![CDATA[ They won only two states in 1936, prompting the immortal aphorism that as Maine goes, so goes Vermont. They won only six states in 1964, suggesting to many analysts that a great political party was in eclipse. They saw a party warhorse defeated by an upstart governor in 1992, making them fear that their dream of a Republican era was imperiled. Things have been bleak for the Republicans before.

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The recent news from Wall Street concerning the governments plan to bail out financial markets and stick taxpayers with the bill has made it difficult, if not impossible, for the advocates of universal health coverage to fulfill their goals. Democratic presidential candidate Barack Obama recently said that some of his plans for spending would have to be curtailed if, as expected, the bailout of Wall Street passes Congress. The money just wont be there.

For those Americans without health insurance who were counting on at the least some discussion of the issue during the campaign and some action for universal health insurance should Obama win in November, the deflation in the credit bubble was too deeply and personally felt. With the government assuming such a vast quantity of private market debt, it appears unlikely that health care reform funded by government will be possible.

But not all hope is lost for a different type of health care reform. The Wall Street/government fiasco should convince many Americans that it is high time to get the financial ship in order, not only in New York and Washington, but in their own households as well. Last year the media reported that for the first time since the Great Depression Americans had a negative savings rate. It is high time we reverse course.

Health care reform which is not predicated on expanding governments role, but rather promoting individual responsibility is best. The creation of a true market for health insurance and consumer health care, would point the best way towards both lowering the number of uninsured in the country as well as the costs of health care.

One way to do this is to change the tax structure which favors the employer-sponsored insurance the majority of Americans still receive. Employers receive the tax benefit for purchasing insurance for their employees. Many Americans who find themselves uninsured or without employer sponsored insurance could find themselves with insurance if they were to receive the tax benefit accorded employers.

Senator John McCain, the Republican candidate for president, has offered a plan whereby a tax credit of $2500 for an individual and $5000 for a family is given which would allow people to purchase private health insurance. McCain has also suggested allowing the purchase of health insurance across state lines so that individuals in high cost states could purchase cheaper insurance products offered in other states. This would not undercut the regulations in each statethe insurance commissioner of a state like Kansas would still be responsible for the soundness of the insurance product. But it would allow for a more competitive marketplace which should lower costs.

Second, encouraging the use of health savings accounts (HSAs) by employers or through the individual marketplace would provide greater individual control over health care costs and allow Americans to build up savings which would be used towards future health care expenses.

There are other ways to reduce health care costs and to increase the number of insured without creating a universal health care system. Wall Streets recent crisis and the response by government need not end reforms of a vital sector of our economy. Rather it should point the way to the prudent and measured reforms which will revitalize the health care sector while government spending is focused on other priorities.

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SEC. 132. INCENTIVES FOR ELECTRONIC PRESCRIBING.

(a) INCENTIVE PAYMENTS.—Section 1848(m) of the Social Security Act, as added and amended by section 131(b), is amended—
(1) by inserting after paragraph (1), the following new paragraph:
(2) INCENTIVE PAYMENTS FOR ELECTRONIC PRESCRIBING.—

(A) IN GENERAL.—For 2009 through 2013, with respect to covered professional services furnished during a reporting period by an eligible professional, if the eligible professional is a successful electronic prescriber for such reporting period, in addition to the amount otherwise paid under this part, there also shall be paid to the eligible professional (or to an employer or facility in the cases described in clause (A) of section 1842(b)(6)) or, in the case of a group practice under paragraph (3)(C), to the group practice, from the Federal Supplementary Medical Insurance Trust Fund established under section 1841 an amount equal to the applicable electronic prescribing percent of the Secretary’s estimate (based on claims submitted not later than 2 months after the end of the reporting period) of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or, in the case of a group practice under paragraph (3)(C), by the group practice) during the reporting period.

(B) LIMITATION WITH RESPECT TO ELECTRONIC PRESCRIBING QUALITY MEASURES.—The provisions of this paragraph and subsection (a)(5) shall not apply to an eligible professional (or, in the case of a group practice under paragraph (3)(C), to the group practice) if, for the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year)—
(i) the allowed charges under this part for all covered professional services furnished by the eligible professional (or group, as applicable) for the codes to which the electronic prescribing quality measure applies (as identified by the Secretary and published on the Internet website of the Centers for Medicare Medicaid Services as of January 1, 2008, and as subsequently modified by the Secretary) are less than 10 percent of the total of the allowed charges under this part for all such covered professional services furnished by the eligible professional (or the group, as applicable); or
(ii) if determined appropriate by the Secretary, the eligible professional does not submit (including both electronically and nonelectronically) a sufficient number (as determined by the Secretary) of prescriptions under part D.
If the Secretary makes the determination to apply clause (ii) for a period, then clause (i) shall not apply for such period.

