The current debate highlights the clear need to reform the private insurance market, provide more affordable choice of insurance plans and eliminate pervasive problems that frustrate patients and physicians.

A co-op could be a good compromise, and AMA has signaled its openness to the concept. As always the devil is in the details.

More than two decades ago, physician delegates to the AMA voted to support co-ops, creating policy that called on the AMA to “encourage unions, trade associations, health insurance purchasing cooperatives, farm bureaus, fraternal organizations, chambers of commerce, churches and religious groups, ethnic coalitions, and similar groups to serve as voluntary choice cooperatives for both children and the general uninsured population, with emphasis on formation of such pools by organizations which are national or regional in scope.”

While the co-ops under discussion may not exactly match the original concept supported by AMA physicians in the 80’s, the underlying rationale – to help extend affordable coverage to as many people as possible – remains the same.

Co-ops would expand patient choice of affordable insurance options as would the exchange concept. These reforms will benefit all Americans--those currently insured and those without health insurance.

Sen. Kennedy was both respected and liked by colleagues on both sides of the aisle during his remarkable 47 years in the Senate.

While he always was firm in his liberal views and we seldom agreed with him, Sen. Kennedy did listen to his Republican colleagues and worked to forge compromises. That bipartisan spirit has been markedly missing during his absence from the Senate this year. The health reform legislation making its way through Congress is rigid and aggressively liberal, without any evidence of bipartisanship, and it is rightly facing a firestorm of opposition.

Sen. Robert Byrd has asked that the bill be named after Sen. Kennedy in hopes that will revitalize its chances of passage. But I think it is too late. The American people understand the huge impact this legislation would have on the lives of 300 million Americans, and they are not going to be swayed by sentiment. The debate will continue.

I testified before Senator Kenned on many occasions. As he did with other conservatives genuinely interested in health reform, he treated me with the outmost civility, respect and courtesy. He listened careful and sometimes made clear he agreed. When he asked tough questions, which he always did, he asked them without any edge of disdain. He wanted to listen to the answers, and see if there were areas of agreement, or points I made that he could convice me were wrong. He was a tough, principled gentlmanly liberal whom we will all miss.

Senator Kennedy was an extraordinary legislator and health care leader. In addition to his longstanding commitment to quality health care for all Americans and his many years chairing the Senate HELP committee, Senator Kennedy was responsible for hundreds of bills that have changed the American health care landscape. The outcomes of his numerous legislative accomplishments are so ingrained in our culture that it is difficult to remember a time when our nation didn’t seek to support individuals who were disabled or mentally ill, fund education and treatment for AIDS, or protect workers from losing health insurance if they changed jobs, to name only a few.

For those of us in academic medicine, Senator Kennedy’s leadership on issues such as Medicare funding for teaching hospitals and physicians, financial assistance for students of all economic levels, and support for the Title VII health professions and the National Institutes of Health was exemplary. Senator Kennedy was not only a vocal champion, but also a passionate and articulate partner. The entire academic medicine community deeply mourns his passing.

Updated at 1:43 p.m. on Aug. 27.

Senator Kennedy was kind and gracious in his treatment of me, even though we had different political views.

His lasting positive contribution was in the area of deregulation of trucking and the airlines. In both cases, he was convinced that free market competition met consumer needs better than regulation.

I never had the opportunity to speak in depth to him, one on one. Given the chance, I would have tried to convince him that what is true of trucking and the airlines is also true of health care.

I would probably have failed. But then again, maybe not.

Comment about Ted Kennedy from former HHS Secretary Louis W. Sullivan:

“We mourn the loss of Senator Edward Kennedy – a national champion on health issues who supported Morehouse School of Medicine (MSM) and its mission. I first met Senator Kennedy in 1975, through then-U.S. Congressman Andrew Young. As a member of the Senate Health Committee, Senator Kennedy supported critical funding efforts for the school’s early development; in the late 70’s, a $5 million construction grant for our first building and in 1982, a $15 million Title III education grant. These two grants and other support through the years from Senator Kennedy were very important to the development of MSM as a school focused on providing our citizens with primary care practitioners and a more diverse health care workforce. Distinguished graduates of MSM, like Georgia Community Health Commissioner Dr. Rhonda Medows, Meharry Medical College President Dr. Wayne Riley and U.S. Surgeon General Nominee Dr. Regina Benjamin are a legacy to the life and health care commitment of Senator Edward Kennedy.”

