Health care reform just took a dramatic and unexpected turn.

Only a few weeks ago it seemed that the Congress was about to complete action on a fundamental overhaul of health care financing and delivery in America, and send this legislation to President Obama, so that he could sign and complete his top domestic policy priority before his first State of the Union Address.

But . the special election in Massachusetts, to fill the seat held for decades by Senator Edward Kennedy - astounded the nation and upended the plans for health reform. Scott Brown was elected - the first Republican to hold this seat since 1952!

This surprising election had many ramifications - but two were uppermost - the Senate Democrats now number 59, no longer can they end a filibuster and have their way; and elected officials around the country, especially Democratic House and Senate members, were asking themselves if they should back away from health reform, lest they suffer the same fate.

For a few days, there were several creative scenarios debated - ways for the Congress still to get health reform done quickly. However, now it seems that has quieted down, and it looks like this will be dragged out much longer.

Will we ultimately see big time health reform this year? I wish I were more optimistic - but I think the chances are now much less than 50-50. As I have repeatedly said - in this blog and elsewhere - we badly need to overhaul how we pay for and deliver health care, so that we cover the uninsured, do so at lower cost and with consistent quality and safety.

It is more likely now that we will see some more modest reform of health insurance, some expansion of Medicaid, and the launch of some demonstration projects for delivery reform. Those are not insignificant - we need to do them, but the disappointment is palpable. What could have been was much more.

My short-term prediction is that health reform will go quiet for several weeks - as the congressional leaders try to work out a smaller package behind the scenes. They will bring it forward only if and when they have it worked out and they are confident that they can get it done.

Once again - stay tuned. Maybe much longer.

There are two weeks left in 2009, and there will be lots of holiday interruptions – so the huge efforts to get agreement on a formula for national health reform, and push it through the Congress will surely go over into the New Year.

Each day seems to bring additional twists and turns to the tale – one day our hopes are dashed, then the next day we learn of a new proposal which seems to have merit and support, then someone shoots it down.

With all of this – I continue to believe that we will ultimately get large scale legislation passed and signed, and that it will overhaul our national health care system in substantial ways. And to be sure, we badly need to do this as a nation.

For months, one of the sticking points has been whether the legislation would establish a new “public plan” for health insurance – that would give real competition to private health insurance. The theory has been that this would lower overall health care spending over time. The proponents of the public plan have criticized private health insurance loudly, and have heralded the public plan as the right idea for the future. Supporters of the public plan have tended to be from the left side of the political spectrum – progressives as they are often called. But the notion of an effective alternative to private health insurance has been a popular notion with a broad array of citizens – private insurers don’t poll well these days.

But this fall the criticism of the public plan has centered on the idea it will simply add cost to an already very expensive health system, without really restraining spending much at all. And the Senate seems to lack the 60 votes needed to break a filibuster and pass the public plan.

Last week Senate Majority Leader Harry Reid came up with a new idea – dropping the public plan altogether, and substituting for it a new idea (which has been around for decades). This new / old idea is to allow younger Americans to buy into the Medicare program – so that people who are age 55 to 65 could join Medicare, with subsidies for those who cannot afford it on their own.

For a day or two it seemed that this might be a way around the impasse, but now some moderate Democrats have criticized this as being even more “liberal” than the public plan.

Who knows how this will turn out? We have many more twists and turns to navigate.

My prediction remains – this will happen, meaning major health reform legislation will pass, in the early part of 2010.

The New Yorker magazine

For the first time, in addition, it seems that a growing number of legislators, policy wonks and pundits want actually to overhaul the health care system in some fundamental ways.

In this spirit, I recommend an article in last week’s New Yorker magazine by Atul Gawande.

I believe he describes well the challenges we face in actually improving America’s dysfunctional health care system.

This week we have had a disquieting reminder of one of the challenges we face in overhauling health care in America – the public are deeply distrustful of “experts.”

The US Preventive Services Task Force – an appointed body of leading clinicians and scientists – issued a new recommendation of when women ought to have mammograms. Because it differed from what had previously been the advice, and especially because it differed from what millions of people thought they knew to be true – the new guidelines were roundly criticized and scorned. By week’s end, the USPSTF had tried to “clarify” what they were saying, and then the US Secretary of Health and Human Services asked the American people to disregard the recommendations altogether.

