page, self-administered survey on moral and ethical beliefs in medical practice, physicians completed four items that bear directly on broad themes in the current health care reform debate, though the questions were not tied to any specific proposal or position. Respondents were asked to indicate their degree of agreement or disagreement with the following statements: “Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligations as a physician,” “Every physician is professionally obligated to care for the uninsured and underinsured,” and “I would favor limiting reimbursement for expensive drugs and procedures if that would help expand access to basic health care for those currently lacking such care.” Then, as part of a longer list of potentially controversial medical practices, we asked physicians to indicate whether they had no moral objection, a moderate moral objection, or a strong moral objection to “using cost-effectiveness data to determine which treatments will be offered to patients.”
The key predictor measures that we considered were physicians’ self-characterization as “conservative,” “moderate,” or “liberal” on “social issues”; their demographic characteristics (age, sex, race, and region); and their clinical specialty, subsequently categorized as primary care, surgery, procedural specialty (e.g., cardiology and gastroenterology), nonprocedural specialty (e.g., psychiatry and medical genetics), nonclinical specialty, and other.
Of the 2000 potential respondents, 61 (3%) could not be contacted. Of the remaining 1939 participants, 991 returned completed surveys, for a response rate of 51%. The characteristics of the respondents are shown in Table 1. Response rates varied somewhat according to region (South, 50%; Midwest, 58%; Northeast, 50%; West, 47%; Other, 50%; P=0.03) and according to age category (<50 years, 48%; 50 years, 56%; P<0.001) but not according to sex or specialty. The results we present here are from unweighted analyses.
A large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data “to determine which treatments will be offered to patients.”
In multivariable logistic-regression models, age, race, and region were not significantly associated with responses to any of the four relevant items. Female physicians were more likely than male physicians to object to using cost-effectiveness data to guide treatment decisions (odds ratio, 1.4; 95% confidence interval [CI], 1.0 to 2.0) but did not differ from male physicians on other questions.
Both specialty and political self-characterization were associated with physicians’ beliefs related to health care reform. As shown in Table 3, surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures (odds ratio for surgeons, 0.6; 95% CI, 0.4 to 0.8; for procedural specialists, 0.6; 95% CI, 0.4 to 1.0; and for nonclinical specialists, 0.3; 95% CI, 0.1 to 0.9). There were also consistent differences between self-described liberals and conservatives.
These data offer several messages. First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.
Why would a majority of U.S. physicians object to using cost-effectiveness analysis in clinical decision making? Both a lack of familiarity and principled objections may be involved. The current health care system reimburses providers primarily on the basis of the quantity of services provided, which favors a higher volume of care and a greater number of procedures rather than care management. Under the current system, which has been fashioned in large part by long-standing Medicare legislation, there is little incentive to use evidence-based information such as cost-effectiveness data to guide treatment decisions.4 Only recently has the Centers for Medicare and Medicaid Services attempted to use evidence to guide determinations about whether services should be provided.5 Thus, a lack of familiarity with such reimbursement practices or fear of change may influence physicians’ acceptance of cost-effectiveness data. But many physicians may also have more principled grounds for their objections, viewing the use of cost-effectiveness data as implicit rationing or unwelcome intrusion on both their professional autonomy and the physician–patient relationship. To gain widespread support from the physician community, advocates of such reform initiatives will need to address such concerns.
Since surgeons and procedural specialists were less willing than other physicians to accept policies that would limit reimbursement for expensive medications and procedures, reformers can expect opposition to reimbursement reform from such groups unless proposed reforms create incentives that benefit those who currently get paid for providing these goods and services. We did not inquire about physicians’ views of policies that might result in lower payment for their own services more generally.
Finally, the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform. These physicians must be engaged if reform is to be successful.
