Update: The Supreme Court and Transparency

The United States Supreme Court recently rendered its decision in a case known as Gobeille v Liberty Mutual Insurance Company. The Court decision rests on an interpretation of ERISA. Nonetheless, in a result illustrative of the tangled complexity of health care coverage, the most profound impact the Court’s opinion may have is to undermine states’ efforts to control health care costs by making medical treatment expenses more transparent.

In an earlier post I provided some background on the case and discussed the import of the (then) pending Supreme Court decision. Now that decision is here and it’s time for a brief update.

Simply put, the Court, on a 6-2 vote, decided that ERISA overrode Vermont’s interest in requiring self-insured health plans to report claims data into a state’s all-payer claims database. As Ronald Mann lays out in his analysis of the case on SCOTUSblog, the Court majority found that Vermont’s requirements were inconsistent with ERISA’s preemption of all but the most trivial state record keeping requirements.

While the decision rested solely on the Court’s interpretation of ERISA, the case will have a substantial impact on the ability of states to use transparency to hold down medical costs. As Erin Fuse Brown and Jame King note in their post on the Health Affairs Blog, “63 percent of America’s workers with employer-sponsored health insurance are in self-funded plans. In Vermont, the ruling eliminates data from 20 percent of the total population ….” In some states this percentage will no doubt be much higher. Self-funding is the approach of choice for many employers with a large number of workers; Vermont has relatively few of these employers compared to other states.

States have sought to establish all-payer claim data bases to enable research into the variation in costs for similar medical procedures. The Court’s decision means these data bases will be unable to capture data from all-payers. It’s hard to see how America’s health care system can become more cost-effective in the future without the means to accurately measure how cost-ineffective it is today.

The majority on the Supreme Court indicated that ERISA may empower the Department of Labor to require self-funded plans to report claims data to state databases. The key word here is “may.” The Court isn’t definitive on the validity of this workaround. Any attempt by the Department to impose this requirement could wind up before the Supreme Court in another few years.

For now, however, Gobeille v. Liberty Mutual will make analysis of cost differences in America’s health care system much tougher.

 

Catching Up With Health Care Reform

I’ve taken a few weeks off from blogging, but health care reform sure hasn’t taken a break. There’s a lot going on, so let’s catch up with some interesting tidbits:

  1. In April the Internal Revenue Service issued guidelines concerning one of the more popular provisions of the new health care reform bill: the tax credit some small employers may use to offset the cost of their health insurance premiums. The credit is available to qualifying group of less than 25 employees, and there’s a cap: the average premium paid for coverage in the business’ state. In other words, the amount of premium paid above these average premiums is not eligible for the credit. The list of average premiums (published by the IRS, but created by the Department of Health and Human Services) is interesting in its own right. For example, employee-only coverage ranges from a low of $4,215 in Idaho to a high of $6,205 in Alaska. (In California, where I hang out, it’s $4,628). Idaho again has the lowest premium for family coverage $9,365), with Massachusetts having the highest family premium ($14,138).
  2. In addition to the original IRS guidelines, the Obama Administration has released additional guidance to the small business tax credit created in the Patient Protection and Affordable Care Act (“PPACA”). There’s some welcome news in the material: dental and vision coverage are eligible for the credit; employers can choose the method of determining hours worked by their employees in whatever way maximizes the tax credit; and the federal credit is in addition to any state health care tax credits or subsidies available to an employer. This document also lists other benefits health care reform delivers to small businesses: the ability to pool together in exchanges; elimination of pre-existing conditions, elimination of the “hidden tax” employers with coverage currently pay (see #5, below) of roughly $1,000 per policy.
  3. You might think all this would be music to ears of small businesses. If so, it’s not enough to satisfy the National Federation of Independent Businesses. The NFIB has signed onto the law suit filed by 20 state attorneys general and governors challenging the constitutionality of the Patient Protection and Affordable Care Act. The key argument of the suit is that the federal government has no power to regulate whether an individual to enter into an intrastate contract. According to the Associated Press article reporting the NFIB’s support of the suit, the government will argue that “a decision to opt out of health insurance is not merely a matter of personal choice. It has consequences for others, since uninsured people will get sick, or have accidents, and someone must pay for their care if they can’t afford it.  Individual decisions to forgo insurance coverage, in the aggregate, substantially affect interstate commerce by shifting costs to health care providers and the public.” Welcome to a gray area of constitutional law. Feel free to argue one side or the other all you want, but there are responsible arguments on both sides. And they’ll be argued before many courts over the next three or four years.
  4. Much of the health care reform debate focused on the pricing practices of health insurance carriers. Now focus is moving towards the pricing practices of medical providers. In Massachusetts, for example, the U.S. Department of Justice is investigating whether one of the state’s hospitals are guilty of violating antitrust laws. According to an editorial in the Boston Globe, the DOJ the inquiry was launched after it was shown that some hospitals are demanding “rates much higher than others … for identical procedures.”  Meanwhile, the same editorial cites a report by Massachusetts Attorney General Martha Coakley that showed that hospitals with “geographic monopolies” use their market clout to push rates up “and contributes to annual increases in insurance premiums that greatly exceed the cost-of-living index.” Nice of someone to notice, isn’t it?
  5. There tends to be a lot of two-sided coins when it comes to health care reform. Take the term “Medical Loss Ratio.” This refers to the percentage of premium dollars spent on medical care and health quality by health plans. The Venture Cyclist blog asked an interesting question, “Why do they call it Medical Loss Ratio? Why is looking after me (or you) called ‘Medical Loss’, when the whole point of a health care system is to look after me (or you)?” He’s got a point. Calling this expense “Wellness Investment” (as the Venture Cyclist suggests), would be as accurate. He goes further, suggesting that what’s not spent on looking after the health of premium payers be termed an “Administrative Loss Ratio.” It reminds me of when folks started referring to cost-shifting (which is the increased cost insured consumers pay to cover expenses incurred by their non-insured neighbors) a “hidden tax.” Words do matter.

