Democrats and Healthcare

Washington Post business columnist Steven Pearlstein was online Wednesday, June 6 at 11 a.m. ET to discuss health care proposals by the Democratic candidates. Particularly, he wonders, if Sen. Hillary Clinton has learned anything since 1993.

A transcript follows.

Read today's column: Health-Care Reform Needs Holistic Approach (Post, June 6).

About Pearlstein: Steven Pearlstein writes about business and the economy for The Washington Post. His journalism career includes editing roles at The Post and Inc. magazine. He was founding publisher and editor of The Boston Observer, a monthly journal of liberal opinion. He got his start in journalism reporting for two New Hampshire newspapers -- the Concord Monitor and the Foster's Daily Democrat. Pearlstein has also worked as a television news reporter and a congressional staffer.

His column archive is online here.

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Princeton, N.J.: Hello Steve. I know we basically disagree on this topic. I will not repeat the statistics about the basic inefficiency of our present system which you so blithely ignore, but will content myself with sniping at some points in your current column.

1. You say doctors are opposed to reform. Most of the facts I have sent you come from www.pnhp.org. pnhp stands for "Physicians for a National Health Plan."

2. You have often accused me of political naivety in advocating an efficient single payer system. In your column you end with a laundry list of good deeds various special interest groups should perform. I think it is politically naive to expect them to do so.

3. You never explain why health care should be supported mostly by the US business community to its competitive disadvantage as compared with businesses in other countries.

4. You say that insurers should realize that they will maximize their profits best if they manage health care well. The trouble with this is that it does not appear to be true.

That's enough for now. Maybe I add some more during the chat. - Len

Steven Pearlstein: I'm afraid once again you fail to rise to the level of moderately convincing.

1. Yes, there is a surprising amount of support among physicians, particularly primary physicians, for a national health plan. But the main medical groups don't support it. In fact, the AMA is painfully uninvolved in the health care debate because the profession is so split on so many issues. But as David Leonhardt very nicely reminds us in a good column in this morning's NY Times, docs have a lot to do with the waste and inefficient use of scarce resrouces in our medical system. They don't follow best practices, because we haven't done a good job of researching them and communicating them to docs in a way that they are willing to accept, and we don't compensate them more if they follow them.

2. Those list of good deeds that you think they won't accept. Trust me, I've talked to all the groups and they are willing to accept those things now as a part of an overall reform program. So it is not only naive -- its news I'm giving you here.

3. You are right that our privatized system putys our companies at a bit of a disadvantage, but not as much as you think. Foreign companies support their system through higher taxes, some of which are rebated on exports (but that is another issue). One way to reduce this burden is to have tax money used to lower the cost of private insurance a bit, which is what the Kerry, now Edwards and Obama, "reinsurance" scheme would do. It is a good idea, most experts support it, and it will be part of the reform.

4. It is absolutely true that we don't have a compensation system that rewards insurers and, more to the point, providers for practicing evidence-based medicine. That is the key to reform. The fact that they don't do it now is merely a statement of the problem.

Nice try.

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Reston, Va.: I have a simple thesis for health care:

1. Individuals should be directly responsible for Primary Care Physician, no employer, insurance or government

2. Specialist should be covered by insurance provided by employer or individual.

3. Hospitals should be covered by Medicare and run by local governments like schools. It is a public service.

4. Drugs should be paid by individuals. May be employer (Savings account) or government will help.

Bottom line - empower individuals and local governments to address health care needs. Federal and state should only assist.

Steven Pearlstein: Some interesting ideas there, but the evidence is that if you require individuals to pay for too much of primary and preventive care, they won't do it and it will increase costs when they get much sicker. But I agree that more responsibility, financial and otherwise, should fall to individuals, within the context of a good managed care system that gives them good information ont he cost benefit of doing things and not doing them. One thing I disagree with is to put specialists on full insurance reimbursement. Overuse of specialists is already a cost driver in the U.s. system, and you want to put the brake on that, not remove the cost sharing we already have.

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Southeast: I can't believe the salaries of the ordinary folks in the business. Don't get me wrong--doctors deserve 200k a year. A respiratory or physical therapist does not deserve to earn 60-90K. They might get a masters but most just have an undergrad. I could learn what they do in 2-3 years.

The salaries are just one reason why it is so bad out there. It will not change, either. Humans are designed to want to survive. This is why there are nurse jobs in even the smallest town in the U.S. with a good wage.