(C) APPLICABLE ELECTRONIC PRESCRIBING PERCENT.— For purposes of subparagraph (A), the term ‘applicable electronic prescribing percent’ means—
(i) for 2009 and 2010, 2.0 percent;
(ii) for 2011 and 2012, 1.0 percent; and
(iii) for 2013, 0.5 percent.’’;
(2) in paragraph (3), as redesignated by section 131(b)—
(A) in the heading, by inserting AND SUCCESSFUL ELECTRONIC PRESCRIBER’’ after REPORTING’’; and
(B) by inserting after subparagraph (A) the following new subparagraph:

(B) SUCCESSFUL ELECTRONIC PRESCRIBER.—

(i) IN GENERAL.—For purposes of paragraph (2) and subsection (a)(5), an eligible professional shall be treated as a successful electronic prescriber for a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year) if the eligible professional meets the requirement described in clause (ii), or, if the Secretary determines appropriate, the requirement described in clause (iii). If the Secretary makes the determination under the preceding sentence to apply the requirement described in clause (iii) for a period, then the requirement described in clause (ii) shall not apply for such period.

(ii) REQUIREMENT FOR SUBMITTING DATA ON ELECTRONIC PRESCRIBING QUALITY MEASURES.—The requirement described in this clause is that, with respect to covered professional services furnished by an eligible professional during a reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year), if there are any electronic prescribing quality measures that have been established under the physician reporting system and are applicable to any such services furnished by such professional for the period, such professional reported each such measure under such system in at least 50 percent of the cases in which such measure is reportable by such professional under such system.

(iii) REQUIREMENT FOR ELECTRONICALLY PRESCRIBING UNDER PART D.—The requirement described in this clause is that the eligible professional electronically submitted a sufficient number (as determined by the Secretary) of prescriptions under part D during the reporting period (or, for purposes of subsection (a)(5), for the reporting period for a year).

(iv) USE OF PART D DATA.—Notwithstanding sections 1860D-15(d)(2)(B) and 1860D-15(f)(2), the Secretary may use data regarding drug claims submitted for purposes of section 1860D-15 that are necessary for purposes of clause (iii), paragraph (2)(B)(ii), and paragraph (5)(G).

(v) STANDARDS FOR ELECTRONIC PRESCRIBING.— To the extent practicable, in determining whether eligible professionals meet the requirements under clauses (ii) and (iii) for purposes of clause (i), the Secretary shall ensure that eligible professionals utilize electronic prescribing systems in compliance with standards established for such systems pursuant to the Part D Electronic Prescribing Program under section 1860D–4(e).’’; and (3) in paragraph (5)(E), by striking clause (iii) and inserting the following new clause:
(iii) the determination of a successful electronic prescriber under paragraph (3), the limitation under paragraph (2)(B), and the exception under subsection (a)(5)(B); and’’.
(b) INCENTIVE PAYMENT ADJUSTMENT.—Section 1848(a) of the Social Security Act (42 U.S.C. 1395w–4(a)) is amended by adding at the end the following new paragraph:

(5) INCENTIVES FOR ELECTRONIC PRESCRIBING.—

(A) ADJUSTMENT.—

(i) IN GENERAL.—Subject to subparagraph (B) and subsection (m)(2)(B), with respect to covered professional services furnished by an eligible professional during 2012 or any subsequent year, if the eligible professional is not a successful electronic prescriber for the reporting period for the year (as determined under subsection (m)(3)(B)), the fee schedule amount for such services furnished by such professional during the year (including the fee schedule amount for purposes of determining a payment based on such amount) shall be equal to the applicable percent of the fee schedule amount that would otherwise apply to such services under this subsection (determined after application of paragraph (3) but without regard to this paragraph).

(ii) APPLICABLE PERCENT.—For purposes of clause (i), the term ‘applicable percent’ means—
(I) for 2012, 99 percent;
(II) for 2013, 98.5 percent; and
(III) for 2014 and each subsequent year, 98 percent.

(B) SIGNIFICANT HARDSHIP EXCEPTION.—The Secretary may, on a case-by-case basis, exempt an eligible professional from the application of the payment adjustment under subparagraph (A) if the Secretary determines, subject to annual renewal, that compliance with the requirement for being a successful electronic prescriber would result in a significant hardship, such as in the case of an eligible professional who practices in a rural area without sufficient Internet access. ‘

(C) APPLICATION.—

(i) PHYSICIAN REPORTING SYSTEM RULES.—Paragraphs (5), (6), and (8) of subsection (k) shall apply for purposes of this paragraph in the same manner as they apply for purposes of such subsection.

(ii) INCENTIVE PAYMENT VALIDATION RULES.— Clauses (ii) and (iii) of subsection (m)(5)(D) shall apply for purposes of this paragraph in a similar manner as they apply for purposes of such subsection. ‘

(D) DEFINITIONS.—For purposes of this paragraph:

(i) ELIGIBLE PROFESSIONAL; COVERED PROFESSIONAL SERVICES.—The terms ‘eligible professional’ and ‘covered professional services’ have the meanings given such terms in subsection (k)(3).

(ii) PHYSICIAN REPORTING SYSTEM.—The term ‘physician reporting system’ means the system established under subsection (k).
(iii) REPORTING PERIOD.—The term ‘reporting period’ means, with respect to a year, a period specified by the Secretary.’’.

