Health Care For All Americans, Part 3: UPDATED

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Over the past few days, Dr. John and I have been having a fascinating discussion about this post from September 2008.  It is one of the first pieces I wrote for Extreme Thinkover,  before President Obama was elected, as well as at least a year before the serious work on what would become the Patient Protection and Affordable Care Act, known as “Obamacare” (but which I prefer to refer as “the ACA”) was being worked on.  It was also before Dr. John and I met and got acquainted.

I deliberately haven’t edited the post below, so our comments will make sense in the context in which they were written will make sense.  I think my readers will enjoy the back and forth between us, and I invite you to add your own comments, should you feel so inclined.

IMPORTANT: Read the comments starting from the bottom of the thread. It is where the discussion starts. And you may have to move up and down a few comments for our replies because of the way WordPress publishes them: by the time stamp of the comment/reply and not directly associated with a given submission.  Sorry for the inconvenience.

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Health Care for All Americans: Part 3

In Parts 1 and 2,  I discussed first, the assumptions needed from a medical perspective, particularly with respect  to the scope of treatment plans that would lead to optimizing the health of Americans, and second, how those assumptions would create a radical transformation in the health of Americans that would work its way through all aspects of daily life.  In Part 3, I now want to describe the logic that shows how the country would benefit.

We’ll start using my first assumption: Preventable diseases are prevented.

We could use any number of examples, but the format of the blog does requires some brevity, rather than a detailed White Paper or journal article.  I also acknowledge that the ideas I  present here have all been suggested by others, but this is how I choose to organize them.

For purposes of our discussion let’s call our example citizen, Larry.  Larry works full time for minimum wage, does not have  health insurance, and cannot afford to buy private insurance.  He also does not qualify for any government health care benefits.  Larry’s wife also works for minimum wage, but only 24 hours per week.

As long as his health holds, Larry can work and he has no medical needs.  He pays local, federal and state taxes and uses no special government services.

But let’s say that Larry gets pneumonia.  It is a very common viral strain, and can be treated successfully with antibiotics, and could have been avoided entirely if Larry had had a pneumonia vaccination.  Now he’s faced with a dilemma.  At first he thinks he just has a chest cold and he can wait it out.  Being a conscientious worker, he toughs it out and goes to work, but exposes his coworkers to the bug through his worsening cough.

By the weekend, Larry is really sick.  Over the counter cough medicines provide almost no relief, and on top of that, his cough is becoming increasingly productive.  He cannot sleep because of the cough and not being able to find a position in bed where he can breathe without effort and  pain.  Larry knows he needs to see a doctor, but having no insurance, he does not have a primary care physician, so he has no idea who to call.  Finally his breathing becomes so difficult that his wife calls  911.  Larry is taken to an emergency room by ambulance, but one on the far side of the city because the hospital closest does not like to take patients without insurance.

By the time Larry gets to an emergency room that will accept him as a patient he is nearly in respiratory arrest.   The ER doctor quickly diagnoses the pneumonia, but that it is so advanced that Larry’s life is in danger.  She intubates him immediately and transfers him to the hospital’s intensive care unit. It is four days before Larry’s condition has improved enough to send him to a “step-down” unit and two more days before he can be admitted to a medical unit room, and he is discharged two days after that.

Larry is fortunate that the hospital he is at has Certified RN and MSW Care Managers.  They work with him and his wife throughout  the hospitalization, develop a treatment plan and a discharge plan, set Larry up with a local medical clinic that treats patients without insurance, and provide his wife with food  vouchers and bus tokens so she can make the long trip back and forth to the hospital.

Despite all this, when Larry is wheeled out to the taxi to take him home, he has a hospital bill that is $250,000.  Since Larry and his wife together make too much money to qualify for Medicare, that bill rests squarely on their shoulders. He has no way to pay it back.  He will not be strong enough to work for at least another three weeks.  He will have not earned a dollar since he got sick, and won’t until he returns to work.  His wife’s income is not sufficient to cover all their bills,  and if they pay the rent, they will not have enough money to buy food.  The hospital sent home a week’s supply of medications, but after that, he will have to pay for them himself, and due to the damage to his lungs, he will need regular medications for at least six months.  Those prescriptions will cost over $800 per month.  Through the free medical clinic he can apply for medication cost support , but that can take up to four weeks to be approved assuming he qualifies.

