The Trail: A Daily Diary of Campaign 2008


Health Care

Reform Politics: The View From Both Sides

By Dan Balz
Raucous town hall meetings have become the political story of August. Images of angry Americans confronting their elected officials fill the screens on cable television and form the backdrop for the commentary surrounding a sharply polarized debate over the future of the nation's health-care system.

The question that looms now is, where are the politics of this debate heading? Has the favorable climate that once existed in support of efforts to change the system been replaced by implacable opposition that will block any legislation? What happens if President Obama eventually wins passage of a health-care bill? How might the two parties be affected by what transpires this fall?

There are competing interpretations of what is now happening. Opponents of the health-care efforts describe the eruptions at town hall meetings as a sign of genuine -- and broader -- anger on the part of many Americans. White House officials have begun to argue that what Americans are seeing on their televisions is a fringe response and far from representative of the population at large.

There is truth in both views -- and some wishful thinking. The health-care debate has now entered a phase in which skepticism has become more widespread. Polls show rising concerns, and the questions from citizens -- angry and otherwise -- attending public meetings underscore the personal concerns people have about how specific changes in the delivery of health care will affect them. Few public policy debates are more personalized than the issue of health care.

But if there is rising concern about the changes now being considered in Congress, the angriest expressions of opposition represent resistance to Obama that goes far beyond the issue of health care. That likely is not representative of the country as a whole, but only of a portion of a sharply divided electorate. Obama hopes to use August to show that the most vociferous opponents don't speak for a majority of the country.

The questions at the town halls display a combination of dismay and frustration with the current system. Citizen complaints highlight why there is support for fixing a system that so many regard as broken: the absence of insurance for more than 40 million Americans; the cost of insurance, especially for those of modest incomes; the sense that the current system is arbitrary in what is covered and what isn't.

All are factors that contribute to the desire for something different and explain why the administration believes there is political support for legislation this year.

Other questions, however, display misunderstanding about the current health-care system. There is understandable confusion about a complex system that baffles nearly everyone who has come into close contact with the way health care is dispensed and then billed. But there is also misinformation that has been injected into the debate. Lawmakers and the president are spending their August trying to answer those questions in an effort to temper the anger and shape the legislative climate for the fall.

Conversations with political strategists over the past few weeks reveal a clear divide over the politics of this debate. Start with Republicans. Many GOP strategists believe that the health-care debate holds great promise for their party. They see the issue as having galvanized opposition to the Obama administration and raising doubts among independents about his agenda. They also believe there could be a public backlash even if Congress approves legislation.

Still, some GOP strategists say the future is so murky on this issue that they are reluctant to draw such conclusions. One of those is Bill McInturff, a Republican pollster who has studied public opinion on health care for many years.

McInturff believes that the health-care debate has raised serious questions about Obama's leadership and agenda. He also believes Democrats are foolish to assume that the anger at the town halls can be dismissed as nothing but the views of a fringe group. But he recalls other politicians who have gotten into difficult fights early in their terms, only to recover and rebound later. Politicians who try to be consequential, he noted, often run into problems from which they can recover.

Democratic strategists see potentially big problems for Republicans in their collective opposition to health-care legislation. They believe that, if Republicans are seen simply as encouraging the most boisterous opponents, rather than contributing to fixing a system that many Americans believe is broken, they will eventually pay a significant political price.

As for their own party, these Democrats are not of one mind. One of Obama's campaign messages was that that he could break the gridlock in Washington. Some Democrats privately argue that enacting health-care reform therefore will produce a big dividend simply because it will demonstrate competence and effectiveness in governing -- even if only Democrats support the bill.

Other Democratic strategists regard that as overly optimistic. Yet they believe the prospect of failure to enact any legislation could be particularly costly because it would confirm doubts about Congress's ability to get anything done. "The political credit for enacting a bill will be limited, if voters don't feel good about the product," Democratic pollster Geoffrey Garin said. "But the downside of doing nothing could be substantial."

That alone may be motivation enough for Democrats to come together this fall to push through a bill, and it is certainly part of the White House calculus that keeps them optimistic about eventual success.

At this moment in the debate, Obama and the Democrats are playing defense and likely will continue in that posture as long as members of Congress are back home. But the tension between public frustrations over a broken health-care system and individual fears about possible changes in that system leave open the possibility that the political momentum could change again once Congress returns.

Posted at 1:27 PM ET on Aug 13, 2009  | Category:  Health Care
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The most ironic thing about the loss of a public option, if it does occur in the final health care reform legislation, is that the people, who hollered and screamed the most at the town hall meetings, are the ones who will be hurt the most by the failure to provide real competition to the health insurance companies. They're losing their insurance coverage at the rate of 2,000 per day, while 1,000,000 of them go bankrupt every year because of unforeseen health care costs. These poor souls will one day realize just how stupid they were in allowing themselves to be duped by the health care industry and its allies in the far right wing.

Posted by: Caliguy55 | August 16, 2009 2:56 PM

Many, maybe a majority, of citizens are easily scared and ready to think the worst will happen. This is easily fed by those who watch Fox News and listen to Rush Limbaugh and lesser lights of the talk radio world. I think Bill Clinton had it right when he said pass a bill and let people see the world does not end and all but the hard core birthers, tea baggers, and screaming fat old white guys will be okay with the new system. When they see that grandma doesn't have the plug pulled, that private insurers continue to prosper and that cost of medicare is reduced without cutting benefits they will come around. As to the media, they are hopeless. Any redneck can scream and holler and get immediate, and repeated, coverage on national TV while intelligent and thoughtful commentors are never heard from again.

Posted by: cdierd1944 | August 16, 2009 8:46 AM

I think a simple bill that has a national insurance exchange, insurance reforms, and an individual mandate would breeze through congress and satisfy 68% of the people worried about losing their health insurance.

Obama would be a Hero!!!

(PS: He could throw in some modest Tort Reforms if he wanted a few Republican votes.)

Posted by: cautious | August 16, 2009 3:11 AM

There will be no consesous till BOTH SIDES stop screaming & start listening!