Not a pretty sight, especially for those who believe that we can improve care and make it more efficient and effective by carefully targeting what is done for individual patients.

I am one of those true believers – in health services research and guidelines for the delivery of care – “comparative effectiveness research,” as it is called these days.

I don’t know what the right advice is for women regarding mammograms. But one thing I do know – if this whole effort is going to work, we have to get to a place where the public has confidence in the experts – else we might as well quit trying.

Maybe this is all due to our American individualism – or maybe it is because so many of us learned to “question authority.” Whatever the explanation, it is not helpful to our efforts to construct a more rational health care system, guided by rigorous research and the consensus of the leading scientists and clinicians.

Until we solve this conundrum, we might want to slow down on our promises of health cost savings from comparative effectiveness research.

Fall has most assuredly arrived in Chapel Hill. The leaves are especially colorful this year, the morning air has been crisp more than once, and, as dean of the UNC School of Medicine I had the honor of delivering my fall address to the faculty.

This year provided ample reason for reflection. We have faced many challenges, many of them stemming from the financial crisis that was felt by individuals and institutions around the world. But I was also able to cite a long list of accomplishments for which the faculty deserve much of the credit. Among those I mentioned:

• We graduated and matched a wonderful class of medical students, and we filled all of our own residency positions with outstanding doctors

• We again ranked second overall for primary care on the U.S. News & World Report “Best Medical Schools” list; and we were twentieth overall and sixth among public schools of medicine for research

• UNC Hospitals was included among the U.S. News & World Report “Best Hospitals,” and ranked among the top 5 percent in H-CAPS scores

• We received the third highest score among all hospitals for patient satisfaction with nursing

• We opened two world-class facilities: the Genetic Medicine Building, the most sophisticated science building ever constructed at UNC, and the long-awaited North Carolina Cancer Hospital, which welcomed its first patients in August

• UNC faculty received more than $350 million in research grants in 2009; our funding from the NIH has increased 15 percent since 2007

• As of October, the medical faculty have received 150 awards totaling almost $50 million from the American Reinvestment and Recovery Act (the Stimulus bill)

However, the loss of jobs across the state has had a significant impact on UNC Health Care because of the growth in uninsured North Carolinians. Unemployment across the country weighs heavily as citizens and members of Congress consider health reform. The economy and health care reform were on the minds of many of the faculty at this meeting.

As I have stated in this blog many times before, health reform is an economic issue as well as a health issue. We feel that very acutely at UNC. I repeated to the faculty my belief that every American ought to be insured, and we, as a nation, need to change the way we provide health care to focus on keeping people well.

Fortunately, UNC faculty are also leading the way in creating and expanding new ways to organize and deliver quality health care services in a more efficient manner. We want UNC to be a national leader in this area.

The faculty asked questions about the challenges of our growth, including the scarcity of space. In some respects this is a good problem to have, but it is surely hard to solve, especially quickly. We also talked about our proposed new hospital in Hillsborough.

Because of the economy we have tightened our belt, but the Imaging Research Building is under construction, and we hope to open the Hillsborough hospital, if we get CON approval, in 2014.

Many of our challenges are not unique to UNC. They’re faced by practically every academic medical center in the country. However, the level of excellence and the spirit of collaboration and collegiality among UNC faculty sets us apart. It is through their efforts that we answer challenges creatively, and will continue to find innovative ways to conduct research, provide patient care and educate.

Friends,

My blog had some technical difficulties Sunday (Oct. 11) and Monday (Oct. 12), but I’m happy to report we’re back up and running.

Over the past several years, this blog has been a great forum to spark discussion and share information and opinions, and it is here to stay. I look forward to continuing our conversation about health care issues.

Last week, President Obama spoke to a joint session of Congress about health reform, and polling afterwards has shown an upturn in support for him and for his recommendations for overhauling health care in America.

Today, Senator Max Baucus, the chair of the Senate Finance Committee, unveiled his long-awaited proposal. I continue to believe the SFC will be the main focus of congressional action on this very important issue. Click here to download a pdf version of the proposal.