Now multiply this basic scenario by twenty or thirty million Larrys a year. Every year. That is health care in America.

Here’s what happens.  The only good news is that Larry has survived a brush with death, ironically from a completely preventable disease.

Larry and his wife now owe the hospital $250,000.  They have no assets.  Even though they signed a promissory note with the hospital, no one is under the illusion that he will be able to pay back more than a few thousand dollars if he is a very conscientious person.

Larry and his wife owe the ambulance service perhaps $3,000.  They cannot pay it, or they will have to try to pay it off in very small amounts per year at a probably high interest rate.

Larry will lose at least a month’s income, and perhaps more if his recovery is longer than expected.  If he is very fortunate, his employer will hold his job until he can return.  In the meantime, his wife’s income is not large enough to cover their essential bills, starting with rent and food.  If Larry’s wife cannot get more hours from her current work, her only realistic option is to get another part time job, likely at minimum wage.  Whether that will at least let them pay for their basics is not certain.  It is also uncertain how flexible their landlord will be to let them catch up with their current rent.

It should be clear by now, that one simple, preventable illness has created a cascade of events that affects the economy, are extraordinarily expensive and completely unnecessary.  Yet, this is the true consequence of the current American health care system.

The hospital will have to write off the $250,000.  To compensate they will have to pass this loss, as well as hundreds of others per year, to their patients with insurance.

The ambulance company will have to spend a lot to try and recover their fee from Larry, and will pass those added expenses along to their other customers who can pay, either privately or with insurance.  If Larry doesn’t keep up with the payments, they may turn him over to collection, which will damage his credit.

Larry’s employer loses productivity from a good worker.  The company may have to hire temporary labor to fill Larry’s absence, which will be more expensive.

Larry and his wife lose essential income, which at minimum wage is marginal to begin with, and may jeopardize their ability to even house and feed themselves.

Every day that Larry does not work means that his wages do not generate taxes, local, county and federal, as well as FICA withholdings.  Multiply that by twenty or thirty million Larrys year after year and the loss is well into billions.  The impact of this loss of tax revenue and productivity is staggering on the national economy.

All this from a preventable disease that could have been stopped before it was started if Larry had had access to the most basic medical care.  Everybody loses.  The nation is weakened through attrition in ways no external threat could impose on us.   This national “epidemic” is progressive, it is close to end-stage, and we could all too easily end up with a terminal prognosis.  We may reach a point that we literally will be too unhealthy to survive as a nation.

We still have a choice.  Until the epidemic takes that away.

30 Governors Open Health Care Ghettos: October 1, 2013

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The governors from over half of the 50 states have or are considering refusing to establish Health Care Exchanges and to participate in Medicaid as provided for by the Affordable Care Act, (ACA) cynically known as “Obamacare.”  My assessment is that the consequences of this decision by the Chief Elected Officers of these states is going to in actuality create a third-tier, low quality health care environment.  Simply put, those states that offer to their residents full participation in the rights and privileges provided by the ACA, which is the law of the land, will develop in a few short years, into first-tier, high quality health care systems.  The states  that don’t, however, will within a similar number of a years see their health care, both private and public, degenerate into a ghetto of medical inferiority.

I call it…Read More

The Supreme Court and the ACA: The Ultimate Death Panel?

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I started Extreme Thinkover in the fall of 2008.  The presidential race was in full swing.  Universal health care was one of the major topics that the candidates, media, and the public were debating.  One of my primary motivations for creating the blog was to have a forum in which to express my ideas about the health care debate.

I’ve worked in the health care industry for nearly 16 years and have daily contact with patients and families in the hospital.  I hear their stories, good and bad, about what these hospitalizations are doing to their lives.  Yes, what the hospitalization is doing to their lives.

Here in America, going to the hospital is not just about getting medical treatment; it’s also about entering a very broken and extremely expensive system. It nevertheless tries to limp along: In all fairness to the medical professionals who work very hard on behalf of their patients, in most cases, if you find yourself hospitalized, you get reasonably good medical care.