Of course, associations that have been identified in a cross-sectional study cannot establish causal relationships. Moreover, it is possible that the attitudes of physicians who did not respond to the survey differ from those who did respond, and physicians’ responses to the survey questions do not necessarily reflect their likely responses to specific proposals before Congress. Nevertheless, our data suggest that efforts to mobilize physicians can build on their sense of professional responsibility — but also that such efforts may encounter considerable opposition from some quarters of the profession, particularly to elements of reform that impinge on physicians’ decision-making autonomy or threaten to reduce reimbursement for the costly interventions they provide. Politicians and policymakers should work directly with these groups of physicians to achieve the consensus necessary for comprehensive and sustainable reform.
From the Mayo Medical School (R.M.A.), the Program in Professionalism and Bioethics (R.M.A., K.M.J., J.C.T.), the Mayo Knowledge and Encounter Research Unit (K.M.J., J.C.T.), and the Division of General Internal Medicine (J.C.T.), Mayo Clinic, Rochester, MN; and the Section of General Internal Medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (F.A.C.).
References
Fisher ES, Berwick DM, Davis K. Achieving health care reform — how physicians can help. N Engl J Med 2009;360:2495-2497. [Free Full Text]
Cortese DA, Smoldt RK. Healing America’s ailing health care system. Mayo Clin Proc 2006;81:492-496. [Free Full Text]
Avorn J. Debate about funding comparative-effectiveness research. N Engl J Med 2009;360:1927-1929. [Free Full Text]
Neumann PJ, Rosen AB, Weinstein MC. Medicare and cost-effectiveness analysis. N Engl J Med 2005;353:1516-1522. [Free Full Text]
Tunis SR. Why Medicare has not established criteria for coverage decisions. N Engl J Med 2004;350:2196-2198. [Free Full Text]
Ryan M. Antiel, M.A., Farr A. Curlin, M.D., Katherine M. James, M.P.H., and Jon C. Tilburt, M.D., M.P.H.
In an address to the American Medical Association on June 15, 2009, President Barack Obama acknowledged that he needed physicians’ support on health care reform and offered to work with physicians to achieve the reform he believes is essential. In recent months, commentators have called on physicians to be “our most credible and effective leaders of progress toward a new world of coordinated, sensible, outcome-oriented care” and to “find a brave voice” for changing health care’s funding structures in a way that “puts quality of care before financial gain.”1 Are U.S. physicians prepared to play such a part?2
Previous research suggests that physicians endorse a public role for the profession and believe they have an obligation to care for people with limited resources. But it remains unclear whether physicians in 2009 see participation in the formation of health policy as part of their professional responsibility or accept the potential consequences of reform. Furthermore, individual physicians may have strong financial incentives to downplay their responsibility for caring for the uninsured and underinsured. Although physicians tend to agree in the abstract that health care resources should be distributed fairly, they may be unwilling to endorse concrete policies that expand coverage for basic health care by limiting reimbursement for costly interventions. And despite widespread discussions about using cost-effectiveness data or comparative-effectiveness research to guide clinical decisions, physicians may remain skeptical about such practices.3,4 Thus, physicians may not be willing to take on the role that the President and health policy advocates want them to play.
In May 2009, we mailed a confidential questionnaire to 2000 practicing U.S. physicians, 65 years of age or younger, from all specialties in order to explore these issues. (Detailed information about our methods appears in the Supplementary Appendix, available with the full text of this article at NEJM.org.) As part of an eight-page, self-administered survey on moral and ethical beliefs in medical practice, physicians completed four items that bear directly on broad themes in the current health care reform debate, though the questions were not tied to any specific proposal or position. Respondents were asked to indicate their degree of agreement or disagreement with the following statements: “Addressing societal health policy issues, as important as that may be, falls outside the scope of my professional obligations as a physician,” “Every physician is professionally obligated to care for the uninsured and underinsured,” and “I would favor limiting reimbursement for expensive drugs and procedures if that would help expand access to basic health care for those currently lacking such care.” Then, as part of a longer list of potentially controversial medical practices, we asked physicians to indicate whether they had no moral objection, a moderate moral objection, or a strong moral objection to “using cost-effectiveness data to determine which treatments will be offered to patients.”