(c) GAO REPORT ON ELECTRONIC PRESCRIBING.—Not later than September 1, 2012, the Comptroller General of the United States shall submit to Congress a report on the implementation of the incentives for electronic prescribing established under the provisions of, and amendments made by, this section. Such report shall include information regarding the following:

(1) The percentage of eligible professionals (as defined in section 1848(k)(3) of the Social Security Act (42 U.S.C. 1395w– 4(k)(3)) that are using electronic prescribing systems, including a determination of whether less than 50 percent of eligible professionals are using electronic prescribing systems.

(2) If less than 50 percent of eligible professionals are using electronic prescribing systems, recommendations for increasing the use of electronic prescribing systems by eligible professionals, such as changes to the incentive payment adjustments established under section 1848(a)(5) of such Act, as added by subsection (b).

(3) The estimated savings to the Medicare program under title XVIII of such Act resulting from the use of electronic prescribing systems.

(4) Reductions in avoidable medical errors resulting from the use of electronic prescribing systems.

(5) The extent to which the privacy and security of the personal health information of Medicare beneficiaries is protected when such beneficiaries’ prescription drug data and usage information is used for purposes other than their direct clinical care, including—

(A) whether information identifying the beneficiary is, and remains, removed from data regarding the beneficiary’s prescription drug utilization; and

(B) the extent to which current law requires sufficient and appropriate oversight and audit capabilities to monitor the practice of prescription drug data mining.

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Something Ive been thinking about over the past few days is the tick in American discourse of labeling foreign leaders or as if America is likely to be the primary thing on their mind. But obviously when youre talking about actors on the other side of the world theyre probably mostly worried about other stuff. People in Pakistan are thinking about India. Indians are thinking about Pakistan and China. Not that they dont have opinions about the United States, but these kind of considerations are secondary to the main point.
But because the United States, though not the obsessive focus of every single foreigner everywhere on the planet, really is the most important single country in the world, it becomes important for us to be wary of manipulation. You see a remarkable amount of credulity about the need to back leaders from Ahmed Chalabi to Mikheil Saakashvili to Pervez Musharraf and whomever else when in fact none of these people (as Chalabi and Musharraf have managed to make crystal clear over the years with certain betrayals) are, in fact, monomaniacally focused on advancing American interests. Thats not to say theres anything wrong with the fact that Musharraf cares more about his own interests and those of Pakistan than he does about the United States; thats just the way it is and these things need to be seen for what they are. Saakashvili didnt send Georgian troops to Iraq, for example, out of deep-seated pro-American convictions he did it in exchange for actual and hoped for assistance in achieving his main goals vis-a-vis Russia and Georgias breakaway regions. And thats the stuff of which diplomacy and international relations is made, which is fine. But that means it behooves us to make sure that these kind of relationships are actually beneficial to the United States rather than thinking that theres a certain timeless class of individuals to whom we must deliver infinite support.
Conversely, its wrong to look at every situation around the world where some countrys perception of its interests goes against what the United States wants to see happen and then label that behavior as Countries are going to do things we dont like, in which case it will often be appropriate for us to push-back. But absent actual evidence that the thing we dont like is genuinely being undertaken with specific anti-American intent theres no reason to pathologize behavior as driven by an anti-American agenda.

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The Washington Note and have written quit a lot about why the pragmatic center in American politics needs people like you [Bloomberg], Hagel, and others going after the top jobs." I said that I was impressed with what his communications director Kevin Sheekey had pulled off in terms of the "possibility of a Bloomberg run." Bloomberg said, "Even Sheekey couldn't take all the heat and speculation any more so he's left town for a week. Vacation."
And then Bloomberg, who seemed to know The Washington Note more than the New America Foundation said, "Steve, you want me to tell you what you should write about?" Sure, of course, I nodded, sort of stumbling in a kind of affirmative way. . .
"You need to write about how these guys [McCain and Obama] are going to work with Congress. Who cares if they say they are going to sign this or promise that?! Congress authorizes and funds -- and without Congress, their grand plans are nothing. Nothing! How are they going to work with them? No one is drilling into the reality that it's Congress in the end that makes this stuff happen -- and you need to write about this."
So I will. It's an important point because if Obama wins, he'll still need Republican votes to move things -- and on economic policy and on national security strategy, the Dems are seriously divided.
Bloomberg was fun to watch at this dinner of New York heavyweights. He knows he's a rock star and he wears a bit of New York style arrogance because it's expected -- but when one watches how he works a room and interacts with people, there's far more humility in his manner than I expected. He listens too. Surprised me. And he makes his engagement with people matter if they are able to get by the friendly but perfunctory "Hi, I'm Mike Bloomberg."
I was quite impressed with him I must admit.
There's no chance that Obama will take him as a VP -- but having someone with the executive skills of a Bloomberg is one of the other game-changing and game-winning choices Obama could have made. I know he won't -- and I expect a flood of catcalls in response to this, but I do think that America needs problem solvers in federal office today like Bloomberg.
Tom Daschle is a problem solver, pragmatic. So is Chuck Hagel. I also like Biden. Tim Kaine 'seems' like the kind of solutions oriented doer I prefer; I just wish we had more time on the clock with him to see other problems he had solved. I know Birch Bayh is a doer -- but that's the dad.
The son -- the incumbent Senator Evan -- just doesn't have the sizzle or the record of execution that others on this list have. Birch Bayh got two amendments to the Constitution passed -- and nearly passed the Equal Rights Amendment. He's now living out on the Eastern Shore of Maryland working hard on getting states to reform voting rights -- ultimately designed to do away with the electoral college. But I don't think Evan Bayh is involved in any of the interesting, public-minded efforts that the mythical Birch Bayh is undertaking.