However, in the middle of this is an ongoing battle with the major health care players (hospital systems, health insurance, pharmaceuticals, medical equipment providers, etc.) all wanting to maximize their profits in an economic power race that too often is at the expense of the quality of care delivered to the patients who pay for their services, as well as forcing ever-increasing demands on their care givers to do more with less.  Admittedly, it doesn’t happen everywhere, but it is far too pervasive in Rube Goldberg “system” that passes for health care in America.

I wrote in fall 2008:

Here’s the question: What kind of treatment and medical care is needed so that all Americans can be healthy, or as healthy as possible?

That perhaps is not the question you expected to hear. The national conversation has focused on how much will it cost to provide all Americans with health insurance, how will the spiraling costs of health care be brought under control, will taxes have to be raised to pay for it, what will the roles of the health insurance industry, and the medical industries, and most of all the federal government be? Tough questions all around.

That question, “What kind of treatment and medical care is needed so that all Americans can be healthy, or as healthy as possible?” remains the key to a successful national health care program.  It also remains almost totally ignored by politicians, lobbyists, and, sadly the American public, none of whom have yet realized that without answering this question first, in my opinion, the debate about the cost cannot be resolved.  I contend this is why the health care law polls low for national support.

The current law, the Patient Protection and Affordable Care Act, passed in 2010, nibbles at the edges of what I think is essential, but it, also, is far too focused on trying to control medical costs.  And in case you are wondering, yes, I’ve read the law cover to cover.

Beginning Monday, March 26, the Supreme Court of the United States is going to hear arguments for and against the PPACA.  The primary question before the Court is whether Congress overstepped its authority regarding the interstate commerce clause of the U.S. Constitution by mandating all Americans (sort of) be required to purchase health insurance.  The debate is guaranteed to be rancorous, even in the sedate and forcibly polite setting of the Supreme Court.  The debate, though, once again is all about the money.  A healthy America will likely never even come up. The pundits will have a field day with this, without question, but I doubt any will see the fundamental flaw in all the arguments, based on my point of view.

Will the justices see past the smoke screen of political ideology, special interest group pressure, and inflammatory rhetoric that is fueling these proceedings?  If they do, and declare the law constitutional, there is hope that the ACA can continue to be refined, actually moving toward being a mechanism to support a healthier America.  If they don’t, by striking down all or parts of it, the Supreme Court will, for all intents and purposes, become the Ultimate Death Panel, condemning tens of millions of Americans to poor health, premature, and in some cases, an agonizing death because they will have been denied the right to even the most basic level of health care.  And that, tragically, just months before a law already on the books would have given them the care snatched away by the Supreme Court Death Panel.

Now we wait to see how this court rules on the fate of Americans’ health for generations to come.

The Thinkover:  When Patrick Henry uttered those iconic words, “Give me liberty or give me death!”  he wasn’t suggesting that death was preferred outcome of that stand for patriotism.  So far, the opponents of the ACA have been clueless to this obvious distinction in demanding “liberty” from the ACA mandate.

Sunrise: Health Care For All Rises Above the Horizon

The Sun has Risen for Health Care in America. Photo Courtesy: Bolte Medical

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Now is the time for health care to be added to those moments of sublime national change, to join those great reforms, cast as the finest, hardest steel into our Nation of Laws as an inalienable right and an eternal Blessing of Liberty.  D. Waggoner, Phd, 2009.

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Oregon Health & Science University: Oregon's Premier Medical School and Research University. Photo Courtesy OregonLive.com

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President Barack Obama:  Our presence here today is remarkable and improbable.  With all the punditry, all of the lobbying, all of the game-playing that passes for governing in Washington, it’s been easy at times to doubt our ability to do such a big thing, such a complicated thing; to wonder if there are limits to what we, as a people, can still achieve.  It’s easy to succumb to the sense of cynicism about what’s possible in this country.

But today, we are affirming that essential truth -– a truth every generation is called to rediscover for itself –- that we are not a nation that scales back its aspirations. We are not a nation that falls prey to doubt or mistrust.  We don’t fall prey to fear.  We are not a nation that does what’s easy.  That’s not who we are.  That’s not how we got here.

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Pres. Obama Signs Health Care Reform Act into Law. Photo Courtesy: Saul Loeb, AFP/Getty Images.

