About 16 million previously uninsured people seemed to have vanished during President Obama’s speech before the joint session of Congress. "There are now more than 30 million American citizens who cannot get coverage," he said. In every other speech he has given, he has cited Census Bureau numbers showing about 46 million people uninsured. The latest numbers show the number little unchanged.

It's not clear what the president subtracted to come up with the 30 million number.

Legal and illegal immigrants account for about 10 million and therefore would not be classified as "American citizens." About 10 million more are eligible for existing government programs but are not enrolled. Another 9 million make more than $75,000 and are assumed to be able to afford coverage. And 6 million are eligible for but not enrolled in employer-sponsored coverage.

By that calculation, less than 12 million Americans are without affordable options for coverage. Let's keep going, Mr. President. By targeting programs to those who truly need insurance, we can solve this problem!

Fine oratory but little of the real leadership needed at this stage, and no serious attempt at bipartisanship. To lead he needed to say which major titles of existing, competing leadership bills actually constitute “our bill” – he didn’t. Talking about malpractice reform demonstrations was almost amusing as an excuse for bipartisanship. We all know that to deep six anything you set up either a study commission or a demonstration (and this one will even be organized by a former director of the Kansas Trial Lawyers Association). If he was serious about bipartisanship he would have embraced such existing bipartisan bills as Baldwin-Price/Feingold-Graham to spur radical state action to expand coverage. Or a cap on the tax exclusion (yes, for affluent Americans) to give equitable tax help to other Americans to buy insurance. But he didn’t.

President Obama is a remarkable orator, no doubt about that. He made his case for health system reform fairly effectively despite receiving a cold shoulder from Republicans. It is apparent that the public option is not off the table from his smile and Speaker Pelosi’s obvious excitement, but there were some subtle messages in the address that show openness to compromise.

First, his apparent enthusiasm for the public option was tempered significantly by his acknowledgment that it is not an essential part of the strategy. That allows Senator Baucus to propose reforms that do not include a true public option (or any public option at all). And the President’s comment that health system reform will not contribute one dime to the deficit is another way of possibly suggesting that the solution for getting a bill passed will be reconciliation. To use reconciliation, which the Republicans will hate (although it was used to pass the Bush tax cuts), the net has to be budget-positive or budget-neutral. However, reconciliation does pose problems as key issues in reform process could possibly be eliminated, including changing how care is delivered, providing for preventative medicine and the modernization of the health system infrastructure.

It was encouraging to hear President Obama allude to payment reforms and again mention universal coverage. Changing the way we reimburse doctors is a key reform to not only reduce costs but also increase quality. And providing care for all Americans is one of the most important aspects of these reform efforts. Having those issues mentioned in President Obama’s address was a positive step.

There’s support across the political spectrum for initiatives to make health insurance more affordable and accessible, and we know that legislation has to slow the rate of growth in health care costs, or the situation will get worse instead of better. The speech could have been pivotal for bipartisanship if it had been clear-cut in ruling out the prospect of a new government-run plan. By leaving it up to Congress, where key leaders in both the House and Senate support a government-run plan and control the ultimate outcome, the President passed up a big opportunity.

Here is what I heard:

President to the Town Hall Voters: We didn't Hear a Thing You Said.

President Obama made two key points tonight. Number one, and most practically, he is still willing to compromise with those who still have an open mind, despite the way implacable ideological opponents have behaved this August (and before, and still tonight, Mr. Joe Wilson (R-SC), and no doubt tomorrow and forever). He signaled this through his willingness to implement malpractice reform, taxes on high end benefit packages, and linking the pace of coverage expansion with realized system savings. The latter in particular signalled both his commitment to fiscal responsibility and his confidence that so many experts we can all name are correct, we can reduce cost growth while improving quality.