E. Neil Trautwein, vice president of the Employee Benefits Policy Counsel, National Retail Federation, had this to say about Ted Kennedy:

"Like many Americans, I was saddened this morning to hear of Senator Edward Kennedy’s death. Sen. Kennedy (D-MA) – Ted or Teddy Kennedy to many or most – was a true giant of the U.S. Senate. I will miss him.

Kennedy’s own words – essentially that we live on past our years in the future we create for others – sum up his life best. There is an excellent retrospective on Kennedy in today’s New York Times if you seek greater detail on his life.

Ted Kennedy was a true lion of the Senate, dominating its agenda regardless of the politics of the day and forging pragmatic alliances heedless of the recriminations of anyone’s base. He was there to advance the public good and understood well that sometimes progress comes in grand leaps but more often it comes in smaller steps. Each kind of progress was valued and celebrated. We would never be in the mess that we are in now on health care reform had Kennedy been in good health.

He has been a fixture in my life in Washington, from my earliest days as a staffer on the Senate Judiciary Committee to the latter days of health reform. I knew him best during the mental health parity reform fight where he bridged the differences between employers and mental health advocates and forged the ultimate compromise. Even in illness, he still delighted in the specific personal touch that advanced the unlikely politics. He was a master legislator, much admired even when he was our fiercest adversary. He understood clearly that today’s adversary was tomorrow’s ally – a lesson too often lost in political life today.

Ted Kennedy’s life was more than the battles we fought and the causes we shared. But, it is hard to think of the past 50 years of history without finding his imprint through and through. It is harder still to think about a future without Kennedy to consider in some degree. Perhaps the most fitting tribute to him of all will be to assume Kennedy’s lifelong ethic and get quickly back to work building the better future for those who will come after us. He would appreciate that.

The National Coalition on Health Care joins the Nation in mourning the loss of Senator Edward M. Kennedy and celebrating his unmatched legacy of public service, perseverance and leadership in the legislative arena.

For over three decades it has been our honor to work with Senator Kennedy in building bipartisan support for a better future for all Americans. His commitment to a nation of high principle and bold endeavors immeasurably improved countless lives.

In this time of remembrance, we rededicate ourselves to seeing what Ted Kennedy called the cause of his life – the enactment of sustainable reform to ensure that every American has access to quality, affordable health care -- is realized. To quote one of his final public speeches, today, for us “the work begins anew.”

Updated at 3:39 p.m. on Aug. 26.

We share the nation's sadness in mourning the loss of Senator Ted Kennedy, a lifelong champion for health whose leadership on such monumental legislation as the State Children's Health Insurance Program and the Americans With Disabilities Act leaves a lasting legacy that benefits the nation as a whole.

Over nearly five decades, Senator Kennedy has been a powerful force for good with few peers. As a leader and a legislator, he appreciated the importance of medical progress for patients here and around the world.

Like the rest of the nation, we are grateful for Senator Kennedy's decades of service to this nation. We have truly lost a remarkable gentleman and Congressional giant.

Today, the American Medical Association joins the nation in mourning the death of Senator Edward Kennedy.

During his many years in public service, Senator Kennedy was a champion for America’s patients – working until the end to make improvements on their behalf. For example, Senator Kennedy was a leading voice in efforts to expand access to health care for children and to secure fair health coverage for the mentally ill.

Earlier this year, the AMA honored Senator Kennedy with its highest award for government service, which is bestowed on those who go above and beyond the call of duty to improve public health.

His triumphant and deeply appreciated return to the Senate floor after brain surgery last summer helped Congress preserve seniors' access to care by halting steep Medicare physician payment cuts, demonstrating the depth of his commitment to our nation's most vulnerable citizens.

No doubt Senator Kennedy’s legacy will be burnished by his many contributions to improving America’s health system over the years – including his work that helped pave the way for this year’s effort to provide affordable, quality health insurance coverage to all Americans.