The Baucus plan is still being analyzed by all the pundits and policy wonks – I plan to write soon about its details. But based on the summary I’ve read, I like it. I believe it is a serious effort to deal with the big issues we face – in an honest fashion.

Our concerns about the cost of care, the lack of access due to uninsurance and the quality and safety of health care in America are very real – and they deserve to be faced and dealt with in a comprehensive fashion. The American people know that a lot is up for grabs, and they want this done right.

On September 17th, I will be part of a press conference at the National Press Club in Washington, DC. Several of us will be speaking on behalf of a much larger group of people who have worked on these issues for a long time – researchers, clinicians and other leaders. This group – from across the ideological spectrum – is urging the Congress and the President to work together to make the most of this opportunity to put right some basic problems in our health care system.

Here is a link to the letter – and a partial list of those of us who have signed it: http://www.healthreformusa.com/petition/index.php

Also, the leaders of the four medical schools and academic medical centers in North Carolina have come together to put forward our recommendations on health reform. Drs. Victor Dzau from Duke, Paul Cunningham from ECU, John McConnell from Wake Forest and I wrote a letter, which we sent last week to Senator Kay Hagan and Senator Richard Burr.

We believe that the academic medical perspective on health reform is important to the national effort – but it is especially important in North Carolina, given our major role in research, teaching the future health workforce, and caring for so many of our most vulnerable citizens. We will be working together to articulate these issues and concerns over the coming weeks.

This major national debate is now at full stage – but it will go on for a while yet. In football terms, I’d say we are mid-way through the third quarter now.

Stay tuned – much more to come.

Today the news is filled with stories about the passing of Senator Edward Kennedy of Massachusetts from an incurable brain tumor.

During his almost fifty years in the Congress, Senator Kennedy has been a dominant leader in so many areas of our national life – health and health care, education, civil rights, and on and on.

Twenty years ago, in the summer of 1989, as a mid-level member of President George H. W. Bush’s White House staff, I was tapped to be the Administration’s negotiator with the Congress for what came to be known as the Americans with Disabilities Act.

My chief counterpart in those negotiations was a person on Senator Kennedy’s staff – and across that summer I had many, many long meetings up on Capitol Hill. Some of those sessions included our bosses – and there I was privileged to meet and get to know Senator Kennedy a bit.

I grew to admire him a great deal – for his earnest commitment and tireless energy and focus. He was, and we were, ultimately successful, and the ADA is now the law of the land.

Of all the activities I have been involved with, across a number of government jobs, I am proudest of my work on the ADA.

Today I recall proudly and fondly my time twenty years ago – and how I intersected briefly and in a small way with Senator Edward Kennedy.

He will be greatly missed.

Several people have asked me in the past few days for my perspective on what’s happening to health reform in Washington.

For what it’s worth, here goes –

Congress is in recess until Labor Day, and they are back home having lots of meetings with their constituents. President Obama is also hosting events almost daily to discuss health reform with the American people.

We have a governmental system that is chaotic and messy at times – and this is surely one of them. Remember the quote about making laws is like making sausage …

Several points I’d make –

1. Although President Obama won handily (53 percent to McCain’s 47 percent), there are a lot of Americans who did not vote for him. So it should be no surprise that many of them are showing up at events and town hall meetings and voicing their opposition to whatever the Democrats and the Obama Administration are working toward. The fact that politics has intruded is shocking to some people, I know, but that’s the American way.

2. We still badly need to reform the American health care system – and as hard as this public policy and political process is, we need to press ahead as a nation.

3. As we deal with the all too familiar problems of the cost of health care, the lack of access due to uninsurance, and the quality and safety of health care in America, a lot is up for grabs. A few weeks ago it seemed like the Congressional leadership were just going to steamroll the process and enact thoroughgoing reform of the entire system. Now the sheer magnitude of all this is scaring a lot of people, especially at a time of such great economic uncertainty.