Number two, he framed his commitment to reform in moral terms, and challenged us all, and specific senators, to remember both the better angels of our nature -- the character of our country -- and the bi-partisan nature of Senator Kennedy's most lasting achievements. Quite simply, he called on us to become the great nation we imagine ourselves to be or want to be, and in so doing, he elevated the issue out of partisan morass and into a compelling vision for a stronger, more united country facing 21st century challenges with an abiding faith that we shall indeed continue to overcome.

It is clear that the status quo is unacceptable. The AMA will continue to work for reform that makes the system work better for patients and physicians. We must seize this opportunity this year to achieve meaningful health reform for America’s patients and physicians.

The President outlined three essential goals that are vital to reform efforts in this country, including: ensuring the current system remains secure and stable for those who already have insurance coverage and are happy with it; making insurance coverage affordable and accessible to those who need it; and reducing unnecessary costs and waste in the current system.

The AMA believes these core goals are ones that the majority of the American people can and do support, and we urge Congress to find common ground in achieving them.

President Obama recognized what physicians have long known – that medical liability reform is needed to bring down the cost of health care, and he is directing the Department of Health and Human Services to take action now. Recognizing the critical need for medical liability reform is an important step toward reducing unnecessary costs. Everyday physicians across the country are forced to consider the broken medical liability system when making decisions, resulting in defensive medicine that adds to unnecessary health costs. We cannot ignore this problem if health-system reform is going to address the growing cost of care.

Just yesterday, the AMA sent a letter to President Obama and Congress urging them to reach agreement on health reform that includes seven critical elements. Health coverage for all Americans, insurance market reforms that expand choice and eliminate denials for pre-existing conditions, assurance that medical decisions will remain between the patient and physician, medical liability reforms to reduce the cost of defensive medicine, and repeal of the broken Medicare physicians payment formula that threatens seniors’ access to care are among them.

We have a historic opportunity to implement needed reforms to address shortcomings in the current system, while keeping in tact all that is working well. We will stay constructively engaged in the legislative process to ensure the final bill improves the health system for patients and the dedicated physicians who care for them.

This statement is from Richard Kirsch, National Campaign Director of Health Care for America Now:

"President Obama issued a clarion call for reforms that will guarantee all Americans have good, affordable coverage, directly taking on the insurance industry that wants to protect its profits and his political opponents who are engaging in fear-mongering for partisan purposes. He reaffirmed his support for the reforms that are essential to achieving his goals: assuring that people get good health coverage at work; strict regulation of the insurance industry; competition between private insurers and a new public health insurance option; and shared responsibility between individuals, employers and government in paying for coverage. The President reminded us that those who have opposed government programs like Social Security and Medicare in the past are once again working to deny history.

Health Care for America Now will continue to rally Americans at the grassroots nationwide to make sure Congress enacts health insurance reforms that deliver on the President’s historic charge this year."

We all want health care reform that will reduce costs, improve quality and expand access without breaking the bank. The bipartisan talks we’re having in the Finance Committee represent the best chance we have of achieving our shared goals, and I urge Democrat leaders not to close the door on these productive discussions.

To achieve bipartisan reform, we have to set aside the most contentious pieces like the government-run plan and focus on areas where we can reach agreement. The nonpartisan Congressional Budget Office has said the government-run plan won’t reduce costs, the proposal doesn’t have the votes to pass in the Senate, and the American people have made clear they don’t want it.

I hope that the President and Democrats in Congress will drop the government-run plan and work with us to find meaningful ways to boost competition and reduce costs. It’s time to scrap the partisan bills that have already passed in Congressional committees and begin with a new, reasonable and consensus approach that the American people can believe in.

The challenge for the President tonight was to explain how health care reform would help America’s families and businesses. He succeeded in meeting this challenge and, as a result, the President substantially improved the likelihood that meaningful health care reform will be adopted this year.

For the past weeks, the public has only heard about the myths of health care reform and about the most contentious policy issues.