Well, that’s enough catch-up for now, but there’s more to come.

Health Care Reform Odds and Ends

Depending on your perspective – and stress level – every morsel of information about health care reform is either big news or not. But regardless of whether you perceive the information beginning to emerge as substantial or just more hints about what is to come, the good news is the information is coming. This post presents some odds and ends concerning health care reform along with some interesting resources readers may want to know about.

  1. USA Today has a short (surprise, surprise) article on upcoming key dates concerning health care reform.
  2. Publicly traded companies are required to disclose about possible risks to their future earnings and performance. When a number of large enterprises began reporting that health care reform would hurt their earnings, however, some lawmakers were, as the New York Times put it “skeptical.” Now that they’ve investigated the matter, however, the Times is reporting that “House Democrats have concluded that the companies were right to tell investors and the government about the expected adverse effects of the law on their financial results.
  3. Health care reform will not lower the cost of health insurance for most Americans. In fact, given the taxes imposed on medical suppliers and carriers, restrictions on health plans ability to manage risk, the incentives for some healthy individuals to go without coverage until they need it, and a host of other provisions in the bill, it is inevitable that health insurance premiums are headed up – steeply and soon. Politicians will no doubt pound on carriers for this result, but serious lawmakers realize that the only way to restrain the cost of medical insurance is to restrain the cost of medical care. The New Hampshire legislature is showing signs of dealing with this reality. Bloomberg recently reported lawmakers in the Granite State are considering establishing a board to review hospital costs.
  4. The Centers for Medicare & Medicaid Services’ Office of the Actuary released their analysis on the Patient Protection and Affordable Care Act. The independent review is given great weight. Not surprisingly, however, what someone takes away from the report seems to reflect more about that someone than the data in the report. Just check out some of the comments about the CMS report gathered by the Kaiser Health News site. Given that no law delivers on all its promises, or on what critics fear it will bring, an objective view of the bill can’t help but provide ammunition to both sides. And the CMS report does just that.
  5. For those who need to atone for past sins, you can do penance by reading the two bills now known as health care reform.
  6. One group who will need to read the bill are insurance commissioners. They have substantial responsibilities for interpreting and refining the law. The National Association of Insurance Commissioners web site has a thorough library of information about the new reforms. It’s a great resource on various aspects of the reforms.
  7. One of the best resources around concerning health care reform is provided by the National Association of Health Underwriters to its members. If you’re a broker and not a member of Health Underwriters, you’re doing your profession a disservice. And you’re unable to get to NAHU’s resource page. Which is a shame because its definitely worth the price of admission.

There’s a lot more odds and ends out there. I’ll cover more in future posts. Hopefully, however, this is an interesting start.

