A little less than ten years ago, inside a dark hotel restaurant in Utica, New York, Gary Rotzler told me the story of wife Betsy. They had been high school sweethearts and, by the early 1990s, had settled into their version of the American dream: Three young children and a home in Gilbertsville, a village of around 400 people nestled into the foothills of the Catskill mountains. When Gary lost his job at a defense contractor, he lost his health insurance. After piecing together part-time construction work, he got his old job back—but as an independent contractor without benefits. Betsy got sick and, after months of putting off medical care, was diagnosed with terminal cancer.

Betsy died a few months later and, when the medical bills for Betsy’s treatments arrived, Gary filed for bankruptcy. There’s no way to know whether, with more timely care, Betsy could have beaten the cancer. But she probably could have lived longer or in less pain. At the very least, insurance would have alleviated the anxiety over paying for Betsy’s treatments—and spared Gary the indignity of bankruptcy after she was gone.

The story was one of literally hundreds I’ve heard over the last decade-and-a-half—and the primary reason that making affordable medical care became such a passion. To my great fortune, it's a passion others have shared.

In early 2006, Franklin Foer called me with two pieces of news. The first was that he would be taking over as editor of The New Republic. The second was that he wanted universal health care to become the magazine’s new crusade. TNR had published my work on health care since the late 1990s, while giving me the room (and space) to develop what would eventually become my book on the subject. But making health care reform a crusade—that was new. And, for TNR, it had a special significance.

During the last great debate over health care reform, which took place in 1993 and 1994, TNR had published an article called “No Exit.” Written by a then-anonymous, self-declared policy expert named Elizabeth McCaughey, the article purported to expose all sorts of nefarious details about Bill Clinton’s health care plan. McCaughey proved to be no expert at all; her claims proved to be wildly inaccurate. But the article had enormous influence, introducing arguments that—however false—opponents successfully used to thwart reform. Taking up the health care crusade was a chance to make up for that episode. And, at a time when even many Democrats were too skittish to talk seriously about universal coverage, TNR would be carrying out its historic mission as a flagship for liberal thought. As we said in the first editorial of Frank's tenure:

Since President Clinton's health care plan unraveled in 1994--a debacle that this magazine, regrettably, abetted--liberals have grown chastened and confused, afraid to think big ideas. Such reticence had its proper time and place; large-scale political and substantive failures demand introspection, not to mention humility. But it is time to be ambitious again. And the place to begin is the very spot where liberalism left off a decade ago: Guaranteeing every American citizen access to affordable, high-quality medical care.

What I didn’t realize until much later was that my colleagues and I would be redefining more than TNR’s legacy. We were also among those journalists redefining the coverage of policy issues. One reason McCaughey's article had been pernicious was that it was weeks before other writers (including TNR's own Michael Kinsley and Mickey Kaus) exposed its fundamental dishonesty. That was the nature of media coverage then: It was dominated by a relatively small number of mainstream media outlets, abiding by the ethos of objectivity and operating on a daily news cycle.

By contrast, coverage of this past year's health care debate took place at internet speed—which is to say, instantaneously. News would happen and, presto, it was being reported. And it wasn’t just being reported by a handful of establishment news outlets. In addition to The New York Times and CNN, there was the Huffington Post and Talking Points Memo. The change didn’t fully register with me until the night the House passed the Senate health care bill, clearing reform for presidential signature. Sitting up in the House media gallery, next to Politico's Carrie Budoff Brown, I looked around at my colleagues—and realized how few of them would have been there last time around.

Was this a change for the better? I'm biased, obviously, but with some important caveats I think the answer is "yes." We (i.e., the new online media) could generally channel policy expertise more quickly. And we could, in some cases, dispense with conventions of even-handedness—conventions that cynics had long ago learned to exploit for their own purposes. We couldn't stop intellectual saboteurs from introducing new lies into the debate. (Thank you, Fox News.) But I think we were able to expose those lies just a little more quickly--and, hopefully, a bit more effectively.

Consider what happened in September, when the insurance industry released a study purporting to show that reform would cause insurance premiums to skyrocket. The Senate Finance Committee—the logjam in the legislative process—was set to vote on its bill in less than 48 hours. The study, commissioned by the insurance lobby and conducted by a private accounting firm, represented a clear effort to undermine support. It was the kind of move that lobbying groups make all the time—and, in the old days, it might have worked, since nobody would have seen through the study’s tilted assumptions until, as with McCaughey’s old article, the damage had been done. But within hours of its publication, several blogs, including this one, had published critiques showing just how flawed the study was. The critiques circulated in Washington and provoked a backlash against the insurers. Wavering Democrats said they were offended by the effort at political sabotage; the Finance Committee went on to pass the bill, as it had originally planned.

Not that fact-checking was the media's sole job over the last year. Speaking for myself, I certainly spent far more time on the more mundane task of explanation—whether it was describing how a particular policy proposal might work or laying out the political dynamics of a particular moment. Occasionally this writing got a lot of attention, because it included a reporting tidbit that qualified as a scoop. More often, it didn’t. But over time I came to realize that the mere sharing of information has enormous value—even to people in Washington who, you might suppose, already know what they need to know.