Tonight the President’s speech ascended above this confusing din. He explained how key health reform provisions – which are in all the bills, are not the subject of contentiousness, and yet are unknown to the public – will help America’s families and businesses.

As people around the country learn more about what is truly in the health reform legislation, they will strengthen their conviction that the status quo cannot be an option for our nation. The President aided this process enormously tonight.

President Obama made a forceful case for health reform in his address to Congress and the public, stressing the imperative of action on the goals of ensuring stability and security of coverage for those who have it; providing insurance for those who don’t; and slowing the rising health care costs. He paved a centrist path, rejecting extreme solutions from the right and left, but also signaling his openness to the best ideas from all. But most of all he stressed that after a century of inaction, now is the season to act and that failure is not an option. It is too important to those who are harmed by our inadequate insurance system, too important to our economy, and too important to our character as a country.

First, on a personal note, I want to thank the President for his kind remarks about my father. Dad was a great man and he gave his all to see that all Americans get access to health care. It is a testament to his character and determination that he is still recognized today, almost 54 years since he left us.

The President’s remarks remind us what this debate is all about – making sure Americans have access to the best health care in the world and ensuring that our nation can pay for it. His remarks will not stop the lies coming from those outfits paid to defeat our bill, nor will they not stop insurance companies from spending $1.4 million a day to lobby Congress against H.R. 3200, and they will not change the minds of those politicians who simply want to hand the President a highly visible, painful defeat. What the President did do was spell out responsible and practical solutions to our health care crisis. Not everyone will get exactly what they want, but it is clear from this evening’s remarks the President is determined to give us the bill we need. I ask that all Americans take a look at the facts he laid out this evening.

My Democratic House colleagues, many of whom like me endured difficult town hall meetings back in the district during August, are more committed than ever to getting a bill through the House that will create quality, affordable health care for our nation. We will continue to discuss the public option and I will continue to work on a bill that will control costs, protect consumers and make our system more competitive. I am pleased that the President clearly stated his support for the public option again this evening. I will also work with my colleagues – from Blue Dog to Progressive and all points in between – to find common ground, and perhaps we can agree on a ‘trigger’ that would make all sides happy. President Obama included Republican proposals in his address this evening – an important step towards bipartisanship. There is room to deal on all sides. We must sit down together and work out the details that divide us so we can get to the enormous goal that unites us – creating secure and stable health care for all Americans.

If you look at the Energy and Commerce Committee, you can see terrific suggestions coming from Members like Anthony Weiner and Bart Gordon, who come from very different places on the ideological spectrum, but both are determined to finding solutions and averting a certain calamity heading our way. This is the spirit we need now. Political opportunists who want to grandstand and demagogue this issue – your time in the spotlight is over. Come willing to work with us on a good bill or be prepared to watch from the sidelines.

Many of the Presidents suggestions are already part H.R. 3200, including as the much needed reforms of the insurance industry and making health care more affordable for all. We even addressed medical malpractice issues, one that the President highlighted, in an amendment that passed during Energy and Commerce mark up. As we continue to move through this legislative process we will refine the bill based on the Presidents priorities so that we develop the best possible package.

The President has given us something strong to work with. I would be the first to say it if he needed to do something different. Now, we must take the policy prescriptions he has put forward and make it reality. I owe all those who’ve fought this battle before me and along side me – from my dear old dad to my friend Senator Kennedy – to find a way to make this happen. We can get a deal done… and we will. That is my promise.

I thank the President for his address to our nation this evening. This is a complex issue. We saw over the August break that special interests and right wing fanatics spread lies that scare the American public and make it more difficult to achieve real health reform.

We agree the status quo is not sustainable. That is why health plans last year did something industries rarely do: stepped up and offered solutions to address the health care concerns raised by the American people. We proposed health insurance reform to guarantee coverage to all Americans, eliminate pre-existing condition exclusions and rescissions, and no longer base premiums on a person’s health status or gender. To keep coverage as affordable as possible, these reforms must be paired with an effective coverage requirement to get everyone into the health care system.