Throughout his Senate career Senator Kennedy was an eloquent and effective leader in efforts to ensure access to quality health care for all Americans, and his many significant legislative achievements brought millions of American families into the health care system. While we have lost a valuable voice in efforts to improve health care for all Americans, the legacy of Senator Kennedy is evident in today’s efforts to reform our health care system, which builds on the goals and ideals Senator Kennedy stood for: that health care for all Americans is an economic and well as moral imperative for our nation.

Beyond the specific legislation he championed, the Senator raised the level of the debate on health care. He forged bipartisan consensus on important issues such as expanding health insurance coverage to low-income children and kept health care reform on the forefront of the national agenda.

Highlights of notable health care legislation enacted with Senator Kennedy's leadership include:

• The Community Health and Mental Health Centers Acts of 1967-70, establishing a national program of neighborhood health centers.
• Legislation to establish early models of HMOs that were non-profit and local.
• Legislation to expand physician training, especially family medicine and primary care.
• Health planning and cost containment bills, including the National Health Planning and Resource Development Act of 1974.
• The Kennedy-Griffiths and Kennedy-Corman national health insurance bills of the 70s.
• The COBRA bill to provide unemployed workers access to health insurance coverage.

Additionally, Senator Kennedy worked with Republican Orrin Hatch of Utah to enact one of the most important expansions of health insurance coverage, the Children’s Health Insurance Program of 1997, to provide coverage to low-income children. After the reauthorization of the legislation earlier this year, the program was expanded to cover an additional 4 million uninsured children.

Senator Kennedy had a wide and deep understanding of health care policy, and connected the goals of universal coverage with high-quality, efficient care. He understood the importance of organizing the delivery of health care to integrate specialized services and allocate resources efficiently. He was also forward-looking in learning from the health care systems of other industrialized countries; in the 1970s he studied systems in European countries and Israel. Today we hope to realize many of his health reform goals.

We -- the nation, the world -- lost a good, gentle giant last night. Ted Kennedy was the finest, the most accomplished, legislator in our lifetime. Through his public service, he enriched the lives of countless people -- people who needed a passionate and compassionate voice in the seat of power. His strong, emphatic voice was often the clarion call that made possible historic advances in civil rights, equal education opportunities, removal of barriers for people with disabilities, judicial justice, workers' and retirees' rights, and, of course, it has led us to the cusp of decent, affordable health care for everyone. Ted was a dreamer and an idealist. He also mastered the all-too-rare art of blending lofty ideals with political practicalities. He, better than anyone, understood what was achievable -- and he made it happen. Ted loved humanity. He also showered great warmth and affection to the people who had the opportunity to work closely with him. We will miss him more than words can express. May his example shine in our hearts so that we re-dedicate ourselves to the mission he has left for us to complete! We will enact high-quality, affordable health coverage and care for all Americans this year.

Sen. Edward M. Kennedy (D-Mass.) served in the U.S. Senate for nearly 47 years before succumbing to glioblastoma at the age of 77. Even through this challenge he waged a gallant effort. The “lion” of the Senate, Sen. Kennedy championed many progressive issues through his storied career, but none more consistently than his passion for health care. His clear vision was that all Americans should have access to affordable, high-quality care.

Known as the most organized and capable member of the Chamber of Colleagues, he was more able than any member in recent history to reach across the aisle to form bipartisan agreement on the toughest issues and with his toughest adversaries. He exhibited extraordinary and youthful leadership in helping President Lyndon B. Johnson with the passage of Medicare and Medicaid in 1965, just five years after assuming his brother's Senate seat at age 30, and just two years after President John F. Kennedy’s assassination. It was then that he earned, and has maintained, a reputation as a man who was consistently true to his word and his promises, an increasing rarity in the politics of today.

Sen. Kennedy’s death comes during a week when the financial world has become especially jittery about increased federal spending and big initiatives, with the announcement that projections of the national debt greatly exceed previous forecasts. What timing: the sentiments and loyalties to the Lion will certainly tilt Congress' agenda toward passage of some kind of historic health reform bill. Whatever it contains, it will be more than it might have been in his honor and memory. Regardless of partisan views and his often liberal leanings, all members of Congress, citizens of the nation, and members of the College should pause in respectful recognition that a great man has left the world stage, but that his legacy will surely live on in the health of our nation.