Indeed, one of the many lessons I learned over the last year is that, even at the very highest levels of power, people frequently operate with limited knowledge and perspective. That’s true of how they think about policy and that’s true of how they think about politics. As one high-ranking official memorably told me in February, while everybody was scrambling to salvage reform after the Massachusetts Senate race, nobody really sees the whole playing field.

This lack of adequate information is not always, or even usually, for lack of effort or commitment. Having spoken with and watched quite a few key players in this debate up-close for the last 16 months, I can tell you that they worked ridiculously long hours, at no small costs to their physical and emotional well-being. (One Hill staffer told a story of getting dressed one morning, bleary-eyed, a muffin in one hand and an earring in the other. She meant to eat the muffin but ate the earring instead.) No, the reason that people in this debate operated with imperfect information was that they were human beings and, thus, imperfect. Hopefully blogs like this one helped rectify that situation, at least a little bit.

To be clear, those of us covering the health care debate over the last year haven’t been perfect, either. Far from it. The new media can certainly react more quickly than the old media did. But speed is not always a virtue. Rushing to be first can mean rushing bad information into publication—particularly if, say, the information is based on one source that doesn't know as much as he or she thinks. And for all of the policy expertise some of us brought to the discussion, most of us—and I’d certainly put myself at the top of the list—were and still are relative novices at covering the political process itself.

That’s one reason I’ve gained so much admiration for colleagues like Julie Rovner, of National Public Radio, or Karen Tumulty, formerly of Time and now the Washington Post, whose sophistication spanned both policy and politics. It’s no accident, I think, that both came from “establishment” media, even though they were at ease blogging, and that both had years of experience as reporters. At a time when the financial support for their kind of journalism is increasingly hard to find, I wonder whether future policy debates will benefit from such broad expertise.

Another problem for the new media is that, as time goes on, we’ll fall into the same bad habits that plagued the old media. Groupthink? Biased reporting? Source capture? Rest assured, we’re as prone to that as the generation we are replacing. At various points, critics on the right and the left felt the reporting and analysis in this blog—and others like it—was incomplete, one-sided, or otherwise flawed. And I wondered constantly whether they had a point.

I remember, in particular, one moment of self-doubt when Marcy Wheeler, a (very) smart blogger from FireDogLake, took me to task over my analysis of how the Senate health care bill would affect middle-class Americans. Having spent so much time defending the health care reform bills moving through Congress, had I become ignorant—or at least overly dismissive—of their flaws?

After a long back-and-forth on that particular controversy, I decided I had been right. (I think Marcy concluded the same about her position--which means that readers, and historians of the future, will have to render their own judgments.) And I suppose that’s ultimately one of the best features of online journalism. It is more of an ongoing, evolving conversation—one in which it is easier to hash out and refine arguments. Those of us covering politics and policy today can make as many mistakes as our predecessors did. But perhaps we have more opportunities to become aware of those flaws and to correct them.

If that sounds like coverage is becoming more of a collaborative process than a competitive one, that’s because for me it has frequently seemed that way. My relationship with Ezra Klein is a case in point. If you read this blog, then you probably read Ezra’s, as well. (If not, you really should!) We cover the same beat and, as best as I can tell, talk to many of the same sources. We should be rivals, I suppose, but I’m proud to call him a friend. He’s taught me an enormous amount—as my frequent links have hopefully made clear—and he's made this entire debate far richer than it would otherwise have been. 

Speaking of collaboration, this would be a good moment to thank a few people who helped with this blog. Covering health care policy is difficult, even for somebody like me who’s been writing about it for what seems like forever. I can’t tell you the number of times I came across a policy or politics question, read through the available material, and said to myself: “Huh?” To help me sort through those situations, I frequently relied on other writers, like Austin Frakt or Jeffrey Young. I also built a small committee of experts to whom I could turn for a quick reality check.

Some of them made appearances on this blog as guest contributors. But one person remained mostly anonymous. It's Larry Levitt, a vice president of the Henry J. Kaiser Family Foundation and the single most knowledgeable person on health care policy I've encountered. He is intellectually honest to a fault—even when it’s politically inconvenient—and he has the patience of a saint. Also, to my very good fortune, he’s been based in Rome for the last year, making him awake and available by e-mail at precisely the late hours when I tend to write. Although I quoted Larry rarely, I turned to him constantly—and owe him a huge debt.

(By the way, among the Kaiser Foundation's many other contributions to this debate was the establishment of Kaiser Health News, the independent news service for which I've been writing a column that also appears at tnr.com. I'm hardly objective about this, but I imagine their influence will only grow as the debate moves to implementation--and their expertise becomes even more valuable.)

I’m also grateful to the writers who shared this space with me. Anthony Wright provided the perspective of somebody who deals with health care policy on the front lines. Suzy Khimm was a ridiculously dogged journalist who, among other things, had the good sense to tell me--on more than one occasion--that reporting had proven my hunches wrong. Trust me when I tell you she'll be breaking big stories for a long time to come. And I’m not sure I can sufficiently thank, or recognize, the contributions Harold Pollack made to this project. Instead, I’ll simply let you in on a personal insight: He is every bit as decent and kind a person as his writing suggests. (He's incredibly smart, too, although I guess you knew that part.)