Posted by: asclepious2 | August 15, 2009 9:31 PM

FrankiesCoffey writes:
"Read page 63 of the bill, electronic ID cards for everyone, infor on how much you have to pay and if U qualify for a certain procedure, doctor or hospital. Tell me if this reads this way?"

I don't quite follow. Page 63 of HR.3200 (in the middle of sec. 1173A) is about inserting definitions into the electronic data protection law. Perhaps you meant another page?

Posted by: iamweaver | August 14, 2009 4:57 PM

This article shows clearly the problems I have with the media. There is the ultra right, like Fox and IBD, etc., and then there is the middle of the road like the WaPo. The whole media has pivoted heavily to the right in the past 10 or so years. As an example, this article essentially treats both sides of the health care debate equal, insinuating that both have some good points. NO, most of the right's points are intentional lies, like death panels and eliminating choices and bureaucrat between you and your doctor (anyone who had a major medical procedure and has insurance today knows that in fact there is a bureaucrat between him/her and the doctor: the insurance company bureaucrat, who is heavily incentivized by his pay package to deny any and every care he/she can). You have to call a spade a spade and a bold face shameless lie a lie, not "the opposing honest argument". We got into Iraq on shameless lies from the Bush government, because the media was afraid of calling their bluff and calling it what it was: a lie. Now, again, the right has no hesitation to lie and the media, even the media not yet owned by Murdoch or some other right wing ideologue billionaire, like WaPo, for some reason is frightened and meek and gutless to call them on it clearly and unequivocally. If the media does not put its act together and does not find its courage and gut to speak the truth and not try to play "fair" when the truth is clearly on one side or the other and not in between, our democracy is in trouble.

Posted by: simon7382 | August 14, 2009 4:43 PM

let's not compare gov. run Heathcare to the post office, let's compare it to the IRS a mighty fine gov run adgency, you want to see your money disappear, you won't even see it, it will be withheld just like medicare.
Just think or look up on and the forms and laws, rules think maybe healthcare will be run like the IRS, take your money that you earn. If you had to write the IRS a check every 3 months instead of having it held out, then you'd realize just how much taxes you are paying, and guess what, they know this, what U don't ever have won't be missed.

Posted by: frankiescoffey | August 14, 2009 3:49 PM

Read page 63 of the bill, electronic ID cards for everyone, infor on how much you have to pay and if U qualify for a certain procedure, doctor or hospital. Tell me if this reads this way? They will have information on very person and if you're not near your doc or hospital then what?

Posted by: frankiescoffey | August 14, 2009 3:40 PM

You too, JakeD.

Posted by: iamweaver | August 14, 2009 3:05 PM

Well, they can only get in on the deal if they are close enough to a US hospital to be taken there if an emergency happens.

The thing is - it clearly *is* a can of worms. So how you you recommend that we 100% (no false positives, no false negatives) figure out who is the illegal alien, and who is not?

The very idea of mistakenly refusing emergency care to someone who should get it is, to me, chillingly cold-blooded - and, frankly, if that person dies, the hospital is about to be very, very sorry as soon as the family brings this issue before the US justice system.

Do you really believe that the societal cost is so high that we should chance killing off our own members to save on the cash?

Posted by: iamweaver | August 14, 2009 2:43 PM

Thanks for the civil discussion though. Have a great weekend : )

Posted by: JakeD | August 14, 2009 2:42 PM

Over SIX BILLION people in this world want to get in on that deal, so where (or "if") do we draw the line?

Posted by: JakeD | August 14, 2009 2:32 PM

I agree, JakeD. If we are serious about illegal aliens, we should look at issues like this.

But the problem with modifying the laws is that it opens a horrid can of worms. What if the unconscious, bleeding Hispanic in a community with lots of migrant workers, and without US ID, is a tourist? Or simply missing his wallet, because he's been mugged? What if he's conscious, but lies and claims that, in the wallet that was stolen from him was his health care info?

For me - morally, you fix the person, then worry about how they will pay for it.

Posted by: iamweaver | August 14, 2009 1:57 PM

No, JakeD - I am not sure of that, any more than I am not sure that my doctor won't have his staff call me every day trying to convince me to have an annual, rather than a biennial physical.

But the important thing is that the doctor has no legal backing to continue that conversation. If he persists, there are actually legal avenues that you could take, if you so desired. Better yet - use your power in the free market, kick that overzealous idiot to the side, and get yourself a doctor that you value, and that values your decision-making.

There are *tons* of horror stories about mismatched personal physician/patients.

Posted by: iamweaver | August 14, 2009 1:52 PM

That answers why we have to treat them (although federal law could be changed about that), not why we aren't arresting / deporting them as soon as their condition is stable enough.

Posted by: JakeD | August 14, 2009 1:50 PM

Not that anyone cares, but there's only 1 initial "A" in TANSTAAFL. Oops.

Posted by: iamweaver | August 14, 2009 1:48 PM


And, if a patient says "Doc, I don't want to discuss that" you are ABSOLUTELY CERTAIN that none of them -- since they all have such kind, caring bedside manners -- none of them will say: "I understand, just hear me out on these specific items of Advanced Care Planning"? Kinda like doctors won't continue with informed consent laws even if the patient starts to get a bit squimish?

Posted by: JakeD | August 14, 2009 1:45 PM

JakeD writes:
"hy do we have to treat (rather than arrest and deport) illegal aliens in the first place, and why is the FEDERAL government reimbursing hospitals for said treatment of illegal aliens?"

Because in many emergency-room situations, there's no way to know if the person who needs treatment is an illegal alien (or uninsured). It's against the law, by the way, for emergency service to be denied anyone. So, what you are saying is that, instead of the Feds reimbursing the hospitals, everyone living in the vicinity of that hospital who needs treatment should pay for it?

TAANSTAAFL, Jake. Someone, somewhere, will pay for required treatment. I am more comfortable spreading the required costs of emergency-room treatment across all our shoulders, rather than burden those needing to use a particular hospital's services. But the free market system will charge someone, if not done by the government.