Steven Pearlstein: Its true that medical salaries are out of whack -- specialists get too much, primary care physicians too little, nurses too little. Don't know about physical therapists.

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Silver Spring, Md.: Steve - great column today.

I still think I'm with Hillary because I feel like she's lived through one disaster on health care and knows better what the pitfalls are. The clout of these entrenched groups is difficult to estimate.

One thing you didn't mention when you enumerated the groups that will have to accept compromises is the general public. Controlling costs and following evidence based care decisions may entail individuals accepting more responsibility for themselves. Maybe not demanding and receiving the latest, but not necessarily the most effective test (I'm thinking of a recent article in the Health Section about a woman on a quest for an MRI when she'd been advised to merely have a 6 month follow-on), being told/forced to make lifestyle changes instead of drug/surgical solutions.

With so much spending going towards treatment of chronic conditions I think it will be hard to hold down costs and extend coverage to all without individuals making the difficult changes to their own lifestyles.

While I think there is saving to be gotten from the bloated health-care delivering institutions I also think consumers will find they have their own changes to make.

Steven Pearlstein: Consumers will have to change their behavior and expectations in order to have a universal system we can all afford. That requires rationalization, or rationing to use the less polite word. And the people who will be doing that rationing will be the insurers, although hopefully better than they did it during our last attempt at managed care. This time they will rely on specialty medical societies to determine the best practices, based on scientific evidecne of medical efficacy and cost-benefit analysis. They will have professionals communicate with docs if they are not following protocols, not clerks. And they will have both financial carrots and sticks at their disposal. Or to put it another way, consumers won't do it on their own. They--and we-- will need the help of the insurers who are being portrayed as the bad guys but are, in fact, already doing some the best work in this area.

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Staten Island, N.Y.: For the first time in my life I am paying directly for a health insurance policy. It's not for me but for my daughter who aged out of my own and my wife's policy from our jobs. The payment is for a continuation of my policy under COBRA and will expire next November when we will have to pay full market rate for her. The irony of this, to me at least, is that my wife and I are covered by three policies, my work, my wife's work and tri-care because I am retired from the US Army. Why can't we just schmooze some of the excess coverage my wife and I have over to my daughter?

To me, the question facing the country is not health care per se, but the financing of it. Making young people like my daughter pay the equivalent of a weeks wages for a months coverage when they are at the lowest point of their earnings potential and are far less likely to access the health care system is just unfair. It is the main reason so many young, healthy people are self underwriting.

Steven Pearlstein: You are right about all of it. Not sure what we can do, within the context of a privatized system, about the overlapping coverage, unless you want to get into payments from the one employer who covers to the one employer who doesn't. That's tricky. As for young people, it is imperative that we get them into the system, if for no other reason than we need them to contribute premiums when they are healthy to help pay for the people who are sick, which they will be some day. We ought to have low premium-high deductible policies, however, available to them, which is not the case in many states. And if they are really low wage, they need some sort of subsidy from taxpayers, which is a feature of nearly every Democratic reform plan.

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Great Falls, Va.: I enjoyed Friday's deregulation column, but had a quibble or two. Early in the piece, you acknowledged that Maryland's higher prices were partially because of the increased cost of oil and natural gas, while Virginia relies more prominently on cheaper coal and nuclear power. First, I doubt Maryland is running any oil-fired plants, so the cost of oil is probably irrelevant. But more important, I think you neglected to make the point that there is a cost to the political decisions that a state makes. You would NEVER get a new nuclear plant built in Maryland because of the political atmosphere. That's fine; a state is entitled to make that choice ... but it has consequences. Chief among those consequences is an increased vulnerability to the cost of natural resources. If you ask me, Maryland's higher rates are simply a term of the bargain it has struck over the past few decades.

Steven Pearlstein: Fair enough.

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Danvers, Mass.: The extra share of GDP we spend compared to western countries with universal care and better results goes into somebody's pocket. (4 percent to 6 percent GDP excess cost.) I guess you're fingering the docs, the hospitals, the drug co's the insurers.

These guys under the current system expect an unending stream of these profits to flow their way. To get them to go along, don't we have to pay them off? And how much does it have to be to get them to give up all that future dough?

Steven Pearlstein: That's an interesting way of looking at it. I think you have the magnitudes about right. And squeezing out some of that waste will result in lower incomes and profits for providers. But since you do this over time, it won't be all that painful. And probably even more of the "savings" will come from reduction in the number of people involved in the process, number of hospital beds, number of MRI machinees than there otherwise would have been. To that extent, it won't be that painful. Those people who would have been working in the health care system will be doing something more productive, and so will the investment.