The key predictor measures that we considered were physicians’ self-characterization as “conservative,” “moderate,” or “liberal” on “social issues”; their demographic characteristics (age, sex, race, and region); and their clinical specialty, subsequently categorized as primary care, surgery, procedural specialty (e.g., cardiology and gastroenterology), nonprocedural specialty (e.g., psychiatry and medical genetics), nonclinical specialty, and other.
Of the 2000 potential respondents, 61 (3%) could not be contacted. Of the remaining 1939 participants, 991 returned completed surveys, for a response rate of 51%. The characteristics of the respondents are shown in Table 1. Response rates varied somewhat according to region (South, 50%; Midwest, 58%; Northeast, 50%; West, 47%; Other, 50%; P=0.03) and according to age category (<50 years, 48%; 50 years, 56%; P<0.001) but not according to sex or specialty. The results we present here are from unweighted analyses.
A large majority of respondents (78%) agreed that physicians have a professional obligation to address societal health policy issues. Majorities also agreed that every physician is professionally obligated to care for the uninsured or underinsured (73%), and most were willing to accept limits on reimbursement for expensive drugs and procedures for the sake of expanding access to basic health care (67%). By contrast, physicians were divided almost equally about cost-effectiveness analysis; just over half (54%) reported having a moral objection to using such data “to determine which treatments will be offered to patients.”
In multivariable logistic-regression models, age, race, and region were not significantly associated with responses to any of the four relevant items. Female physicians were more likely than male physicians to object to using cost-effectiveness data to guide treatment decisions (odds ratio, 1.4; 95% confidence interval [CI], 1.0 to 2.0) but did not differ from male physicians on other questions.
Both specialty and political self-characterization were associated with physicians’ beliefs related to health care reform. As shown in Table 3, surgeons, procedural specialists, and those in nonclinical specialties were all significantly less likely than primary care providers to favor reform that expands access to basic health care by reducing reimbursement for expensive drugs and procedures (odds ratio for surgeons, 0.6; 95% CI, 0.4 to 0.8; for procedural specialists, 0.6; 95% CI, 0.4 to 1.0; and for nonclinical specialists, 0.3; 95% CI, 0.1 to 0.9). There were also consistent differences between self-described liberals and conservatives.
These data offer several messages. First, the President, lawmakers, and reform advocates can vigorously engage physicians in deliberations on health care reform, cognizant that most physicians see it as part of their professional responsibility. However, more controversial elements of reform, such as limiting reimbursement under Medicare (i.e., expanding the ranks of the underinsured), using cost-effectiveness data in treatment decisions, and limiting reimbursements for expensive drugs and procedures — all of which are elements of current reform proposals — may face serious opposition from segments of the medical profession.
Why would a majority of U.S. physicians object to using cost-effectiveness analysis in clinical decision making? Both a lack of familiarity and principled objections may be involved. The current health care system reimburses providers primarily on the basis of the quantity of services provided, which favors a higher volume of care and a greater number of procedures rather than care management. Under the current system, which has been fashioned in large part by long-standing Medicare legislation, there is little incentive to use evidence-based information such as cost-effectiveness data to guide treatment decisions.4 Only recently has the Centers for Medicare and Medicaid Services attempted to use evidence to guide determinations about whether services should be provided.5 Thus, a lack of familiarity with such reimbursement practices or fear of change may influence physicians’ acceptance of cost-effectiveness data. But many physicians may also have more principled grounds for their objections, viewing the use of cost-effectiveness data as implicit rationing or unwelcome intrusion on both their professional autonomy and the physician–patient relationship. To gain widespread support from the physician community, advocates of such reform initiatives will need to address such concerns.
Since surgeons and procedural specialists were less willing than other physicians to accept policies that would limit reimbursement for expensive medications and procedures, reformers can expect opposition to reimbursement reform from such groups unless proposed reforms create incentives that benefit those who currently get paid for providing these goods and services. We did not inquire about physicians’ views of policies that might result in lower payment for their own services more generally.