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New York Penal Law Section 110.00 establishes that a defendant is guilty of an attempt to commit a crime when, "with intent to commit a crime, he engages in conduct which tends to effect the commission of such crime." Well, if you are accused of attempting to commit a robbery in Brooklyn, an assault in the Bronx, or a burglary in Manhattan, this definition offers little assurance and even less guidance. That is why you need an experienced criminal defense attorney and former prosecutor to fight for your rights and hold the prosecution to their burden of proof.
While mere preparation, with nothing else, is not enough to establish an attempt to commit a crime, if an individual comes "dangerously close," courts usually find that that the attempt has gone far enough. To help fully understand when there is an attempt to commit a crime that is "dangerously close" we will deal with attempt in the context of the crime of Attempted Murder.
It is safe to say that pointing a loaded gun at another is not sufficient to satisfy the elements of attempt. Other facts must be provided such as having the finger on the trigger or pulling it. In fact, the First Department in New York has held that there was no attempt to commit the crime of Murder when a defendant pointed a loaded gun at an officer without any evidence that the defendant at least had his finger on the trigger or came very near the accomplishment of the crime. The First Department did find sufficient that there was an attempt to complete a crime, however, when ballistics records showed that the trigger had been pulled, a bullet had been fired, the gun was pointed at the police officer and there were thirteen rounds in the magazine, but none in the chamber.
As recent as last month, the 4th Department held that there was an attempt to commit the crime of Murder when the defendant was found near the home of his intended victims. The defendant was standing near a loaded gun with the trigger lock removed. Additionally, the defendant had a list in his pocket of how he planned on killing his victims. This, the majority argued, was beyond mere preparation and was "dangerously close."
Obviously, there is no clear cut rule as to how far one must go to attempt a crime. To make sure that the prosecution has the evidence to prove beyond a reasonable doubt that your activities are "dangerously close," you need an experienced criminal defense attorney to stand up to the prosecution and fight zealously for your rights.

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Presidential debates come and go, Iraq, Afghanistan, bankruptcy laws, offshore oil drilling and on-shore political spats and all that: The single eternal verity of presidential campaigns is that candidates spend untold hours financing the things. So Tuesday night we spent five hours riding the Brother Can You Spare $28,500 finance circuit with Barack Obama.
This particular night — Tuesday — began at The Rocks, Senator Jay Rockefeller’s chateau away from chateau deep in the hills of Rock Creek Park in Washington D.C. To reach this place you wind along the lush edges of the park, and then turn up a steep long and curling driveway that one might imagine would employ a battalion of neighborhood boys to shovel out in the winter.
There are oaks and Chestnut trees and vines and the occasional wayward deer, and then you spot the three- story house, with four Ionic columns and a slate roof and 17 windows across the front, and it rapidly becomes apparent that these Rockefellers suffer no critical shortage of guest bedrooms.
It is a useful reminder, too, that before the Gates and Bloomberg and Warren B. and minor Geffens and Weils, there was John D. Rockefeller, who bequeathed successive generations of his descendants with a truly astonishing boodle of money.
But I digress. This particular fund-raiser was standard issue, if it’s Tuesday night aren’t we going to enjoy a $57,000 dinner with Barack affair? Your faithful scribes sat outside in an air-conditioned van whilst drinks were sipped. Then a staffer led us to an ante-room, graced by “The Reclining Bather” by Pablo Picasso. Just a wild thought, but I’d place a mid-two figure wager this was not a print.

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The Wisdom of Patients: Health Care Meets Online Social Media - CHCF.org: "Social media on the Internet are empowering, engaging, and educating health care consumers and providers. While consumers use social media -- including social networks, personal blogging, wikis, video-sharing, and other formats -- for emotional support, they also heavily rely on them to manage health conditions.

The Internet has evolved from the information-retrieval of Web 1.0 to Web 2.0, which allows people who are not necessarily technologically savvy to generate and share content. The collective wisdom harnessed by social media can yield insights well beyond the knowledge of any single patient or physician, writes report author Jane Sarasohn-Kahn. The outcome of this development is Health 2.0 -- a new movement that challenges the notion that health care happens only between a single patient and doctor in an exam room.

Using examples, this report describes how the Web is becoming a platform for convening people with shared concerns and creating health information that is more relevant to consumers. Social networks, ranging from MySpace to specific disease-oriented sites, are proliferating so rapidly that new services are already under development to help health consumers navigate through the networks.