My name is the one at the top of this blog. But it is part of The New Republic, which means it is part of a bigger enterprise, managed by editors and supported by researchers of uncommon talent--and by that I mean not just Frank, whose support for the blog and the idea of health reform never wavered, but also online editors Greg Veis and Zvika Krieger, who managed this website. Among the less glamorous duties they drew: Staying up late so I could file my items for the next day's home page just before midnight. (Yup, just as I am now.) Editors never get the credit they deserve. That's particularly true in the cases of those three.

This is probably the longest item ever to run on the Treatment. And, as you may have guessed from the self-referential tone, it will also be the last. TNR created this blog to cover the debate over whether to pass comprehensive health care reform. That debate has ended. Now it is time for this blog to do the same.

Of course, the story of health care reform isn’t over. In a sense, it’s just beginning. Implementing the new law will involve its own, very different set of challenges. And that’s assuming it withstands the coming efforts to repeal it. While I’ll be on hiatus from full-time blogging for a short time, in order to finish a print piece or two, I'll make cameos over at Jonathan Chait's venue as events warrant. (My apologies in advance to readers about to become further confused about our respective identities.)

But just as this isn’t the end of my life as a health care reporter, so this isn’t the end of my life as a TNR blogger. To my surprise, I found I actually liked blogging. I even started a Twitter feed, although I've had trouble convincing Noam to do the same. I'm not giving up either endeavor.

More on all of that soon. In the meantime, I’d like to thank The Treatment’s readers--those of you who followed it religiously and those of you who stumbled here through random links, those of you who shared its sense of mission and, yes, those of you who hated it. You were part of this story, too. I’m grateful for your attention, support, and feedback.  Please stick around for the next chapter.

Update: Perhaps fittingly, I accidentally left out a few passages when cutting and pasting last night. I've now restored them.

Anthony Wright is executive director of Health Access California, the statewide health care consumer advocacy coalition. He blogs daily at the Health Access Weblog and is a regular contributor to the Treatment.

While there are several benefits from health reform that kick in this year, the common understanding is that the core coverage expansions will not take place until 2014. However, starting this month, April 2010, states have the option of expanding Medicaid to low-income individuals early--and getting at least 50 percent matching funds from the federal government.

Most states are in deep budget crises, and probably won't consider expansion. They were already mulling cuts instead. Here in California, with the particularly tough economic downturn, Governor Schwarzenegger has actually proposed taking more than 1.5 million people off Medicaid and eliminating our version of the Children's Health Insurance Program, Healthy Families, which covers another million children. These cuts have thankfully been prevented by the "maintenance of effort" requirements in first the stimulus act and now the new health reform law. (Cuts to Medicaid benefits and other health and human service programs are still pending.)

As I wrote earlier, this is a turnaround for Governor Schwarzenegger, who had his own state-based health reform a few years ago which, like the new federal health reform, would have expanded Medicaid to 133 percent of the poverty level and brought in poor adults without children at home. Back then, he extolled the virtues of expanding Medicaid and bringing in those federal matching funds to our state's health system, money that otherwise would be "left on the table" in D.C.

In fact, there's a powerful argument that states should expand, not cut, public insurance programs right now--despite the recession and budget deficits. The most obvious case is that there is greater need--the whole point of a social safety net is to be there during tough economic times, when people are less likely to have private, employer based coverage. But expanding coverage can also speed economic recovery. Too many elected leaders see Medicaid merely as a budget burden, rather than as a way to bring federal funds into their state economies and thus spur economic growth.

In fact, nothing else a state can do can have such a positive economic impact. Medicaid spending provides more “bang for the buck” economic impact than other state fiscal decisions, according to a recent University of California-Berkeley report. Put another way, spending (or cutting) a billion dollars in Medicaid will create (or eliminate) over 35,000 jobs. In comparison, an upper-income tax increase (or cut) has a much smaller 6,400 “jobs per billion” impact, and an oil severance tax even less.

Spending more on health and human services gives the economy a bigger boost not just because of the federal matching funds coming into the state, but also because of the “multiplier effect” it has on local economies. Health services, by definition, can’t be outsourced out-of-state. Also, the benefit goes to low-income patients and middle-income health workers. Both tend to spend the money immediately, recycling it into the economy.

Governors should not see Medicaid as a spending item that they want the “flexibility” to cut, or even just as a core safety-net program that it especially necessary during these tough times, but as the center of an economic recovery strategy. Hopefully health reform, through matching dollars or maintenance of effort requirements, will help not just expand Medicaid, but transform the thinking of state leaders in realizing the program's potential.

Anthony Wright is executive director of Health Access California, the statewide health care consumer advocacy coalition. He blogs daily at the Health Access Weblog and is a regular contributor to the Treatment.

Former Massachusetts Governor Mitt Romney is not the only Republican Governor trying to rewrite history, distancing himself from the new federal health reform law that mirrors the proposal he once championed for his own state. California Governor Arnold Schwarzenegger is doing it, too.

To be fair, Schwarzenegger has tempered his remarks, highlighting positive elements of the health reform, and has stated a commitment to implement the new reforms. But he and others in his Administration have also complained about the cost to the state, saying it would cost California $2 to 3 billion more, largely in Medicaid expenses, than the state-based reform he supported but that ultimately failed to pass two years ago.

