How About Some Really Out-of-the-Box Thinking?
Many of the comments responding to our disparities postings have reflected a certain cynicism and skepticism about our calls to address the public’s health using intervention approaches that fall outside of the health care or even traditional public health arena.
Let’s take physical activity, my favorite example of non-pharmacological, non-surgical, non-psychotherapeutic “medicine.” Physical activity is one of the most potent and grossly underutilized tools in our prevention arsenal. The data supporting the effectiveness of modest “doses” of exercise in preventing, managing and, on occasion, even curing a host of chronic disease maladies is overwhelming. Participation in doses as modest as 50-60 minutes of moderate-to-vigorous intensity physical activity per week confers some health benefits; engaging in at least 150 weekly minutes is associated with a full spectrum of protection across most health and wellness domains, and augmentation of disease management and rehabilitation—from A to Z, academic achievement, Alzheimer’s disease and depression, to obesity, stroke and other vascular diseases. Yet, a recent study of data from the National Health and Nutrition Examination Survey (NHANES) gathered from objective monitoring of activity levels revealed that Americans participate in an average of only 6-10 minutes of at least moderate intensity physical activity each day. A study of ours a few years ago [PDF] found that more than 40% of Los Angeles County’s more than 10 million residents is completely sedentary, engaging in fewer than 10 minutes per week of continuous activity.
An early and concerted emphasis on physical activity should assume primacy in any comprehensive effort to promote health and well-being, prevent chronic disease and contain medical care costs. Preventing weight gain, much less achieving healthy weight status is highly unlikely to be sustainable at the low levels of physical activity in which most Americans engage. Yet we constantly look elsewhere for solutions, rather than looking for delivery vehicles for this “miracle drug.” So here are three focused strategies for achieving sufficient increases in physical activity across the entire population to realize meaningful health and wellness benefits. This will not only ease the strain on the medical care system but also on the overall economy by increasing productivity, decreasing injury and workers’ compensation liability, and improving student and employee morale and retention:
1) Adopt “opt-out” or “push” organizational practices and policies that make the physically active choice the default option or path of least resistance, and the sedentary choice difficult, in schools and workplaces, especially government-run and government-regulated agencies, e.g., exercise breaks at a certain time of day or reserving parking within a 5-minute walk of the workspace for people with disabilities. (See this NPR story for more.) This includes setting day care, pre-school and after-school standards for minimum amounts of physical activity per hour spent in child care. Legislators and other policymakers have wide spheres of influence and this is a “mirror” strategy—rather than instructing others, what can you do within your own decisional latitude? Incentives, e.g., tax rebates, for workplace wellness programs not built on these opt-out strategies will not produce a sustainable return on investment. That’s because the people most likely to take advantage of on-site fitness facilities or programs are healthier and more active than most employees—and willing to spend their own discretionary time and income on active pursuits. Poor structuring of workplace wellness tax breaks will merely shift costs now borne by these individuals to employers and taxpayers.
2) Improve the quality of physical education (PE) by investing resources to increase the number of PE teachers, training of all elementary school teachers in PE, activity-focused PE implementation support materials and equipment), even before much-needed efforts to increase PE duration. We conducted a statewide assessment of PE and physical activity in California public schools [PDF] a few years ago, and found that kids in low-resource schools typically spend only 4-6 minutes being moderately-to-vigorously active (walking, running or jumping) during a 30-minute PE class. More PE time without quality improvement translates only into more time spent sitting or standing around.
3) Impose an excise tax on sedentary behavior-promoting goods and services, e.g., movie tickets, inactive video game consoles and software, private automobiles and cable TV packages. Like tobacco excise taxes, not only would this provide a funding stream for ramping up and scaling up public health coordination of physical activity promotion, but price elasticity would also decrease consumption among adolescents. The revenues might also permit the redress of the inequities in park space in low income communities and communities of color, so kids have someplace to bounce a real ball!
Out-of-the-box thinking? Maybe once we’re strong enough to punch our way out!