This is not the same thing as guaranteeing illegal aliens full health care. This is the preexisting issue of critical care.

Posted by: iamweaver | August 14, 2009 1:45 PM

No-one has to submit to any counseling, JakeD. But if *you* choose to have a consultation with a health professional regarding end-of-life options, then your insurance has to pay for it, as long as the consultation is thorough. And by "thorough", I mean that it covers the specific items in the definition of "Advance Care Planning Consultation".

In addition, you can CHOOSE to have such a consultation once every 5 years and have it covered by health care, IF you choose to do so (because that's in the definition of the service). Plus, if your health undergoes a noticeable change (possibly affecting your current end of life plans), you can CHOOSE to have another session, covered by your Insurance - because that's in the definition of the service.

All this is voluntary. It would not surprise me if you doctor recommends that you have a session - any more than I was surprised when my doctor reminded me that, at my age, I should consider having annual checkups. But *I* choose whether to have a checkup or not.

Just read the actual law that would have the definition of "Advanced Care Planning Consultation" added to the term "Medical and other health services". I provided you a link to the definitions section down below. From there, its an easy step to see how this definition is actually used.

Posted by: iamweaver | August 14, 2009 1:33 PM

HOLD THE PRESSES!!! Now, mikeinmidland says on the other thread that most of us seniors DO get sick a lot:

Therefore, we will be subjected to "voluntary" end-of-life counseling, right?

Posted by: JakeD | August 14, 2009 1:08 PM

mikeinmidland believes that those of us over 65 can simply not go into to see any doctor for 5-10 years at a time -- I wish that were the case -- cost savings either way, I guess.

Posted by: JakeD | August 14, 2009 12:52 PM

vpepascoe. I have read Section 246, but "affordability credits" is just one portion of the entire bill -- Section 152 could be used as the crack in the door to health insurance for illegal aliens (especially if they are actually paying taxes). Why do we have to treat (rather than arrest and deport) illegal aliens in the first place, and why is the FEDERAL government reimbursing hospitals for said treatment of illegal aliens? The Dems in the House REFUSED an amendment to H.R. 3200 that would explicitly stop said reimbursement.

Posted by: JakeD | August 14, 2009 12:51 PM

I see that, as ever, JakeD has purposely misconstrued my words. I don't believe that "patients can just sit there and not say anything." There is no mandate or requirement in HR 3200 for the patient to submit to any counseling of any kind.

Going back to my posts from 5:05 to 5:59pm, I said that the patient doesn't have to talk to the doctor. I meant they didn't have to go in to see the doctor, not that their only form of resistance was silence. And that is clear from the other posts.

Posted by: mikeinmidland | August 14, 2009 12:46 PM

I agree with you, Rooster54 - this is one of the areas that needs to be addressed. There is a tension between what a company owes its shareholders and what it owes its customers. OK - not much of a tension - it's pretty much "whatever our shareholders want" - though market share should have a large influence (more on that later).

Unfortunately, for the last few decades, shareholders have been looking closely at the Medical Loss Ratio that you are referring to - and when it starts to head upwards (indicating a more efficient company - but one that's disbursing more of its funds), a company's stock takes a beating. MLR has dropped significantly, from well over 90% to its current point, which varies at around 70% (though insurance company *profits* have not changed all that much)

The consumer side difficulties are exacerbated by the incredibly clunky fiscal mechanics involved. This isn't like choosing another loaf of bread - the consumer is NOT the end user, but the company buying the insurance plan. What's more, medical insurance has so many details, and is inherently (and irreducibly) so complex, that weighing all these factors (especially in light of the driving need at the corporate consumer level for price) that the market seems to barely respond to these changes in Insurance Company policies.

Posted by: iamweaver | August 14, 2009 12:30 PM

Insurance companies do not provide health care. They hold our money until we need it for healthcare. The problem is that they want to continue taking our money, but they don't want to return it as agreed for medical services when we need them.

Currently insurance companies are paying 1.5 million dollars per day to disrupt democracy as we try to get the better system we voted for. (We pay twice as much as the next country but are rated 37th in terms of quality.)

30% of our healthcare costs go to the people who don't actually do anything, the insurance companies.

They're using our money against us. They deserved to be fired. At least with a public optiomn or single payer we'll be treating them better than they've treated us.

Posted by: rooster54 | August 14, 2009 11:39 AM

And WaPo whiffs again. The press isn't handling health care reform lies any better than they handled Bush-Cheney pre-Iraq lies or the Swift Boat lies. They haven't learned to say, "Hey, folks, the story here is that people are lying to you, and we're going to tell you who...." Except Rachel Maddow--but the Washington Post should be doing it. If I were a member of the news media I would be totally embarrased at the ineffectiveness of the press if even one person actually is influenced by this nonsense.

Posted by: seller11 | August 14, 2009 11:30 AM

This really concerns me, MedicalAndy. There are a number of JAMA articles, all relatively recent, and all discussing the high cost of defensive medicine, etc.

This is an issue that simply cannot be ignored, despite poo-pooing of the subject by a number of pundits. There's simply too much evidence that shows that our current malpractice system wreaks havoc with health care costs in many states.

Posted by: iamweaver | August 14, 2009 10:06 AM

The new legislation is intended to save money. Being a medical device manufacturer, I am well aware that a LARGE portion of medical care costs are due to the threat of liability lawsuits. Everyone in the medical device manufacturing and delivery chain adds premiums (up to 1000% ) to the cost of their material or value added service. There is no discussion of controlling this liability anywhere in the current bills in congress or the senate. All countries with one-payer health care limit liability which is why U.S. medical device and drug manufacturers are willing to sell their products at reduced prices outside the U.S.

Why is this issue off the table? It is the one place to immediately save money without negatively impacting healthcare delivery.

Posted by: medicalandy | August 14, 2009 9:52 AM


In the words of Rosana Rosanadana, "Never mind". Obviously too early in the morning for thought.

