hitters in health policy to discuss the present environment

and Medicare.  It is worth a view or even to see it in

streaming video from C-SPAN.

http://www.c-spanvideo.org/program/MedicareReform32

The most interesting fact was that between 1998 amd

2007 physicians were able to increase volume and

intensity for their Medicare beneficiaries by 40% while

enduring 5% reduction in payment schedule.

It was also pointed out that up and down the line,

American physicians were paid substantially more

than their European counterparts.

Finally, a minor factoid of interest was that the

utilization of medical care in the U.S. increased

by 600% between 1950 and 1990.

I will be in Washington, D.C., the week of April 7 with 60 Health Care UST MBA students. This is my 19^th D.C. seminar for our 19^thUST MBA cohort, which keeps getting larger each year. We have a health policy seminar faculty of 28 this year, all experienced Washington hands from Congress and the Executive branch and all the influences thereon. We are fortunate to always strike a balance among the experienced and articulate left and right and bipartisans. 

THE CORRUPTION OF CAPITALISM IN AMERICA

Former Michigan Congressman and Reagan OMB Chief David Stockman makes the case for the mess that eight decades of government management of the U.S. economy has done to our institutions,  our economy, the stock market and to our future as a nation.  He does so in a page-one piece in the New York Times Sunday Review entitled “Sundown in America” and in his new book The Great Deformation.  Economist Paul Krugman (LINK) responds as only he can in an article on April 5, 2013.

Stockman will appear in person at noon April 24 at Jimmy’s Conference Center, 1132 County Road E in Vadnais Heights, MN. The event is sponsored by the White Bear Lake Chamber of Commerce. I will be introducing Stockman, a friend since I entered the Senate back in 1978. He lays out a path to heading off his “sundown,” but suggests the corruption of tax and monetary policy by risk averse Wall Street businesses, and the corruption of representative government by money and what it can buy in political courage, will make the task difficult. 

THE U.S. SUPREME COURT AND THE LEGITIMACY OF POLICY MAKING

What continues to amaze about red/blue, either/or politics in this country is the fact that the U.S. Supreme Court is buying the program as well. Those whose single-issue business it is to maintain political polarity have made judicial appointments, and especially the Supreme Court, a part of the national election battleground. The result makes political hash out of the advice and consent role of a divided Senate. One might assume the U.S. Supreme Court is above all this; apparently not.

Justice Scalia announced recently that he is an expert on legislative intent, not the Senate or the House.    Then Chief Justice Roberts, in the Defense of Marriage Act, Section 3, case,  informs us that lobbyists, not voters, have the greater influence on law making: “You don’t doubt that the lobby supporting the enactment of same-sex marriage laws in different states is politically powerful, do you?” he asked an appellant’s lawyer. And followed with: “As far as I can tell political figures are falling over themselves to endorse your side of the case.” While Justice Thomas remains mute. As always.

So the real question is: What role does the Supreme Court intend to play in influencing public opinion about the constitutional legitimacy of any controversial laws passed by the Congress?

WHAT ROLE WILL YOU AND I PLAY IN DECIDING THE FUTURE OF MAYO CLINIC AND SANFORD HEALTH?

Elected officials in Minnesota are asking to play a role in deciding whether our largest nonprofit, The Mayo Clinic, will grow its future in our state and whether Sanford Health, because it’s a South Dakota nonprofit, should be allowed to become a Mayo competitor in Minnesota by acquiring a controlling interest in Fairview Health and its relationship with the University of Minnesota Academic Health Center and physicians practice group; or, whether the University of Minnesota and its Board of Regents should be allowed to acquire Fairview Health.

The Minnesota Legislature has been asked by Mayo to help finance a part of the development costs which will make the state’s largest employer twice its current size, to make Rochester, MN, one of just a handful of “Destination Health Care Cities” anywhere in the world. Minnesota Attorney General Lori Swanson, citing a century of public investment in both the UMN and Fairview, wants to know what a hospital system from Sioux Falls, S.D., with a wealthy benefactor from St. Paul, has in mind. And UMN President Eric Kaler suggests we the people might benefit from a UMN takeover of Fairview.

No one so far has asked us, the people of Minnesota who finance all these institutions, what we think about selling our interest in Fairview to the U or to Sanford or what stake we have in investing in a Destination Health Care City.

With health care costing what it does today, and health reform being as complex and as polarizingly political as it is, 7 or 8 million people living in Minnesota, the Dakotas, northwestern Iowa and western Wisconsin might have more at stake in knowing what’s up than the legislative tax committees, the Legislature’s appointees to the UMN Regents or the attorney general.  So why not ask both Mayo and Sanford to tell us what they see health care being like 10 years from now if they get their way? Old time experts at the U suggest it may not be worth our time to ask the university since it may be part of the problem, but why not ask them all?

What’s the future of health care in our community; of health care research; of health professions education? To whom should we entrust this future? To the institutions that have helped create the cost/quality/access problems we are paying for? What’s at stake for those of us who will be reaping the benefits of the presumed better health care quality and access, while paying the bill for it as well? Yes, and what’s that bill likely to be if the stakeholders in the health system  get their way compared with where we’d be without their new investments of our resources?