Finally, the 28% of physicians who consider themselves conservative were consistently less enthusiastic about professional responsibilities pertaining to health care reform. These physicians must be engaged if reform is to be successful.
Of course, associations that have been identified in a cross-sectional study cannot establish causal relationships. Moreover, it is possible that the attitudes of physicians who did not respond to the survey differ from those who did respond, and physicians’ responses to the survey questions do not necessarily reflect their likely responses to specific proposals before Congress. Nevertheless, our data suggest that efforts to mobilize physicians can build on their sense of professional responsibility — but also that such efforts may encounter considerable opposition from some quarters of the profession, particularly to elements of reform that impinge on physicians’ decision-making autonomy or threaten to reduce reimbursement for the costly interventions they provide. Politicians and policymakers should work directly with these groups of physicians to achieve the consensus necessary for comprehensive and sustainable reform.
From the Mayo Medical School (R.M.A.), the Program in Professionalism and Bioethics (R.M.A., K.M.J., J.C.T.), the Mayo Knowledge and Encounter Research Unit (K.M.J., J.C.T.), and the Division of General Internal Medicine (J.C.T.), Mayo Clinic, Rochester, MN; and the Section of General Internal Medicine and the MacLean Center for Clinical Medical Ethics, University of Chicago, Chicago (F.A.C.).
References
Fisher ES, Berwick DM, Davis K. Achieving health care reform — how physicians can help. N Engl J Med 2009;360:2495-2497. [Free Full Text]
Cortese DA, Smoldt RK. Healing America’s ailing health care system. Mayo Clin Proc 2006;81:492-496. [Free Full Text]
Avorn J. Debate about funding comparative-effectiveness research. N Engl J Med 2009;360:1927-1929. [Free Full Text]
Neumann PJ, Rosen AB, Weinstein MC. Medicare and cost-effectiveness analysis. N Engl J Med 2005;353:1516-1522. [Free Full Text]
Tunis SR. Why Medicare has not established criteria for coverage decisions. N Engl J Med 2004;350:2196-2198. [Free Full Text]
Tuesday, September 8, 2009
Obama's Plan -- –What Will He Do Next?
It is crunch time. The President is going to the nation tomorrow with a proposal.. What will he offer? Robert Laszewski suggests that there are two alternatives. I am betting on some modification of #2, i.e. no public option, and something short of universal coverage.
Obama will live with the disappointment (and presumably anger) of his liberal base. But with the financial crisis still ongoing, high unemployment, and 90% of the American people not wanting to risk any changes in the health insurance status quo, Obama knows what is the most he can get at this time,
It is the old story; the perfect is the enemy of the good. Obama will settle for good.
by ROBERT LASZEWSKI
How’d you like to be a fly on the wall in those White House health care meetings this week?
It looks to me like they have two choices—neither attractive to them:
1. Full Speed Ahead, Damn the Torpedoes – This might also be called the Pelosi Option for the Speaker’s intransigence for compromise. Just keep driving the existing Democratic bills through. This has the advantage of keeping the liberal wing of the Democratic Party happy but has some pretty tough potential negative consequences.
With a health care approval rating in the low 40s, this invites the continued strong opposition on the right and lots of continued middle-America nervousness over a “government takeover of the health care system” and “spending another trillion dollars when we can’t afford it.” Even if the public option is ditched, that means continuing to push a thousand page health care bill in an environment when the health care reform well has likely been poisoned.
This option includes the threats for using reconciliation rules. As I have said before, you don’t ram anything through with a 41% health care approval rating. And that presumes the reconciliation idea makes sense in the first place. I don’t think it does:
The Republicans have a ton of parliamentary maneuvers they can use to tie things up indefinitely.
The suggestion to “split” the bills into one unpopular bill and one popular bill––presuming moderate Democrats and some Republicans might be dumb enough to vote for one and pretend that second bill had nothing to do with the more problematic first one––is foolishness.
