Quality

HEALTH REFORM: A Reporter's Guide to Covering Health Issues

Paul Testa — Tue, 17 Feb 2009 20:43:00 -0500

The Alliance for Health Reform has released the first chapter in the new edition of Covering Health Issues—an online guide to the major topics in health policy. From national health reform to local health disparities, each chapter provides readers with the basic facts, background on the issue, and overview of the likely policy debates.

The first chapter, written by our colleague Joanne Kenen, tackles the issue of health reform in its entirety. Kenen lays out likely policy debates, noting that "this time around, politicians and policymakers are talking about the intertwined issues of coverage, cost and quality." She provides an overview of the ongoing debates in each, while also addressing related reform issues such as public health and health information technology.

Designed with reporters specifically in mind (although it's useful for other people working in health policy or just wanting to learn more), each chapter also features helpful tips and story ideas for covering health issues. Kenen, formerly an award-winning reporter for Reuters, offers up her own thoughts on some of the common mistakes in health reporting, such as equating more health care with better health care.

The Alliance for Health Reform will post new chapters shortly, and will also add an updated list of sources and resources —-some familiar voices, and some new ones.

QUALITY: On-the-Job Training Lowers Turnover Rate of Nurses

Health Policy — Tue, 17 Feb 2009 19:15:00 -0500

After decades of letting newly-licensed nurses sink-or-swim on the job, some hospitals are finally tossing their new nurses a life preserver. The goal is both better quality care—-and fewer newly-minted nurses who quit.

According to the Los Angeles Times, a recent national study found that one in five newly licensed nurses quit within their first year of work. This is not what we need given our nursing shortage. Peter Buerhaus, of the Vanderbilt University Medical Center, told the LA paper that we could have a shortage of 500,000 nurses by 2025, due to increasing rates of retirement and the demands of the aging baby-boom generation. This shortage too comes at a time when nurses may actually have a larger role to play in a reformed health where we place more emphasis on primary care, care coordination, and management of chronic diseases.

Many nurses point to stress, lack of supervision, and poor on-the-job training as their reasons for leaving the field. Unlike medical school graduates, nurses have no formal residency in which they can get comfortable with their jobs, practice their skills, and gradually take on more responsibility for patient care. Most nurses are simply left to figure everything out on their own, a practice which strains their ability to deliver patient care.

In 2004, Childrens Hospital in Los Angeles started a program to help train new nurses and combat the high turnover rates. The Versant RN Residency, which has now spread to more than 70 hospitals across the U.S., pairs up new nurses with more experienced nurses. At first, the new nurse will just observe as she completes a lengthy checklist of competence in vital skills, but by the end of the 18-week partnership, the new nurse will be doing hands-on patient care work while the more senior nurse supervises.

Even though programs such as Versant cost about $5,000 per resident, the cost of replacing a nurse, including recruiting, training, and covering for a short-handed staff, will usually cost about 10 times as much. The Versant program in particular has been successful for many hospitals; the Baptist Health South Florida in Miami reports that the nurse turnover rate has dropped from 22 to only 10 percent since the program was implemented a year and half ago.

We sometimes fail to appreciate the vital role nurses play, both in the direct care they provide for patients as well as their insights into how to improve care systems. For any new care model to be successful, the cooperation and support of nurses is necessary. They are playing a big role in programs to help ease patients from hospital to home. Nurses are very close to the day-to-day work of a hospital, giving them an excellent vantage point for spotting problems in care delivery and innovating solutions. So nurse retention is good economics, and good medicine.

QUALITY: Comparing Perspectives in Comparative Effectiveness Debate

Paul Testa — Mon, 16 Feb 2009 16:13:00 -0500

The New York Times' Robert Pear examines the content and contentiousness of the comparative effectiveness provisions of the $787 billion stimulus package.

HR 1 provides $1.1 billion (pdf starting on page 156) to AHRQ, NIH and the HHS to evaluate the relative effectiveness of different health care services and treatment options. The goal is to create a process of funding and disseminating comparative effectiveness research that is transparent, professional and free from conflicts of interests. As the Dartmouth Atlas' Elliott S. Fisher, MD, tells Pear, the funding would be used to try to answer questions such as:

Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of "talk therapy" and prescription drugs to treat mild depression?