NOT-FOR-PROFIT HEALTH COMPANIES HAVE A COMMITMENT TO POPULATION HEALTH

The new world of health reform is first and foremost about reducing the public costs of health care by improving the health of everyone who lives in this community. That is an effort which is not competitive but collaborative. It is not just about tobacco taxes, food labeling, organic farming, fitness and acupuncture. It’s also about dealing with the social determinants of health more adequately than government programs and non-profits in their silos have been able to do.

The attorney general will tell us that we have from their beginning freed nonprofit health systems and health insurers of the burden of being taxed for government programs in exchange for their undertaking to improve health and access to healthcare. None of our hospital systems or health insurers are spending anywhere near the dollar value of their subsidy on the community benefit of health improvement for those who need it the most, and on health care access for those without means.

MEDICARE REFORM IS IN THE AIR

No president in our history has accomplished so much in health policy reform and said so little about it as has President Obama. It’s no wonder that behind the congressional curtain there is significant bipartisan dialogue over reforming the Medicare program. The conversations have not yet reached the stage of considering how to return to the 1985 experiments with privatization of the program. But they are starting with efforts I helped the Senate lead in 1987-88 in passage of the Medicare Catastrophic Act. The effort now, as then, is designed to change traditional Medicare in important ways that aligned its essential benefits and beneficiary cost sharing with today’s best private health insurance plans.  Provide catastrophic benefits and make the second purchase of “supplementary insurance” unnecessary. 

THE LESSON OF MEDICARE REFORM IN 1988

The Medicare Catastrophic Act passed with very large margins in House and Senate and a year later was repealed by an even larger margin in the House and less in the Senate. Only because it contained a means-tested tax on income earners 65 and older earning over $85,000 a year which offended mainly double and triple-dipping military retirees in FL, TX and AZ. That new Medicare tax was put back in the law at $80,000 a few years ago and no one blinked an eye. Interestingly, the 1988 Medicare reform included a prescription drug benefit and, critically today, it included the first serious effort to reform long-term care insurance.

 INDIA’S REVOCATION OF EVERGREEN PATENTS

Were it not for the nearly absolute control PHRMA has over health policy reform in this country, we might long ago have introduced market forces into medical technology innovation, marketing and pricing. There seems to be a pill or device or diagnostic for every ill, and a public subsidy for every health care purchase. And American consumers pay every single cost of each product, whether really new or simply iterative. The costs of research, development, acquisition, legal defense of patent infringement, legal defense of product failures (see this Wall Street Journal article on St. Jude Medical lawsuits) marketing to the prescribing physicians as well as the consuming public. It’s too easy in this country for the producer to set the price because Americans fear a government role in access and pricing the same way gun owners fear government will take their guns.

India’s Supreme Court decided last week to reject Novartis’ effort to sell a modified version of the cancer drug Gleevec (aka Glivec) by another name. Other large drug companies face similar challenges.  The prices for Indian generics are 5% of the newly patented modification price. This is a rare intervention and therefore newsworthy. The international drug industry deftly provides cover for their monopoly modifications by claiming to provide low-cost access to high priced drugs for certain special populations in need. As in this country, physicians and other prescribing professionals are enlisted to support the newly patented “Gleevec by another name” because they are accustomed to using it and they are provided tons of free and low cost drugs for low income patients. Some of which always seems to escape into the regular patient population.

CHANGING THE ROLE OF GOVERNMENT – PLAN B

We’re all for it until it gets specific. Along comes PLAN B for changing the role of government, the “Morning After pill.” The pregnancy prevention pill was approved by the FDA as a “safe and effective” prescription drug in 2001. In 2006, the Bush FDA approved its over-the-counter sale to over age 18 women. In 2009 over-the-counter sale was approved for 17 and older.

During his 2012 campaign, President Obama backed up the decision by HHS Secretary Sebelius to override the FDA’s decision that it was safe and effective for sale to anyone saying “it’s important we apply some common sense when it comes to over-the-counter medicine.” This week a federal district court judge called the president’s decision “politically-motivated, arbitrary, capricious and unreasonable” and ruled in favor of the Obama FDA.HHS Secretary Sebelius’HH

CHANGING THE ROLE OF GOVERNMENT – VOUCHERS ARE HOT

For more than 20 years, school reformers like me have been committed to improving quality and affordability in public education by providing families with school choices which reflect accurate comparative assessments of both the quality and the cost of learning from childhood through secondary school. We saw charter schools created and managed by teaching professionals and local families as a means to that end.

Public financing would take the form of vouchers paid for by the state with supplementary federal vouchers for those students especially challenged by environment, disability, or illness. I offered my first tuition tax credit legislation in about 1983 when HHS published its assessment of primary education in America entitled, “A Nation at Risk.”

Some, but not all, teachers unions and some, but not all, advocates for separating church and state opposed school choice. Charter schools were tried, but only rarely by public school boards and therein lies another problem with behavior change in education. Vouchers were tried, but usually in places like Arizona as a parental option to choose private rather than public education. Today Indiana and Louisiana again test the viability of vouchers and again it’s public v. private rather than managed competition within public school districts using public financing. 