New health insurance reforms and consumer protections will solve the problem without creating a new government-run plan that will disrupt the quality coverage that millions of Americans rely on today. We share the concerns that hospitals, doctors, employers, and patients have all raised about the significant unintended consequences of a government-run plan.

Health care reform must also include a serious commitment to cost containment to ensure coverage is more affordable and to put our health care system on a sustainable and fiscally responsible path. New taxes on health care coverage will have the opposite effect by making coverage less affordable for families and small businesses across the country.

Health plans will continue to work with policymakers and stakeholders to advance comprehensive, bipartisan health care reform. The nation cannot afford to let this historic opportunity pass us by.

Tonight the President re-focused the nation’s attention on all the reasons we need to reform our health care system. He cut through the smokescreen of distortions and outright lies that too frequently dominated the debate in August.

This is about every American who is one step away from losing their health insurance if they lose their job. This is about people who see their premiums soar when they develop a health care problem. This is about people who can’t get coverage if they have a pre-existing condition. This is about every family and every business struggling with health care costs.

He told us his vision for what we need to do, and set out specific approaches for moving forward that includes both Republican and Democratic ideas. And he made it clear he will use his prestige and all his considerable leadership and communication skills to achieve a meaningful health care reform bill that will affect every American. I am ready to do all I can to work with the President and my colleagues in the House and Senate to pass this legislation and enact it into law.

Rep. Charles Boustany, R-La., Delivers Republican Health Care Address following President Obama's speech to Congress tonight

“Good evening. I’m Dr. Charles Boustany, and I’m proud to serve the people of Louisiana’s Seventh Congressional District. I’m also a heart surgeon with more than 20 years of experience, during which I saw first-hand the need for lowering health care costs.

“Republicans are pleased that President Obama came to the Capitol tonight. We agree much needs to be done to lower the cost of health care for all Americans. On that goal, Republicans are ready – and we’ve been ready – to work with the President for common-sense reforms that our nation can afford.

“Afford is an important word. Our country is facing many challenges. The cost of health care is rising. Federal spending is soaring. We’re piling huge debt on our children. And families and small businesses are struggling through a jobless recovery, with more than 2.4 million private-sector jobs lost since February.

“It’s clear the American people want health care reform, but they want their elected leaders to get it right. Most Americans wanted to hear the President tell Speaker Pelosi, Majority Leader Reid and the rest of Congress that it’s time to start over on a common-sense, bipartisan plan focused on lowering the cost of health care while improving quality. That’s what I heard over the past several months in talking to thousands of my constituents.

“Replacing your family’s current health care with government-run health care is not the answer. In fact, it’ll make health care much more expensive. That’s not just my personal diagnosis as a doctor or a Republican; it’s the conclusion of the nonpartisan Congressional Budget Office – the neutral scorekeeper that determines the cost of major bills.

“I read the bill Democrats passed through committee in July. It creates 53 new government bureaucracies, adds hundreds of billions to our national debt, and raises taxes on job-creators by $600 billion. And, it cuts Medicare by $500 billion, while doing virtually nothing to make the program better for our seniors.

“The President had a chance tonight to take government-run health care off the table. Unfortunately, he didn’t do it.

“We can do better, with a targeted approach that tackles the biggest problems. Here are four important areas where we can agree, right now:

“One, all individuals should have access to coverage, regardless of preexisting conditions.

“Two, individuals, small businesses and other groups should be able to join together to get health insurance at lower prices, the same way large businesses and labor unions do.

“Three, we can provide assistance to those who still cannot access a doctor.

“And, four, insurers should be able to offer incentives for wellness care and prevention – something particularly important to me. I operated on too many people who could have avoided surgery if they’d simply made healthier choices earlier in life.