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We are a nation that faces its challenges and accepts its responsibilities.  We are a nation that does what is hard.  What is necessary.  What is right.  Here, in this country, we shape our own destiny.  That is what we do.  That is who we are.  That is what makes us the United States of America.

And we have now just enshrined, as soon as I sign this bill, the core principle that everybody should have some basic security when it comes to their health care.  And it is an extraordinary achievement that has happened because of all of you and all the advocates all across the country.

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A Promise Fulfilled.

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The Dawn’s Early Light…A New Era of Health Care For Americans

Dawn's Early Light. Photo Courtesy Pike Pictures, UK

Now is the time for health care to be added to those moments of sublime national change, to join those great reforms, cast as the finest, hardest steel into our Nation of Laws as an inalienable right and an eternal Blessing of Liberty.  D. Waggoner, Phd, 2009.

A Promised Fulfilled...A New Dawn of Health Care for America

That large-heartedness — that concern and regard for the plight of others — is not a partisan feeling. It’s not a Republican or a Democratic feeling. It, too, is part of the American character — our ability to stand in other people’s shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise…

I understand how difficult this health care debate has been. I know that many in this country are deeply skeptical that government is looking out for them. I understand that the politically safe move would be to kick the can further down the road — to defer reform one more year, or one more election, or one more term…

But that is not what the moment calls for. That’s not what we came here to do. We did not come to fear the future. We came here to shape it. I still believe we can act even when it’s hard. (Applause.) I still believe — I still believe that we can act when it’s hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history’s test.

President Barack Obama.  Address to Congress and the Nation, 9 Sept 2009.

Health Care Reform–The Train is Ready to Leave the Station

Universal Health Care? Don't Be Silly! Image: oldamericancentury.org

Update 18 Mar, 12:50 p.m., PDT:  The U.S. House Rules Committee has just posted the text of H.R. 4872–Reconcilation Act of 2010.  http://bit.ly/aUWBUK #healthreform.

The very first post for Extreme Thinkover was to advocate for health care reform.  Although I have written dozens of posts since September 2008, my most frequent theme has been to make the needed, and yes, sweeping changes to the nation’s health care system that will establish access to medical care as a right and not a privilege available to only those who can afford to pay for it, that these reforms rectify an endemic injustice that mushroomed into a national health crisis of unprecedented historical proportions.

By July 2009, it had become evident that the Big Medicine, often led by the

The Sniffer. My Buddy to Detect Nuclear Radiation. Photo: Ajax

American Health   insurance Providers (AHIP), while publicly mouthing support for reform was, in fact, spending hundreds of millions of dollars and perhaps the most intense lobbying in U.S. history to kill reform once and for all.  They were gearing up to use what I labeled their “Nuclear Option”–to destroy the health care reform legislation in one large blast.  To accompany me on this journey, I invented The Sniffer.    The Sniffer has been constantly busy, doggedly pursuing every whiff of anti-reform nuclear odor, as Big Medicine worked and spent millions of our dollars paid for our care to try to deny us the very care we were paying for.    The Sniffer was “semper fi” in his work.  He helped reveal attempt after attempt to do in the legislation.  Big Medicine ratcheted up the pressure week after week as the President and the Democrats (with the exception of the shameful behavior of the “Blue Dog” Democrats, who on more than one occasion nearly succeeded in pushing the button), struggled through a barrage of anti-reform initiatives, advertising and lobbying, and the increasing pitch of outrage by such groups as the Tea Partiers.

Nuclear Option Button. Photo: Courtesy Getty Images

The Town Hall Meetings of August 2009 devolved into the summer of discontent and ended up as the month that will be remembered as the time when throwing political tantrums erupted onto the American political scene or else a new form of Primal Scream Therapy had become vogue.  It was difficult at times to distinguish which one was happening at the moment.  To be honest I experienced moments of angst and despair that this negative energy might provide the critical mass Big Medicine needed to construct its nuclear device.  One thing I was very certain of is that with the support of the congressional Republicans, if the legislation appeared to have the votes to pass, the Anti-Reform Mission Control would press the button.