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America needs health care and health insurance reform. The number of people who have health insurance, but are underinsured are 25 million. This means they have health insurance, but not enough to pay costs. This election is different than any other on the issue of health care because both candidates are giving us serious blueprints to reorganize America's health care system and those blueprints are very very different.
As voters, you have a huge and critically important choice on health care.
There are dozens of details upon which they differ and for those I would point you to my comprehensive posts on the McCain Health Care Plan and the Obama Health Care Plan.
But to understand their big idea differences, I would point you to our pension system to better understand where McCain and Obama are going on health care.
Back in the 1960s and 1970s, it was common for workers to have what is called a defined benefit pension plan. The worker got a promise from the employer that when retirement came he'd get a certain monthly benefit--often about 60% of his final average earnings. That might be $2,000 a month--every month for the rest of his life. Therefore a defined benefit.
But starting in the 1980s, employers came to find that they couldn't afford these very expensive defined benefit pension plans. Employers started backing away from these plans by no longer making new employees eligible for them or simply terminating them and freezing the benefits for those who had been participants.
Instead, employers more often offered a defined contribution plan--most often in the form of a 401(k)
plan. A 401(k) pension plan is based primarily on employee contributions that are made pre-tax. Often, the employer matches the employee's contribution at some percentage of what the employee contributes--a defined contribution plan.
401(k) plans are popular with employers because they have no big funding requirement--defined benefit plans required them to contribute whatever it cost to keep the expensive benefit promise. Now, the risk of having enough money to retire on was shifted from the employer to the employee.
With workers changing jobs more often than in the 60s and 70s, employees also had a portable plan. Defined benefit pension plans have vesting schedules so a worker that stayed less than 10 years perhaps left with no pension benefit. With a 401(k), the employee leaves with all of his contributions and investment earnings as well as most or all of the employee's contributions. The departing employee can roll his account over to his own IRA or his new employer's plan and continues to accumulate toward retirement.
401(k) plans are popular with workers because they own them, control them, and make investment decisions for them.
The pension plan story is what the big idea difference between McCain and Obama's health plan is really about.
Obama: Do we continue down the same incremental line with health care reform--building on the employer-based system where the employer provides so many of us with generous defined benefit health insurance plans that the employer continues to pay most of the cost of no matter how expensive they are?
McCain: Or, do we change the health insurance focus from relying on the employer to relying on individual responsibility and a structure that enables the individual to build their own health care security and not have to rely upon the generosity of one employer or another?
Just has we have learned from our pension experience, one approach is not necessarily good or bad. Both have some very important advantages and some very important disadvantages.
Liberals often believe that the best way to provide health care is via a large group. Lots of people coming together to spread the risk and cost of health insurance has worked well for consumers. The great health benefits most of us get from employers may be the best thing going in our problematic health care system. The worry is that if we push people out of these plans and into the individual health insurance market to fend for themselves consumers will be subject to the vagaries of the market that include underwriting and health insurance premiums in the thousands of dollars.
But conservatives often worry that the employer-based system is at the heart of why our costs are out of control. A third-party, the employer, pays for care the doctor and the patient demand. There is little in the way of incentives for the buyers to care much about costs. American employers are also saddled with by far the most expensive health care system in the world as they try to shoulder those costs and still be competitive in a global market--the cost of health care that goes into the cost of making an American car is much more than the cost of steel in that car. Conservatives also argue is is unrealistic to think the employer-based system is anymore sustainable than the old pension system was.
Conservatives also worry that Obama's endorsement of the defined benefit approach also applies to government making even more promises than it does now by guaranteeing more access to government plans and promising expensive subsidies so everyone can get into a health insurance plan. That is a legitimate concern particularly in the light of Massachusetts enacting an Obama-like plan last year that is proving to be giving us an incomplete result toward getting everyone covered for an unsustainable cost.
But liberals counter that McCain would the traditional employer-based system of health care and push consumers into a very expensive and even less regulated health insurance marketplace with a reputation for wanting to cover only healthy people.
Liberals believe we have a moral imperative to get everyone covered sooner rather than later--in Obama's case by spending many billions upfront. Conservatives believe we have a moral imperative to avoid making promises we can't keep if the system isn't made to be affordable first.
In my mind, both sides have legitimate points.
I also believe either system can work--how well is a matter of what the details look like. The most important of these details is how costs would be controlled. When the day is done, controlling costs is what it is about so we can get everyone insured, sustain that, and make America competitive in the global economy.
So it comes down to the security afforded by employer-provided defined benefit group plans with the potential for cost savings and the advantages of portability that come with a defined contribution approach.
In many ways, Senator McCain makes the more radical proposal--not what you would expect from the Republican on health care. But with our system as unaffordable and globally uncompetitive as it is that is by no means a criticism on my part.
As a voter, you have a big decision to make in November when it comes to health care.
Obama has a defined benefit health care plan that asks us to give up less--but will it get the job done in making health care more affordable for us and our products and services more competitive in the world?
McCain asks us to make the biggest health care leap with him and give up the security we have had, but a security that may not be sustainable anyway.
Boy! Do you have a big decision to make.