From Richard Kirsch, National Campaign Manager, Health Care for America Now:

"Health Care for America Now joins the nation in mourning the passing of Senator Kennedy, for whom our mission - winning a guarantee of good health care for all - was his life's work. We dedicate ourselves in the next few weeks to realizing the vision, passion, and hopes of this great American, firmly in the knowledge that enacting health care reform will rightly be seen as Ted Kennedy's legacy."

I've worked on a face to face basis with Sen. Ted Kennedy for the past 33 years, ever since I came to work as a young legislative assistant to Sen Jacob Javits on what was then the Labor and Human Resources Committee . His passing last night leaves a huge leadership vacuum in the ongoing effort to better our health system. But while his legislative accomplishments were huge, my memories of him keep coming back to three themes:

1. His joy in life and in legislating. It seemed he always had a smile and always was glad to engage others. He was the embodiment of good cheer. He was full of life and expansive in bringing others into it. He made it fun to be part of any enterprise he was leading.

2. His ability to inspire loyalty among staff. He always had a large and very able staff. Once you were part of it, you were always part of the family. As a result, he built a huge network of key former staffers in both private and public sectors that continued to work with him on a wide range of issues and concerns. Lifelong staff loyalty to him was in itself a tribute and an important asset.

3. His strategic ability to craft legislative compromise with an eye to the long run. He understood that getting the infrastructure and basic design in place was often more important than the level of spending or benefits, because those things could be addressed later. His legislative legacy is so large in part because he knew the difference between what was essential and what could be addressed in future years.

Co-ops are not harmful or pointless, but they're definitely not helpful. And they're certainly not a substitute for a public health insurance option.

Jacob Hacker, the father of the public option policy idea that became part of the health care plan President Obama won and ran on, has laid down the definitive word on co-ops last week:

The Senate Finance Committee’s cooperative model is not good, nor even not-so-good. It is “ugly.” Although few specifics about the model are available, there is absolutely no reason to think that cooperatives of any sort could achieve the three crucial goal that a competing public plan must accomplish—provide a backup option offering health and financial security to individuals without employer coverage, a cost and quality benchmark, and a cost-control backstop that drives payment and delivery system reform.

In a call with Representatives Grijalva and Ellison, Hacker released his new report on the public option proposals in Congress, calling the co-op proposal a "cop-out."

He doesn't just say it, of course. He proves it:

Consumer cooperatives would have several severe disadvantages. First, they would require building a new set of plans largely from scratch in markets often dominated by one or two powerful insurers. This would mean forfeiting the administrative, economic, and political advantages of building on the Medicare infrastructure to a get a new alternative to private plans up and running quickly. Second, such models would also require forfeiting another major advantage of a Medicare-like public plan: the ability to provide enrollees with a broad choice of providers. The only two sizable examples of consumer health cooperatives, Group Health Cooperative of Puget Sound and HealthPartners in Minnesota, are both health maintenance organizations (HMOs) with restricted provider networks. And they have had decades to become established. New cooperatives would face the same problems breaking into markets that smaller private competitors face in many markets today. Analysts at Oppenheimer, Carl McDonald and James Naklicki, report that “as the co-ops are currently described, we think they would be a big positive for the managed care group, but it seems to us that they would be destined to fail from the moment of creation.”

The history of health cooperatives backs up McDonald and Naklicki’s pessimism. Cooperatives of various sorts have been discussed and sometimes created to provide health care in the past. After the Great Depression, the Farm Security Administration encouraged the development of health cooperatives–which at one point had about 600,000 members, mostly in rural areas. But the cooperatives crumbled in the face of physician resistance (including boycotts), the lack of financial wherewithal of the cooperatives themselves, and the eventual withdrawal of government support.