“We do have ideas the President hasn’t agreed with. We’re grateful the President mentioned medical liability reform, and we hope he’s serious. We need to establish tough liability reform standards, encourage speedy resolution of claims, and deter junk lawsuits that drive up the cost of care. Real reform must do this.

“Let’s also talk about letting families and businesses buy insurance across state lines. I and many other Republicans believe that that will provide real choice and competition to lower the cost of health insurance. Unfortunately, the President disagrees.

“You can read more about all these reforms at healthcare.gop.gov. These are common-sense reforms we can achieve right away – without destroying jobs, exploding the deficit, rationing care, or taking away the freedom American families cherish.

“This Congress can pass meaningful reform soon to reduce some of the fear and anxiety families are feeling in these very difficult times. Working together in a bipartisan way, we can truly lower the cost of health care while improving quality for the American people.

“I’m Dr. Charles Boustany. Thanks for listening.”

For 35 years, the health care debate has been about covering the uninsured. Tonight the President made it about the middle class. There is no underestimating the impact this will have on the debate. Congressional Republicans may have decided to oppose this bill for political purposes, but many Republicans and Independents outside the beltway will take another look at this debate because the President has made it about the middle class.

Remarks of President Barack Obama – As Prepared for Delivery

Address to a Joint Session of Congress on Health Care

Wednesday, September 9th, 2009

Madame Speaker, Vice President Biden, Members of Congress, and the American people:

When I spoke here last winter, this nation was facing the worst economic crisis since the Great Depression. We were losing an average of 700,000 jobs per month. Credit was frozen. And our financial system was on the verge of collapse.

As any American who is still looking for work or a way to pay their bills will tell you, we are by no means out of the woods. A full and vibrant recovery is many months away. And I will not let up until those Americans who seek jobs can find them; until those businesses that seek capital and credit can thrive; until all responsible homeowners can stay in their homes. That is our ultimate goal. But thanks to the bold and decisive action we have taken since January, I can stand here with confidence and say that we have pulled this economy back from the brink.

I want to thank the members of this body for your efforts and your support in these last several months, and especially those who have taken the difficult votes that have put us on a path to recovery. I also want to thank the American people for their patience and resolve during this trying time for our nation.

But we did not come here just to clean up crises. We came to build a future. So tonight, I return to speak to all of you about an issue that is central to that future – and that is the issue of health care.

I am not the first President to take up this cause, but I am determined to be the last. It has now been nearly a century since Theodore Roosevelt first called for health care reform. And ever since, nearly every President and Congress, whether Democrat or Republican, has attempted to meet this challenge in some way. A bill for comprehensive health reform was first introduced by John Dingell Sr. in 1943. Sixty-five years later, his son continues to introduce that same bill at the beginning of each session.

Our collective failure to meet this challenge – year after year, decade after decade – has led us to a breaking point. Everyone understands the extraordinary hardships that are placed on the uninsured, who live every day just one accident or illness away from bankruptcy. These are not primarily people on welfare. These are middle-class Americans. Some can’t get insurance on the job. Others are self-employed, and can’t afford it, since buying insurance on your own costs you three times as much as the coverage you get from your employer. Many other Americans who are willing and able to pay are still denied insurance due to previous illnesses or conditions that insurance companies decide are too risky or expensive to cover.

We are the only advanced democracy on Earth – the only wealthy nation – that allows such hardships for millions of its people. There are now more than thirty million American citizens who cannot get coverage. In just a two year period, one in every three Americans goes without health care coverage at some point. And every day, 14,000 Americans lose their coverage. In other words, it can happen to anyone.

But the problem that plagues the health care system is not just a problem of the uninsured. Those who do have insurance have never had less security and stability than they do today. More and more Americans worry that if you move, lose your job, or change your job, you’ll lose your health insurance too. More and more Americans pay their premiums, only to discover that their insurance company has dropped their coverage when they get sick, or won’t pay the full cost of care. It happens every day.