Key California members of Congress responded, saying that any new cost the state will incur needs to be weighed against the more than $100 billion in benefits the state will receive. But the Governor also just misstates the comparison. His California health reform proposal may have been better in some respects, but two years ago Governor Schwarzenegger would have jumped at the financing arrangement the new federal law offers.

Back then, Governor Schwarzenegger’s proposal was to expand Medicaid to all people at less than 133 percent of the federal poverty level. Since Medicaid is a joint federal-state program, he was asking federal permission to extend California’s standard financing arrangement, in which the feds and California covered an equal share, to more people (mostly adults without children at home, sometimes called the “medically indigent”).

Under the new federal law, Medicaid eligibility will expand to 133 percent of the federal poverty level (except for undocumented immigrants). In other words, it's the same expansion Schwarzenegger proposed before. But for the first three years, from 2014 to 2016, the federal government will actually pick up all of the costs of the newly-eligible population. After that, states will have to contribute some money. But the federal government will still be contributing 90 percent of the cost of newly-eligible.

That’s not a burden. That’s a bargain. 

Some may say that even the modest state contribution is too much when states are already struggling to balance budgets. But remember: The states don't have to provide those funds for many years, by which time they should be out of the present economic crisis.

This argument also ignores the fact of where the responsibility for providing safety-net medical care to the “medically indigent” currently rests. Health reform should be properly seen as the federal government providing significant help in areas previously borne solely by county and state governments.

In practice, the states will recognize the deal and take it. The State Child Health Insurance Program was created over ten years ago and voluntarily offered states the option to cover children just above the poverty level, with the federal government providing a two-to-one match. Some states expanded coverage more than others, but all took up the offer in one way or another. The health reform offers a nine-to-one match--that is, an even better deal.

To be clear, Schwarzenegger and other state elected leaders are absolutely right about the need for more federal help right now, given the budget crises affecting so many states and possible cuts to vital health programs that will follow. But that's something the federal government can and should address through other legislation, such as extending the enhanced Medicaid matching dollars that was in the stimulus act.

Harold Pollack is a professor at the University of Chicago School of Social Service Administration and Special Correspondent for The Treatment.

The current Pediatrics includes a timely article, which in its way is as frustrating as any account of Tea Party protesters shouting about death panels. The article by David Sugerman and colleagues recounts a 2008 measles outbreak in San Diego. This outbreak began when an intentionally unvaccinated 7-year-old contracted measles on a trip to Switzerland. The boy unintentionally exposed 839 people before the outbreak was contained. Three-quarters of those who actually became infected were intentionally unvaccinated. Seventy-three unvaccinated children (including 48 who were too young to be vaccinated) were placed under 21-day quarantine. As is often the case, geographic and school clustering of intentionally unvaccinated and under-vaccinated children provided an epidemiological niche in which infection was especially likely to spread.

This is not a story about a low-income community lacking basic information or access to medical services. Most of the parents who chose not to vaccinate their children were college educated. A large proportion of parents who chose not to vaccinate had six-figure incomes. Fortunately the overall community had strong vaccination coverage. Public health authorities effectively intervened, and the outbreak was contained. The measureable economic cost of this outbreak and its control was estimated at about $176,000. The intangible costs were surely much higher. This is such a frustrating waste of time and resources.

In the larger picture, it's not surprising that many parents go this route. We live in a time of widespread distrust of medical authority and the pharmaceutical industry,. This is mistrust is sometimes sadly warranted. Millions of parents are influenced by compelling but unfounded rumors that vaccines cause autism.

We also live generally free of the ravages of infectious childhood disease. Parents are understandably tempted to avoid the potential adverse effects of immunization in the hope that herd immunity will still protect their children. I think this is a bad bet. In this era of constant population movement, airplane travel, and immigration, you don't know what bug the guy next to you in the subway might really be carrying.

Intentional unvaccination is most obvious in the case of measles, but it shows up in other arenas, too. We could save thousands of lives if young people got their flu shots every year, for example.

Some people want to tighten the legal requirements for vaccination. I'm not willing to take this step. I'm not in the camp that wants to berate parents who choose not to vaccinate their kids, either. Many of these parents have had real experiences with the health care system that lead them to distrust it. We need to win that trust back through persuasion rather than through compulsion.

It's a slow and frustrating process. There really is no alternative.

As some of you you may have noticed, I took a short vacation after President Obama signed the Patient Protection and Affordable Care Act passed. It seems that Obama and his advisers didn't.

With the ink on the presidential signature barely dry, administration officials announced that Don Berwick would be the president's choice to run the Center for Medicare and Medicaid Services.

Who's Berwick? And why is his impending appointment so important? Let's start with the second question.

CMS, as the agency's name suggests, administers the government's two massive insurance programs: Medicare and Medicaid. That gives it purview over the insurance coverage for tens of millions of Americans.

But the influence of CMS will extend far beyond those two programs. In order to make medical care more efficient, the Affordable Care Act envisions CMS changing the way Medicare pays for medical services. The hope is that these changes will force the providers and producers of medical care to change their behavior--by, say, focusing more on treatments that work or avoiding preventable errors. The government would save money. So would everybody else. And the quality of care would actually improve.

To make this happen, CMS needs a leader who not only understands this mission but believes in it.  And that's Berwick.