You are absolutely right - there is the potential of credit vouchers costing the US more than they collect from taxes, and would require additional input into the Trust Fund. This is indeed likely in times of protracted recessions, or perhaps some epidemic. If the creators of the bill have saddled us with a Cadillac "basic" plan, there is a danger. The government (and ultimately, the taxpayer), would be paying out of their pocketbook to cover others at the very time when they would like to hold on to their cash.

However, as a knee-jerk liberal, I find the idea of supporting those most hurt by the recession during difficult times of more importance then climbing out of a recession as speedily as possible.

Posted by: iamweaver | August 14, 2009 9:19 AM

I wondered if that's what you meant, Gainer.

Still, section 222 doesn't state that the plan must fully finance the particular individual that is covered by the policy - it states that the entire plan must be fiscally sound. That means that, rather than raise taxes, any such error will result in an increase in the public option, driving consumers back to the Health Insurance Exchange and into the public market, yes?

Posted by: iamweaver | August 14, 2009 8:51 AM

iamweaver, in HR 3200, there are provisions for reduced premium amounts based upon income level. Additionally, these premiums will be paid out of income taxes, which are withheld instead of collected, so those falling in the lower tiers (which most people drawing unemployment insurance would surely fall) wouldn't see the net effect until they came off of unemployment. The point I was attempting to make is that the laws of unintended consequences could very well kick in and destroy the current health care system as a whole. Hey, you would be paying taxes to cover the premiums anyway, so why not take advantage of the coverage, right? How many senior citizens do you know who refuse Medicaid, Medicare, and Social Security even though they are financially solvent? They paid in, they get out.

Posted by: Gainser | August 14, 2009 2:16 AM

What are you talking about, Gainser? Since when is health care "free"? Methinks you need to read Subtitle B (Public Health Insurance Option).

The public health care option is required to charge enough to be self-sufficient, and must meet all the criteria of private insurance options (it's "just another player" in the Health Insurance Exchange). Obviously, it has one advantage over a private provider in that it need not be profit-positive; on the other hand, if the Federal government is as grossly inefficient as most of us think, the 2% difference (current average reported profit for Insurance carriers) will vanish.

Posted by: iamweaver | August 14, 2009 12:41 AM

First we had a corrupt stimulous that hasn't created a single real net job. Now we have a confusing, corrupt, wreck of a health care plan while people keep losing their jobs by the millions. Obama just needs to stop. The American people don't support corrupt Obamacare while millions lose their jobs and we pile up more debt than in the history of the world. He needs to stop and work on the economy. When Unemployment is back to 4% and the Government doesn't have to borrow and print trillions and trillions we can slowly and carefully work on reforming the health care system!

Posted by: valwayne | August 14, 2009 12:31 AM

Let's outline a scenario here. Health care reform passes, giving 30,000,000 Americans a publicly paid option. Let's say for the sake of argument 20,000,000 Americans go back to work after going on the public plan. Employers offer these new employees a health care option in which the company covers 90% of the costs, and the employees cover 10% of the costs. Let's also say for the sake of argument, that an employee who has a wife and two kids explores health care options that the employer offers, and determines that his policy will be $160/month out of pocket. Said employee decides to forgo employer option and stay on the public option. Said employee then goes to other workers in the company and tells them of how he saves $160/month by staying on the public option. Many workers decide too, that they can save money by opting out of the private system. This effect snowballs until enough people drop private coverage, and those who remain on the private plans begin paying more per month due to lost revenues by the insurance companies. Eventually, a large majority of people are on the public plan, and those who are not pay even higher premiums. Meanwhile, in Washington, D.C., politicians decide that in order to cover the costs of all of the new people on the public plan, taxes need to be raised, especially since health care is free, medical costs rise as many people go to the doctor for things that they might treat themselves. Taxes go up, insurance premiums go up, and those with private plans are paying for their family's coverage and a portion of everyone else's. As medical treatment costs rise, the government puts in price controls to keep costs down. Pharmaceutical companies don't have retained earnings capital to do meaningful drug research, and medical school attendance falls off as it becomes less attractive to become a doctor. Now, none of this is written into the bill at hand, but those who can think logically can see this as a potential scenario down the road in about 10 - 15 years. Oh yeah, the bill is also written statically, not taking into account epidemics and pandemics, which would put a strain on the health care community, wiping out any "savings" promised in the bill, leading to higher taxes to pay for these costs. Now tell me again why I should support the public option?

Posted by: Gainser | August 14, 2009 12:01 AM

CincinnatiRick, there's no reason for this to be "a pig in a poke". You and your congressperson can read the current version(s) of the bill, online. Nothing hidden, no big "back-door" secrets here. Though in my opinion it's incredibly wasteful of all our time to be arguing a bill that hasn't even made it out of committee.

Posted by: iamweaver | August 13, 2009 10:52 PM


HR 3200 as shown in says:

Division A, AFFORDABLE HEALTH CARE CHOICES, Title II (Health Insurance Exchange and other Options) Sub-title C (Individual Affordability Credits) Section 246-- NO PAYMEMT FOR UNDOCUMENTED ALIENS. Nothing in this subtitle shall allow Federal Payments for Affordability Credits on behalf of individuals who are not lawfully present in the United States.

Check it out yourself.

Posted by: vpepascoe | August 13, 2009 10:23 PM

I can understand that many sophisticated observors are frustrated that people have been using inappropriate characterizations to describe what they are opposing and incoherent yelling to get their point across. But they are sadly mistaken if they do not understand that these are simply metaphors for their frustration at a government that is not listening to them and, where many key figures even seem contemptuous of them. To some extent this is the inevitable outcome of the fact that the administration has vigorously campaigned for a plan that they have not specified and the fear of the law that will likely be crafted in back room deals and voted in the middle of the night by a Congress that doesn’t even know what is in it. In short, the public is being asked to buy a “pig in a poke.” As a result, all the passion is with the opposition and it is the proponents that have been driven to the embarrassing expedients of bussing in props and using children as plants. This doesn’t faze the “true believers” evidently to judge by the rationalization that this is all the product of "vested interests" (ignoring the fact that the administration has already bought off most of them).