One man from Illinois lost his coverage in the middle of chemotherapy because his insurer found that he hadn’t reported gallstones that he didn’t even know about. They delayed his treatment, and he died because of it. Another woman from Texas was about to get a double mastectomy when her insurance company canceled her policy because she forgot to declare a case of acne. By the time she had her insurance reinstated, her breast cancer more than doubled in size. That is heart-breaking, it is wrong, and no one should be treated that way in the United States of America.

Then there’s the problem of rising costs. We spend one-and-a-half times more per person on health care than any other country, but we aren’t any healthier for it. This is one of the reasons that insurance premiums have gone up three times faster than wages. It’s why so many employers – especially small businesses – are forcing their employees to pay more for insurance, or are dropping their coverage entirely. It’s why so many aspiring entrepreneurs cannot afford to open a business in the first place, and why American businesses that compete internationally – like our automakers – are at a huge disadvantage. And it’s why those of us with health insurance are also paying a hidden and growing tax for those without it – about $1000 per year that pays for somebody else’s emergency room and charitable care.

Finally, our health care system is placing an unsustainable burden on taxpayers. When health care costs grow at the rate they have, it puts greater pressure on programs like Medicare and Medicaid. If we do nothing to slow these skyrocketing costs, we will eventually be spending more on Medicare and Medicaid than every other government program combined. Put simply, our health care problem is our deficit problem. Nothing else even comes close.

These are the facts. Nobody disputes them. We know we must reform this system. The question is how.

There are those on the left who believe that the only way to fix the system is through a single-payer system like Canada’s, where we would severely restrict the private insurance market and have the government provide coverage for everyone. On the right, there are those who argue that we should end the employer-based system and leave individuals to buy health insurance on their own.

I have to say that there are arguments to be made for both approaches. But either one would represent a radical shift that would disrupt the health care most people currently have. Since health care represents one-sixth of our economy, I believe it makes more sense to build on what works and fix what doesn’t, rather than try to build an entirely new system from scratch. And that is precisely what those of you in Congress have tried to do over the past several months.

During that time, we have seen Washington at its best and its worst.

We have seen many in this chamber work tirelessly for the better part of this year to offer thoughtful ideas about how to achieve reform. Of the five committees asked to develop bills, four have completed their work, and the Senate Finance Committee announced today that it will move forward next week. That has never happened before. Our overall efforts have been supported by an unprecedented coalition of doctors and nurses; hospitals, seniors’ groups and even drug companies – many of whom opposed reform in the past. And there is agreement in this chamber on about eighty percent of what needs to be done, putting us closer to the goal of reform than we have ever been.

But what we have also seen in these last months is the same partisan spectacle that only hardens the disdain many Americans have toward their own government. Instead of honest debate, we have seen scare tactics. Some have dug into unyielding ideological camps that offer no hope of compromise. Too many have used this as an opportunity to score short-term political points, even if it robs the country of our opportunity to solve a long-term challenge. And out of this blizzard of charges and counter-charges, confusion has reigned.

Well the time for bickering is over. The time for games has passed. Now is the season for action. Now is when we must bring the best ideas of both parties together, and show the American people that we can still do what we were sent here to do. Now is the time to deliver on health care.

The plan I’m announcing tonight would meet three basic goals:

It will provide more security and stability to those who have health insurance. It will provide insurance to those who don’t. And it will slow the growth of health care costs for our families, our businesses, and our government. It’s a plan that asks everyone to take responsibility for meeting this challenge – not just government and insurance companies, but employers and individuals. And it’s a plan that incorporates ideas from Senators and Congressmen; from Democrats and Republicans – and yes, from some of my opponents in both the primary and general election.

Here are the details that every American needs to know about this plan:

First, if you are among the hundreds of millions of Americans who already have health insurance through your job, Medicare, Medicaid, or the VA, nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: nothing in our plan requires you to change what you have.