Final Thoughts on Rethinking Our Approach to Spending
Dr. Claudia Chaufan makes some good points in her recent post about the excesses of U.S. health care finance. Like her, I can’t justify executive salaries at for-profit health plans in the tens or hundreds of millions. But the stratospheric total she cites – $1.75 billion in compensation in 2002 – still represented only about one-tenth of one percent of all national health spending that year. Could it have been better or more justly spent? Undoubtedly. Would redirecting all of that executive compensation cover appropriate care for all Americans, an aspiration that Dr. Chaufan and I share? No. Urban Institute researchers estimate that extending care to all currently uninsured Americans would cost between $34 and $69 billion in 2001 dollars. Not a large sum compared to total annual health expenditures (about $1.6 trillion in 2002, $2.2 trillion at last count [PDF]), but a great deal more than health plan executive salaries.
What about Dr. Chaufan’s concern that serious consideration of a single-payer approach has been missing in the national health reform debate, and her implication that enacting a single-payer plan would solve the cost conundrum? The Congressional Budget Office may not have estimated the cost of a single-payer approach, but the California Legislative Analyst’s Office (LAO) did just that in 2008, in the context of pending California legislation (SB 840, Kuehl). The LAO concluded that the proposed single-payer plan would require new payroll taxes of about 8 percent paid by employers and 8 percent paid by workers. That totaled 16 percent – not coincidentally, the share of the total economy that goes to health care today. A single-payer approach would cause health spending to flow in radically different ways, but to change the total amount we spend would require additional steps.
In my original post, I laid out a few ways to fundamentally alter how much we pay for health services. None of these is quick or easy. We can change the way care is provided or how we pay for it. We can invest in prevention and health promotion so that less care is needed. We can work to eliminate the use of ineffective care while encouraging cost-effective approaches.
To make progress with any of these approaches will require greater transparency and accountability within the health care delivery system and among those who pay for care. It will leave some of us with less in order to provide others with more.
David Brooks of The New York Times wrote this week that “We’ve built an entire health care system (maybe an entire government) on the illusion of something for nothing. Instead of tackling that basic logic, we’ve got a reform process that is trying to evade it.” The risks and rewards inherent in the political process tend to perpetuate that illusion; human nature inclines most of us to accept it. Given the importance of the task, though, I hold out hope that policy makers and citizens will tackle the tough decisions needed to move the country toward more affordable and appropriate care for all.
Reflections on Last Week’s Health Dialogues
I hope that as many people as possible were able to listen to the June broadcast of Health Dialogues, in which I had the privilege of discussing health reform with Dr. Toni Yancey of UCLA and Dr. Tony Iton, Director of the Alameda County Public Health Department. These two public health professionals and I had very different views of who should be responsible for improving our health.
Dr. Iton is Canadian, like myself. When invited to comment on so-called “universal” health care in Canada, he stressed the sense of “solidarity” that he believes Canadians feel about everybody belonging to the same health plan, run by government. Well, to the victor, the spoils, I guess. Because the government won the fight for Canadian health care, its advocates get to write the history. However, back in 1962, when the province of Saskatchewan introduced its government-run, “universal” plan, the doctors went on strike. They caved in when the government relented on letting them practice outside the government plan. Later, when private competition frustrated government’s ability to control medicine, Ontario’s doctors went on strike in 1986, as a result of a new law preventing “balance billing” (even if patients voluntarily chose to pay the difference between government’s fees and what a doctor wanted).
For both ethical and financial reasons, the doctors’ bid for autonomy from government failed. It took until 2005 for the Canadian Supreme Court to determine that government-monopoly health care violates Canadians’ civil rights.
But if you want to call it “solidarity,” I can’t stop you.
These public health professionals do hold one idea with which I am in full agreement: that which we call the health care “system” accounts for only about ten percent of our health care. The rest is due to a complex of environmental factors. Dr. Yancey emphasized schools, which she asserts poorly serve certain communities. I certainly agree with this, but the schools are already a government monopoly in the U.S., so I hardly see how the failure of government schools, to date, supports an argument for a similar take-over of health care!
But the public health establishment poses a bigger challenge: everything in our environment has an impact on our health status. Furthermore, our competence at defining and measuring these impacts is proceeding at a far faster pace than our ability to do anything about them. If we accept that government is responsible for anything that impacts our health, then there’s nothing that it can’t control.
And people still wouldn’t be universally healthy – not even if they put us all in cages, fed us kibble and made us run on large hamster wheels for a couple of hours a day!
Why the White House Opposes Single Payer, and What You Can Do About It
If you were puzzled that none other than Secretary of Health and Human Services Kathleen Sebelius made the clearest point thus far that President Obama does not support single payer, you are not alone.