How do drugs and "watchful waiting" compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient's blood pressure and weight?

In health care, though, simple questions rarely have simple answers. Nor will answers be static; biomedical science changes at a pretty astonishing clip. We wrote about this topic twice last week, and we expect to hear more about it as the health reform debate intensifies. Last week Kyle Noonan wrote about some of the alarmist rhetoric surrounding the issue, and Joanne Kenen wrote a longer piece about how comparative effectiveness fits into "health" as well as health care reform. We also want to point out Bob Laszewski's posts at the Health Care Policy and Market Place Review, which has provided interesting coverage on this topic. In his most recent post he worries that the final bill's focus on clinical effectiveness will not translate into cost effectiveness. Commenters on the post have suggested that getting the clinical data right is the hard part and that once that information is available it will be easier to work out the questions of cost and value.

Beginning to measure what works best for what patients or populations under what circumstances can provide a baseline. Providers and patients will have access to information that will help them better understand their choices and the likely consequences. Providing that information in a manner that is transparent, credible, and easily understood will go a long way to ensuring that all Americans receive the most effective care whether they live in Florida or Nebraska or California.

QUALITY: A State of the Health Care Union

Paul Testa — Thu, 12 Feb 2009 16:21:00 -0500

In less than two weeks, on February 24, President Obama will address the Congress in what amounts to his first State of the Union. Health care, The Atlantic decided, couldn't wait that long.

Hosting a State of the Union for Health Care on Wednesday, the magazine brought together experts from across the health care spectrum to lay out where we are and where we need to go in the coming year.

In terms of where we are, much should sound familiar to our readers. Health care costs too much. It covers too few, and the care it does provide is too often mediocre.

As David Walker, President & CEO, Peterson Foundation, told the audience, health care is our nation's single largest fiscal challenge, with the potential to bankrupt our government and cripple our competitiveness. The fact that some 46 million are left without health insurance, Walker said, was shinola.

In terms of quality, Mark Chassin, M.D., President, The Joint Commission, noted that each day there are about six wrong-site surgeries in the U.S. "Twenty five years ago, health care was cheap, safe and totally ineffective," Chassin said. "Today, health care is effective, expensive and totally unsafe." It's not surprising then, as Mary Woolley of Research! America told the audience, that more than 70 percent of Americans no longer believe we have the best health care system in the world.

As for fixing that system, Senator Bob Bennettt (R-UT)—in a welcome reminder that there are some who still want to solve the health care crisis on a bipartisan basis—laid things out clearly describing what he called the "big Aha moment" in health reform. "If you have health reform that focuses on quality health care for everyone you save bundles of money," he said. "The secret to cost control in health care is quality. The best health care is the cheapest."

So how do we get to a high-quality, high-value health care system? The event's discussion focused around the concepts: transparency, public reporting, and realigning incentives to drive better outcomes.

As we've said before, you can't manage what you don't measure. Much has been made about the need for more public reporting in health care. The real consumers of this information about outcomes and quality are not patients but providers, argued University of Virginia's Elizabeth Teisberg, Ph.D. As Toby Cosgrove, CEO of the Cleveland Clinic said, "There's no group that's more competitive than doctors. These are people used to being at the head of their class... You put the numbers up, the quality will improve."

In constructing these measures, Teisberg asserted that it was important to distinguish between process measures (did a patient receive this recommended treatment or test) and outcome measures (not just mortality, but readmission rates, length of stay, etc.).

Furthermore, Chassin argued that more attention and effort had to be paid to getting what we know works adopted as a standard of practice. It takes close to 17 years for the introduction of medical innovations to achieve general acceptance in our health care system. Publicly reporting process and outcome measurements can help speed up that process. It can serve as the foundation for the kind of comparative effectiveness research our colleague Joanne Kenen talks about in a post early today. It can help realign incentives so that we're paying for better outcomes and higher value care. And it can happen soon.