What this plan will do is to make the insurance you have work better for you. Under this plan, it will be against the law for insurance companies to deny you coverage because of a pre-existing condition. As soon as I sign this bill, it will be against the law for insurance companies to drop your coverage when you get sick or water it down when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or a lifetime. We will place a limit on how much you can be charged for out-of-pocket expenses, because in the United States of America, no one should go broke because they get sick. And insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies – because there’s no reason we shouldn’t be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives.

That’s what Americans who have health insurance can expect from this plan – more security and stability.

Now, if you’re one of the tens of millions of Americans who don’t currently have health insurance, the second part of this plan will finally offer you quality, affordable choices. If you lose your job or change your job, you will be able to get coverage. If you strike out on your own and start a small business, you will be able to get coverage. We will do this by creating a new insurance exchange – a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices. Insurance companies will have an incentive to participate in this exchange because it lets them compete for millions of new customers. As one big group, these customers will have greater leverage to bargain with the insurance companies for better prices and quality coverage. This is how large companies and government employees get affordable insurance. It’s how everyone in this Congress gets affordable insurance. And it’s time to give every American the same opportunity that we’ve given ourselves.

For those individuals and small businesses who still cannot afford the lower-priced insurance available in the exchange, we will provide tax credits, the size of which will be based on your need. And all insurance companies that want access to this new marketplace will have to abide by the consumer protections I already mentioned. This exchange will take effect in four years, which will give us time to do it right. In the meantime, for those Americans who can’t get insurance today because they have pre-existing medical conditions, we will immediately offer low-cost coverage that will protect you against financial ruin if you become seriously ill. This was a good idea when Senator John McCain proposed it in the campaign, it’s a good idea now, and we should embrace it.

Now, even if we provide these affordable options, there may be those – particularly the young and healthy – who still want to take the risk and go without coverage. There may still be companies that refuse to do right by their workers. The problem is, such irresponsible behavior costs all the rest of us money. If there are affordable options and people still don’t sign up for health insurance, it means we pay for those people’s expensive emergency room visits. If some businesses don’t provide workers health care, it forces the rest of us to pick up the tab when their workers get sick, and gives those businesses an unfair advantage over their competitors. And unless everybody does their part, many of the insurance reforms we seek – especially requiring insurance companies to cover pre-existing conditions – just can’t be achieved.

That’s why under my plan, individuals will be required to carry basic health insurance – just as most states require you to carry auto insurance. Likewise, businesses will be required to either offer their workers health care, or chip in to help cover the cost of their workers. There will be a hardship waiver for those individuals who still cannot afford coverage, and 95% of all small businesses, because of their size and narrow profit margin, would be exempt from these requirements. But we cannot have large businesses and individuals who can afford coverage game the system by avoiding responsibility to themselves or their employees. Improving our health care system only works if everybody does their part.

While there remain some significant details to be ironed out, I believe a broad consensus exists for the aspects of the plan I just outlined: consumer protections for those with insurance, an exchange that allows individuals and small businesses to purchase affordable coverage, and a requirement that people who can afford insurance get insurance.

And I have no doubt that these reforms would greatly benefit Americans from all walks of life, as well as the economy as a whole. Still, given all the misinformation that’s been spread over the past few months, I realize that many Americans have grown nervous about reform. So tonight I’d like to address some of the key controversies that are still out there.

Some of people’s concerns have grown out of bogus claims spread by those whose only agenda is to kill reform at any cost. The best example is the claim, made not just by radio and cable talk show hosts, but prominent politicians, that we plan to set up panels of bureaucrats with the power to kill off senior citizens. Such a charge would be laughable if it weren’t so cynical and irresponsible. It is a lie, plain and simple.

There are also those who claim that our reform effort will insure illegal immigrants. This, too, is false – the reforms I’m proposing would not apply to those who are here illegally. And one more misunderstanding I want to clear up – under our plan, no federal dollars will be used to fund abortions, and federal conscience laws will remain in place.