By this time – 30 years after “A Nation at Risk” – public education should be going where health care reform is going. And higher education may be heading.  Means tested public financing plus family financing of tuition through tax credits. We’re a long way from it; and seemingly headed for those “freedom from religion” wars.  When we should be focusing on the social determinants of poor schools which condemn poor kids from poor families to learn where they live; rather than learning how they can live and learn to create a different future for their children.

http://www.youtube.com/watch?v=0B-jUOOrtks

“I shall make my home above them; I shall be their God, and they will be my people.”. . . The Jewish prophet Ezekiel 37-27

“God cannot be understood;  he cannot be grasped by the human mind.  The truth escapes our human capacities.  The only way to come close to it is by a constant emphasis on the limitation of our human capacities to “have” or to “hold” the truth.  We can neither explain God nor his presence in human history.   As soon as we identify God with any specific event or situation, we play God and distort the truth. 

We can only be faithful in our affirmation that God has not deserted us but has called us in the middle of all the unexplainable absurdities of life.  It is very important to be deeply aware of this.  There is a great and subtle temptation to explain to myself or others where God is working and where not, and when he is present and when not, but nobody, no Christian, no priest, no monk has any “special” knowledge about God.  God cannot be limited by any human concept or prediction.  He is greater than our mind and heart and perfectly free to reveal himself where and when he wants. . .

After having done everything to make some space for God, it is still God who comes on his own initiative.  But we have a promise on which to base our hope:  The promise of his love.  So our life can be rightly a waiting in expectation, but waiting patiently and with a smile.  Then, indeed, we shall be really surprised and full of joy and gratitude when he comes.”

Henri J. M. Nouwen quoted from Show Me The Way, Readings for Each Day of Lent

THE POPE ON THE BUS

The surprise for Lent in 2013 may well be the resignation of Pope Benedict XVI and the choice to succeed him.  As one contemplates the polarity over authority that exists among the people of the world today, it would be well to consider the dearth of trustworthy institutional leadership.  Anywhere.  Everywhere.  I hear it in class, in my social and social media conversations, in the news and print and cable opinion, and in the questions that follow my public speaking. Now consider how many people claim leadership and authority because they have a “special knowledge about God.”

So it is that Pope Francis I, the Argentine, exhibits a too rare leadership trait.  Authenticity. Francis I seems to live his persona and his beliefs, having had them tested by experience, by his elevation to positions of authority, and by occasional conflict in what the Catholic hierarchy has come to refer to as its “culture wars.”  In the course of which he resorts to dialogue to build relationships with those who disagree with him, but who deserve his respect for their positions and experiences in life.  A quarter of the world’s population professes his religious beliefs and hope for a leader who is one with God and His creation.  This Pope needs our prayers and our support to be such a leader.

LEADERSHIP IS ABOUT KNOWING REALITY

Jim Daly has replaced Rev. James Dobson as president and CEO of the $98 million Focus on the Family ministry.  Daly asks an interesting question of a variety of audiences:  “To what degree have some of us Christians turned homosexuality into a ‘super sin’?”  It’s an interesting question.  The Roman Catholic Church and the American bishops have done much the same of late for family planning employing artificial contraception which is coming as an uncomfortable shock to the 70-80% of American Catholics who admit to practicing it. And to the Republican Party, especially its more libertarian wing, which may be reassessing its definition of conservative government.

TO REWARD RISK WE MUST BE WILLING TO ACCEPT OCCASIONAL FAILURE

I recall that my father educated me always to step out, to the tune of “nothing ventured, nothing gained.” Advice that does not seem to be followed by members of Congress who have become so risk averse they will never take an unpopular stand on issues.  As party allegiances call members out as red or blue, the “bipartisan” refuses to take risks on issues that divide constituents by party.  And seek out legislative problem-solving by means with which no one could disagree. 

VICE PRESIDENT BIDEN ON PRESENT DAY SERVICE IN CONGRESS:

Last week Joe joined those who have committed themselves to push for new gun laws, despite the obvious reluctance of members on both sides of the congressional aisle to join in the effort.  This is what he said of some of those who serve where he served 36 years of his life: 

“It must be awful to be in public office and conclude and believe in your heart that you should take action but you can’t take action because of the political consequences.  What a heck of a way to have to make a living.”

I can’t recall a time when I would have said that about Senator Joe Biden; quite the opposite.  He probably carried or rallied more unpopular causes than most members of the Senate.  He didn’t mind losing if he believed his cause was just.  “Authentic” describes Joe Biden now and then. To a T.

AFRAID TO GO “COLD TURKEY” ON CONSTITUENT PLEASERS

Watching members of Congress deal with the hometown consequences of the “sequester” and of their pledge to end their dependence on “earmarks,” suggests it will not be easy to change the role of government taxing and spending; especially the national government which is not required annually to balance the effect of each.  With defense and homeland security jobs at stake in every congressional district we observe how the most conservative Republicans define national defense in constituent terms.  Cong. Michele Bachmann is reportedly suggesting that money to earmark highway spending in her district should come from cutting spending in the White House.  Reduction in the use of sugar in soft drinks has caused publicly financed sugar price supports to kick in to protect 4,000 sugar beet farmers in the Red River Valley of MN-ND.