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Virginia:"universal coverage is inevitable"

Really? Anything else in your crystal ball? Who's going to win the world series this fall?

Steven Pearlstein: Red Sox, of course.

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Great Falls, Va.: Gee, without the drug companies and the oil companies, we'd be living in a utopia, huh?

Steven Pearlstein: Who said that?

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Falls Church, Va.: Steven, I approached your column with great interest today as I have been following the developing debate on health care reform. I have to ask that when your focus was on bi-partisanship and including all the players, why you didn't even mention the Healthy American's Act? It is the first comprehensive bi-partisan bill (Sen. Bennett has recently co-sponsored) in over a decade on this issue, and if you listen to Sen. Wyden's rhetoric since he introduced it last December, every group from the drug companies, providers, hospitals and insurers you mention, to the trial lawyers and labor unions will have "skin in the game". This proposal seems to be exactly what you were writing about - Am I missing something?

Steven Pearlstein: I didn't mention it, but I am certainly aware of it (I met with Sen. Wyden about ti) and think it is can be considered the first rough draft of what we are heading toward. He, and Bennett, have done a great job. And it is that proposal that has attracted the attention of both the White House, in the person of Al Hubbard at the National Economic Council, as well as the National Federation of Independent Businesses, in the person of its new chief executive, Todd Stottlemyer. And I'm sure there is a lot in the plan that the Business Roundtable, AARP and the SEIU could agree about.

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Santa Fe, N.M.: In considering the idea of "holistic health care", why is it that none of the candidates (on either side) have a stated position on mental health and substance abuse insurance parity -- particularly in the private sector - or on how the prevention and/or treatment of mental health and substance abuse issues can have a direct positive impact on an individual's physical health?

Steven Pearlstein: Actually, I think all the Democrats have mentioned more parity for mental health and substance abuse. But I have to say we should be careful about this. People who have problems with substance abuse, or people with serious mental problems deserve coverage. But the rest of us shouldn't have to pay for Woody Allen's 5 years of psychotherapy. And unfortunately, the mental health establish has done a lousy job of helping us draw a reasonable line somewhere, hiding behind the hackneyed defense that doctors and patients are in the best position to decide what is medically necessary. This is another example of what I said before, that the docs are missing in action on this health care debate.

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DC: The reason why a lot of the dem candidates plans won't work is simple ... nobody is willing to take a step back for the greater good when it comes to medical care. Meaning, we are the only country in the world were 80-year-olds have replacement surgeries. Where no matter how old you are, insurance or the gov will pay for large operations late in life.

Yes, it is a disgrace we have so many uninsured, but how many of us would be willing to reduce the quality of car we receive for the greater good? That's what it would take for a single payer system. I for one am not.

Steven Pearlstein: You can have some of the advantages of a single payer system, in which care is rationed according to evidence-based medicine, without actually having a single payer system, but maintaining the mixed system we have today. Medicare and Medicaid should take the lead in establishing the best practice protocols, and once they do, the private insurers will be able to fall back on them and improve them. But without that political and research backstopping by the government, the insurers will be left hanging out there, vilified by politicians like Ted Kennedy and Pete Stark, who have a ridiculous hatred of managed care, and moviemakers and journalists who will make hay of any denial of care. And as you point out, the hardest decisions will be involving end of life care.

On that last point, I learned last week that the reason there are now privatized fee-for-service plans under the Medicare Advantage Program (the fastest growing segment of that program) is not because the industry asked for it, but because the right to life movement wants it. Why? Because they don't want to be forced into managed care plans that won't cover end of life treatment that is considered to have low benefit relative to cost.

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Rockville, Md.: Since I just retired and now have Medicare and a good Blue Cross policy I kept from my FDA days, I am happy with my insurance. How likely is it that a future health system will include me? Will Medicare be part of the new future?

Steven Pearlstein: Yes and yes. One of the political lessons from 1993 is that there are lots of middle class and wealthy people who are quite satisfied with their health care, and any reform should leave them alone as much as possible.

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Washington, D.C.: Your column raises the prospect of my doctor saying "you need back surgery" and my HMO saying "no you don't." Haven't we already gone through this scenario, with the HMOs being demonized as soulless cost-cutters denying needed care? How does one re-package managed care so that it's not politically DOA?