Representative Frank Pallone, Jr. (D-NJ) spoke at lunch about trying to move comprehensive health reform legislation this year. Congress, Pallone said, had already laid a strong foundation with SCHIP and the Stimulus bill. He said that leaders in Congress and the administration were committed to moving forward as quickly as possible, and that his committee planned to begin holding health reform hearings after the President's Day break. We hope we here a similar message two weeks from now in the president's address to Congress.

HEALTH REFORM: Prospects Remain High for 2009

Len Nichols — Wed, 11 Feb 2009 13:12:00 -0500

This post appears on the National Journal's Health Care Experts Blog where you can also see what other health policy analysts have to say on Health Information Technology.

The prospects for health reform in 2009 are still high, despite Senator Daschle’s withdrawal and the worsening economy. In fact, the economic crisis has made the case for reform even more compelling. Indeed, it is useful to remember that the health reform debate is far larger than any one man or woman and the underlying reasons for reform are unchanged.

Our health system is on a trajectory that cannot be sustained. The costs of inaction are high and they will only rise over time. Families, employers, and governments are all threatened by rising health care costs. These trends will not change on their own. In fact, they will worsen. This issue is not going away and neither are the "strange bedfellow" coalitions of business, labor and consumer groups that helped make health care a decisive issue in the 2008 campaign.
Our struggling economy has revealed and worsened the flaws in our health system and the call for reform will grow more urgent as a result. More and more families are losing insurance along with their jobs and are finding themselves unable to afford essential health care services. Countless interviews and media reports have documented jobless families who view affording health care as one of their most immediate economic concerns. The economic crisis only further demonstrates the need for reform and will only heighten the public's awareness of our system's gaps. It also raises the ante for Congress. While partisan posturing will not end tomorrow, most members will not be able to do nothing and declare victory to the people this time. Doing nothing on health care will be seen as a failure, much as failure to pass a stimulus package will be seen as irresponsible.
Health reform remains a priority for the Obama Administration and for Congress. David Axelrod captured this best when reminding reporters last week that "this issue has great power of its own." President Obama has stated consistently that making insurance affordable for all Americans is a primary goal of his administration. This goal is shared by key Congressional leaders, including Senate Finance Chair Max Baucus, HELP Chair Ted Kennedy, Energy and Commerce Chair Henry Waxman, and Ways and Means Health Subcommittee Chair Pete Stark. Now that SCHIP is signed with the economic stimulus package soon to follow, the full attention of these key leaders will shift to comprehensive health reform.
The American people, throughout the 2008 campaign and beyond, have called for a better, more affordable health system. The people who sent Barack Obama to the White House will not change their views on our health system because of Tom Daschle's withdrawal. They elected Obama to do a job, and what particular individual holds what particular job matters little in the grand scheme of the overwhelming desire for "real change."

As many of you know, I was a senior adviser at the Office of Management and Budget (OMB) during the Clinton-era reform efforts. Throughout the past week, I was compelled to recall what we were all doing in February 1993. At this moment (and many other moments) 16 years ago, we were going through an Ira Magaziner "toll gate" exercise with 500 of our closest friends. In large working groups, we were trying to write down a detailed blueprint of a new health care system that did not exist in nature.

Look where we are now. This time, the chairs of Finance and HELP have pledged to work together to build upon our existing system, while making it work better for all. We also have a president who understands that the lessons of 1993-4 require (among other things) an unshakable commitment to bipartisan conversation. (And yes, health reform must and can still be bipartisan).

Further, many more stakeholders, like our own group Health CEOs for Health Reform, and countless other employers and labor leaders are willing to say, "The status quo is unsustainable and we CAN work collectively to align interests and reform our system to serve everyone."

We should not lose sight of how much further along the health reform debate is today compared to the winter of 1993. Congressional leaders have emerged; bipartisan conversations have been initiated; and, industry leaders have shown some signs that they are willing to engage, rather than obstruct. The moral and economic motivations for this issue are too strong, the costs of failure too high, and the progress towards our goal too great for our optimism to wane. Now remains the time to act.