SENATORS KLOBUCHAR AND FRANKEN AND THE MEDICAL DEVICE COMPANY TAX

Amy Klobuchar is a particularly persuasive advocate for bipartisan causes.    On the eve of the third anniversary of Obamacare’s becoming law, she passed a “Sense of the Senate Resolution” 79-20 to shift $20 billion of its costs from device companies to hospitals and doctors.  The resolution says the tax elimination will be “revenue neutral” but efforts to make up $20 billion for health care access from reducing oil and gas subsidies (a Democrat’s amendment) or from wind power tax credit elimination (a Republican’s) failed.  So you know where it’s going to come from.  Sponsors claim the tax was killing Minnesota jobs.  Not true. 

Competition and value purchasing in reforming health systems is causing hospitals to be more discriminating purchasers of devices.  Therapies other than surgically implanted devices often provide better outcomes.  Increased price competition and comparative effectiveness analysis are slowing job growth, not a tax that is passed on with the costs of worldwide marketing or the costs of paying fees to surgeons who advocate for the diffusion of these devices – paying them for their research, their advice, their consultation with other surgeons, their continuing medical education, and the medical education of surgeons still in academic settings.

MINNESOTANS PAID ANGEL DEVICE INVESTORS $11.4 MILLION TO CREATE 153 JOBS

…in 2012.  What wealthy investors really need is confidence that there is enough real “innovation” in new medical technology to create a market for them at worldwide product marketing firms such as Medtronic, St. Jude Medical, Boston Scientific, or Johnson and Johnson, who will double or triple their investments in a few short years.  Few of the 153 “start-up” jobs will survive the acquisition because the large acquiring companies have been “right-sizing” for a number of years. Just as the U.S. health care system is “right-sizing” and demanding evidence of performance value-add from medical technology.

THE FACE OF THE FUTURE OF AMERICAN HEALTH CARE

Reed Abelson in 3/20/13 NYT  suggests that Kaiser Permanente’s history of continually re-engineering health care payment and delivery may be the “affordable future” of American health care.  Kaiser’s CEO is Menagha, MN-born George Halvorson, who is retiring effective the end of 2013.  George admits that Kaiser is just beginning to move the affordable health care needle, but that he and it know what it takes to do so.  George is a prolific author on the subject over the years and a traveler and speaker.  He and his wife, Lori, now have a new home on Lake Minnetonka which George calls “the smallest house on our block,” and which Lori, whose specialty is carpentry, is re-doing.

OBAMACARE AND THE PRICE OF HEALTH INSURANCE

The chief lobbyist for America’s Health Insurance Plans says hospital prices are rising steeply.  Citing inpatient hospital prices from four states in 2008-2010, AHIP says hospital mergers make it more difficult for insurance companies to negotiate lower payment costs.  This despite the fact that five of the largest insurance plans have 75% of the privately insured market in this country, that they all are rapidly acquiring smaller plans that serve Medicare and Medicaid, thus building up competition in the publicly insured market, and that they keep setting records for earnings and profits.

The problem seems to be two provisions in Obamacare designed to increase competition and lower costs.  One is limiting medical loss ratios to 85% and 80% of annual premiums depending on the size of the group insured.  The other is risk assumption rules designed to go into effect next year.  State insurance regulators must have the guts to insist that all health insurers play by the same rules and that health insurance exchanges have the ability to qualify plans on the basis of quality improvement and risk reduction.  Then qualified plans will use claims data, narrow network deals with providers, to facilitate health status and health care improvement. 

SMALL BUSINESS, INDIVIDUALS AND CONSUMER DIRECTED HEALTH PLANS

Hundreds of high-deductible, low risk-bearing consumer directed plans will go back into the casualty insurance business unless they can win a lobbying battle waged on their behalf by Republicans in Congress.  A UnitedHealth Group spokesperson is quoted as saying individual premiums could go up as much as 116% and the small group market by 25% to 50%.  In large part this is due to the fact that risk assumption rules pool risk among younger/healthy and older/sick, so younger individuals and groups go up and older go down.

STOP BEATING UP ON OBAMACARE

With 15 Democratic senators up for re-election in 2014, you’d think the party would worry about Obamacare, but they are not. But long-time tea leaf readers such as Chris Jennings say Republicans are wasting their time and money on an issue which didn’t win seats for them in 2012.  “If you keep on running against something that isn’t changing, people will say, ‘I have other things I want to focus on this time.”  In addition, Republican governors are starting to make peace with implementation; and opinion polls say most Americans still don’t understand how the law is impacting them.

On the other hand, Republicans in Congress are doing everything they can to stop the authorized appropriations to CMS, which are essential to the law’s implementation.  Republican sponsors of the Bush Medicare drug benefit expansion in 2003 did all they could to fund CMS marketing of the benefit and CMS efforts to develop call centers to assist consumers.  This year they killed a $949 million request to help consumers apply for Obamacare coverage.  And supporters of the law are increasingly hard on President Obama himself for not educating the public and putting the law’s critics on the defensive.

AND WORK ON THE MANY WAYS IT COULD BE IMPROVED

Which of course would take both Republicans and Democrats to accomplish.  Republicans to come forward with the ideas they held back during the original debate lest they appear to be soft on government spending/taxing policy.  Democrats to ensure the issues of economic security are not sacrificed to paying to protect “jobs-jobs-jobs” in inefficient industries such as drugs, devices, and diagnostics.  Democrats seem satisfied to go through another election cycle low-keying the new law and its consequences.  Republicans have a base that they talked into believing Obamacare is about socialism, abortion and religious freedom.  So only a huge consensus push on entitlement/tax reform could bring the sides together on important reforms.