Medical Cost Savings Experiment Launches

In Washington, Democrats are contemplating ways to move health care reform forward in a filibuster-sensitive Congress and the White House is pivoting towards emphasizing job creation. Meanwhile, in the real world, Indiana and North Carolina are the site of two pilot projects that could have a significant impact on the quality and cost of medical care.

The Centers for Medicare and Medicaid Services (“CMS”) announced earlier this week the launch of what Health Data Management describes as “the first large-scale Medicare study of a multi-payer, quality reporting and improvement, and pay-for performance program. Data from Medicare, Medicaid, private insurers and employer-sponsored health plans will be combined with clinical data to test if quality improvement and pay-for-performance programs are more effective in a multi-payer environment.”

In other words, the folks who operate Medicare are testing a method of moving from paying medical providers for what they do to a means of compensating providers for what they accomplish. At the same time the program will “provide participating physicians with better information on the patients they are treating,” according to a press release issued by the CMS. This demonstration project will take place in Indiana.

In North Carolina, meanwhile, CMS is working with a group to test ways of better coordinating care, implementing performance incentives and measuring the quality of care received by low-income Medicare beneficiaries. The test is for model termed “medical home,” which Health Management Data describes as “redesigned practices that are more functional and workflow-friendly” and that “focus on quality, safety and alternative reimbursement methods.” The model also requires extensive use of health information technologies (think e-prescribing, clinical decision support, and electronic health records.)

My background is in selling health insurance and the politics and substance of health care reform. So I may be misinterpreting the import of these pilot projects, but my take is that they are baby steps down a very significant path: constraining the cost of health care. Most significantly, they are being done by the Obama Administration without the need for further Congressional authorization, without the need for bridging partisan chasms, and without a lot of fuss or bother. The CMS is just doing what the CMS is supposed to do. Their authority? According to the CMS press release,  the demonstrations are authorized by the Medicare Prescription Drug, Improvement and Modernization Act of 2003. No new or additional authority required. 

Given the lack of fanfare and attention given to these efforts, this may or may not be a signal that President Barack Obama and his administration are launching a coordinated effort to implement meaningful health care reform on their own as I wrote about earlier this week. I’m not sure it matters, however. The key fact is that these experiments could identify methods of wringing savings from the current health care system without the political sausage making inherent in legislative undertakings. So even while health care reform is at a political standstill, the real work of reform seems to be moving forward.

That’s encouraging.

Obama’s Health Care Speech a Beginning, Not an End

Whether you support President Barack Obama or not, his address tonight on health care reform to a joint session of Congress is a major event. American want reform, but are increasingly wary of the what they are hearing is likely to emerge from Washington. Of course, much of what they hear about what’s being considered is wrong or concern proposals that no one expects to reach the President’s desk, but the public’s unease is troubling for reformers nonetheless.

A well established political law holds that it is easier to attack than to propose and promote change. Reformers, consequently, are always at a disadvantage. The White House has seen the tenor and substance of the debate hijacked by charges both serious and silly. Worse, from their perspective, President Obama is being tied to reform bills he has neither endorsed nor blessed. The media and voters describe Congressional proposals as those of the Administration even though the President has stated only principles for reform, not details.

That changes tonight. Or at least, it starts to change tonight. President Obama is going to step into the health care debate over the next several weeks in a far more forceful fashion than before. While it’s unclear how specific he will get tonight, there is little doubt that he will be very clear about what he wants in a health care reform bill – and what he does not – over the next several days. My guess is he will use the introduction of mark-up of legislation by the Senate Finance Committee, expected to begin as early as next week, as his foundation. But whatever vehicle he commandeers (to mix metaphors), we are very close to moving past accusations concerning what Obamacare is to seeing what actually what the President’s plan actually looks like.

And this process begins with tonight’s speech. The folks over at Politico have a good “what to look for” post. Among the most significant items:

  1. Will President Obama keep it simple – and, consequently, comprehensible?
  2. Who will serve as the President’s foil? (My guess – insurance companies).
  3. Where does President Obama stand on a government-run insurance plan? We know he wants one, but will he threaten to veto a bill without a public plan?