Health policy wonks treat Berwick like a celebrity, throwing around words like "pioneer" and "visionary." He's a Harvard-educated pediatrician who, during the 1980s, took charge of improving quality for the Harvard Community Health Plan, a managed care organization with a reputation for doing what HMOs were always supposed to do: Provide better care for less money.

Over time, Berwick increasingly turned his attention away from curing individual patients to curing the medical care system as a whole. He eventually established the Institute for Healthcare Improvement, a perch from which he became something of an evangelical for improving the quality of care. If you recall reading or hearing about a groundbreaking report chronicling the huge financial and human costs of medical errors, then your familiar with Berwick's handiwork, since he was one of the people behind that study.

People who know this field better than I do have enormous respect for Berwick. And they seem positively thrilled by the announcement, as the Century Foundation's Maggie Mahar noted on her blog, The Health Beat:

He’s a revolutionary, but he doesn’t rattle cages. He’s not arrogant, and he’s not advocating a government takeover of U.S. healthcare.

Berwick stands at the center of a healthcare movement that would reform the system from within. ... In 2005, Modern Healthcare, a leading industry publication, named him the third most powerful person in American health care. In contrast to others on the list, Berwick is “not powerful because of the position he holds,” Boston surgeon Atul Gawande noted at the time.  (Former Secretary of Health and Human Services ranked no. 1, while Thomas Scully, the head of Medicare and Medicaid services captured the second slot.) “Berwick is powerful,” Gawande explained, “because of how he thinks.” ...

Soft-spoken, and charismatic Berwick is as passionate as he is original. His style is colloquial, intimate, and ultimately absolutely riveting. He draws you into his vision, moving your mind from where it was to where it  could be.

Berwick isn’t just another ivory-tower philosopher. He’s “an extraordinary leader when it comes to inspiring people and creating the will to move forward,” Dartmouth’s Dr. Elliot Fisher told me in a phone conversation Friday. “And he can teach people how to do it. He has demonstrated his ability to teach people how to implement change in a complex system.”

Bob Wachter, a leading scholar of hospital medicine at the University of California-San Francisco, offered even more effusive praise on The Health Care Blog:

While the health reform bill will have many effects, one of its most profound will be to unshackle the Centers for Medicare & Medicaid Services (CMS). Under the legislation, CMS is now far freer to undertake a variety of pilot programs and demonstration projects designed to improve quality, safety and efficiency, and to convert the successful ones into policy. And, if that wasn't enough for those who have long been praying for a more activist CMS, we now learn that President Obama will select Don Berwick, the world's most prominent advocate for healthcare quality and safety, to be the next CMS administrator. Although I've sparred a bit with Don over the years on matters of philosophy, I think he is a superb choice.

Don’s story is well known--a Harvard pediatrician and policy expert who became passionate about improving healthcare well before it was fashionable, he ultimately left his full-time academic perch to pursue his calling. In 1991, he founded the Institute for Healthcare Improvement, which ran on a shoestring for its first decade, fueled largely by the considerable power of Don’s vision and personality. ...

IHI became the essential organization--a source of networking, best practices, conferences, sustenance, courage, and more. To many in the quality and safety world, IHI became their church, and Don its Pope.

I admire Don enormously, and have no doubt that the world is a far better place thanks to his, and IHI’s, work. I've seen scores of examples of Don's impact over the years, at hospitals, nursing homes, and clinics in the U.S. and around the world.

Berwick will have to go through Senate confirmation and, I'm sure, Republicans will try to use those hearings in order to litigate health reform all over again.

A recent Boston Globe article suggested that critics have raised questions about whether Berwick's Institute has exaggerated the success of pilot quality programs it helped start. I suppose the Republicans might seize on that, as well, although the disputes sound like minor academic quibbling to me.

Of greater concern, perhaps, is the fact that Berwick is a relative novice at politics who has never run a large organization. A lot will depend on the people around him and how the administration chooses to organize the implementation of reform.

I still think, as I wrote recently, that the administration needs one point person to coordinate the activity of all the different agencies working on health care. And I wonder if it should be somebody not just outside of CMS but outside of the Department of Health and Human Services, as well. (CMS is part of HHS.) But that's a more complicated question for another time...

Photo used under a Creative Commons license from Flickr user Sarah G...

My former TNR colleague Suzy Khimm had a nice piece yesterday about a familiar but hugely important issue: poor Medicaid reimbursement rates that lead primary care doctors and specialists to avoid treating poor people. This issue was only partly addressed in health care reform. No one doubts it will fester, becoming a sore point between providers and policymakers and between the states and the federal government.

By chance, the electronic version of Pediatrics also arrived yesterday. It includes a depressingly clarifying essay "Has leisure time become Medicaid's new competitor?" by Indiana professor Samuel S. Flint. Flint briefly describes the ways that states have induced the past generation of pediatricians to take Medicaid patients:

Historically, state Medicaid programs have counted on the immutable economics of private practice. The vast majority of practice overhead costs are fixed (e.g., nonphysician personnel, rent, malpractice insurance premiums), but the marginal cost of treating each child is minimal. Consequently, it makes economic sense for physicians to accept some patients with Medicaid, because Medicaid fees for an otherwise unused appointment exceed low marginal treatment costs.