Let us speculate: did Sebelius want to make sure that you had no doubts about it – or maybe make up in case you missed the president’s address to the American Medical Association? In this meeting, as the president faced an audience of conservative doctors (a dwindling, increasingly unrepresentative sample of practicing doctors in America), President Obama reassured them that he would personally guarantee that doctors would continue to have the pleasure of dealing with for-profit private insurers rather than with “government bureaucracies”– European, Canadian or Japanese style, God forbid!
Now, in case you cannot see the president’s point — why you should fear a “government bureaucracy” more than you fear the bureaucracy of your health plan (assuming, that is, that you still haven’t lost your coverage because you lost your job, or that your coverage has not gone up so much that you can no longer afford your share, employer provided or not) — White House Chief of Staff Rahm Emanuel intends to clarify just that. According to Emanuel, the president is against single payer (even if he was for it as a young and idealistic senator) because what matters is “not the means but the objectives”, namely, cost control and universal coverage (yes, he said this with a straight face).
What? You don’t see the relationship between controlling costs and covering everybody, and opposing single payer, i.e., Emanuel’s argument? Again you are not alone; neither do I.
A critique of Emanuel’s answer I found in cyberspace (well worth reading) may provide a hint of what makes our democracy tick. The gist of this critique is that Congress and the White House do not want to hear that single payer health care – a mere change in financing, not in delivering, health care — would save money, cover everybody and set the right system of incentives to improve the quality of care. Which is why the White House and most members of Congress are rather pleased that the Congressional Budget Office is not analyzing it as it did with other proposals (e.g. “public option choice”), and they are even getting in the way of this analysis. (After all, who would want to hear that?)
What the CBO has said about current proposals for reform is consistent with the assertion that none of the “traditional” explanations for our high costs work, really: the Japanese, among many others, have higher utilization rates (visits to doctors, MRIs, etc) than we do, greater percentage of elderly in the population than we do and, to our knowledge, do not eat more broccoli than we do. And yet, they pay 50% of our price tag (per person) when it comes to health care [PDF].
Why? Because they collectively foot their medical bills (“social insurance” in health policy jargon), which enables them to cut costs through reduction of administrative overhead, bulk purchases and cross-subsidization, as I explained in my former posts, and because they take shared responsibility seriously — that is, everybody has to pay into the system, but only a proportion of their income, because the point of the system is precisely that you not go bankrupt, and receive medical care according to need, not ability to pay. So do Germans, Britons, Canadians and so forth.
So, it looks like to achieve health care reform we cannot wait for the winds of Washington to blow favorably in the direction of the American people’s welfare. Rather, the American people will have to make these winds blow all by themselves. And why not dream big, with audacity? (How about “The Audacity of Hope?”)
Thankfully, Americans have some historical precedents; after all, Martin Luther King did not say, “I have a dream, but it is not politically feasible right now, so let us just settle for equal rights for some as a step towards equal rights for all when the time is ripe.” And health care reform is already a matter of civil rights, as well as of economic sanity and survival.
If you wish to join, two loose coalitions of single payer supporters, Single Payer Action and One Payer Now (among many others), invite you to sign up so that they will inform you about health care reform, gather your signature for petitions and organize rallies that you can attend.
My guess is that when enough people lose their jobs and are dumped from those plans that, according to President Obama, “the majority” of Americans “like” and “want to keep,” and find out that they have the “choice” to buy good yet expensive coverage, affordable yet skimpy coverage, pay a fine or request a “hardship waiver,” enough of us will be pissed off and we’ll get single payer.
POSTSCRIPTUM: Nope. David Leonhardt still hasn’t read my third posting. Clearly, he still seems incapable of “imagining” any other way to cut the skyrocketing costs of health care than going after you, the patient, and to a lesser extent against those brave health providers that cater to poor people.
So, be prepared to have your employer benefits taxed (especially if they qualify as the “Cadillac” sort, buy a policy (whether it will actually protect you from medical financial ruin or not) and see major cuts in community clinics serving Medicaid and SCHIP patients.
Wonder why Leonhardt forgot to first eliminate, say, high CEO salaries at for-profit health insurance companies, amounting to $1.75 billion that went to 20 people in the private health insurance sector in 2002, and a total annual compensation of $1,153,864,691 — including stock options — going to the highest paid executives in 2002 [PDF]? Now there are some costs that could be really cut so that the money can buy health care for the American people!