VOICES OF REFORM: Collaboration Key to Affordable, Safe Health Care for All

Health Policy — Tue, 10 Feb 2009 14:00:00 -0500

Gary S. Kaplan, MD is the Chairman and CEO of the Virginia Mason Medical Center in Seattle, Washington. In recent years, Dr. Kaplan has worked with local employers to control health care costs, while improving value. Dr. Kaplan is a founding member of Health CEOs for Health Reform and a leader in payment reform policy. Today, Dr. Kaplan shares Virginia Mason's story and why he believes every American can have access to high-value care at lower prices.

Collaboration Key to Affordable, Safe Health Care for All

By Gary S. Kaplan, MD

The numbers are staggering. Nearly half the $2.6 trillion in the U.S. health-care system is waste. Take a moment to let that sink in. More than a trillion dollars—that's 12 zeroes behind the 1—adds no value for patients and sometimes even causes harm.

At Virginia Mason Medical Center, we don't claim to have all the answers to this dilemma. But we have seen what's possible and are anxious to share our experience in improving care and reducing cost. It isn't going to be easy, but the result we think is achievable makes it all worthwhile: quality, affordable health care for all Americans.

Virginia Mason's focus on quality, access and affordability of health care began in earnest more than seven years ago when our board and executive team began to realize how much of all health-care expenditures did not add value for patients. A big part of the problem, our leadership determined, was that health-care processes were not, in reality, designed around patients receiving care but rather built for physicians, nurses and the care-delivery team.

With this shift in thinking, VM leaders traveled to Japan to study the legendary Toyota Production System. We returned committed to creating waste-free, patient-centered care. Since then, we have successfully adapted Toyota's methods to patient care. Along the way, we have become an international leader in creating systems that enable health-care providers to achieve previously unattainable levels of safety, effectiveness and efficiency.

Employers' Challenge Marks Turning Point

An important point in our journey came in 2004 when employers issued VM a straightforward challenge to reduce the cost of health care. We responded by inviting several employers and their health plan, Aetna, to work with us to redesign health-care delivery systems—based on methods we learned from Toyota—and restructure dysfunctional reimbursement methods. This marked the beginning of our marketplace collaboratives, which have turned out to be an invaluable tool during the past five years.

The hallmark of marketplace collaboratives is working with groups of stakeholders to deconstruct—then reconstruct—the delivery of health care, again using processes gleaned from Toyota's methods and content derived from evidence-based medicine. Cost-accounting methods also are used to compare reimbursement with the true cost to deliver care.

Bringing employers, providers and health plans together in a transparent, innovative environment of mutual accountability isn't easy at first—but it is well worth the effort. We are able to tackle medical conditions of high cost to employers with a sharp focus on reducing variation in quality and access that drives much of medicine's expense. Costs to purchasers begin to decrease within months after each collaborative's first meeting, while quality and patient satisfaction improve significantly.

Our first marketplace collaboratives centered on back pain and migraine. They introduced a number of breakthrough innovations to ensure reliability in quality and cost, provide real-time performance information for employers, and align reimbursement and value. Among the innovations were:

Mistake-proofing to ensure imaging for back pain and migraine is value-added
Real-time measurement of patient satisfaction and appointment access
A method for measuring absenteeism and presenteeism
A gain-sharing model based on better outcomes and reduced cost for back pain
Introduction of product specifications as performance standards for providers

Encouraged by these initial successes, we formalized the marketplace-collaborative model with the launching of our Center for Health Care Solutions at Virginia Mason in 2007.

Paying for Value

Designing a product that facilitates payment for value is one of the important goals of any collaborative. Typically, doctors are paid for the quantity of care they provide, not the quality of care they deliver. They are paid well for tests and procedures regardless of value. When doctors substitute low-margin, high-value care for high-margin, low-value care, they incur an immediate financial penalty. Ironically, doctors often receive much less reimbursement or no payment at all when they provide simple, value-added care.

However, direct cost of care represents a fraction of the burden of overall medical expenses. Our marketplace collaboratives seek to reduce the indirect costs of health care that do not show up on a medical bill. For many conditions, the cost of employees missing work due to illness or showing up for work when they shouldn't is much greater than the direct cost of care. For employees who are ill, delayed access to care is also a driver of indirect cost.