With all due respect to a sensible progressive, Camille Paglia, who has called for Pelosi’s head, the senior people from safe districts who run Congress can thumb their noses at the opposition and attempt to divert attention to the manner it is expressed. That will work just fine for their constituents. But the so-called "blue dogs" will be decimated if things continue as they are now about health, cap-n-trade and other issues. Even the 42% of the people who support "reform" are, by and large, NOT in their districts.

This entire charade is a product of political wilfulness and hubris on the part of an immature President who has yet to grasp the limitations of his greatness. A basic change such as this requires consensus. The AMA and the drug companies may have been co-opted onto the reform bandwagon (for a price)...but this will all be undone in the near future if a SUBSTANTIAL majority of the people are not on board. If Republicans can profit from this blunder by Obama, well sobeit. We all learn from our mistakes. Perhaps it will make him a better President.

Posted by: CincinnatiRIck | August 13, 2009 9:51 PM

Jake, the only lines you need include were the ones that told you (and anyone else who reads the bill) into which law this text that we discuss is to be inserted. Its at the front of subsection 1233 - the lines preceding the ones you quoted. Here you go:

6 (a) MEDICARE.—
7 (1) IN GENERAL.—Section 1861 of the Social
8 Security Act (42 U.S.C. 1395x) is amended—
9 (A) in subsection (s)(2)—
10 (i) by striking ‘‘and’’ at the end of
11 subparagraph (DD);
12 (ii) by adding ‘‘and’’ at the end of
13 subparagraph (EE); and
14 (iii) by adding at the end the fol15
lowing new subparagraph:
16 ‘‘(FF) advance care planning consultation (as
17 defined in subsection (hhh)(1));’’; and
18 (B) by adding at the end the following new
19 subsection:
20 ‘‘Advance Care Planning Consultation
21 ‘‘(hhh)(1) Subject to paragraphs (3) and (4), the

and etc., through the quote you already made. It's pretty clear.

All text from there for the next 6 pages are inserted. That covers most of the entire subsection. There's another bit that amends the same law in the directive section of it that refers to periodicity of optional services, and lastly, there's a bit that is to be added to the "Medicare and You" handbook. Not too hard to understand.

Posted by: iamweaver | August 13, 2009 8:58 PM

Odd how the polls don't come up in this -- 85% of Americans like their current insurance, they don't like the democrats plan, and they think they are being lied to.

After the stimulus "push" where unemployment wasn't supposed to go above 8% and phony math about saved jobs and non-existent "green" job and then the push for cap-and-trade with hand written give aways put in as the bill was being passed and no one had read it.

Congress gone wild, and the media is the porn-camera operating encouraging it. Well, the American People have seen the DVD, and it loses its UMPHHH after a few views. We sick and tired of the democrats reading more into their "mandate" than they were given. They got the Congress by pushing conservative democrats, and now the conservative democrats are being marginalized.

So, we will vote republican. Obama is our president until January 20, 2013. Our congress has a lot of turning over to do before then.

Posted by: Cornell1984 | August 13, 2009 8:38 PM


I'm not pasting the previous (or subsequent) lines because there's a maximum per post here at the Fix, and H.R. 3200 is over 1,100 pages long. The portion I quoted shows that "consultations" are authorized (is that a better word?) every five years. If it's so harmless, why won't the Dems take it out?

Another point is why did the Dems refuse to include language specifically disallowing Obamacare for illegal aliens?

Posted by: JakeD | August 13, 2009 7:41 PM

While we are at it - subsection 1233 was recommended by the AMA, back before it showed up in HR.3200.

So - folks are suggesting that doctors in the US are looking forward to sending their patients into the grave?

Not only is that a disturbing thought, but it rather goes against logic.

Let us suppose that doctors are out for themselves. Thus, they recommend that patients die quicker so that they can earn less money from then. Oh, wait...

Posted by: iamweaver | August 13, 2009 7:33 PM

Jake -why aren't you pasting the previous lines? Those are the ones that SPECIFICALLY state which US Law will be altered by this bill - and PRECISELY where this text will be inserted.

There's no guesswork involved. You don't have to suppose anything.

Just browse on over to Section 1861 of the Social Security Act (42 U.S.C. 1395x),
and look at where para (FF) will be inserted. While you are at it, look at the title of section 1395x. It's clearly labeled, "Definitions".

This is a definition, Jake. That's all it is.

Bills like this usually do two things. They usually alter existing law (usually in a whole lot of places), and they create new laws. In this particular case, in this particular subsection of HR.3200, it is altering pre-existing law.

Posted by: iamweaver | August 13, 2009 7:28 PM


That section has nothing to do with the IRS charging a tax to anyone who doesn't sign up for health insurance, but H.R. 3200 includes that too. Trust me, this is a little more complicated than just one section. Section 1233 reads:

"Subject to paragraphs (3) and (4), the term `advance care planning consultation' means a consultation between the individual and a practitioner described in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation within the last 5 years ... advance care planning consultation with respect to an individual may be conducted more frequently than provided under paragraph (1) if there is a significant change in the health condition of the individual, including diagnosis of a chronic, progressive, life-limiting disease, a life-threatening or terminal diagnosis or life-threatening injury, or upon admission to a skilled nursing facility, a long-term care facility (as defined by the Secretary), or a hospice program."

I read that as a requirement every five years (but permissively more often). Those like "mikeinmidland" think the patient can sit there and simply say nothing, so it's not a "requirement". Fine, both sides are entitled to our opinions, but since the STATED GOAL of Obamacare is to reduce costs, it is reasonable to assume that pressure will be brought to bear on seniors to sign DNR orders. Re: "penalty" I don't recall that being included in the many provisions that the IRS will now enforce, but you are welcome to check Sections 301-453.

Posted by: JakeD | August 13, 2009 7:19 PM

Caught totally off guard by the negative response to reform and what I thought was a very informed population.