THE I.O.M. TAKES ON HEALTH CARE PAY EQUITY

For several decades Dr. Jack Wennberg and his colleagues at Dartmouth have been making a case for the application of the evaluative sciences to health care delivery, from early comparisons of local area practice variation and Yale and Harvard Hospitals practice variations, to the Dartmouth Atlas illustration of 310 ”hospital regions” of the country based on medical practice hospital referral patterns. The Dartmouth researchers developed the theory of health care quality measured by over-use, under-use, and misuse of medical goods and services.  There are distinct parts of the country in which over-use, under-use and misuse are substantially lower than in others, the six-seven state upper Midwest region being by far the largest.  Out of this came the suggestion that Medicare compensate for outcomes in ways that reward better outcomes at less cost.

Now Professor Joe Newhouse of Harvard and his IOM Committee have studied both the Medicare data used by Dartmouth and others, plus data from private health plans serving predominantly younger patients.  They are about to suggest that “Areas don’t make decisions; doctors, hospitals, and delivery systems make decisions.”  Acknowledging that wide variation exists, the committee will recommend that because variation also exists within regions, the payment reforms focus on care providers rather than communities or regions.

The problem with this thinking is something that academic researchers will always miss because they aren’t trained to acknowledge it exists.  That behavior change has always been a function of local culture and practice; and resistance to change is, as well.  For example, you will find that the lowest incidence of over-use, under-use, and misuse will be in regions such as Hawaii, the Pacific NW and northern CA, the Intermountain and Upper Midwest regions, and in much of New England.  By the same token, quality innovation in payment and delivery of care comes most assuredly from these same regions, because that’s how medicine and medical politics is practiced there.  More to come, you may rest assured.

WHAT WOULD JESUS BREW?

Sacrilegious?  Hardly.  This one comes to us from the craft beer brewing industry and efforts by non-affiliated Christian churches looking to attract membership by “meeting people where they are.”  Catholics will tell you evangelism appeals to many tastes and if wine makers don’t pick up the WWJB habit given its symbolic role in religion, then beer ought to because it’s so much easier to make and less expensive to drink.

EXCEPT AT THE UNIVERSITY OF MINNESOTA

UMN President Eric Kaler has been pressed all session by the Minnesota legislature to get rid of as much educational overhead as possible.  He is fighting back with consultant studies.  And promises.  Last session the university asked the legislature to permit it to sell beer and wine in tents set up at its new TCF Stadium.  This year they reported selling $900,000 worth of beer at $7.25 a paper cup and LOSING MONEY!  Probably too much overhead. . .  Alonzo “Tubby” Smith completed his fourth season as men’s basketball coach and as the highest paid employee at the U.  Then he lucked out.  His team was chosen to play in the NCAA tournament which earned him a $100,000 salary bonus plus another bonus of $150,000 when the Gophers beat UCLA.  His luck ran out with Sunday’s loss to Florida and by Monday he was out the door with a check for $2.5 million.

Health care defies regulatory norms by Edward Lotterman, St. Paul Pioneer Press

http://www.twincities.com/business/ci_22699533/real-world-economics-health-care-defies-regulatory-norms

Mooching Off Medicaid by Paul Krugman, New York Times

http://www.nytimes.com/2013/03/04/opinion/krugman-mooching-off-medicare.html?_r=0

This comes during an historic week in which, among other events, Pope Benedict XVI became the first head of the Catholic Church to resign his office since 1415.  And for reasons everyone seems to have applauded.  To Catholics and others who are Christians there is an often quoted description of love in Paul’s first letter to the Corinthians chapter 12:31-13:13 which was part of the February 3^rd liturgy this year. No one has expressed it to me in contemporary terms as well as the pastor of St. Raphael’s Mission Church (founded by Fr. Junipero Serra in 1817) who began his homily with a survey of what 4^th and 5^th graders most want to hear from their mothers, starting with “I love you” followed by “yes” and “Time to eat”.  It’s what Fr. John Balleza has to say after that I “heartily” recommend to your reading. (Click here for the homily)

THE STATE OF THE UNION

It is the one annual event that brings our government leaders together in the same chamber in Washington D.C.  Who would expect that this speech is anything but political and that, as national politics becomes more polarized, the speech would be non-partisan?   So the President positions himself to the left or right of the current policy agenda.  The opposite party, by its body language, its official broadcast response, and its congressional members’ efforts at memorable one-liners, does the opposite.   There are also the theme props for the speech.  Warren Buffet’s secretary for the tax reform theme and the victims of gun violence this year.

Who is the audience for the speech?  They are Americans who are interested enough to tune in, among them, those associations of Americans with a special interest in legislative or regulatory policy.   Whose lobbyists eagerly await a “mention” of their issue in the speech, as an indication that they are worth what they are being paid. The speech is also a source of the words and phrases which can be turned into sound bite materials. To be used for the “reactions” that play to members’ supporters in forums large and small.

 “WE KNOW WHAT NEEDS TO BE DONE.”