Even today’s remnants of the cooperative movement do not provide the most inspiring of lessons. The only survivor of the 1940s experiment is Group Health Cooperative of Puget Sound. It is a well-regarded HMO, paying doctors on a salaried basis but, unfortunately, is now little different from other nonprofit HMOs, with around a half million members in Idaho and Washington State. By contrast, WellPoint—the nation’s largest insurer and a major force behind the defeat of health care reform in another West Coast state, California—has more than 33 million members.

As Hacker says, this co-op idea will not work to hold insurance companies accountable and drive down costs, and as such, in his words, it's "not ready for primetime."

Though it's amusing to see Mr. Butler from the Heritage Foundation go after co-ops as if they were a public health insurance option. All that proves is that Republicans are not interested in coming to the table with constructive proposals to fix our health care crisis, they're just interested in saying, "No!"

Certain local cooperative health organizations that provide health insurance as well as an integrated delivery system provide top-quality integrated, coordinated care. But co-ops take years to become established, and more importantly, it is unlikely that such organizations would have sufficient purchasing power in their negotiations with health care providers to control health care costs in the long-term.

Whether we are considering a public health insurance plan or nonprofit cooperative plan, if the plan does not link payment to Medicare rates, it loses the advantage of representing the share of enrollees, and therefore provider revenues, needed to obtain lower prices. The Congressional Budget Office estimates that only 9 to 12 million people would be enrolled in these plans as currently designed. Negotiating provider payments for the 10 million or so people estimated to enroll in a public plan or private co-op plan is unlikely to yield significant savings.

After all, commercial insurers dominate the market in most geographic areas, and, with the exception of three states, the two largest health insurance plans in each state account for 50 percent or more of all private insurance enrollment. In local markets where there are dominant health care providers, hospitals and other providers are able to demand higher rates.

To truly contain costs, health reform needs to include some mechanism for controlling both medical outlays and insurance administrative overhead. A strong public plan is one effective option. There are certainly other options. For example, one approach would be a system of negotiating provider payment applicable under all plans--public or private. This is the model followed by most industrialized countries that leverage purchasing power by having a single entity--either a government agency or a nonprofit entity acting in the public interest--negotiate provider payment rates and methods on behalf of the entire population.

Another option would be to charge states with designing and implementing all-payer methods of provider payment. States with a plan that ensures fair and reasonable payment rates and methods that reflect value, harmonizes payment under public programs and private insurance, and effectively controls the growth in costs over time could be permitted to establish their own systems.

Still another course would be to extend Medicare payment innovations to private insurers. The health reform bills in the House and Senate go a long way toward improving Medicare’s payment system. They would establish a Center on Payment Innovation with the authority to test new methods of payment that reward value not volume of services, and spread the most successful of those payment methods rapidly. The bills call for in-depth analysis of ways of eliminating geographic disparities in Medicare payment. They also create strong independent authorities to establish Medicare payment rates and methods with requirements on Congress to act expeditiously, or failing action, for the recommended changes to take effect.

A broader charge to harmonize Medicare payment and private insurer payment--and to engage in multi-payer payment innovations--could spur more rational payment methods throughout the health system, enhance their impact, and lower administrative cost and complexity.

What should be unacceptable is to continue with our current system of provider payment--one that lacks leverage and coherence, results in an ever rising share of economic resources going to the health sector without commensurate value, and has high administrative costs due to fragmented and inchoate payment mechanisms all pulling in different directions.

If it walks like a duck….. And if it has all the characteristics of a public plan option then it is a public plan option. Had Senator Conrad and others wanted to make more private options available to Americans by empowering member-owned co-ops to offer health insurance he could have proposed that. It would merely require changes in the tax law to allow true nonprofit co-ops to operate like mutual insurance companies.

But instead, the federal co-op proposal is just an attempt to create a public plan by another name. Rather than relatively minor tax changes there would be federal legislation to design a new form of national or regional co-op and set rules for how these would be run. There would be yet another federal board (presumably with yet another czar) to keep a close eye on them and to make sure they remember who is in charge. And billions of dollars in federal money to keep them tied to Washington. In short, a public plan with a co-op veneer.

If the Administration and majority leadership would just recognize that their obsession with a public plan is a major obstacle to reform – whatever it is disguised as –and drop it, we could begin to make some progress.