Here’s some other questions to keep in mind while watching the President’s speech:

  1. Is the President specific about ways of reducing medical costs?
    Health insurance premiums reflect the underlying cost of health care. So does the burden of public programs like Medicare and Medicaid. Will President Obama make this clear? And will he have ideas for dealing with them?
  2. How will the President frame the rationing issue?
    The spurious fear mongering around death panels not withstanding, the public has legitimate concerns about what reform will mean to their own access to health care. There is rationing of care under the status quo (based primarily on the quality of one’s health insurance), but it’s mostly hidden and subtle. Every health system rations care in some way. How explicit will the President be about the inevitable rationing resulting from his plan?
  3. What type of Health Care Exchange does the President support?
    Does he see these exchanges as bringing together information or are they actively negotiating with carriers concerning rates and benefits? Will they replace brokers or supplement them?
  4. How does President Obama describe the efforts in the Senate Finance Committee to shape bi-partisan reform?
    Does he describe their efforts as central to health care reform legislation or as just one of many sources? Does he give its chair, Senator Max Baucus, political support and cover or leave him to fend for himself? As regular readers know, I’m one of those who believe the bill the Senate Finance Committee produces will be close to what eventually emerges from Congress. Part of my reasoning has been that President Obama wants reform legislation . Which brings us to …
  5. Does President Obama show more interest in practical results or partisan purity?
    Will he seek to please the liberals or the moderates? Will he show a willingness to accept less than a full loaf or will he insist a host of specific elements be included in the reform bill?
  6. Will President Obama succeed in making the status quo unacceptable?
    The devil known is always more welcome than the unknown variety. Right now those attacking reform have the easier task. The President needs to reverse the argument, putting the burden on his critics to demonstrate that the current system is worth preserving – or that it can be preserved. If he fails, the Administration will remain on the defensive. Not a fatal setback, but a serious problem.

Watching the spin doctors go to work on the speech will be a fascinating lesson in politics. Watching them will also be annoying. One can predict what Fox News and MSNBC will be saying, but they don’t really matter. They preach primarily to established constituencies. The public that still has an open mind on the issue will be tuned to the networks, CNN and waiting for their morning paper.

As you listen to the reaction, keep in mind that tonight’s speech is only the beginning of the Administration’s final push for health care reform.  The game isn’t over tonight. It’s just beginning.

Walgreens Free Health Clinic Visits a Sign of the Times

You can look at this story in several ways. Walgreens is offering free health clinic visits to unemployed and uninsured individuals. According to the Associated Press, individuals and their uninsured dependents who become unemployed and uninsured after March 31 will be able to receive free treatment at Walgreen’s in-store clinic, which operates under the Take Care brand name. The typical visit costs $59 or more. Take Care’s lab partner, Quest Diagnostics, is helping out by offering tests for strep throat and urinary tract infections at no cost.

How you interpret this says something about your health care reform biases. Some will see this as further proof that the private sector can fill in the cracks of the safety net. After all, Take Care clinics are a for-profit entity. The press their receiving for this program and the positive word-of-mouth they’ll be receiving. Additionally, since the Take Care program provides free services for treatment that might otherwise wind up in an emergency room or urgent care center, they may make some sales of their other services such as immunizations or makes additional over-the-counter drug sales. So what they’re doing is an example of a market-driven win-win: consumers get care; Walgreens gets more customers.

The other perspective is that this effort highlights the cracks in the system. Newly unempl0yed who don’t qualify for government medical assistance through Medicaid or the State Children’s Health Insurance Plan (SCHIP) are poorly served by today’s system. Without employer based coverage and unable to afford individual insurance, they must rely on a drug store for their health care. There’s something wrong with that picture.

My take: Walgreens is to be commended for reaching out a helping hand to those who need it, even if they’ll profit from the gesture. And universal, portable and affordable health care coverage is needed and needed soon. The current system works well for most Americans, but as a nation it’s our culture not to leave anyone behind. The lesson here isn’t that we need a government-run system, but that we need a more comprehensive, integrated and sensible system to assure basic health care coverage to all Americans.

Medical IT: Is Free Free Enough?

The health care investments contained in the recent economic stimulus bill could go a long way toward reducing medical costs — the number one priority if we’re to strengthen the U.S. health care system. By moving the provider community toward more widespread adoption of electronic records and other useful technologies, the stimulus package seeks to increase efficiency and reduce errors, both costly problems.

The government’s approach to encouraging adoption includes both carrots and sticks, the strongest carrot being the “free” technology. As others have found before, however, sometimes free isn’t free enough. That was WellPoint’s experience when it offered free PCs and prescription-customized PDAs to its network providers. The cost of changing behavior was too high to lead to widespread adoption.