In his first State of the Union address in his second term, President Obama suggested to members of Congress and their constituents that a lot of progress had been made in four years in improving the state of the nation.  And much, much more (an hour’s worth) remained to be done.  Then, with the constituents in mind, the President asked:   “What’s it take to do it?  And suggested the answer should be as obvious to them as it was to him and, by implication, to their constituents.  “It requires us.  Working together.” 

Senator Marco Rubio (R-FL) was chosen by Republicans to respond to the President because he is their fly trap for Latino voters and he did what they expected of him.  Laying out a philosophy of economic liberty to guide government’s  response to the many challenges  Americans face, he asked average Americans to believe they had to make a choice between two starkly different views of the role of government.  By implication, there is no room to accommodate the differing views of Democrats like the President and of Republicans in Congress.  

You and I are left to ask ourselves what the President and his party in Washington, and the Republicans in Congress have in common -other than the “God Bless America” ending to their speeches.  Where is the common ground and those willing to stand on it necessary to balance the federal budget, reduce the federal deficit, and incentivize economic growth?

“WE WERE SENT TO MAKE WHATEVER DIFFERENCE WE CAN MAKE”

President Obama was at his most eloquent Tuesday evening in describing the unique role of representative government and the responsibility of the elected which our founding fathers intended.  Republicans reacted to the President’s assessment as more government. To which, of course, the typical Republican has been elected to say, “Government is the problem, not the answer.”  And quoting President Clinton’s second term State of the Union speeches to that effect.

But suppose we think of “government” as our elected representatives, in both legislative and executive branches of government, at the national, state and local government level.  Not as government that taxes, government that spends, government that regulates; nor as government entitlement programs.  Define government as our founders defined it.  Governments in this country are the men and women whom we elect to assess our commonly experienced needs, and what it is that “we” can do about them.  We are a self-governed nation.  We should assess the quality of the people we elect by the quality of the results they, along with others, produce.

It may have been too subtle for many, but the President aptly expressed this view of the role of government as the way in which “we look out for our fellow Americans the way they look out for each other.” What role should those in Washington play, and what role should be played by others?  State and local leaders.  Leaders in business, the professions, government and in the voluntary sector.

THE ROLE OF LEADERSHIP MAY BE TO CALL US TO COMMON CAUSE

Obama spoke to health reform and changes that can be agreed upon in our current policy and programs and even in Obamacare.  If leaders of both parties were willing.  In elementary, secondary, and higher education.  In energy, transportation, the environment, housing finance, and national security.  Some of this requires major tax reform, he said, if leaders of both parties are willing. Some of it requires entitlement reform to the extent both parties are honest. Are Republicans willing to do “common cause?”   Who knows?  We have come to know over the last four years what Republicans in Congress and in state government are against.  What are they for?

ASSUMING WE THE PEOPLE ARE SELF-GOVERNED

We elect people like us to serve us.  How well do they represent us?   Obama gave them a couple tests.  One of these is on voting rights.  Why should that be contentious?  Everyone should have the right to vote.  So the President is appointing a commission led by two men from his campaign and Governor Romney’s to define some of the problems surrounding the vote in America.  Not all of them by a long shot.  But at least it’s a start at bringing us together.  Is this possible?  Who knows unless a President who cannot run for re-election commits to try.

“THEY DESERVE A VOTE”

The second test of Congressional Republican willingness to do common cause is national legislation to   lessen   gun violence in America and to change the uniquely American gun culture.  Coming at the end of his hour-long speech on the State of the Union, nothing could match the emotional appeal of the right we all have to ask every single elected representative to vote on the various proposals to deal with protecting Americans as well as protecting their Second Amendment rights. 

No single issue group in America has the power of the gun lobby called the National Rifle Association.  No single issue should determine anyone’s right to a seat in the United States Senate or its House of Representatives.  This is the time to determine who each of these 535 people represent.   I hear that’s a tough vote for old time Democratic politicos like Harry Reid and Pat Leahy.  Well, make them take that vote, along with everyone else, on every single legislative proposal.  We the people are more important to the future of America than is their re-election.

If this “they deserve a vote” campaign is successful, maybe we can put pressure on both Democratic and Republican leaders of the U.S. Senate to change the filibuster rules and  the rights of any Senator to put a “hold” on the consideration of any legislation or any Presidential nomination that have cleared the Senate committee of jurisdiction.  Wouldn’t that be something?

AMERICANS SACRIFICE THE FUTURE FOR THE PRESENT

In Carpe Diem Nation, David Brooks 2-12-13 speaks to how Americans in what he calls “a nation of futurity” have changed over the last several generations. “Today Americans have inverted this way of (future) thinking.  Instead of sacrificing the present for the sake of the future, Americans now sacrifice the future for the sake of the present.”   Since helping Congressman Jim Jones (D-OK) start Americans for Generational Equity in 1984, this is exactly how I think about the so-called “entitlement programs.”

Not simply the social insurance income transfers from payroll taxes to Social Security, Disability, and Medicare payments, but the $500 billion a year in tax free spending on health care and the similar tax spending programs that prefer home ownership over rental housing, and non-means tested access to free education, food stamps, agriculture subsidies, closure-free useless military bases and a long list of other programs Americans can’t seem to do without.