Steven Pearlstein: I hope I've addressed that already, but let me reiterate: the HMO has to have good evidence to back up its decision, the government has to endorse it, and it has to be communicated in the right way to patients and doctors. If we don't do this, there can be no effective reform and universal coverage will become a financial timebomb. This is the crucial point of health reform: to rationalize care. HMOs did it badly last time, but for all their ham-handedness, it actually worked in slowing utilization and premium increases. And when everyone switched to PPOs, with no management, utilization and premiums resumed their previous steep upward paths.

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Falls Church, Va.: Very good column today, but I'm conflicted over your point about the expensive medical treatments driving up the cost of coverage. Aren't catastrophic costs the area where a person needs insurance the most? If we put into place a universal system that doesn't cover such costs, then people with means will buy supplemental coverage, won't they? And then we're back to a two-tiered system for rich and poor.

Steven Pearlstein: I think you misunderstand. Nobody is suggesting that catastrophic coverage -- coverage for expensive, serious illnesses or accidents--should be curtailed. It should be what health insurance is all about. The stuff that might not be covered is the stuff between preventive medicine and catastrophic. In that realm, the evidence is taht cost sharing helps to rationalize utilization.

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Princeton, N.J.: Hm-m-m, you say

1.Yes, there is a surprising amount of support among physicians, particularly primary physicians, for a national health plan.

2. Trust me

3. You are right that our privatized system puts our companies at a bit of a disadvantage, but not as much as you think.

4. It is absolutely true that we don't have a compensation system that rewards insurers and, more to the point, providers for practicing evidence-based medicine.

And you say _I_ am not convincing.

Steven Pearlstein: And your problem with that....????

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Washington, D.C.: I have two questions. First, do you know what percentage of the uninsured in this country are illegal immigrants? Second, do you think it is at all realistic for our government to try to get Mexico to reimburse the states for at least some of the costs of health care for uninsured illegal aliens, on the grounds that we (US taxpayers) are paying for health care that the Mexican government otherwise would have to provide? Thank you.

Steven Pearlstein: Of all the problems with our health care system, this is really small potatoes. But I will say this: once there is a mandate for everyone to buy insurance, and for every employer to offer it, low-wage immigrants may wind up the winners. Why? Because they will get health insurance along with government subsidies to pay for it.

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Alexandria, Va.: My view is that universal care should be treated by the government putting money into a health account for each citizen while they are young, followed by requiring that they contribute to that account from wages.

At least a guaranteed renewable catastrophic policy would be strongly encouraged from birth together with one of several possible means to encourage preventive care. The policy premiums could be paid from the health account.

Many of the problems you discuss in your column, Steve, would be solved by the market under such a system; and doctors would flow to the ghetto and rural areas and to weekends because the inhabitants would have sufficient money to raise prices enough to encourage doctors to practice there.

Steven Pearlstein: As our correspondent from Princeton is quick to point out, I believe we can use market mechanisms to insure a health care system that is innovative and competitive on price and quality and gives people choices. But please, please let's set aside this fantasy that if we only used tax-free accounts and remove all regulations, the market would solve this. That has been the Bush approach and it is not only a badly flawed policy prescription, but it has even less political support than national health care. Health care is simply not amenable to a pure market solution, for all sorts of reasons, the first of which is that, as a civilized society, we don't let people go without treatment even as we let them go without other goods and services. Nor should we. IT is also complicated, and people don't make the right decisions which not only cost them, but cost the rest of the people who finance the system. And we want to have doctors, hospitals and providers who think about something other than profit and income maximization. So this is my plea: please put these fantasies aside. They really get in the way of Republicans participating in a constructive way in the health care reform debate. They are a fantasy of think tanks, not the real world.

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Ottawa, Canada:"Doctors and hospitals know that, in the future, they will be have to give up some of their autonomy..." What autonomy are you talking about? Doctors in the U.S. spend large amounts of time arguing with insurance companies about what treatments they can provide patients without going over the limits of the insurance coverage.

Steven Pearlstein: Please. Doctors have incredible autonomy. There is no other way to explain the huge variation in practice patterns that the researchers at Dartmouth Medical School have documented year after year. It is not patients that decide what is done, for the most part. It is the doctors who decide or heavily influence the decision. The insurers have been pushed back so far that their "restrictions" are fairly tame.

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Rockville, Md.: Interesting that you berate Dems for the rhetoric given at the debates, but don't provide specifics about what the Dems plan to do about health care.

I've read HRC's plan to cut the costs of health care and her plan covers many of the things that you cite in the article, i.e. evidence-based health care, promotion of prevention. Have you actually taken the time to read her plan or the other Dems' plans? If not, why not?