And, if you are puzzled and upset as I am, click here to write your letter to the editor of the New York Times and comment about Leonhardt’s omission. Having your voice heard makes a difference.
Focusing the Health Care Debate on California
In my recent post, I referenced how California consumers can get involved in the national health reform debate. But even with so much happening in Washington, D.C., Californians should also pay attention to what’s going on in Sacramento.
My colleagues Ellen Wu and Lark Galloway Gilliam appropriately spotlighted the state’s fiscal crisis and the potential impact of the budget cuts proposed by Governor Arnold Schwarzenegger. The health care cuts could deny coverage to nearly two million Californians [PDF] and have severe impacts on a range of health programs, services and providers on which we all rely. Health Access has a one-page flyer that summarizes all the health cut proposals [PDF] by the Governor.
California has better budget choices, including raising the taxes and revenues needed to prevent these and other devastating cuts. We need to avoid not just the tragic human impact of the cuts, but the consequences to our health system and our economy. For example, we lose two federal dollars for every dollar we cut to Healthy Families, the State Child Health Insurance Program (SCHIP) that insures low-income kids which is proposed to be eliminated. So for every dollar the state cuts, that’s a three dollar cut to our health system and our economy, and a greater multiplier effect beyond that.
The loss will be even greater with the passage of national health reform. In the proposals in Congress, Medicaid and SCHIP is the foundation for additional coverage expansions—and these cuts would attack that foundation in California. We would further undermine our state’s ability to bring in federal dollars and take advantage of the benefits of reform if we undo our health system’s infrastructure at this crucial time.
But Californians should not just prevent steps backward; we should take some steps forward at the state level. State-level bills on comprehensive health reform have stalled for the year, as legislators focus on the budget crisis. But there’s still progress on specific health reform on a policy level.
One bill, AB786 (Jones), sponsored by Health Access California, would set some basic standards in the individual insurance market, and help weed out “junk” insurance that gives coverage a bad name. Lark Galloway Gilliam spotlighted this issue when asking: what’s the value of coverage, anyway? We’ve talked to many patients who find out that their insurance doesn’t cover very much—often not until it’s too late. That’s why there needs to be better information and labeling of insurance products, so consumers can comparison shop and know what they are getting.
Along with the provisions of the bill which I detail at The New Republic’s The Treatment — a useful blog for those following the national health reform debate — there’s research that indicates it is impossible for consumers to figure out exactly what their policy does and does not cover. And even then, consumers aren’t actuaries, and thus have limited ability to figure out what risks they need to insure against.
The bill, authored by Assemblyman Dave Jones, chair of the Assembly Health Committee, takes a needed step toward helping consumers comparison shop in the near term. But the provisions have been part of comprehensive health reform in California, and are being considered in the federal health reform conversation. Even in a bad budget situation, California can make progress in health reform.
My Rules For Creating a Competing Public Plan
There has been a lot of discussion about creating a public plan that would compete with the existing panoply of private options. I am not ideologically opposed to having a public alternative, but it must be done in a way that levels the playing field. We should look to historical precedent in this matter, and I can think of two examples: Freddie Mac and Fannie Mae. These two institutions were set up to encourage home ownership, and were run in such a political manner and so fiscally irresponsibly that they contributed in large measure to the financial mess in which we now find ourselves.
So, if we go to a public plan, I have a list of minimal requirements that must be met:
1. Health decisions must be left in the hands of an independent authority, including decisions about what and whom to cover, how benefits are managed and the premiums
2. There would be a statutory requirement that government cannot use its revenues to support the public plan
3. There would be no hidden subsidies relative to private plans, i.e., :
a. Pays taxes on any profits;
b. Has capital requirements like anyone else
(Fannie Mae and Freddie Mac got very big precisely because of #3.) This also means that if the government wants to pay the premiums of a particular group (say 55 to 64 year-olds), they have to offer a voucher that can be used in private or the public plans.
Looking at this list–and thinking about the current situation–I realize this may be untenable. This government just gave $50 billion to General Motors. If the public plan gets into trouble because it covers everything - just like Medicare - then is it reasonable to assume they won’t be bailed out?
The bottom line is that I don’t see a way to ensure a level playing field.