IF any of this did work and result in a very controversial bill you have to wonder just what the consequences would be come November 2010—or even 2012. You also have to wonder what the consequences would be for simply trying it.
2. Scale Health Care Reform Down to Something at Least Moderates in Both Parties Can Live With––This sounds easier than it really is.
As I have posted before, doing just health insurance reform would cost something close to a trillion dollars. Getting rid of pre-existing conditions provisions and medical underwriting requires getting about everyone in the health insurance pool to avoid the insurers getting stuck with only the sick. Health insurance subsidies to accomplish this are by far the most expensive part of the existing bills. In the House bills, the insurance subsides are worth almost $775 billion and the Medicaid expansion is worth almost $450 billion more. Scale those subsidies back and you are still in the $800 billion to $1 trillion range.
A bill that costs that much still scares those worried that this kind of entitlement expansion is too costly—particularly because the bills on the table so far have had little in the way of real cost containment.
An even more modest bill would likely be necessary to get moderates onside.
You could probably get a smaller cost bill—perhaps $250 billion over ten years—by targeting subsidies on the small employer market. Dollars could be targeted, limited in scope, and make a “down payment” toward covering at least a few million people. A targeted expansion of Medicaid could be part of such a package but nowhere near the 130% target in existing bills.
This has the advantage of creating a bill you could likely get moderate Democrats and even a lot of Republicans to support. It would settle down voter opposition.
But it would also constitute a “huge missed opportunity” to really create a universal health insurance system. Liberals would likely go ballistic believing the White House has abandoned the signature domestic promise of the campaign.
The Democrats are in a hell of a health care political hole.
Neither of these options is politically attractive--each has both extreme opportunity and consequences.
Sort of reminds me of what Stan told Ollie: “Well, here’s another nice [health care reform] mess you’ve gotten me into.”
Or, you could just hope for a miracle phone call:
Obama will live with the disappointment (and presumably anger) of his liberal base. But with the financial crisis still ongoing, high unemployment, and 90% of the American people not wanting to risk any changes in the health insurance status quo, Obama knows what is the most he can get at this time,
It is the old story; the perfect is the enemy of the good. Obama will settle for good.
by ROBERT LASZEWSKI
How’d you like to be a fly on the wall in those White House health care meetings this week?
It looks to me like they have two choices—neither attractive to them:
1. Full Speed Ahead, Damn the Torpedoes – This might also be called the Pelosi Option for the Speaker’s intransigence for compromise. Just keep driving the existing Democratic bills through. This has the advantage of keeping the liberal wing of the Democratic Party happy but has some pretty tough potential negative consequences.
With a health care approval rating in the low 40s, this invites the continued strong opposition on the right and lots of continued middle-America nervousness over a “government takeover of the health care system” and “spending another trillion dollars when we can’t afford it.” Even if the public option is ditched, that means continuing to push a thousand page health care bill in an environment when the health care reform well has likely been poisoned.
This option includes the threats for using reconciliation rules. As I have said before, you don’t ram anything through with a 41% health care approval rating. And that presumes the reconciliation idea makes sense in the first place. I don’t think it does:
The Republicans have a ton of parliamentary maneuvers they can use to tie things up indefinitely.
The suggestion to “split” the bills into one unpopular bill and one popular bill––presuming moderate Democrats and some Republicans might be dumb enough to vote for one and pretend that second bill had nothing to do with the more problematic first one––is foolishness.
IF any of this did work and result in a very controversial bill you have to wonder just what the consequences would be come November 2010—or even 2012. You also have to wonder what the consequences would be for simply trying it.
2. Scale Health Care Reform Down to Something at Least Moderates in Both Parties Can Live With––This sounds easier than it really is.
As I have posted before, doing just health insurance reform would cost something close to a trillion dollars. Getting rid of pre-existing conditions provisions and medical underwriting requires getting about everyone in the health insurance pool to avoid the insurers getting stuck with only the sick. Health insurance subsidies to accomplish this are by far the most expensive part of the existing bills. In the House bills, the insurance subsides are worth almost $775 billion and the Medicaid expansion is worth almost $450 billion more. Scale those subsidies back and you are still in the $800 billion to $1 trillion range.