Also since you're a reporter, do you know when the next 2 parts of her health care plan will come out? thanks

Steven Pearlstein: Of course I read her plan, and Obama's and Edward's. And there is nothing I wrote to suggest that they don't include these things. They now represent the political and expert consensus on what needs to be done, which is why I can say, at the end of the column, that all these interest groups are now willing to come to the table.

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Gaither, Md.: Steven, thanks for your column. Don't take the comments and criticisms too personally. It is a hot hot topic. My question is twofold. Do you think that the '93 health plan was substantively good and just the presentation/promotion/timing was bad, or was it bad bad bad? Where/how can I obtain a copy of that 'Hillary' plan?

Steven Pearlstein: Don't know about where to obtain a copy. But you make a good point: all of the various plans being tossed around today are variations on the Clinton proposal for managed competition. The problem with the Clinton plan is that it went two or three steps too far. It tried to nail down every eventuality and solve every potential problem with insurance markets. And the coverage it wanted to offer everyone was too rich, at least to start out. There was also the political calculation that it was better to have an employer mandate rather than an individual mandate. In hindsight, its pretty clear you need an individual mandate (a la Mass, Calif) with subsidies and a mandate that employers participate in some fashion.

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Reston, Va.: Thanks for your response. You are correct about specialist. When I came to this country in the 60s we used to have BC/BS to take care of basic medical and hospital for all the citizens of a state and Major Medical for expensive procedures for those who can afford. Private insurances entered and cherry picked the basic services and destroyed the simple system. It is the same they are trying with Electric utilities. There are some things in society that require public and private cooperation with public oversight. Health care is one of them...

Steven Pearlstein: Thanks.

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San Juan Capistrano, Calif.: Although most proposals would perpetuate the private insurance plans, that model is obsolete. Private insurers cover the healthiest sector of society: the healthy workforce and their young healthy families through employer-sponsored plans, and exclusively healthy individuals in the individual insurance market. Premiums are barely affordable for this healthy sector. Impose mandatory guaranteed issue and community rating and premiums will be unaffordable for average-income families. We will not get around this dilemma until we decide to adopt a universal risk pool and fund it equitably (i.e., progressive tax policies). Private insurers may still have a role in claims processing and information management, but we have to give up on the idea that they should continue to manage our system of fragmented risk pools.

Steven Pearlstein: I don't think you are right about that, although it is a debatable point. A private system with mandatory issue and community rating (with regulated premium variations for age and smoking, etc)should create very large risk pools, which is what you are after. And if there is a federal reinsurance program to cover the most expensive cases, financed by the government in some fashion (like a tax on all health services), then you do create a universal risk pool.

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Falls Church, Va.: Does the split among doctors correspond to specialists vs. primary care? I.e., specialists oppose single-payer since they would take the biggest hit to income, while primary-care doctors might even benefit financially?

Steven Pearlstein: Precisely.

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Arlington, Va.: Definitional question: What does "deregulation" actually mean in the context of electricity? If rates are capped to consumers, and utilities are restricted in the sorts of supply contracts they can execute, what is being deregulated? I don't mean this as a rant; I'm honestly curious.

Steven Pearlstein: What is deregulated is that rates are not fixed absolutely by the government in a system that guarantees the utility a specified rate of return. In a strict sense, it is partial deregulation, or managed competition, if you will.

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Baltimore County, Md.: I don't think taking personal responsibility for health care is going to be universally acceptable when the deck is so stacked against the individual right now. I am tired, period, of having to take individual responsibility for everything. I work a long week, am old, and was turned down for an individual policy (no health insurance available through work) and frankly, I don't have the energy to explore alternative options, like the state fund they mentioned in the reject letters. (BTW, reason for rejection is a barely too high BMI, not any pre-existing conditions). Also, what's reasonable to you for health care insurance expenses may not be to me. Because I work hard, and housing costs are high in this area, I don't see myself affording a $300 payment per month for basic high-deductible care on a $40K salary.

Should I be working to pay only my rent, utilities, and health care insurance? Sorry, not enough incentive for me. I want to have disposable $$, and if I die before reaching Medicare age, so be it.

Steven Pearlstein: Well, that's a point of view. Not sure if it is universally shared, however.

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Troy, N.Y.: Hi Steve. I read your column last night online and noticed the headline this morning is different. Is portraying the drug industry as anything less than villains that unpopular? I'm pretty sure that drugs are only about 10 percent of the expenditures in health care, so I've always wondered why they seem solely blamed for high costs.