Most of what many already in the present system, which crumbles and offers less in access and quality by the minute. Not to mention, constantly rising costs which are not sustainable.

Even at the best hospitals in this country.. 'quality assurance' and access for average Americans are not guaranteed given the system is so paper driven.
Speak with the CEOs or any Hospital Administrator..nurses, who understand what direct patient care means and they will explain given costs alone as a consideration, something better must and should be implemented. The answer lies in reform.
That the insurers may win the day, would be a very sad day in contemporary American society. How did misinformation take the lead over the facts? Absolutely amazed!

Posted by: Victoria5 | August 13, 2009 7:19 PM

No friend of mine, Gatsby10. Here's the HOUSE Finance Committee's schedule (next working day is Thursday, August 20, 2009 for the Subcommittee on Housing and Community Opportunity and that's about Hurricane Katrina, not healthcare:

Posted by: JakeD | August 13, 2009 7:15 PM

Because its not an optional part of the DEFINITION, Jake.

Again - its a DEFINITION of a physician-offered service. No parts of the definition are optional. But the SERVICE *is*.

Please - just look at the actual law that this section of the bill alters. It's a list of definitions. Not required services.

I hope that cleared it up for you.

Posted by: iamweaver | August 13, 2009 7:12 PM


Here is the link from CBS:

Pay particular attention to the second paragraph which states the following:

" ... Senator Chuck Grassley of Iowa, top Republican on the Senate Finance Committee...

Once again, you confirm that you are both stupid and ignorant.

Now, go scream some nonsense at a townhall somewhere...

No, I have no idea how many death threats the Bush Boy received -- likely all of them elated to his bloody little war of vanity, nor do I care.

It takes a serious nutjob(a friend of yours perhaps?) to picket a townhall meeting abut health reform with a sign reading "Death to Obama" on top and "Death to Michelle and her two stupid kids" right unerneath.

Posted by: Gatsby10 | August 13, 2009 7:08 PM


So, then why isn't the word "optional" used in that entire portion you just linked to?

Posted by: JakeD | August 13, 2009 7:04 PM

"No, it's not just about the doctor wanting to get paid for a service. While I agree the patient can sit there and say nothing, end-of-life counseling and the "benefits" thereof MUST be explained to them every five years maximum. Are you retracting, or not?"

Article 1233 is an append to 42 U.S.C. 1395x, section (s).
This section is a list of DEFINITIONS of OPTIONAL services. Not required actions.

Posted by: iamweaver | August 13, 2009 6:57 PM

LOL, Gatsby10, SENATOR Grassley has no control over the HOUSE Finance Committee (which is not meeting, regardless of what your feverish mind thinks). He did release a statement criticizing the House version, if that's what you are trying to refer to.

Care to answer my first question now?

Posted by: JakeD | August 13, 2009 6:54 PM

Where is the tort reform - DEMOCRUDS ?

Posted by: hclark1 | August 13, 2009 6:43 PM


You just proved my point about your ignorance.

Congress may be in recess, Einstein, but the Committees are working.

Grassley dropped the provision in the House Finance Committee this aternoon.

You also proved my point about your stupidity, by opening your big mouth without thinking first.

Ignorant, dumb, and proud of it. That's the right-wing for you.

Posted by: Gatsby10 | August 13, 2009 6:42 PM


Go read the bill, dumb a*s!

You and your ilk are too lazy to do your homework, and you prefer to believe whatever enormity the Alaskan floozie and the freaks at Faux News sputter on a daily basis, while stuffing your face.

The American right-wing: no brains and no breeding.

Posted by: Gatsby10 | August 13, 2009 6:34 PM

Lines 4-12 of that bill define what an "Advanced Care Planning Consultation" is. It does not require one to be performed every five years. It says that it doesn't count as one if it has been less than five years.

"See you later," like "anyone else?" is Jake-speak for "I can't fool you so I give up."

Posted by: mikeinmidland | August 13, 2009 5:59 PM

Or what, Jake? What if the patient doesn't go to the doctor for 5 years? Are they coming to the house with a court order and the sheriff?

Are they going to be refused services?

Posted by: mikeinmidland | August 13, 2009 5:50 PM



1. to euthanize involuntarily based upon age based rationing, or disease protocol.

2. to lie and misrepresent #1

3. slang--to kill, snuff out, the robbers ObamaCared their victims.

Posted by: JaxMax | August 13, 2009 5:49 PM

Oh, O.K., thanks. See you later.

Posted by: JakeD | August 13, 2009 5:48 PM

No, it's not just about the doctor wanting to get paid for a service. While I agree the patient can sit there and say nothing, end-of-life counseling and the "benefits" thereof MUST be explained to them every five years maximum. Are you retracting, or not?

Posted by: JakeD | August 13, 2009 5:47 PM

That would be a NO. I am not retracting my statement of 5:19 pm.

Posted by: mikeinmidland | August 13, 2009 5:46 PM

No where in any of the proposed legislation is there any requirement for a patient to listen to anyone telling them about end-of-life care or DNR orders.

If a doctor wants to get paid for a service, that doctor must provide the service, anything else is called insurance fraud.

Posted by: mikeinmidland | August 13, 2009 5:44 PM


So then you are retracting your statement from 5:19 PM "It DOES NOT say they MUST be done"?

Posted by: JakeD | August 13, 2009 5:39 PM

Yeah, the counseling must be done if the physician wants to be paid for the counseling. The patient does not have to talk to the physician.

Posted by: mikeinmidland | August 13, 2009 5:38 PM


Has Section 1233 been removed from the bill?! How did that happen if Congress is in recess? Also, you never answered my first question to you: do you know how many death threats were issued toward GWB?

Posted by: JakeD | August 13, 2009 5:31 PM

We're not reading the same bill then. The counseling MUST be done, but DNR orders are not mandated, if that's what you are trying to say.

Posted by: JakeD | August 13, 2009 5:24 PM

Ouch, called names but a conservative repukin doofus.

Gee, that hurts.

How's that minority status treating you, bubba?