Then something else arose out of the smoke and mirrors of the August tempest.  It began to lose steam.  In reality, the tantrums burned themselves out.  The American Public, being smarter and more insightful than given credit by  either many politicians, in particular the Republican Leadership, one Rep. John Boehner and Sen. Mitch McConnell (minority leaders in their respective houses), or the political consultants and pundits, soon tired of endless pictures and TV video of people, appearing to be adults in terms of their chronological age, acting like four-year olds who hadn’t gotten their way at the pet store because mom or dad refused to let them buy that cuddly little mastiff puppy.

In the midst of this din of obstructionism and protest being broadcast at a volume equivalent a Rolling Stones concert at Yankee Stadium, the House passed their version of the health reform bill.  I held my breath.  The Senate was still wrangling over the details.  In October 2009 I wrote:

America’s Health Insurance Plans pushed the button on their “nuclear option” bomb to blast health care reform into oblivion. The safety was released, the countdown went to zero, and “click!”

The device failed to detonate.  Through November and into the Holidays, the Senate sat paralyzed as Montana Democratic Senator, Max Baucus, employed a strategy to get his version out of committee.  He did, when Sen. Olympia Snowe (R-ME) finally broke and said she’d vote yes, but only to move to the floor of the Senate for a final vote.  It passed finally on December 24 on a strict party-line vote.

The Late Sen. Ted Kennedy with Pres. Obama. Photo: PBS.org

When Massachusetts held its special election to fill the seat left by Ted Kennedy (who had died months earlier from brain cancer), which had been filled by an appointee Democrat and the voters chose a Republican, the champagne bottles were uncorked by the Anti-Reformers.  The Democrats had lost their filibuster-proof majority and could no longer pass a bill over the heads of the Republican opposition.  The airwaves fairly sizzled with pundits announcing that without Kennedy to champion the cause it was over; health care reform was dead.

Instead the Opposition made a fatal strategic error in their plan of destruction.  The Republicans failed to have at the ready a full-blown alternative bill to introduce as the savior of health care to fill the vacuum.  Their “start over with a clean sheet of paper” backfired, because no one in America believed it was possible, including those who opposed reform.  The tide shifted.

House Health Care Reform Bill. Photo: Jesse Blumenthal.

After the Health Care Summit in which President Obama invited members of both houses and parties to participate, the Republicans during the televised seven hours long event had nothing to offer. They repeatedly sniped at the bills that had passed and the fact they were over 2700 pages long , copies of which they had sitting on their tables as a prop making an impressive stack.  The pundits also got it wrong.  The Republicans spoke with a carefully rehearsed unified voice, but rather than its intended affect to present to the people a solid wall of principled objection, they showed a solid wall of obstructionism–and with nothing behind it to present to the public.  They had been determined to cause the failure of this bill and Obama’s presidency.  They failed on both accounts.  The President and the Democrats came out energized.

As I write this post, three days from now, the House of Representatives will vote on the final version of the bill.  The Senate then will vote, as well.  The Republicans are desperate to stop it, but only have an expensive nuclear dud left in their arsenal.  AHIP and Big Medicine are still spending millions to thwart it.  This last ditch effort is failing on both fronts.  If they have something up their sleeves, a secret device they can detonate and kill the process, now is the time they must use it.  That they apparently are losing ground, and that they appear to have been outflanked by both Pres. Obama and the Democratic leadership in both houses seems to be the evidence they have no nuclear option left to use.

Short of a secret weapon unleashed, the bills will pass and health care reform will begin to move, like a freight train beginning to roll, almost imperceptibly at first, but with an inexorable increase in velocity rumbling down the track, creating in its path an new era for Americans and their health and medical needs.

Photo: Cape Care, MassCare

Professor Obama: The Presidential School of Bipartisan Education.

You may have thought the summit President Obama presided over today was all about health care reform.  It wasn’t.  Health Care Reform was the topic, but the subject was a six-plus hour seminar in front of a national audience on how to  be bipartisan led by the professor-in-chief, Barack Obama, J.D.   The pundits and bloggers, well, like, me are pounding away at their computers trying to wring every bit of meaning and nuance from the day’s-long exchange.

Health Care Reform was the topic, but the subject was a six-plus hour seminar in front of a national audience on how to  be bipartisan led by the professor-in-chief, Barack Obama, J.D.