Focusing only on direct care ignores what often is the greatest opportunity to lower health-care costs for employers. Our model is geared toward patients' rapid return to best possible function, and includes paying attention to both direct and indirect costs.

As a result, cost to purchasers has decreased dramatically, while outcomes and patient satisfaction have improved significantly. Reducing the cost of providing health care and partnering with employers and health plans in this effort can mean better financial performance for doctors, even as unnecessary care is eliminated.

Based on our experience, we believe easy access to a system of reliable, evidence-based care produces much better outcomes at a fraction of the cost of conventional high-variation care. We are beginning to experiment with payment systems that align reimbursement with value and believe this is possible on a much larger scale.

In our view, applying reliable systems to health-care delivery and aligning health-care financing with value would permit all Americans to benefit from high-quality care at an affordable price. It starts with changing our mindset and committing to a shared agenda that requires reform in both care delivery and payment systems.

It won't be easy, but to quote Robert F. Kennedy, "All of us might wish at times that we lived in a more tranquil world, but we don't. And if our times are difficult and perplexing, so are they challenging and filled with opportunity."

Gary S. Kaplan, MD, is Chairman and CEO of Virginia Mason Health System in Seattle.

IN THE STATES: Yearly Check-up for State Reform Efforts

Meredith Hughes — Fri, 06 Feb 2009 15:35:00 -0500

It's been a tough year but many states have shown determination to make progress on health reform, even amid their economic challenges. State Coverage Initiatives, created by a partnership between the Robert Wood Johnson Foundation and AcademyHealth, recently released its "State of the States" 2009 report. Here's a brief overview of the findings:

Coverage Initiatives. Massachusetts is easily the most well-known. The only State to have implemented an individual mandate, it now reports that 97.4 percent of its residents are insured. Vermont has also made significant progress. Between 2005 and 2008, Vermont's uninsured rate dropped from 9.8 to 7.6 percent, and the goal is near-universal coverage by 2010. Even before yesterday's reauthorization and expansion of SCHIP, 10 States, particularly Iowa and New Jersey, were able to push forward on expanding children's enrollment in health care programs in 2008.

Cost Control. Rising unemployment and increasing Medicaid enrollment are big issues for States, as they add to the strain on their already overburdened budgets. States, such as Pennsylvania, Ohio, West Virginia, Maryland, and North Carolina, have taken steps toward aiding small businesses who are struggling to afford health care coverage to their employees, through subsidies, reinsurance programs, benefit plans, and tax cuts or credits. Minnesota enacted broad legislation that emphasized payment reform, price and quality transparency, chronic care management, administrative efficiency, and public health.

Quality Improvement. The report found that States are increasingly likely to consider both cost and quality along with access in their health reform initiatives. Many States, most notably Vermont and Massachusetts, have included quality as a significant part of their agenda in health care reform, believing that a focus on quality of care will also lead to efficiency and cost reduction. Iowa established the Iowa Electronic Health Information Commission to develop a statewide plan to expand the use of electronic health records, which can help control costs and enhance quality. The trend toward linking cost, coverage and quality is particularly heartening to us at New America's health policy program as it's a big theme of our work.

Arkansas, Connecticut, Ohio, Oregon, and Utah were among the States that worked during 2008 to build consensus for future action. State governments, however, are limited in the tools they have to address the many complexities and challenges of health care reform. But innovations at the State level should inspire leadership on a national level.

QUALITY: Radiation Variation

Tom Emswiler — Fri, 06 Feb 2009 12:24:00 -0500

Ever worry about standing too close to the microwave as it works its magic for you in the kitchen? Or maybe think that you spend too much time on your cell phone? Sure, neither give off a ton of radiation in a single dose, but sometimes you might wonder what's safe?

That leads us to a big story that broke this week about computed tomography (CT) scans. According to a JAMA piece, published by researchers from Germany and the Mayo clinic, patients who receive a single heart CT scan are exposed to the same amount of radiation they'd receive from 600 chest X-rays. That 600 is a median figure; patient weight, heart rhythm, and length and type of scan affected the amount of radiation. Some patients received more, some less.