A bill that costs that much still scares those worried that this kind of entitlement expansion is too costly—particularly because the bills on the table so far have had little in the way of real cost containment.
An even more modest bill would likely be necessary to get moderates onside.
You could probably get a smaller cost bill—perhaps $250 billion over ten years—by targeting subsidies on the small employer market. Dollars could be targeted, limited in scope, and make a “down payment” toward covering at least a few million people. A targeted expansion of Medicaid could be part of such a package but nowhere near the 130% target in existing bills.
This has the advantage of creating a bill you could likely get moderate Democrats and even a lot of Republicans to support. It would settle down voter opposition.
But it would also constitute a “huge missed opportunity” to really create a universal health insurance system. Liberals would likely go ballistic believing the White House has abandoned the signature domestic promise of the campaign.
The Democrats are in a hell of a health care political hole.
Neither of these options is politically attractive--each has both extreme opportunity and consequences.
Sort of reminds me of what Stan told Ollie: “Well, here’s another nice [health care reform] mess you’ve gotten me into.”
Or, you could just hope for a miracle phone call:
Monday, September 7, 2009
Politico; Under fire, Obama shifts strategy
By: Mike Allen and Jim VandeHei
September 1, 2009
Aides to President Barack Obama are putting the final touches on a new strategy to help Democrats recover from a brutal August recess by specifying what Obama wants to see in a compromise health care deal and directly confronting other trouble spots, West Wing officials tell POLITICO.
Obama will address a joint session of Congress on health care reform in prime time on Wednesday, Sept. 9, a senior official tells POLITICO, and the president plans to give lawmakers a more specific prescription for health care legislation than he has in the past, aides said.
And although House leaders have said their members will demand the inclusion of a public insurance option, Obama has no plans to insist on it himself, the officials said.
“We’re entering a new season,” senior adviser David Axelrod said in a telephone interview. “It’s time to synthesize and harmonize these strands and get this done. We’re confident that we can do that. But obviously it is a different phase. We’re going to approach it in a different way. The president is going to be very active.”
Top officials privately concede the past six weeks have taken their toll on Obama's popularity. But the officials also see the new diminished expectations as an opportunity to prove their critics wrong by signing a health care law, showing progress in Afghanistan, and using this month's anniversary of the fall of Lehman Brothers to push for a crackdown on Wall Street.
On health care, Obama’s willingness to forgo the public option is sure to anger his party’s liberal base. But some administration officials welcome a showdown with liberal lawmakers if they argue they would rather have no health care law than an incremental one. The confrontation would allow Obama to show he is willing to stare down his own party to get things done.
“We have been saying all along that the most important part of this debate is not the public option, but rather ensuring choice and competition,” an aide said. “There are lots of different ways to get there.”
The content of Obama's presentation is still being debated in the West Wing. Aides have discussed whether to stick to broad principles, or to send specific legislative language to Capitol Hill. Some hybrid is likely, the officials said.
“I’m not going to put a date on any of this,” Axelrod said. “But I think it’s fairly obvious that we’re not in the second inning. We’re not in the fourth inning. We’re in the eighth or ninth inning here, and so there’s not a lot of time to waste.”
Obama's specifics will include many of the principles he has spelled out before, and aides did not want to telegraph make-or-break demands. But Axelrod and others are making plain that Obama will assert himself more aggressively — a clear sign that the president will start dictating terms to Congress.
"His goal is to create the best possible situation for consumers, create competition and choice," Axelrod said. "We want to bring a measure of security to people who have health insurance today. We want to help those who don't have coverage today, because they can't afford it, get insurance they can afford. And we want to do it in a way that reduces the overall cost of the system as a whole."