Steven Pearlstein: They are a big fat political target because of they enjoy very high profit margins and returns on equity relative to other industries, because they are spending lots of money on advertising and marketing that increases utilization of drugs in ways that are not always cost-efficient and because they have been politically thuggish here in Washington rather than engaging in an intellectually honest debate. Their answer to every issue, every criticism, every proposal is that anytime you regulate us, you are going to kill the innovation of the industry and kill people. There is some truth to it, but things are more complicated than that, and they have refused to engage in a public discussion of how drugs ought to be priced, marketed, etc. Their idea is to let the market do everything. But, of course, these are companies that survive because of government-funded basic research, government-given monopolies in the form of patents, and government-paid insurance for half of what they sell.

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Jurancon, France: Mr. Pearlstein,

Maybe a little time under "universal healthcare" systems of The Czech Republic, Poland and even western socialized healthcare countries might give one a different perspective. It sure soured me on the prospect of trying to make it available to everyone. I am afraid there are winners and losers in all aspects of life.

Steven Pearlstein: Merci for injecting that dose of reality into our conversation. I hope Mr. Princeton is still listening.

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Greenwich, Conn.: Under our current system, a huge proportion of our health insurance premiums pay for marketing, lobbying and executive salaries. Please explain why our health insurance premiums should pay for these things rather than health care.

Steven Pearlstein: First of all, that is not factually true. It is not a huge portion of our premiums. That's not to say that executive salaries, marketing and lobbying are excessive. But if you were to eliminate it all, my guess is it wouldn't even eliminate one year's worth of health care inflation. Sorry.

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Princeton, N.J.: To get away from sniping. I agree with a lot of what you say, but I think it is a lot harder to do than you believe. In the long run (more than 20 years), we have to do what you say. But in the short run, we can solve a lot of our current health care problems by simply putting in a more efficient system like every other developed country. In health care WHO ranks the US 37th, above Bolivia, but below Slovenia

Steven Pearlstein: Those statistics are a wonderful statement of the problem: we spend the most and get the least.

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Annapolis, Md.: Good Morning, Steven.

Thanks for another thought provoking column. I have two comments.

1. I have spent large portions of my life self-insured. I've usually bought these policies through BC/BS, Aetna, or some other large provider. I'm in Maryland, healthy in my early 30s. I've never paid more than $2400/yr for an 80-20 PPO. Yet I am always hearing about the lack of affordable health insurance. Why don't more people take advantage of policies like the ones I have been living with?

2. I very much favor the idea of moving normal healthcare out from under the insurance umbrella. For normal maintenance and preventive check-ups, we should all just be willing to go to the doctor and pay the bill. However, GPs can not go on charging $100 or more for a 10 minute or less office visit. My child's pediatrician charges $140/visit, but accepts about $50 from insurance. Why don't they and all other doctors just charge the $50? Think how much we could all save by skipping the long route of billing and filing to receive reimbursement! This kind of thing makes no sense, and I've never been able to get a doctor to explain it to me.

Steven Pearlstein: Your second point is a good one: we have to get away from the variable pricing model that disadvantages people who are self-employed or work for small companies. Its crazy. And your first point, about the effectiveness of a high-deductible, low premium policy is spot on. That needs to be the basis for what is mandated for all individuals as a minimum (as long as standard preventive care is included). I'm in total synch with what you say, even if Senator Kennedy will get all red in the face and yell about how terrible is would be if any plan is not as comprehensive as the one enjoyed by all members of Congress.

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Washington, D.C.: Think a large part of the problem is the high insurance that these doctors pay, caused in large part by trial lawyers. And guess what the politicians that are looking out for us, are mostly lawyers.

Steven Pearlstein: Actually, I should have mentioned that even the Democrats now concede we need a better system for handling medical errors, so that docs and hospitals don't have such a big incentive to deny that they happen and try to cover them up, and insurance policies aren't so expensive. Variously they talk about more regulation coupled with mandatory arbitration of disputes, which presumably will greatly reduce the punitive damages. All that is a positive development (even Edwards, the former trial lawyer, concedes some reforms are necessary). But that said, let's not overstate the importance of malpractice premiums and defensive medicine in driving up medical costs. It is not insignificant, but it is hardly the big explanation for our higher medical costs. That's another right wing fantasy.

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Steven Pearlstein: We've actually exceeded our alloted time. Thanks for that good discussion. "See" you next week, I hope.

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