While a dosing algorithm called "electrocardiographically controlled tube current modulation" reduced radiation by about 25 percent in about three-quarters of patients, another technique called "sequential scanning" (according to Bloomberg, it's when the CT scan of the heart is done in pieces, with the X-ray on for a brief part of each scan) reduced the dose of radiation by 78 percent. But it was only used six percent of the time.

To be fair, sequential scanning cannot be used on every patient and the evidence base for it is not yet broad. However, the authors say their findings are in line with other recent studies.

Additionally, Bloomberg mentions a previous New England Journal of Medicine study that said CT scans weren't as reliable as cardiac catheterization for finding heart disease. While looking for that article, I came across this one that says one-third of CT scans are not justified by medical need. Reuters tells us:

While strategies are available that can substantially lower radiation doses from CT scans, such as reducing voltage, some of these techniques are not being widely used, the researchers found. That could be because many clinicians may still be unfamiliar with the magnitude of radiation exposure that is received from a cardiac CT scan, they said.

In fact, the NEJM article referenced above cites this survey of radiologists and emergency physicians— where three-quarters of respondents significantly underestimated the radiation dose from a CT scan. Bloomberg elaborates:

"If you have a patient with no chest pain and no shortness of breath, then a test that uses that level of radiation isn't right," said study author Gerber, a cardiologist at the Mayo Clinic branch in Jacksonville, Florida, in a telephone interview today. "If the patient feels great and hasn't got much in the way of risk factors, and the doctors insist they have the test, it might be reasonable to question it."

According to the JAMA article, "A basic principle of radiation protection is to keep radiation exposure ‘as low as reasonably achievable' (ALARA principle)."

So are CT scans ever worth it? Absolutely. Former New America colleague and neurosurgeon Guy Clifton has a new book titled Flatlined: Resuscitating American Medicine that details how pre-1976 brain tumors were detected: it was messy. Now with CT and MRI scans, physicians can determine whether "a mass is a blood clot or a tumor, what kind of tumor it is, how close it is to speech and movement centers, and how it is affecting the surrounding brain." Dr. Clifton calls the difference "night-and-day." But Dr. Clifton, in a post on this blog a few months ago, also wondered about whether CT heart scans were being used wisely.

The key is to better understand when a CT scan is necessary. When it comes to your head, sometimes it is clearly necessary. When it comes to your heart, it is safe to say some overutilization is occuring. But apparently we're just getting started. An accompanying piece in JAMA by Dr. Andrew Einstein of Columbia University writes that the number of CT scanners installed in US cardiology practices has tripled in the past two years. Unfortunately, those machines don't pay for themselves by sitting idle.

A center for comparative effectiveness research would be a great start to disseminating how to reduce the risk of overradiating people, don't you think?

HEALTH REFORM: A Presidential Call to Action

Paul Testa — Thu, 05 Feb 2009 17:32:00 -0500

Yesterday, President Barack Obama made a down payment on health reform signing the SCHIP law that extends and expands coverage for low-income children. Today, he makes a pitch for the next installment.

In a call to action in an op-ed in today's Washington Post, Obama outlines how the proposed economic recovery package is a not just a burst of short-term spending but a "strategy for America's long-term growth." Health care figures prominently. He writes:

In recent days, there have been misguided criticisms of this plan that echo the failed theories that helped lead us into this crisis—the notion that tax cuts alone will solve all our problems; that we can meet our enormous tests with half-steps and piecemeal measures; that we can ignore fundamental challenges such as energy independence and the high cost of health care and still expect our economy and our country to thrive. [...]

Every day, our economy gets sicker—and the time for a remedy that puts Americans back to work, jump-starts our economy and invests in lasting growth is now.

Now is the time to protect health insurance for the more than 8 million Americans at risk of losing their coverage and to computerize the health-care records of every American within five years, saving billions of dollars and countless lives in the process.