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The other day I was listening to music when I noticed that the sound wasnt right. After a few minutes I found that one of the speaker wires had come loose. My stereo system - without that wire attached - wasnt really a system. It hit me that the same could be said of our health care system. Oftentimes the various components arent connected. Perhaps our specialist is across town and not part of the hospital network. We might be on vacation and need to access care - again, the provider of care is not connected to the rest of our care. What we needed, I realized, was a health care system that revolved around us not around institutions - a Personal Health Care System - with the patient at the center and their doctors, hospitals and others as integral team members in the system.
How do we get to a Personal Health Care System? A critical first step is that the patient has to have access to their medical information irrespective of where that care is provided. Personal Health Records (PHRs) provide a repository for medical data to meet this need. But, a PHR, alone,  isnt connected to anything.
Next generation PHRs, like our SHAPE PHR,™ bring us closer to having a Personal Health System by working with doctors, hospitals and other providers to communicate and input information into the PHR. These connections,with the patient at the center - and with the patients permission - maintain a more complete record of a patients care and allow other providers to have a more complete picture of the patients health care. As importantly, doctors and medical providers must be assured that the PHR is HIPAA-compliant (as the SHAPE PHR is). A PHR of this type will encourage doctors to provide data thereby reflecting care no matter where it is received within the hospital or provider network or across the globe.
The next step is the most important. A Personal Health System must be at your fingertips when you need it. Our SHAPE Card™ allows the patient to securely and privately access their PHR with their SHAPE Card and their fingerprint in the doctors office or at the hospital. Were using the power of the Internet powered by the most powerful security and encryption technology to make this Personal Health System private, reliable and secure.
What can a Personal Health System mean for someone? For a starter, no more annoying clipboards at the doctors office. No more fear that, in an emergency a drug allergy will be overlooked. And, studies show that quality of care is enhanced and costs are reduced for patients, medical providers and insurers.
 A Personal Health System - connecting care with the patient at the center and the medical community as integral parts of the team - now thats music to my ears.

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His is the only one of the candidate proposals that has a chance of getting medical costs under control. An argument for some free-market sanity.

By Shawn Tully, editor-at-large

(Fortune Magazine) -- Fellow Americans, choose your revolution. One way or another, we're getting a new health-care system. The old one is obviously broken. The U.S. now has 47 million uninsured, and costs are out of control. The Department of Health and Human Services predicts that if things continue as they are, health spending will almost double by 2017 to $4.3 trillion, or one-fifth of GDP, vs. 16% today.

The crisis has gotten so severe that fixing the system is no longer a partisan issue. Everyone understands that something has to change, and fast. In this presidential race, both sides are proposing radical fixes that would totally transform the way health care is delivered and paid for in America. Both the Democrats and the Republicans embrace the same goals: John McCain, Barack Obama, and Hillary Clinton are all putting forth ways of making health care affordable for every American and stopping a disastrous escalation in costs. Both sides also envision a world where employers play a much smaller role in medical benefits. The differences, of course, are in the way each candidate intends to reach those laudable goals. In essence, McCain wants to create a kind of national insurance market that shoves more decision-making power into the hands of consumers; the Democrats are aiming for a Medicare-like federal superprogram. (We'll stick with the "Democrat" label in this story. The nominee status was still unclear at presstime, and, intraparty sniping notwithstanding, the Clinton and Obama plans are extremely similar.)

So far, the press and public haven't paid much attention to the implications of these dueling visions. This stuff is complicated, and the most revolutionary provisions are buried deep in jargon-filled position papers. But parsing the plans is worth the work: This issue is crucial to America's economic future, and the differences between McCain and the Democrats are profound.

Who has the best plan? Both have huge flaws, but on balance McCain's is better.

McCain's main pillar is the elimination of a tax break that employees receive if their employer provides their health care. That may not sound like a shocker, but it is. The exclusion dates from World War II, when the federal government imposed controls on wages, but allowed companies to compete for workers by offering tax-free health benefits in lieu of pay. The law is largely responsible for the nightmarish patchwork of corporate-provided medical plans we enjoy so much today. Employees and their unions demanded richer and richer packages, and employers complied, since they could buy far more benefits for their employees than workers could buy with after-tax dollars on their own. Americans have paid a steep price, however, by sacrificing their raises as corporate insurance bills exploded, never more so than now.

McCain suggests that we junk all that. Say you're earning $100,000 a year and your company provides about $9,000 toward your $12,000 family premium, which is about average. Today you're taxed only on the $100,000. Under McCain's plan, you'd also pay on the $9,000. That could mean an extra $3,000 or so in federal taxes alone. To compensate for the extra levy, McCain would provide a $2,500 federal tax rebate for individuals and $5,000 per family, meaning a family would simply subtract $5,000 from its tax bill, the equivalent of a big cash payment.

Here's where it gets interesting. Employers would no longer be able to buy more health care with $9,000 of their employees' money than the workers could buy on their own. The raison d'être for corporate health benefits would vanish. Employers have another compelling reason to pass the ball to the employee: While wages are rising around 3% ayear, their health-care costs are growing at three times that rate. "I predict that most companies would stop paying for health care in three to four years," says Robert Laszewski, a consultant who works with corporate benefits managers. Hence, an employer that pays $9,000 for your benefits would simply pack an extra $9,000 a year into your paycheck. (Why? Because in a competitive labor market, companies would have to hand over that cash to employees or risk losing them.) So you'd have $6,000 after tax, plus the $5,000 family credit, to buy insurance. That's $11,000 in new cash that employees can set aside for health care.