TWO EASY TO UNDERSTAND ‘MUST READ’ ROAD MAPS TO TAX REFORM AND SPENDING REFORM

Do you care about entitlement reform?  Enough to plot your own strategy for going way beyond the two trillion or even the four trillion dollars President Obama talked about Tuesday?  Then go to a bookstore and pick up: Bruce Bartlett’s The Benefit and the Burden and learn how to reform taxes; and WSJ columnist David Wessel’s Red Ink, on the politics of the federal budget.  Where the trillions come from, where they go, and why inaction imperils your/our future.  Clear, concise, researched and very simply written by two of the experts on the subjects.

AND BUSINESS AS USUAL THE DAY AFTER

So far this year that happens to be in the Senate, which is not legislating as much as it is engaged by the Republicans in filibusters over the qualifications of most all the President’s nominations.  Since Republican leader Mitch McConnell declared war on President Obama in early August of 2009, it is the principal means chosen to discredit the presidency, to dilute its leadership potential, destroy its policy effectiveness, and blame the result on Mr. Obama. 

Senate majority leader Harry Reid is catching deserved heat for not changing the Senate rules regarding the “rights” of the minority and the “rights” of any Senator to bring any Senate action to a halt.  There is no longer any comity between the party leaders on anything.  Comity at the party leader level has always been the prerequisite for productivity in the “greatest deliberative body in the world.”   So the public approval of Congress is at an all-time low, as it has been since November 2011, but no one seems to give a darn!   Most members seen to have concluded that the only public opinion that counts is their elections.

PRESIDENT OBAMA SEEKS MEDICARE PHYSICIAN PAYMENT FIX

With Sen. Jay Rockefeller (D-WV) I authored the 1989 prospective payment reform of Part B of Medicare as a follow-on to the DRG hospital payment reform the Congress authored in 1983.  The primary goal was to restrain the rapid growth in Part B which resulted from (1) the changes in Part A which reduced utilization of hospitals, but increased Part B doctor visits services; and (2) the escalation in physician sub-specialization which meant more patient visits to more highly paid doctors incented to see more/do more.

On recommendation from the Bush 41 White House and its HCFA (now CMS) director Gail Wilensky, we added volume performance standards to reduce payments to all docs if the national service volume exceeded the rise in average medical inflation.  A much tougher volume test – the SGR – was substituted in BBA 1997 and Congress for the last decade has been forced to offset the impact by supplemental payments.

WHY NOT ENCOURAGE MEDICARE MODERNIZATION

CBO recently revised its cost estimate for a reformed SGR from $300 billion to $138 billion over ten years.  A new reform bill was introduced Feb. 6^th.  A National Commission on Physician Payment Reform convened by the Society of General Internal Medicine and co-chaired by Dr. Bill Frist (former Senate Republican leader) and Dr. Steve Schroeder is also reporting recommendations to address the “doc fix” and bundled payments in Washington on March 4^th. 

Other reformers seek a more permanent fix in making Medicare Advantage a more attractive and effective approach to paying for performance rather than for discreet services as traditional, Medicare has done.  This brings us to the not so radical suggestions Republicans like Cong. Paul Ryan (R-WI) have made that health insurance for the elderly and disabled be financed by a combined social insurance and income tax subsidy of private insurance premiums. 

This would require two important bipartisan political decisions:  (1) Bring the essential benefit and cost-sharing structure of Medicare into the 21^st century; and (2) Agree on the formula for the premium support which favors performance enhancement by providers and discourages inappropriate and unnecessary service utilization.

In a weekly newspaper column, the editor invited seventy-five fourth and fifth graders to submit the words they most like to hear from their mother. Here are the five big winners, repeated over and over by almost all the children:
• I love you.
• Yes.
• Time to eat.
• You can go.
• You can stay up late.

Surely, there are no better-sounding words from a mother to her child than “I love you.” And we can get a sense of this in the Book of Proverbs: “Like apples of gold in a silver setting is a word that is aptly spoken.” (Pr. 25:11). 

In our everyday words, great eloquence, likened to gold and silver may be too much to ask for. But I for one long for the time when our general discourse was conducted on a somewhat higher level than it is today. In messages conveyed to us virtually every minute of the day — both public and private — from our friends and family, co-workers and political leaders, television and movies — it seems the general tone of our conversation has been “dumbed down,” to use a popular phrase. And if it sounds like the recent debates in Congress have devolved into those of teenagers, it’s because they have. In fact, according to a new study, discourse in the United State’s House and Senate has dropped a full grade level -– to the equivalent of a high school sophomore. And to all the high school sophomores present here today, I offer my sincere apologizes for the likely unwelcome comparison!

According to the nonpartisan foundation which compiled the recent study, the problem is, “politicians are gearing their speeches as sound bites or YouTube clips.”

In sharp contrast with some of the present discourse, Luke tells us in today’s Gospel Lesson that when Jesus began preaching His sermon, the congregation responded to His eloquence with high praise. “He won the approval of all,” Luke says, “and they were astonished by the gracious words that came from His lips” (Luke 4:2-2). The congregation was spellbound! Jesus was saying things the congregation wanted to hear. And they wanted to hear even more from this great preacher who was thinking like them. But, as Jesus continued to speak, the congregation’s mood suddenly turned ugly. Jesus was saying things the people didn’t want to hear. Jesus was saying things that contradicted their thinking. Suddenly, Luke tells us, 

“Everyone in the synagogue was enraged. They sprang to their feet and hustled Him out of town; and they took Him up to the brow of the hill their town was built on, intending to throw Him down the cliff, but He slipped through the crowd and walked away” (Luke 4:28-30). 