Also this fall, Obama wants to slap new regulations on Wall Street firms, a goal that is now considered a higher priority than cap-and-trade energy legislation in the West Wing. White House officials think the legislation will show voters, especially wavering independents, that he is serious about making the culprits of the economic crisis pay. It also helps that it doesn't carry a big price tag, like other Obama priorities.
The president also plans to send Congress a report on Afghanistan by Sept. 24 that is designed to build patience after two months in a row of the highest U.S. casualties since the invasion eight years ago. Aides say they recognize they need to show progress over the next 12 to 18 months, or risk losing the support of key Democrats in Congress, who already have balked at funding Obama’s 20,000-troop buildup.
But health care remains front-and-center in Obama’s fall strategy. “I understand the governing wisdom here in town as to where this is right now,” Axelrod said. “I feel good about where it is right now. I understand that there’s been a lot of controversy. I understand that there’s been a lot of politics. But the truth is, we’re a lot closer to achieving something than many thought possible. People look to the president for leadership on this and other issues. He feels passionately about this, and you can look for him to provide that leadership.”
Obama has been criticized for deciding to cede much of the debate to Capitol Hill -- or, as Axelrod put it, “allow Congress to consider the whole range of ideas.”
“History will judge whether this was right or it was wrong,” Axelrod said. “We feel strongly that it was right. As a result of it, we have broad consensus on over 80 percent of this stuff, and a lot of good ideas about how to achieve the other 20. Now, people are looking to the president and the president is eager to help lead that process of harmonizing these different elements and completing this process so that we can solve what is a big problem in the lives of the American people, for our businesses and our economy.”
White House officials say they are looking forward to "a break from the August break" -- a chance to take back control of the debate after a grim month where news coverage of the issue was dominated by vocal, emotional opponents at lawmakers’ town meetings, railing against the cost and complexity of the plans being debated.
So Obama and Democrats will return from vacation wounded, divided and uncertain of the best way to turn things around. Many Democrats, especially in the House, were spooked over break by the rowdy town hall meetings and flurry of polls showing independent voters skeptical of their leadership and spending plans.
The mood swing is hitting some top leaders hard: Senate Majority Leader Harry Reid (D-Nev.), for instance, is trailing little-known GOP contenders in his re-election race now. The news swing has been no less brutal. There has been saturation coverage of the town halls and rising casualties in Afghanistan -- the latter leading to a big drop in support for the war.
All of this makes for a tumultuous -- and wildly unpredictable -- fall for Obama and his party.
Axelrod said he isn’t worried. “Part of it is born of long experience,” he said. “In Washington, every day is Election Day. I’d be lying to you if I told you I don’t look at polls -- I do. But I’ve also learned that you have to keep your eye on the horizon here and not get bogged down. I am not Polyannish, but I am also not given to the hysteria that's endemic to this town.”
September 1, 2009
Aides to President Barack Obama are putting the final touches on a new strategy to help Democrats recover from a brutal August recess by specifying what Obama wants to see in a compromise health care deal and directly confronting other trouble spots, West Wing officials tell POLITICO.
Obama will address a joint session of Congress on health care reform in prime time on Wednesday, Sept. 9, a senior official tells POLITICO, and the president plans to give lawmakers a more specific prescription for health care legislation than he has in the past, aides said.
And although House leaders have said their members will demand the inclusion of a public insurance option, Obama has no plans to insist on it himself, the officials said.
“We’re entering a new season,” senior adviser David Axelrod said in a telephone interview. “It’s time to synthesize and harmonize these strands and get this done. We’re confident that we can do that. But obviously it is a different phase. We’re going to approach it in a different way. The president is going to be very active.”
Top officials privately concede the past six weeks have taken their toll on Obama's popularity. But the officials also see the new diminished expectations as an opportunity to prove their critics wrong by signing a health care law, showing progress in Afghanistan, and using this month's anniversary of the fall of Lehman Brothers to push for a crackdown on Wall Street.
On health care, Obama’s willingness to forgo the public option is sure to anger his party’s liberal base. But some administration officials welcome a showdown with liberal lawmakers if they argue they would rather have no health care law than an incremental one. The confrontation would allow Obama to show he is willing to stare down his own party to get things done.