The problem with this strategy is that it is predicated on the notion that leisure time has little value, and that is changing, particularly among young physicians.

That's standard fare, but what gets interesting is Flint's effort to put dollars-and-cents numbers behind the argument. He notes that 38% of pediatric residents sought (and 21% accepted) a part-time position as a first job. This proportion surprised me. At least partly, it reflects the striking gender mix across the medical profession. Almost 70 percent of pediatric residents are women. Many pediatricians are working mothers, whose job schedules must accommodate work-family balance concerns.

Anyway, Flint calculated that such part-time positions would shorten doctors' annual work output by 2,094 visits, while reducing income by about $34,000. Doing the long division, Flint finds that pediatricians willing to work part-time vote with their feet to forego about $18.50 per visit.

You can pretty much guess what comes next.

This value ($18.50) exceeds the Medicaid payment for a brief office visit (Current Procedural Terminology [CPT] code: 99212) in Indiana and subsequent newborn care (CPT 99433) in New York, Florida, and Pennsylvania. It is greater than the Medicaid reimbursement for an emergency visit (CPT code: 99282) in 5 states, a subsequent hospital visit (CPT code: 99231) in 7 states, performing a venipuncture for a child under the age of 3 (CPT code: 36400) in 21 states, performing an arterial puncture (CPT code: 36600) in 16 states, reading a chest radiograph (CPT code: 71010) in 20 states, and performing developmental testing (CPT code: 96110) in all but 9 states.

Although the phobic in me would happily skip that arterial puncture, this overall pattern isn't healthy. We want pediatricians to regard children on Medicaid as desirable, paying customers. Right now, these kids are often viewed as charity cases for whom a pittance will be paid--late—after a load of paperwork is done. Not surprisingly, health economists and clinical researchers document the large proportion of doctors who won't take Medicaid. More disturbing than the implicit tiering of American medical care is the evidence that Medicaid patients receive lower-quality care. Sandra Decker documented, for example, that doctors devote less time and attention to Medicaid patients. Low Medicaid reimbursement has also been linked with higher infant mortality.

You get what you pay for. Seniors who worried that their options would be constrained by the public option should ask themselves what their lives would be like if they relied on Medicaid. And don't forget: Primary care for kids is probably the easiest and cheapest problem in this entire area. Imagine that your family depended on Medicaid. Now imagine that you, your son or daughter, or your spouse had a serious cardiovascular, psychiatric, or orthopedic problem, or a high-risk pregnancy. For millions of Americans and more than a few TNR readers, this is no hypothetical concern. They face this every day.

This problem needs to be fixed.

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This week's On the Media laments the low quality of press coverage in health care reform. It's certainly easy to find examples of shoddy journalism and public ignorance to bolster this charge. Every night, one could watch cable TV screamers trafficking in untruths about death panels, or commentators offering with certitude political predictions that (a) were generally wrong and (b) generally detracted from discussing the actual substance of a hugely important piece of legislation.

The Wall Street Journal editorial page and Fox News were predictably awful, though the apotheosis of groundless polemic must have been the Investor's Business Daily's assertion: 

 

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

The second own-goal prize goes to the Daily for its subsequent correction:

This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the U.K.

It's equally easy to find signs of public ignorance and innumeracy. These failings are pervasive across the political spectrum. Perhaps oddly, I find these failings especially annoying among people who disagree with me.

Because it is so easy to find bad reporting and public stupidity, it is easy to overlook something. Press coverage of health care reform was the most careful, most thorough, and most effective reporting of any major story, ever.

Throughout this past year, moderately informed and inquisitive readers could get more accurate information, more quickly, and more carefully-analyzed than one ever could before. I concede that one needed to know where to find this information. If you relied (say) on Fox News or the New York Post as your cognitive portal, it was easy to remain severely misinformed about even the broad outlines of what was proposed. I don't know how much of the resulting ignorance should be laid at the broader media's doorstep. My judgmental half wants to apply the term "operator error" rather liberally here. If you read any of the top five or ten national newspapers or (often even better) their accompanying websites, you were only a few clicks away from a remarkable and free library of analysis and supporting information of remarkable depth and diversity. If people don't look, there is only so much the media can do. My less-judgmental half is more forgiving. Many Fox viewers or New York Post readers don't realize how misleading (and sometimes straight-out false) the coverage really is.

Among the biggest consumers of these news resources were … TV, web, and print reporters. Many of these reporters began the 2008 campaign in complete ignorance of the most basic features of American health policy. I spent dismaying amounts of time on e-mail or on the phone with reporters explaining the difference between Medicare and Medicaid or what SCHIP was. A few months later, some of these same reporters knew more than I did about key provisions in the final bill.

This lesson came home to me last Thursday, when my daughter and I watched a spirited debate on health reform. Those representing the Democratic side started strong, quoting Norm Daniels on health as a human right, Jacob Hacker on the eventual need for a public option, Paul Krugman on the determinants of rising health care costs. They included poignant anecdotes of people denied care, and they noted the inefficiency of job lock addressed in health care reform.

Republican speakers responded by noting the possibility of adverse selection within the exchanges. They argued that legislated penalties were too low to really enforce the individual mandate. They worried that expanding Medicaid enrollment will hurt state budgets.