Posted by: jasperanselm | August 13, 2009 5:24 PM

It DOES NOT say they MUST be done. It says they will be paid for every five years.

Posted by: mikeinmidland | August 13, 2009 5:19 PM

Actually, Sec 1233 DOES change that such counseling sessions must be done every five years (or more often, depending on deteriorating health) and therefore provides a financial incentive for DNR orders.

Posted by: JakeD | August 13, 2009 5:13 PM

95% of folks over 65 are enrolled in Medicare, which is a government-funded and government-controlled health care system.

The great majority of end-of-life decisions are therefore made by the government already. Call it rationing or death panels if you wish, but it already exists and nothing in the proposed legislation changes that.

Posted by: mikeinmidland | August 13, 2009 5:05 PM


I'm not comparing the two (since the war was legal as was PRESIDENT Bush ; )

Posted by: JakeD | August 13, 2009 5:00 PM

As watch disruptive people put on their show at the town hall meetings this summer, I can't help be reminded of several things.

One is how frequently I've seen people choose an undesirable status quo over change. "Vote for the devil you know" was the mantra of one of my friends in South Carolina when I asked why she voted for a man she described as a "do-nothing congressman."

The second is how frequently some in the media prefer spectacle and fables to unpleasant realities. Sure, shouting people make for interesting TV and provocative front-page photos, and of course it's fun to speculate about who's up and who's down and whether such-and-such a party will be able to exploit this or that. But health care is a complex issue and the mistakes -- I dare say sins -- of the past have brought us to a situation in which too many people are bankdrupted, go without care, and/or die. That is the reality here.

And lastly I must say that words must be judged not by how loudly they are delivered and whether the media was there to cover them, but whether they were true, just, fair, and right. Like it or not, Mr. Balz, you and your colleagues are granting a considerable degree of deference to some people who are, at best, ignorant, and at worst spiteful, hateful, and mendacious. They may deliver their comments with passion and at top volume, but that doesn't mean what they are saying is of any use whatsoever in making policy or even in conducting debate.

We've all dealt with bullies and manipulators. They don't take their aggressive or underhanded approaches because they care so deeply. They do it to control other people.

Posted by: AnotherHagman | August 13, 2009 4:58 PM

jakey, you're being absurd as usual. There's a big difference between death threats to W over an illegal war and death threats to O over health care reform. To compare the two shows what a complete idiot you are!

Posted by: jasperanselm | August 13, 2009 4:51 PM

num nuts.

Want to see that argued in a court of law? Want to see both sent to jail for the same amount of time.

Only a fkn democrat would come out with a comment like that.

jesus, your such a tool.

Posted by: LiberalBasher | August 13, 2009 4:54 PM

jakey, you're being absurd as usual. There's a big difference between death threats to W over an illegal war and death threats to O over health care reform. To compare the two shows what a complete idiot you are!

Posted by: jasperanselm | August 13, 2009 4:51 PM

I have an answer to this whole thing. I bet neither the right wingers or left wingers don't have the balls to put up or shut up.

The bill gets hashed out and completed. Then congress does what our founding fathers did. They will place articles in all the major newspapers about what is in the plan and explain what it means. EXACTLY WHAT IT MEANS. The founding fathers did this with the constitution, it was called the federalist papers(i know you democrats don't know your history, have to help you out here).

A period of 3 months for public review is done, and then a vote is done to accept or deny the passing. A referendum.

Got the balls democrats? You think you can handle a public vote on this?

put up or shut up.

Posted by: LiberalBasher | August 13, 2009 4:47 PM

You are such an uninformed idiot! And the fact that you are referring to the preposterous article by Lane in WaPo convinces that there is no hope for you.

The bill provided for Medicare to cover the cost of voluntary counselling once every five years. It's now been removed from the bill.

Thanks to that floozie, Palin, and cohorts of morons like you, many seniors will likely spend their remaining time in hospital care, hooked to tubes, and in pain, because they were never informed that they could have made a living will, or that they could have ended their days with dignity in hospice care.

Maybe you want to end your life hooked up to tubes, dying a slow death, and imposing humongous costs on your relatives, but a whole lot of us do not. That's why we make living wills in case we find ourselves unable to say that we do not want to be ressucitated, and turned into vegetables. That's why we inform ourselves about hospice care. Since we all going to die, we might as well make provisions for that death to be as dignified as possible.

That has nothing to do with euthanasia, death panels, and all the other cr*p that the inflammatory idiots from Fox News and a.m. radio have been feeding you, and that you and your fellow sheep thoughtlessly regurgitate.

Posted by: Gatsby10 | August 13, 2009 4:36 PM

maybe if you scum sucking liberals would have put up full disclosure about the bill in the first place. You wouldn't have such harsh reactions from people when items are found.

your getting the type of anger your party deserves for trying to hide items such as that.

Posted by: LiberalBasher | August 13, 2009 4:43 PM


You really think that "euthanasia counseling" is a good idea? It is not "voluntary" if it is mandated at least every five (5) years for anyone over 65 (more often if health is already deteriorating).

"Undue Influence: the House Bill Skews End-of-Life Counsel"

Posted by: JakeD | August 13, 2009 3:57 PM

You are such an uninformed idiot! And the fact that you are referring to the preposterous article by Lane in WaPo convinces that there is no hope for you.

The bill provided for Medicare to cover the cost of voluntary counselling once every five years. It's now been removed from the bill.

Thanks to that floozie, Palin, and cohorts of morons like you, many seniors will likely spend their remaining time in hospital care, hooked to tubes, and in pain, because they were never informed that they could have made a living will, or that they could have ended their days with dignity in hospice care.

Maybe you want to end your life hooked up to tubes, dying a slow death, and imposing humongous costs on your relatives, but a whole lot of us do not. That's why we make living wills in case we find ourselves unable to say that we do not want to be ressucitated, and turned into vegetables. That's why we inform ourselves about hospice care. Since we all going to die, we might as well make provisions for that death to be as dignified as possible.