The Most Dangerous Thing in American Health Care is Barack Obama Carrying the Dartmouth Atlas
President Obama spent last weekend excited by Atul Gawande’s article in the New Yorker. In it, Dr. Gawande travelled to McAllen, Texas, one of those places where health care is very expensive and not very effective. Dr. Gawande put a human face on the research contained in the Dartmouth Atlas and related publications produced by a team of scholars that has spent decades documenting variances in health spending and outcomes across the U.S. The White House has promoted the simple idea that if “we” could make the worst performing areas meet the standards of the best performing areas, “we” would reduce spending by 30 percent without harming patient outcomes.
Unsurprisingly, President Obama traveled to the polar opposite of McAllen: Green Bay, Wisconsin. At a rally of the faithful, Mr. Obama proclaimed that “we” is the federal government. Through various levers (especially health IT, a boondoggle for high-tech companies), his health reforms would bring the whole country up to the health care standard of this high-quality, low-spending community.
The Obama White House has succumbed to the fundamental fallacy of socialism: believing that the government can collect information, analyze it and then command its citizens to act in accordance with the government’s conclusions. In this case, the information is the Dartmouth Atlas, a well-known body of research that documents variance in Medicare spending and outcomes across the country. While places like Green Bay demonstrate low spending and high quality, places like Miami or Los Angeles demonstrate the opposite.
Advocates of the practice of medicine by government dramatically oversimplify the implications of the Dartmouth research, claiming that the variance is caused by too much medical care delivered to patients who actually suffer from it. If the government just commanded all medical providers to deliver the same volume of care nationwide, we’d cut health spending by 30 percent.
Oh, really? If President Obama believes that he’s got enough charm to convince Miami’s seniors that Medicare is going to cut back their access to care by 30 percent (sorry, we’ve already done all the coronary artery bypass grafts allocated to this ZIP code for this year), then he’s got political guts – that’s for sure.
Nor are scholars united on the reason for the variance, which is unexplained by medical necessity. The Dartmouth researchers lean towards provider-side reasons. Like most academics, they tend to dismiss the idea that patients “demand” health care. Instead, they do what their doctors tell them. So, the volume of care delivered depends on doctors’ financial incentives and their local culture (for example, following the doctors from whom they have learned).
But the truth is more complex. Greg Scandlen, currently a health policy analyst, was working at Blue Cross Blue Shield of Maine, the source of much of the original data. The data indicated that women in Lewiston, Maine were something like three or four times more likely to get a hysterectomy in their lifetimes than were women in Wiscasset, just thirty miles away. Mr. Scandlen points out that Lewiston was heavily French Canadian and Roman Catholic, while Wiscasset was almost entirely Yankee Protestant, concluding that women in Lewiston were using hysterectomies as a form of birth control after having six or more children.
Furthermore, in the journal Health Affairs, Dr. Richard Cooper analyzed data which included private health spending, as well as Medicare spending, and concluded that more spending did result in better outcomes. Dr. Cooper’s findings indicate that it is the centrally controlled Medicare program that has trouble paying for quality, not the 1,800 private insurers that compete against it.
Health care is far too complex for a central government planner to reduce costs without harming quality, in a quest to “cover the uninsured.” Greater choice and higher quality in health care will come from less government control, not more.
Are We Ready to Make the Public Good a Priority?
Anthony Wright’s recent post correctly urges readers to participate in this summer’s health reform debate. If legislation passes, it will have far-reaching impact on U.S. households and the health care system. The priorities and concerns of health care consumers should be central as the discussion unfolds. But what individuals want is only part of the picture.
In an earlier post, I urged readers to consider the sacrifices they might be willing to make in order to assure a fairer, more efficient and higher quality system for all. The lack of response to that post, and to the cost containment topic more generally, confirms that these are not popular or easy subjects. Yet we all must engage. Achieving sustainable long-term reform depends on converting the vague goal of “shared responsibility” into concrete consensus about how costs will be allotted and benefits assured.
So I would pose a few more hard questions:
• For patients with insurance that covers virtually any service you ask for or your doctor suggests: Are you ready to pay more for services that are often ineffective, or that provide reassurance but little clinical benefit? (A recent report [PDF] by the Center for HealthCare Decisions helps tease out what matters most, and what matters least, for coverage.)