In response, Democrats responded with a detailed defense of the mandate. They also noted that managers' amendments included additional monies for states to cushion the financial blow.

The people making these arguments were not health policy experts or professional politicians. They were members of the Homewood-Flossmoor High School debate team. Starting with essentially zero knowledge and age-appropriate skills, they had gone out and mastered the debate with admirable detail and clarity.

In part, the high quality of news coverage reflected the sheer commitment of journalistic resources in a time of economic challenge to the entire industry. The New York Times and The Washington Post fielded a dozen of the best reporters in America for a year to cover this story. The Wall Street Journal, Newsweek, the Atlantic, and Time made major commitments, too. The legislative slog was maddening and sometimes boring. Yet the slow pace gave reporters time to actually understand the intermingled health-system and public health challenges the president and Congress were trying to address. The public cared, too. Health care touches everyone in America. So do the accompanying costs. Millions of people wanted to know what is happening, and how it affects them.

Coverage also reflected the capacity of the Internet to go deeper and faster into news stories than one could do before. When the Tea Partiers shouted "Read the Bill!" one could get on the web and do precisely that. Someone will even read the bills to you, if you wish. I was amazed by the number of key players willing to give long and detailed on-the-record interviews to more knowledgeable reporters than those who populate the Sunday talk circuit.

No legislation of this scale is passed without some backroom dealing and hard bargaining. Much of this dealing and bargaining was reported on the web or in print within hours of being done. At times, the process was too transparent. I worry that Congress and the president need more private space to get things done.

There was so much information that the biggest problem was to sift through it all. Reporters, citizens, advocates, and policymakers all struggled to figure out what complicated provisions actually meant. Some provisions of the final bill—for example the CLASS Act—were themselves 14-figure initiatives which would, in any other context, be viewed as major changes in American social policy.

Over time, reporters and organizations that could clarify these complexities became critical resources. The Congressional Budget Office, despite its challenges and shortcomings, was the one indispensible resource.

Other essential resources were developed over many years and reflected longstanding commitments by several foundations to support health policy research and reporting. The Kaiser Family Foundation has spent years developing tools and expertise in analyzing legislation and policy concerns in Medicare, Medicaid, and a host of other programs. Virtually every reporter, advocate, and policymaker ruthlessly mined KFF's side-by-side comparisons to understand the profusion of competing proposals and bills. The Robert Wood Johnson and Commonwealth Foundations played similar critical roles, supporting Institute of Medicine reports, disseminating health services research, and more. Peer-review medical journals such as JAMA and the New England Journal published dozens of clinical and policy commentaries that were vetted through peer review and that influenced media coverage. As a field, health policy can be contentious and political. Yet it includes a diverse group of interest groups and constituencies that can mobilize impressive expertise to advance their perspectives.

Some reporters, professors, and commentators cemented their star status by performing this translation function well. The heavy lifting went beyond a relative handful of famous people covering the story. I and many others religiously checked David Dayen's whip count at Firedoglake, for example. Celebrity reporters were calling and citing people who are not always household names, but who belong to a huge expert community of people who genuinely know something about pressing health policy concerns.

For example, Timothy Jost and Joseph White became leading commentators on legal and administrative obstacles to reform. Howard Gleckman wrote important material on disability policy. Dana Goldstein, Digby, and Michelle Goldberg covered reproductive rights. Michael Chernew, Austin Frakt, and others clarified long-term budget matters and the drivers of medical expenditure growth. Merrill Goozner, Shannon Brownlee, and Maggie Mahar did similar work understanding the necessity, but also the limitations, of comparative effectiveness research and health information technology in controlling costs. I can't possibly name everyone; I certainly won't try to. Covering major reforms to a $2.6 trillion economic sector required a deep, deep bench.

One other element was quite noticeable in this health reform debate: The everyday commitment and skills of working journalists pursuing the story. I'm proud of some of the work I've done, but I'm not a real journalist in the same way many of my colleagues are. I bring complicated biases and constraints as a public health researcher and advocate. With rare exceptions, I was not doing shoe-leather reporting, chasing down news sources, or cajoling congressional staff for leads. I spent much of the past year analyzing and discussing information gathered by others. There is a craft to good reporting and careful journalism. I have huge respect for people who practice their craft well.

Sustaining the journalism enterprise isn't easy. Much as I admire the coverage of health reform, I worry that coverage will lag behind on other important matters, climate change being the most obvious case in point. The best reporters on this beat are as good anyone writing on health. As a rule, though, reporters generally know less about these issues. These issues seem complicated, unfamiliar, and boring. They do not touch people in the immediate way that health care does. As in health reform, there is an advocacy base and an academic infrastructure to help reporters convey a technical subject to the wider public. Yet that infrastructure seems weaker and less diverse in viewpoint, skills, and material interests than is available in the arena of health.

Matching what was done on health care will be a daunting challenge. That's scary, because climate change (and immigration and financial reform) are no less important. 

Well, maybe not actually fishing, but I'm off until Thursday. Thanks for reading, and I'll be back soon.

Just now on CNN, the hosts will reading recent viewer e-mails about health care reform. Among them was an e-mail attacking the new law. If health care reform is so good, the writer wanted to know, why are politicians exempting themselves from it?

I've heard critics of the bill, from Republican senators to random internet writers, say this many times. And it's frustrating, because it's not true.