4. Proposed reform that does not take seriously the need to constrain cost growth should not itself be taken seriously. And as much as I support prevention (and I do, I put “Prevention” in the name of the CDC), it likely will not reduce health care expenditures – though it will make us all healthier. And as much as I support Health Information Technology (and I do, very much), it is likely to add to costs – for the foreseeable future, not save.

5. We need to have a serious discussion as a nation about end of life care – and we are beginning that conversation now. We waste (yes, that’s the right word) a huge amount of resources there. But we as a nation don’t want the government making these decisions – like taking your mother off the respirator. My sister and brothers and I had some tough decisions to make as our mother and father were gravely ill, and we made them. But not the government.

6. But critics of the President are crassly scaring the American public with this issue – and we need to counter their fears with an honest conversation about the limits of medical care, and help patients and families with those tough decisions.

7. There are some things the government does right – and the Medicare program is one of them. We should be proud of it. And I am proud to say that for several years in the 1980s I was responsible for administering it. But it is not a model for the rest of the health care system – it is outmoded and frozen in time, tied to a payment system of fee for service that does not make sense for doctors or patients.

8. That is one of the risks of the “public plan option” that is being debated right now – can a government plan innovate and be creative over time?

9. Also, Medicare pays rates to doctors and hospitals that are below the actual costs of delivering that care. A new public plan, if linked to Medicare, would have tremendous clout in the market place – institutions like ours would almost certainly have to take whatever rates they offered, even if greatly below our costs, which would surely worsen the crazy quilt of cross subsidization that we now have in health care finance in our country.

10. One of the ironies right now is that many in Congress are insisting on the “public plan option” because of their faith in the government’s ability to run the program, yet many of the same Members are urging that a new independent body – “MedPAC enhanced” – be set up to make decisions and oversee the entire system, because they don’t trust the regular governmental agencies (like HHS and CMS) and processes (like the Congress) to manage things well.

11. So … where are we? I think the Senate Finance Committee proposal, which is yet to be completed, will be the plan that ultimately holds sway. Yes, there will be some who say it is too conservative, and others will say that it is too liberal (whatever those words mean in this complicated area). But I believe it is likely to pass this fall, surely amended many times. The political stakes are just too high for the President and the Congress – they cannot allow failure.

12. So I’d suggest you keep your eye on Senator Baucus and his colleagues on the Senate Finance Committee, and try not to get too distracted by the sound and fury around the whole process.

13. Will such legislation be good for the country? I very much believe so. But this is woefully complicated – and it needs to be done right. So taking a little more time is not a bad thing.

14. And what will such legislation mean for UNC Health Care? It’s way too soon to answer that question with any finality, but given our huge problems with the uninsured, we would have to be better off, at least in the short and medium term, if those now uninsured are covered. The longer run is harder to predict – because the risk is as costs rise, and they inevitably will, will our payments be cut so much that we end up worse off? Time will tell.

15. And in the meantime, we have recently launched an effort to redesign how we deliver care, so that we can be one of the places that people point to as an institution that delivers top quality care in an efficient manner, with lower overall costs. I very much believe that is do-able, but it won’t be easy. It will stretch us as an institution, requiring our doctors and hospitals and others to work together in creative ways that we haven’t even begun to try yet. But we must – I want us to be a part of the solution, not a part of the problem.

More to come … stay tuned.

We flew home overnight - and arrived today at RDU.

It was simply a wonderful trip - we learned a lot, we saw the UNC global health partnership in action and we got to know a bit about the people and history of Peru.

Today was our last full day in Cuzco. It was low-key and pleasant.

We went on a driving tour of several sites south of Cuzco, including a beautiful old church, a large pre-Incan site and an elaborate Incan structure.

This visit has really taught me a lot about the history and culture of Peru. It is a country with much history and an extensive series of archeological sites that make that history come alive.

We saw first hand the pride and the challenges of the people of Peru today — especially when we visited the health institutions in Trujillo with Dr. Luis Diaz.

The global health partnership between UNC and UNT (the National University of Trujillo) is a great way for us to strengthen our two institutions, and it provides many opportunities for our students and faculty.

I feel really privileged to have been able to make this trip with Luis Diaz and Doug Morgan.

Tomorrow we head home, via Lima to Miami and then Chapel Hill.