Let’s get one thing out of the way.  How do I grade the debate on health care reform?  I give the Democrats a C, and that’s generous.  Their acting like they are close to the Republicans in the substance of the bill was stretching credulity nearly to the breaking point.  But I give the Republicans a D- and that is because they went out of their way to avoid any semblance comprehension what the summit was really about.  Just a whole day of props and talking points without as much as a single original thought.

Sorry, Mitch, John, Lamar and Eric, starting over isn’t an option.  It wasn’t about how many minutes each side gets to speak, Mitch (that has to be one of the most sophomoric gaffs of your career). You know as well as I do that it is empty rhetoric.  It’s impossible to start with a clean sheet.  The sheets in the health care debate are not paper.  They are hospital bed sheets and have over a half a century of political grime ground into them.  There are no clean sheets.  You can’t rewind history.  The perpetuation and dissemination of ideas follows the one-way arrow of time.  Health care reform does not exist in a bubble undisturbed by the flow of reality in the present environment of human medical needs.

Republicans: It’s time for you to step out of the way and let we Americans have access to medical care that meets our needs, covers us without regard for preexisting conditions, and sets the stage for a era of wellness through preventing those medical conditions that can be prevented.  Your ideas won’t work because your plan has an inherent stinginess to it that is, well, just incomprehensible in a nation  that thrives on being generous.

Republicans: Your ideas won’t work because your plan has an inherent stinginess to it that is, well, just incomprehensible in a nation  that thrives on being generous.

Now, on to the real subject of the summit today.  Prof. Obama led the seminar in bipartisanship.  Neither political party really figured that out, however.  They have over the past year (two? three? twenty?) been overwhelmed by the drumbeat of talking points drilling themselves so deeply into the daily consciousness of our congressional representatives, that it appears almost as if they have lost the capacity to speak in any other manner or with any independence of thought.

Prof. Obama conducted a very well run seminar in what can easily be described as a highly-charged setting.  The representatives of the two parties, both Senators and Congressional Representatives have been sniping at each other, saying  some of the most outrageous things ever entered into the Congressional Register, attacking with a ferocity just shy of out and out fisticuffs.  It’s a good thing the debates in the wells of both Houses are not near windows.  The amount of acrimonious bile spewed at each other could have led to the defenestration of any number of the members in the tradition of the Bohemians in Prague, first in the 1400s and again in the 1600s.

It’s a good thing the debates in the wells of both Houses are not near windows.  The amount of acrimonious bile spewed at each other could have led to the defenestration of any number of the members in the tradition of the Bohemians in Prague, first in the 1400s and again in the 1600s.

But neither side got it.  At least neither side wanted to be the first to admit that they got it.  As soon as they walked out of Blair House and across the street back to the Capitol, the auditory hallucinations of hyperpartisanship appear to have kicked in like throwing the main breaker on a mental trash compactor.

Regarding health care reform, the lack of substance was arguably all that could be expected.  Regarding reestablishing a beneficial and productive dialogue between the two parties, it was right there for all America to see.  The professor, behaving at his presidential best, conducted an exercise in statesmanship.  The comments, although, at times impassioned, were respectful and under the watchful eye of the Professor-in-Chief. The two sides were able to carry on a debate that did not devolve into shouting or irrational charge and counter-charges.  The summit was a demonstration of political civility on the TV screens or computer monitors for all America to see.

So, now we will see how the introduction of statesmanship into this debate will be able to work its way through the consciousness of both our elected leaders and the American people.  Will it grow over time; were seeds planted that will germinate and change the landscape of the national political scene?

Health care reform, just a few weeks ago declared dead on arrival after the Massachusetts election, has survived.  Is it healthy?  That remains to be seen.  But the recovery of  reform is proceeding in ways that could be best compared to an intensive rehabilitation program.

He left no doubt that his skills as President of the United States have grown and matured in ways that give great encouragement to his supporters and equal concern to his opponents.

The summit today, however, was historical for what it may have saved for American politics, more than the result of the final disposition of health care reform.

Professor-in-Chief Obama is undoubtedly exhausted after today’s intensive experience and exercise in democracy.  But one thing is certain.  He left no doubt that his skills as President of the United States have grown and matured in ways that give great encouragement to his supporters and equal concern to his opponents.  I have said on several occasions that America would have to get used to a very smart president.  Today, we just saw one reason why.