Fix the economy or fix health care? President Obama's op-ed shows he rejects the false choices of such a dichotomy. The problems of health care and the economy are closely related. So are their solutions. We cannot put off health reform until we "fix" the economy, because we cannot fix the economy without reforming health care.

Yesterday's reauthorization of SCHIP is an important first step. Dedicating part of the stimulus package to health care can not only spur job-creation and economic activity in the short term, it can lay the foundation for health reform. Incorporating these intitial investments into broader reform is necessary for realizing their long-term potential to lower unsustainable costs, improve care and save lives.

The President writes: "What Americans expect from Washington is action that matches the urgency they feel in their daily lives..." With medical costs contributing to half of all bankruptcies and many home foreclosures, millions of Americans feel that sense of urgency manifested in health care. As the economy worsens, the number of concerned Americans grows. They've made the call for health reform loud and clear—it started with the election and it continues today. It's time to answer.

HEALTH POLITICS: Daschle Out, But Health Reform Still In

Len Nichols — Wed, 04 Feb 2009 21:14:00 -0500

The progress towards national health reform hit a bump in the road when Senator Daschle felt compelled to withdraw as nominee for Secretary of Health and Human Services. Still, it is useful to remember that the health reform debate is far larger than any one man or woman and the underlying reasons for reform are unchanged and compelling.

Our health system is on a trajectory that cannot be sustained. The costs of inaction are high and they will only rise over time. Families, employers, and governments are all threatened by rising health care costs. These trends will not change on their own. In fact, they will worsen. This issue is not going away and neither are the "strange bedfellow" coalitions of business, labor and consumer groups that helped make health care a decisive issue in the 2008 campaign.

Our struggling economy has revealed and worsened the flaws in our health system and the call for reform will grow more urgent as a result. More and more families are losing insurance along with their jobs and are finding themselves unable to afford essential health care services. Countless interviews and media reports have documented jobless families who view affording health care as one of their most immediate economic concerns. The economic crisis only further demonstrates the need for reform and will only heighten the public's awareness of our system's gaps.

Health reform remains a priority for the Obama Administration and for Congress. David Axelrod captured this best when reminding reporters that "this issue has great power of its own." President Obama has stated consistently that making insurance affordable for all Americans is a primary goal of his administration. This goal is shared by key Congressional leaders, including Senate Finance Chair Max Baucus, HELP Chair Ted Kennedy, Energy and Commerce Chair Henry Waxman, and Ways and Means Health Subcommittee Chair Pete Stark. Now that SCHIP is being signed with the economic stimulus package soon to follow, the full attention of these key leaders will shift to comprehensive health reform.

The American people, throughout the 2008 campaign and beyond, have called for a better, more affordable health system. The people who sent Barack Obama to the White House will not change their views on our health system because of Tom Daschle's withdrawal. They elected Obama to do a job, and what particular individual holds what particular job matters little in the grand scheme of the overwhelming desire for "real change."

As many of you know, I was a senior adviser at the Office of Management and Budget (OMB) during the Clinton-era reform efforts. For some perspective on the Daschle road bump, recall what we were all doing on February 4, 1993. At this moment 16 years ago, we were going through an Ira Magaziner "toll gate" exercise with 500 of our closest friends. In large working groups, we were trying to write down a detailed blueprint of a new health care system that did not exist in nature.

Thanks to leaders like Senators Ron Wyden (D-OR) and Bob Bennett (R-UT), and Representatives Deborah Wasserman-Schulz (D-FL) and Jo Ann Emerson (R-MO), we have two years of bipartisan commitment to comprehensive reform to build upon. In addition many more stakeholders, like our own group Health CEOs for Health Reform, and countless other employers and labor leaders are willing to say, "The status quo is unsustainable and we CAN work collectively to align interests and reform our system to serve everyone."

So while we will miss former Senator Daschle, we should not lose sight of how much further along the health reform debate is today compared to the winter of 1993. Congressional leaders have emerged; bipartisan conversations have been initiated; and, industry leaders have shown some signs that they are willing to engage, rather than obstruct. The moral and economic motivations for this issue are too strong, the costs of failure too high, and the progress towards our goal too great for our optimism to wane. Now remains the time to act.