As I've written previously, under the new law, members of Congress and their staffs must enroll in the new insurance exchanges. Those are the exact same exchanges through which millions of other individuals will be buying their coverage.

The law didn't originally read that way. In the first draft, lawmakers and their staffs got to keep their present employer-sponsored insurance, just like most Americans will. Republicans introduced amendments that would require the members and staff to enroll in the exchanges, presumably in an effort to make them look bad. They assumed that no representative or Senator would voluntarily relinquish the coverage they get from the Federal Employees Health Benefits Plan.

But the Democrats did just that.

The one exception is that, under an amendment introduced later, the requirement doesn't apply to committee staff. My understanding from one source is that this was done because the language was so broad that it would have included not just political staff but also many lower employees of the Capitol building. And they saw no reason to disrupt those peoples' coverage simply to prove a point.

But the members themselves and the people who work directly for them are all covered. And, far from pointing out the problems of reform, it demonstrates its virtues: The politicians believe in it enough to entrust their own lives, and those of their families, to the new system.

Again, don't take my word for it. Here's the actual legislative language:

(D) MEMBERS OF CONGRESS IN THE EXCHANGE

(i) REQUIREMENT- Notwithstanding any other provision of law, after the effective date of this subtitle, the only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are--

(I) created under this Act (or an amendment made by this Act); or

(II) offered through an Exchange established under this Act (or an amendment made by this Act)

(ii) DEFINITIONS- In this section:

(I) MEMBER OF CONGRESS- The term 'Member of Congress' means any member of the House of Representatives or the Senate.

(II) CONGRESSIONAL STAFF- The term 'congressional staff' means all full-time and part-time employees employed by the official office of a Member of Congress, whether in Washington, DC or outside of Washington, DC.

The House sure didn't waste any time. Just hours after the Senate passed amendments to the Patient Protection and Affordable Care Act, the House passed them, too, by a vote of 220 to 209. 

And that's it. Congress is done with health care reform, or at least this phase of it. All that remains is for President Obama to sign the amendments into law.

My colleague Jonathan Chait has observed how much the political landscape has changed, almost overnight. It's worth observing that the policy landscape has, too. In the span of one week, Congress passed and the president signed laws that will:

-- Bring insurance to around 30 million people that wouldn't have it otherwise

-- Strengthen the minimum protection that insurance provides to everybody

-- Streamline administrative work for patients, doctors, and companies alike

-- Invest substantial sums of money in the construction of new community clinics and the training of new health care workers, both of which should help the economy even as they help meet our society's unmet medical needs

-- Introduce delivery reforms that should help make the health care system at least a little more efficient and at least a little less expensive

And oh, by the way, they managed to completely revamp the student loan program along the way. At any other time in recent memory, that would have been a huge accomplishment all its own. Today, it's just part of the mix.

President Obama and his Democratic allies should enjoy the moment. This was a hard-fought victory, one not years but decades in the making.

Still, there is work to be done. And some of it must begin soon. In the new issue of Time, Karen Tumulty and Kate Pickert with Alice Park sketch out the major challenges ahead. Among them are action at the state level:

The most important challenge for the states will be setting up health insurance exchanges--marketplaces where small businesses and individuals will be able to shop around, choosing from a selection of insurance policies, much as federal government employees (including members of Congress) do now. ...

But to work right, each exchange will need to have enough enrollees and enough insurance-plan offerings to assure vigorous competition. That's no small challenge, given the near monopoly power insurers have in many states. For instance, Republican Vermont Governor Jim Douglas notes that while there were 75 major insurers competing for business in his state a decade ago, there are now only three. The rest were driven away, he says, when Vermont instituted many of the same reforms that are envisioned under the federal law.

While some states will be able to operate these exchanges on their own, others are likely to join with their neighbors in regional operations. "The borders don't separate where the care might be given, and I have five borders," says West Virginia Governor Joe Manchin, a Democrat. "We're going to work in conjunction with our fellow states, with our fellow governors, to make the best delivery system and the best economy that we can." 

And some states may well return to an idea that generated a lot of controversy during the yearlong battle over health reform: a government-run public option for the uninsured, similar to Medicare. Oregon is already studying the feasibility of including a public option as part of its state exchange. Says Manchin: "All of us are going to have to look at that ... What we've got to do is make [insurance companies] compete--and a public option is probably the only way."

The odds of creating a public option at the state level might seem longer than the odds of getting one at the national level. But if a state really does have a lack of competition, I don't see why determined lawmakers there couldn't add one--or, at the very least, arrange for some kind of Medicare access.

The Senate on Thursday afternoon passed amendments to the Patient Protection and Affordable Care Act. They used the budget reconciliation process, in which Republicans couldn't filibuster. The final tally was 56 to 43, with three Democrats (Lincoln, Nelson, and Prior) voting against one Republican (Isakson) absent due to illness.

Republicans were successful at challenging, and striking, two provisions because of parliamentary rules. As such, the bill must go back to the House for final approval there. But neither change affected health care reform. And only one was meaningful--a provision about adjusting Pell Grant levels that Democrats said they would introduce separately.

The House should be able to approve the reconciliation bill with ease, as early as Friday.

Amazing what the Democrats can do when they put their minds to it, isn't it?