“We have been saying all along that the most important part of this debate is not the public option, but rather ensuring choice and competition,” an aide said. “There are lots of different ways to get there.”
The content of Obama's presentation is still being debated in the West Wing. Aides have discussed whether to stick to broad principles, or to send specific legislative language to Capitol Hill. Some hybrid is likely, the officials said.
“I’m not going to put a date on any of this,” Axelrod said. “But I think it’s fairly obvious that we’re not in the second inning. We’re not in the fourth inning. We’re in the eighth or ninth inning here, and so there’s not a lot of time to waste.”
Obama's specifics will include many of the principles he has spelled out before, and aides did not want to telegraph make-or-break demands. But Axelrod and others are making plain that Obama will assert himself more aggressively — a clear sign that the president will start dictating terms to Congress.
"His goal is to create the best possible situation for consumers, create competition and choice," Axelrod said. "We want to bring a measure of security to people who have health insurance today. We want to help those who don't have coverage today, because they can't afford it, get insurance they can afford. And we want to do it in a way that reduces the overall cost of the system as a whole."
Also this fall, Obama wants to slap new regulations on Wall Street firms, a goal that is now considered a higher priority than cap-and-trade energy legislation in the West Wing. White House officials think the legislation will show voters, especially wavering independents, that he is serious about making the culprits of the economic crisis pay. It also helps that it doesn't carry a big price tag, like other Obama priorities.
The president also plans to send Congress a report on Afghanistan by Sept. 24 that is designed to build patience after two months in a row of the highest U.S. casualties since the invasion eight years ago. Aides say they recognize they need to show progress over the next 12 to 18 months, or risk losing the support of key Democrats in Congress, who already have balked at funding Obama’s 20,000-troop buildup.
But health care remains front-and-center in Obama’s fall strategy. “I understand the governing wisdom here in town as to where this is right now,” Axelrod said. “I feel good about where it is right now. I understand that there’s been a lot of controversy. I understand that there’s been a lot of politics. But the truth is, we’re a lot closer to achieving something than many thought possible. People look to the president for leadership on this and other issues. He feels passionately about this, and you can look for him to provide that leadership.”
Obama has been criticized for deciding to cede much of the debate to Capitol Hill -- or, as Axelrod put it, “allow Congress to consider the whole range of ideas.”
“History will judge whether this was right or it was wrong,” Axelrod said. “We feel strongly that it was right. As a result of it, we have broad consensus on over 80 percent of this stuff, and a lot of good ideas about how to achieve the other 20. Now, people are looking to the president and the president is eager to help lead that process of harmonizing these different elements and completing this process so that we can solve what is a big problem in the lives of the American people, for our businesses and our economy.”
White House officials say they are looking forward to "a break from the August break" -- a chance to take back control of the debate after a grim month where news coverage of the issue was dominated by vocal, emotional opponents at lawmakers’ town meetings, railing against the cost and complexity of the plans being debated.
So Obama and Democrats will return from vacation wounded, divided and uncertain of the best way to turn things around. Many Democrats, especially in the House, were spooked over break by the rowdy town hall meetings and flurry of polls showing independent voters skeptical of their leadership and spending plans.
The mood swing is hitting some top leaders hard: Senate Majority Leader Harry Reid (D-Nev.), for instance, is trailing little-known GOP contenders in his re-election race now. The news swing has been no less brutal. There has been saturation coverage of the town halls and rising casualties in Afghanistan -- the latter leading to a big drop in support for the war.
All of this makes for a tumultuous -- and wildly unpredictable -- fall for Obama and his party.
Axelrod said he isn’t worried. “Part of it is born of long experience,” he said. “In Washington, every day is Election Day. I’d be lying to you if I told you I don’t look at polls -- I do. But I’ve also learned that you have to keep your eye on the horizon here and not get bogged down. I am not Polyannish, but I am also not given to the hysteria that's endemic to this town.”
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