• For workers covered by an employer-sponsored health plan with generous benefits: Are you ready to pay more a) in premiums, b) when you get care or c) through taxes?
• For doctors and hospitals that serve primarily privately insured patients: Are you ready to have payments tied to health outcomes, not the volume of services you provide?
• For health plans whose business models rely on developing complex products that “cherry-pick and lemon-drop:” Rather than competing based on the health status of the members you attract, are you ready to compete by demonstrating and developing incentives for health care quality?
President Barack Obama says, with respect to health insurance, “if you like what you’ve got, we’re not going to make you change.” Over the long term, it will be hard to deliver on that promise. What’s more, considering the flaws in quality, affordability and access that characterize U.S. health care and coverage today, it may not be desirable. What makes me, you or any other individual happy is undoubtedly important. When we share resources, however, a broader perspective – thinking not only about private interests but public good – is important too.
Prevention Isn’t a Cure-All, But It’s a Great Place to Start
One problem with heath care reform is that we speak in platitudes. How many times have we heard the promise to improve quality, lower costs and increase access? This sets unrealistic expectations for reform and, ultimately, its demise when it is shown that the policies can’t deliver.
Prevention is a good example.
Improvements in the health of middle and older aged Americans during the last half century are indisputable products of investments in medical technologies and successful public health efforts to encourage prevention. Efforts to curtail smoking, the development of medications for hypertension and, more recently, statins (cholesterol lowering drugs) are excellent examples.
But there are storm clouds on the horizon. With a growing elderly population — and a larger baby boom generation approaching retirement — the prevalence of chronic diseases will rise. If current trends continue, health care costs will experience a commensurate increase that will consume an ever-increasing share of national income. The future liability of the Medicare program alone is estimated to be $24 trillion over the next 75 years, absent any policy changes.
With this renewed focus on health care costs, policy makers have begun to consider prevention as a place to invest — not only in providing more services but also in research to identify better treatment strategies. Medical or public health interventions in the form of primary prevention should, in theory, have the capacity to slow or reduce the rising prevalence of chronic disease, and simultaneously attenuate the downstream spending associated with it. Thus, if there is a ‘magic bullet’ for rising costs of health care immediately available, basic improvements in population health brought forth by existing treatments may be the best and most economical option.
Unfortunately, when it comes to costs, there is one sad fact that works against prevention – it saves lives. And when people live longer, they spend more money. The best estimates of prevention show that it could save a modest amount of money over a lifetime (maybe 3%). More importantly, however, it can lead to a life that has less disability and more years of active lifestyle. So, while prevention may not save a lot of money, it will make a lot of people feel better, and that, after all, is the point of health care.
Now’s The Time to Tell Washington What You Want
While it’s fun debating what might be an ideal health care system, the more relevant question over the next few weeks and months is: what kind of health reform legislation can get through Congress, and how can California consumers and patients impact the outcome? We’ve discussed the framework that Congressional leaders are starting with — it is not getting rid of Medicare, which apparently John R. Graham wants to do, the Wyden individual market approach preferred by Lucien Wulsin, or the full fledged single-payer system as advocated by Claudia Chaufan. The framework is similar to what President Obama advocated during his campaign, and is one that would be a major improvement over the status quo, depending on the details.
And it is up to our advocacy to help shape those specifics. We in California have an important voice: any health reform will need to go through not just two committees in the Senate, but three committees in the House where Californian Representatives are in leadership positions. It is in these committees that health reform will be shaped, for better and worse.
And so your voice is needed now.
So for readers of this blog, if you want health reform to include an idea or provision — a strong public health insurance option, assistance to low- and middle-income people to pay for coverage, a prohibition on insurers denying coverage for so-called “pre-existing conditions,” or an emphasis on covering preventative care — write to your Representatives today. President Obama did so himself recently, sending key Senators a letter detailing more of his requirements, from more emphasis on cost containment to the need for a public health insurance option.
On Friday, a “draft of a draft” of a health reform bill was released by Senator Ted Kennedy’s office. We’ll have an update and some analysis later at our Health Access blog. (Courtesy of The Hill, here’s a copy of the 170+ pages [PDF], which is understood to be only a part of a broader package.) The House is expected to have its own bill as well, with a similar framework but different details. The hope is that the both the House and Senate will pass their versions of health reform bills by the end of July, allowing for August and September to negotiate the differences and get a bill to the President’s desk.