What did Jesus say to evoke such a violent response? We recall that when Jesus rose to speak, He identified His mission on earth with a Reading from the Old Testament Book of Isaiah: 

“The Spirit of the Lord has been given to Me, for He has anointed Me. He has sent Me to bring Good News to the poor, to proclaim liberty to captives and to the blind new sight, to set the downtrodden free, to proclaim the Lord’s year of favor” (Luke 4:18-19). 

The problem arose when Jesus emphasized to the congregation that those words of encouragement and hope and liberation were meant not just for them, not just for a chosen few, but for everyone — even their enemies. Jesus’ listeners lived in expectation of a Messiah who would liberate them from bondage. They had their own way of thinking about what the Messiah would be like and the kind of leadership He would provide. Consequently, as Jesus continued to speak, they realized that His description of the Messiah’s mission did not correspond with their thinking, and they wanted to kill Him. 

Elevating the discourse to the Divine level, Jesus is asking us to share the Good News with the poor; to help liberate those who are burdened; to shine our light of compassion in the darkest places; to love one another! And He reminds us that “If anyone loves me, he will keep My Word.” Jesus does not ask us to obey Him out of obligation, or out of fear, or out of a desire to get something from Him. Rather He wants us to obey out of love for Him. We don’t follow Jesus because we have to. In truth, we don’t have to. We follow Him because we want to. We follow Him because we love Him. We follow Him because we want to be with Him. We follow Him because we want to make our home with Him. 

Jesus asks us to not only keep His Word, but do His Word. Christianity is not, eloquent speech, but feet on the ground. Christianity is not, head in the clouds, but life in the world. Christianity is not, an exotic plant to be encased and protected from the elements, but a hardy plant to bear fruit in all kinds of weather. Obedience is its root and branch. Nothing we can say to the Lord can substitute for the plain doing of His Will. No calling Him by great and endearing names can take the place of following His teaching and example. We may eloquently proclaim the beauty of breaking bread with Him in His heavenly Kingdom, but it is wasted breath unless we plow and plant in His Kingdom here and now. To remember Him at His table and to forget Him at ours is to have invested in false securities. There is no substitute for plain, every day, down-to-earth obedience to the Lord. “Those who do not love me do not keep my words,” Jesus said to the disciples. 

Jesus’ life and ministry were misunderstood by His own people because they expected God to send them a great king to set them free from their Roman rulers. They remembered the Golden Age of King David. How great it was to be an independent people! How great it was to have armies! How great it was to have power! Although things had gone from bad to worse following King David’s reign, nevertheless they just kept on dreaming through all the centuries, believing that God was going to restore their past glory through a great hero-type political and military leader: a great King-Messiah! They had an obsessive, almost fanatical belief in this. And then Jesus came. 

He was born and laid in a manger. Certainly that would never happen to a great king. He went out into the wilderness after His baptism, and there He wrestled with the temptation to acquire the many things that kings possess: judicial power, economic power, military power, political power. And one by one He turned them down. But His people didn’t understand any of this until after the Resurrection. It was then that the early Christians began looking back through the events of Easter and Good Friday, and into the Old Testament, searching for passages to help explain Jesus and His mission.

In so doing, they made the connection between the Messiah and the famous “Suffering Servant” poems in the book of Isaiah. I will read a verse or two: He was “despised and rejected by men, a Man of sorrows and familiar with suffering, and yet ours were the sufferings He bore, ours the sorrows He carried … He was pierced through for our faults, crushed for our sins” (Isaiah 53:3,4,5). 

The important thing for us to understand now is that God fulfills His purposes most effectively through humble servants, through those who are willing to serve others — even to the point of suffering. Even to the point of death. 

Here today, we may long to return to a golden age when our political leaders, among others, quoted Shakespeare, genuinely engaged in debate and spoke in reasonable and earnest terms. Consider for example Everett Dirksen, the legendary Republican senator from Illinois, who defended a civil rights bill in 1964 by paraphrasing 19th-century French writer Victor Hugo: “Stronger than all the armies is an idea whose time has come.”

But that was then.

And this is now. No matter how eloquent, now is the time to translate mere words, into Christian deeds.

In the manner in which we treat our brothers and sisters everywhere, may our deeds shine like “apples of gold in a silver setting.”

In the manner in which we treat our brothers and sisters everywhere, may our deeds reflect our promise to keep His Word, always.

And to all the high school sophomores who I may have ruffled today, take heart! Like apples of gold in a silver setting, you are the shining future. You are future mothers and fathers, future business and political leaders. You are also future preachers and teachers! And for you, and all of us, no matter where life takes us, may we always keep His Word. Most importantly, no matter where life takes us, may we always DO His word.

The story of Dr. Bill Hazel of Virginia is not a new story.  Check out the story of the Governor Dr. John Kitzhaber of Oregon and Governor Dr. Robert Bentley of Alabama.