So what types of policies would they buy? Employees (and their families) with corporate plans - about 150 million Americans - would probably rush toward high-deductible, low-premium insurance, and use what's left over to pay cash for routine procedures. They would couple those high-deductible policies with Health Savings Accounts, which allow families to put away up to $5,800 ayear, before taxes, for medical expenses. Those plans cost about $10,000. That's not a huge saving from the typical $12,000 corporate plan, but it's a start. More than four million Americans already have HSAs, and the McCain plan would make portable, high-deductible plans the product of choice for a new generation of healthcare consumers.

Besides eliminating the employer exclusion, McCain's plan boasts another nice feature. It would allow consumers to choose an insurance plan that suits their stage of life. If you're young and healthy, for example, you probably want the cheapest plan you can get. If you're 45 and have four dependents, maybe you want something a bit more expensive and generous. Nine states, including New York, California, and Texas already require that as many as 50 benefits be covered, a list that ranges from in vitro fertilization to mental health services to prescription drugs. These requirements increase the cost of insurance; they're a major reason young people have dropped their coverage. Under the McCain plan, insurers in any state would be free to offer the plans with a vast variety of deductibles, co-pays and benefits. UnitedHealthcare and Blue Cross/Blue Shield plans already provide a menu of packages tailored to groups as varied as Gen Xers and retirees.

The problem with McCain's approach - and it is a huge problem - is that McCain ventures so far toward total laissez-faire liberty that he risks leaving the poor and sick behind. Here's why. Perhaps his most drastic proposal is allowing the same insurance products to be sold across state lines. That seems to make sense, and maybe it does: Look what interstate banking has done for pricing and choice in financial services. But in health care, the upheaval would be so brutal that it scares even the most ardent free-marketer. Many states have some form of what policy wonks call "community rating." Under pure community rating, insurers must charge all customers the same premium no matter whether they're 20 or 55, or whether they have cancer or are models of good health. McCain is targeting community rating for good reason. It forces the young and healthy to pay far more than their actual cost by making them subsidize the elderly and sick. Like the mandated benefits, it's pushed millions of Americans in their 20s to drop their health insurance.

But under the McCain plan, states with no restrictions - Pennsylvania, for example - could sell policies for 25-year-olds that cost around $1,200 a year, one-third the price in New York. Young New Yorkers would drop their plans in favor of Pennsylvania providers, forcing New York insurers to jack up premiums for people in their 50s or early 60s, who need those rich, community-rated plans that cover as many procedures as possible - but who no longer benefit from the excessive premiums paid by the youngsters. It gets worse. Anyone with cancer, diabetes, or other pre-existing conditions will see their premiums multiply too.

To his credit, McCain does have a plan for relatively young, low-income Americans who can't afford insurance. "We would increase the tax credit according to income so that poor families could buy insurance," says Douglas Holtz-Eakin, McCain's policy director. But McCain sorely lacks a plan for people in their 50s without corporate benefits, and Americans with pre-existing conditions, who would be brutally stripped of coverage if insurance crosses state lines. "For his plan to work, McCain has to tell us how he would deal with the old and sick," says Jon Gruber, an MIT economist. "If McCain doesn't tax the healthy to pay for pre-existing conditions, as happens under community rating, he has to tax the taxpayer. That means his plan will require huge subsidies he's not talking about."

NOW FOR THE DEMOCRATS. The core of their plan is a "pay or play" option for employers. Large companies would have the choice of either providing benefits for workers or dropping their coverage. If they chose the latter, they would pay a mandatory payroll tax to support a new government-administered system. That system would have two parts: a Medicare-like public program, and a menu of private options similar to the generous plans available to U.S. government employees today. Workers who are self-employed or lack insurance would go straight into one of these two options. Low-income Americans would receive federal subsidies to purchase the premiums.

In practice, the system would quickly swell the ranks of Americans with government-paid health care. Remember, health-care costs are rising far faster than wages, so companies have a strong incentive to pay the tax and erase that rapidly growing burden from the books. It's also likely that the government plan will offer better benefits than many, or perhaps most, corporate plans. In fact, the Democrats call for rich standard benefits packages based on the plan offered to federal employees. Those packages would have deductibles of just $300 and offer prescription drugs, mental health benefits, and "spinal manipulations" (i.e., chiropractic services), among a cornucopia of other benefits. As a result, the federal plan, potentially packed with new benefits pushed for by lobbyists for various medical specialties, will quickly cause an exodus from employer plans.

The standard benefits package isn't just a bad idea because it will substantially raise the cost to taxpayers. It will also make it virtually impossible for Americans to buy insurance tailored to their needs. Suppose you're one of those 25-year-olds. You probably don't want to spring for a full-blown plan that covers old-age diseases like Alzheimer's and would rather save some money and go with a low-premium, high-deductible plan. But the Democrat approach requires that any competing plans be "actuarily equivalent" (Clinton's term) to the federal employee plan - which translates as a generous minimum standard for health insurance. "With that mandate, you rule out high-deductible plans," says Gruber. "It would make it very difficult to design one that would qualify."