That’s the concern of folks over at the web site Software Advice. As the name suggests, they’re a group that provides companies and consumers with advice on software, they match up buyers and vendors, and get a commission from the vendors (it’s free to the buyer). They’ve seen a lot of software installed and have concerns that the electronic health records aspect of the stimulus package could be headed for trouble. In a post by Austin Merritt the company warns that while moving to electronic records is a great goal, “the subsidies won’t change healthcare providers’ late adopter mindsets about information technology.”

I bring this up not to denigrate the IT skills of doctors and other providers. It’s to highlight the complexity of health care reform. President Barack Obama was absolutely correct to include push the provider community to adopt useful IT. Doing so will stimulate the economy, reduce costs in the health care system and save lives. But passing legislation is just the first step. The tough part comes in implementing the system. The real world reacts to new laws and regulations in unanticipated ways. The best and the brightest can’t out-think or out-plan the world. Reforms are needed, but they need to be thought through carefully. And in making change, its important not to destroy the existing support structures that make a system work.

Even when change is free, it’s not always free enough. That goes for health care IT, health insurance and most every other aspect of this complicated system. Legislate. But legislate with caution.

Daschle Withdrawal Could Be Bad News for Reasonable Reform

There are some who will celebrate former Senator Tom Daschle’s decision to withdraw his nomination as Secretary of Health and Human Services and as Director of the White House Office on Health Reform. They should not. Even for those who disagree with his approach to reform — and I certainly disagreed with significant portions of it — the withdrawal is bad news.

First, because Senator Daschle is bright, very bright. And anyone tackling substantial changes to a system as complex, critical and impactful as America’s health care system better be very bright.

Second, unlike many bright people, Senator Daschle is a proven political pragmatist.  He understands the need for buy-in from competing interests and for compromise. This doesn’t mean he doesn’t have principles and a philosophy. He has both. But he also has a commitment to getting reform passed, which means he’d listen to and, where possible, incorporate the ideas of those who oppose his philosophy.

Third, Senator Daschle knows Congress and is trusted by the President. This would enable him to effectively influence the former and to ably represent the latter. Without his presence, reformers in Congress may have more sway and President Barack Obama will have a less forceful voice in negotiations.

Fourth, the individual(s) nominated in his stead may lack any of these strengths. One of the names floated, for example, is former Governor and Democratic National Committee Chair Howard Dean. Governor Dean, a doctor by profession, showed himself to be a smart organizer as head of the DNC. There were also plenty of times, both at the DNC and a presidential candidate in 2002, that he demonstrated a more ideological and erratic approach to issues like heatlh care reform than Senator Daschle.

There are others President Obama could turn to for leadership on health care reform. None are likely to possess the leadership traits possessed by Senator Daschle.

Senator Daschle’s tax return errors says more about the complexity of the country’s tax code than it does about his character. Those who oppose his approach to health care reform may find themselves nostalgic for his approach before long.

Chronic Illness and Rx Expenses Show Difficulty of Reform

There seems to be a growing consensus that meaningful health care reform needs to address the skyrocketing cost of medical care. This doesn’t mean market reforms won’t be central to whatever evolves in Washington, but unlike past efforts, these efforts won’t be the only game in town. Instead what care is delivered, how it’s delivered, and who pays for it will play a leading role in the upcoming drama.

There are some easy ways to restrain health care costs. According to Peter Orszag, then Director of the Congressional Budget Office and now Director of the Office of Management and Budget, 30 percent of medical spending is on “wasteful or low-value services.” Preventing this misspending would save health care system over $600 billion. That’s a meaningful start. Emphasizing preventive care and wellness would also help. So would increasing adoption rates of medical technology. Once you move past this low hanging fruit, however, the issues get more complex and more contentious.

Consider a post today in The American Conscience blog reporting that chronic illness accounts for 75 percent of overall health care spending. According to the post, chronic illness affects 45 percent of the population. Clearly, reducing the incidence and severity of chronic illness will need to be a part of any reform effort. The posting then goes on to recommend eliminating co-pays and co-insurance on prescription drugs. Citing a Journal of Medical Care study, the blog claims $1 spent on prescription drugs for diabetes and cholesterol saves $7.10 and $5.10, respectively, on other medical services. Yet, in part due to the cost sharing required for prescriptions, the incidence of non-adherence to drug regimens is high. And non-adherence, according to a John Hopkins study cited in the post, “increases national health care costs by $100 billion to $300 billion annually.” Consequently, the author calls for reducing or eliminating cost sharing in connection with prescription drugs.