That has nothing to do with euthanasia, death panels, and all the other cr*p that the inflammatory idiots from Fox News and a.m. radio have been feeding you, and that you and your fellow sheep thoughtlessly regurgitate.

Posted by: Gatsby10 | August 13, 2009 4:36 PM

Posted by: JaxMax | August 13, 2009 1:43 PM

your a wack job jack.
My position. If you say single payer, I say civil war. If you say health care reform, I say let's talk and find a middle ground.

Liberals have their diehard Single payers, but refuse to acknowledge them. Go figure. And then they have the balls to btch and complain about conservitives that are against that.

Posted by: LiberalBasher | August 13, 2009 4:33 PM

Democrats defeated an amendment that that would have enforced a citizenship requirement for Obamacare.

Apparently illegal immigrants will not have to worry about anyone checking the status of their citizenship to confirm their eligibility for this entitlement.

That's right, law-abiding, uninsured Americans will be fined if they don't submit to the ObamaCare prescription. However law-breaking border-crossers and deportation fugitives get another free pass.

Establish another immigration law and then intentionally insure it cannot be enforced, just like the rest of them. Crooks!!

Posted by: hunter340 | August 13, 2009 4:15 PM


OR RE: GESTAPO USA ("stream" or "stories" list)

Posted by: scrivener50 | August 13, 2009 4:00 PM


You really think that "euthanasia counseling" is a good idea? It is not "voluntary" if it is mandated at least every five (5) years for anyone over 65 (more often if health is already deteriorating).

"Undue Influence: the House Bill Skews End-of-Life Counsel"

Posted by: JakeD | August 13, 2009 3:57 PM


MSNBC's Keith Olbermann and Rachel Maddow got to the nub of these phony protests last week when they correctly connected the dots between the anti- health care zealots and the teabaggers, the 2000 election recount "Brooks Brothers" demonstrators, and other hard-right rabble-rousing.

The foot soldiers in this ginned-up street theater don't have to be paid by the health care lobbyists who are providing logistical support and public relations muscle for their supposedly spontaneous grassroots uprising. Fact is, many of them appear to be affiliated with, and thus subsidized by, federally-funded community volunteer organizations...

...the same brownshirt-like vigilantes that comprise a highly organized American Gestapo that works with a secretive executive branch "multi-agency coordinated action program" to violate the civil and human rights of unjustly "targeted" neighbors -- making a mockery of the rule of law.

And victims report that silent, high-tech microwave/laser "directed energy weapons" are being used to degrade the health and well-being of the unjustly targeted.

Read the story that the mainstream media cannot or will not tell:

OR (if link is corrupted / disabled):

See "GESTAPO USA" at ("stream" or "stories" list) ***


Posted by: scrivener50 | August 13, 2009 3:56 PM


First, do you know how many death threats were issued toward GWB? Second, if you take a look at the polling on Obamacare, they are pretty much equal. Next canard?

Posted by: JakeD | August 13, 2009 3:48 PM

When Balz, will, you stop giving the same weight to two opposing opinions, one issued with reason, and the other a total fantasy.

Just read the comments on your post. Pay particular attention to JaxMax. That person is downright deranged.

Moreover, every other outfit in the world is currently reporting on the Md. man who was arrested because he was carrying a board that said:"Death to Obama"... Another Neanderthal was holding a protest sign outside of the high school in NH where Obama spoke, and he was wearing a gun clipped to his pants. It's legal in NH, apparently. In CA, there is currently a stand-off between the police and some jerk who issued threats towards the WH...

Are you waiting for the mob hysteria to turn into real violence before you finally stop giving equal voice to the crass ignorance and maliciousness of the conservatives?

Posted by: Gatsby10 | August 13, 2009 3:37 PM

All but the real crazies will calm down once some sort of moderate reform is passed - and it will be.

Posted by: parkerfl1 | August 13, 2009 3:18 PM

Scary and well-written, Jax, but it doesn't add to the debate.

Medical review boards that choose who will recieve life-saving treatment (and live) and who will not (and die) already exist and they will exist in any future health plan. But there will be no "mandatory euthanasia" box to check. There will probably be a "recommend voluntary euthanasia counseling" box, since that is already part of the proposed plan, but that's as far as it will go.

Posted by: ZZim | August 13, 2009 1:55 PM

Great analysis, Dan. Very fair and even-handed.

It will be interesting to see how this one plays out.

Posted by: ZZim | August 13, 2009 1:46 PM

by JaxMax

Miriam dressed carefully, choosing clothes that favored her figure. No coffee today, she reminded herself as she reached for the cup, it causes your blood pressure and pulse to rise. She pinched her cheeks to make them look more healthy.

The Physician glanced at the charts online–Female 70 requests heart bypass, excellent health but clogged arteries. He moved the mouse and made the selection, clicking ME (Mandatory Euthanasia) per the Protocol.

The chart was then e-mailed down the hall to 2 other physicians. Both also made the selection, not looking at the chart.

Miriam looked at the Doctor carefully. She knew she was age based out, but she had heard Doctors had discretion. He just looked bored.

“Ms........" he paused looking at her chart for her name,"Miriam, your blood pressure is high, we are going to give you a shot to lower it for the exam,” he said while squirting the syringe.

Sounds reasonable, Miriam thought as the needle went in.

Suddenly Miriam saw her was years ago in Brooklyn. She was a young girl and he had just come home from work. Her Father would talk with her at the kitchen table in their small apartment while her Mother finished Dinner. She never forgot the day her Father had brought home a large book from the Library and showed her the pictures.

“If every 100 who were murdered had just killed one murderer on their way to die.......” Miriam struggled to remember the rest of what her Father said.

Then she calmly realized she was dying. Her Father had gently told her.

The Doctor was shocked that Miriam had the strength to hurl the heavy metal exam tray. He didn’t have time to move as it crushed his head. He was amazingly calm as he dispassionatley reviwed the location and knew he would die.

He asked himself, "How did she know she was being killed?"

As the Doctor died, Miriam's Father smiled and opened his arms.........

Posted by: JaxMax | August 13, 2009 1:43 PM

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