The Democrat proposals have some additional drawbacks. First, the Dems want to heavily regulate the insurance industry by limiting everything from profits to marketing expenses. If the earning power of insurers is determined by federal regulators, their pricing will be too, and thus they will evolve into the equivalent of public utilities. Would you rather have medical prices set by fiat or by nationwide market competition?

Second, the Democrat plan exacerbates the fundamental problem in the American health-care system, which is that no one has any incentive to care about price. (How much is that MRI center charging for your ankle scan? Who cares? Just hand over the $50 co-pay and never you mind.) Creating a huge new medical superstructure would shift far more spending to third-party providers, chiefly the federal government, giving consumers even less incentive to concern themselves with the price of an MRI - or any other service, from an elective wart-removal procedure to a life-saving heart bypass. "The Clinton and Obama plans would enormously increase total health-care spending, but disguise the extra costs by shifting them to taxpayers," says John Sheils of the Lewin Group, a research firm that does statistical modeling for health-care plans.

Despite all that, the Democrats' plan probably beats McCain's if you're scoring on political viability. Their program doesn't involve anything that smacks of a cut in benefits, and it's just easier to win with largesse.

But on economic merits, McCain wins. For all its problems, at least it puts the consumer in charge. Would that create a world where we're forced to dicker with heart surgeons? No. It will create a world where health care is treated as the precious resource that it is, rather than a costless entitlement; where nationwide competition pushes down the price of catastrophic care and consumers focus their attention and budgets on what's really crucial to their health. That's an important first step. The price of health care is never going to get under control until patients get what they deserve: the right to be customers too.

REPORTER ASSOCIATE Christopher Tkaczyk contributed to this article.

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Only the patients in wheelchairs give away that this is a hospital.   
“All five of Montgomerys community hospitals are in various stages of expansion,” the Post noted. “As they increasingly compete with each other . . . flat-screen televisions and CD players are standard in many rooms at Montgomery General in Olney.
’We want [patients] to leave here and then brag about it,’ John Fitzgerald, president of Inova Fair Oaks told the Post. ‘Theres a competitive nature to health care, and we want to be first. And part of that is the service.’
This trend has its critics, the Post noted, including industry consultants who caution hospitals to remember that their primary mission is to treat patients . . . Some hospital administrators, too, are leery of overspending on frills. Brian A. Gragnolati, president of Suburban Hospital in Bethesda, says: I would rather put money into nursing care and staffing and making sure our doctors are there. At the end of the day, its about taking care of patients.’”
HealthBeat reader Lisa Lindell, the author of 108 Days, the story of her husband’s struggle to survive an accident which left him severely burned agrees: “When youre at your darkest hour, ‘good service’ is no longer defined by valet parking, posh suites, waterfalls and gleaming marble. What you care about is staffing ratios.” There is “no legislative mandate with regard to nurse/patient ratios” in U.S. hospitals, Lindell notes.
As it happens, Lindell works as an accountant in the construction industry, and so, in a comment on HealthBeat, she offers an insider’s look at constructions costs: “I live in a city with a major health care industry, quite possibly the largest in the country. Its nothing short of obscene the amounts of money pouring into the ‘Hospital Building Boom.’ Theres nothing wrong with growth and meeting the needs of the community, and I note how all the press releases boasting of these state-of-the-art works of art always make some reference to ‘serving the community.’
“But nobody in my community cried out for a 90 million dollar vascular institute. Nobody in my community displayed a desperate need for custom imported marble. I made a comment to a co-worker of mine with regard to part of one large-scale project.  I said: ‘You know, you and I are paying for this.’ He said: ‘Oh, this isnt even any part of the patient areas, this is the faculty room.’”
Lindell is right: much of the spending on amenities has nothing to do with promoting healing. And the costs are passed on to you and me in the form of higher insurance premiums and higher Medicare co-payments.
If patients in some part of New Jersey or Westchester County, New York want valet parking or very spacious private rooms, should taxpayers in Iowa pay for it? Iowa’s citizens shell out the same percentage of their paychecks for Medicare, yet Medicare spends half of much, per capita, on Iowans as it spends in regions where health care is more intensive, more lavish—and far more expensive.  (Medicare spending is adjusted for differences in local prices, the overall health of the population in different states, race and age.)
While hospitals that vie for the most affluent patients raise the price on every pill and every pillow in order to cover the cost of the mahogany, the marble, the waterfalls and the spacious rooms, patients in less affluent areas suffer. “As some of the Washington areas hospitals expand at record levels and add amenities,” the Post observed, “others dont have that luxury. They are buckling under the burden of caring for the uninsured, raising concerns about widening disparities in health-care facilities.”
Lindell sees this happening in her city: “My local news did a story this week airing the stark contradiction right here in our community. The mega-health care organizations have major construction projects happening all over the city. Yet in the low income areas, they featured one hospital that had gone into bankruptcy and there are no bulldozers and cranes underfoot. The physicians working there took it over and struggle to keep it open. One problem is they dont have the buying power of the big boys, they have to pay more and get reimbursed less, and they are the ones serving the community. http://www.healthbeatblog.org/2008/04/health-care-s-1.

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