I have no idea if the studies cited in The American Conscience post are valid — the author of the blog doesn’t identify him or herself and the studies sound like what the pharmacy industry would produce. But the underlying point: too many individuals fail to treat their chronic conditions in a cost effective manner, is a legitimate concern. It also highlights the challenge facing lawmakers.

Prescription cost sharing has been shown to cut down on their overuse. According to this blogger, however, it also reduces the legitimate use of medication. How can patients be encouraged to seek lower cost, proactive solutions to their health problems without providing an incentive for anyone with a head cold from stocking up on expensive drugs? Finding that balance is a multi-billion dollar dilemma. But any meaningful reform plan is going to have to try.

Dashcle Appointment Puts Obama Health Care Reform on Fast Track

In case there was any doubt, President-elect Barack Obama made clear today that reforming the nation’s health care system will be an early priority for his Administration.  Hhealth care reform won’t wait while President Obama first focuses on fixing the country’s economic mess, but will instead be an integral part part of that effort. As he said during a press conference announcing the creation of a White House Office of Health Reform, to be led by his nominee for Secretary of Health and Human Services, former Senator Tom Daschle, “If we want to overcome our economic challenges, we must also finally address our health care challenge.” (Here’s a  video of the press conference — the comment is made at roughly the 2:40 mark).

The need to move quickly on health care reform was a central theme of the press conference. After reciting the usual litiany of the current health system’s shortcomings, President-elect Obama said, “We’re on an unsustainable course. The time has come, this year, in this Administration to modernize our health care system for the 21st century, to reduce costs for families and businesses and to finally provide affordable, accessible health care for every single American.” (This statement begins at about the 1:40 mark).

He then directly tied health care reform to addressing the current financial meltdown.  “Now, some may ask, ‘How at this time of economic challenge we can afford to invest in reforming our health care system’. And I ask a different question: ‘How can we afford not to?'” (About the 2:00 mark).

The creation of a White House Office of Health Reform, and the appointment of Senator-soon-to-be-Secretary Daschle as it’s Director is especially telling. By placing the locus of health care reform inside the White House, President-elect Obama elevates the importance of achieving meaningful change. By placing the leadership of the Office in the hands of his HHS Secretary he makes it easier for his Administration to speak — and negotiate — with one voice. By making that HHS Secretary Senator Daschle he assures the reform effort will move forward in a nuanced fashion, sensitive to the legislative process. 

This approach stands in stark contrast to the Clinton Administration’s health care reform initiative.  That fiasco, led by then First Lady Hillary Clinton, was a textbook example of insularity and insensitivity to political realities. It discouraged vigorous debate and excluded Congressional input.

Senator Daschle, who led Democrats for 10 of his 18 years in the Senate and who served in the House for eight years, will take a far different approach. First, he can’t help but reach out to members of Congress — it’s in his DNA. Second, at the press conference he pledged to work with “people from across the country to find a path forward that makes health care in this country as affordable and available as it is innovative.” As a member of the Obama Transition Team he is already coordinating thousands of small meetings across the country on the topic to bring the American people “into this conversation” in order to make “an open and inclusive process that goes from the grass roots up.”  (Beginning at the 7:10 mark).

Senator Daschle is no newcomer to the health care reform debate. He’s studied, and written about, the issue as a Senior Fellow at the Center for American Progress. He is co-author of Critical: What We Can Do About the Health-Care Crisis along with Dr. Jeanne Lambrew, who President-elect Obama named today as the Deputy Director of the White House Office of Health Reform.  Their prescription for reform is not dissimilar from that put forward by Senate Finance Committee Chairman Max Baucus which, in turn, reflects many of the principles put forward by candidate Barack Obama during the presidential election.

During the press conference, both President-elect Obama and Senator Daschle emphasized the many problems apparent in today’s health care system. This shouldn’t be a surprise. When rallying the nation to change a complex and critical component of government service reminding voters of its flaws and the need for reform is standard practice.

It would have been nice, however, if a bit niaive, to hope they would have noted, even in passing, that much of the current system works and is worth preserving. Such a statement would have been as refreshing as it would have been unexpected. And it might even have underscored the new kind of politics President-elect Obama promises to bring to Washington.