My health care proposal has also been attacked by some who oppose reform as a “government takeover” of the entire health care system. As proof, critics point to a provision in our plan that allows the uninsured and small businesses to choose a publicly-sponsored insurance option, administered by the government just like Medicaid or Medicare.

So let me set the record straight. My guiding principle is, and always has been, that consumers do better when there is choice and competition. Unfortunately, in 34 states, 75% of the insurance market is controlled by five or fewer companies. In Alabama, almost 90% is controlled by just one company. Without competition, the price of insurance goes up and the quality goes down. And it makes it easier for insurance companies to treat their customers badly – by cherry-picking the healthiest individuals and trying to drop the sickest; by overcharging small businesses who have no leverage; and by jacking up rates.

Insurance executives don’t do this because they are bad people. They do it because it’s profitable. As one former insurance executive testified before Congress, insurance companies are not only encouraged to find reasons to drop the seriously ill; they are rewarded for it. All of this is in service of meeting what this former executive called “Wall Street’s relentless profit expectations.”

Now, I have no interest in putting insurance companies out of business. They provide a legitimate service, and employ a lot of our friends and neighbors. I just want to hold them accountable. The insurance reforms that I’ve already mentioned would do just that. But an additional step we can take to keep insurance companies honest is by making a not-for-profit public option available in the insurance exchange. Let me be clear – it would only be an option for those who don’t have insurance. No one would be forced to choose it, and it would not impact those of you who already have insurance. In fact, based on Congressional Budget Office estimates, we believe that less than 5% of Americans would sign up.

Despite all this, the insurance companies and their allies don’t like this idea. They argue that these private companies can’t fairly compete with the government. And they’d be right if taxpayers were subsidizing this public insurance option. But they won’t be. I have insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects. But by avoiding some of the overhead that gets eaten up at private companies by profits, excessive administrative costs and executive salaries, it could provide a good deal for consumers. It would also keep pressure on private insurers to keep their policies affordable and treat their customers better, the same way public colleges and universities provide additional choice and competition to students without in any way inhibiting a vibrant system of private colleges and universities.

It’s worth noting that a strong majority of Americans still favor a public insurance option of the sort I’ve proposed tonight. But its impact shouldn’t be exaggerated – by the left, the right, or the media. It is only one part of my plan, and should not be used as a handy excuse for the usual Washington ideological battles. To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it. The public option is only a means to that end – and we should remain open to other ideas that accomplish our ultimate goal. And to my Republican friends, I say that rather than making wild claims about a government takeover of health care, we should work together to address any legitimate concerns you may have.

For example, some have suggested that that the public option go into effect only in those markets where insurance companies are not providing affordable policies. Others propose a co-op or another non-profit entity to administer the plan. These are all constructive ideas worth exploring. But I will not back down on the basic principle that if Americans can’t find affordable coverage, we will provide you with a choice. And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need.

Finally, let me discuss an issue that is a great concern to me, to members of this chamber, and to the public – and that is how we pay for this plan.

Here’s what you need to know. First, I will not sign a plan that adds one dime to our deficits – either now or in the future. Period. And to prove that I’m serious, there will be a provision in this plan that requires us to come forward with more spending cuts if the savings we promised don’t materialize. Part of the reason I faced a trillion dollar deficit when I walked in the door of the White House is because too many initiatives over the last decade were not paid for – from the Iraq War to tax breaks for the wealthy. I will not make that same mistake with health care.

Second, we’ve estimated that most of this plan can be paid for by finding savings within the existing health care system – a system that is currently full of waste and abuse. Right now, too much of the hard-earned savings and tax dollars we spend on health care doesn’t make us healthier. That’s not my judgment – it’s the judgment of medical professionals across this country. And this is also true when it comes to Medicare and Medicaid.

In fact, I want to speak directly to America’s seniors for a moment, because Medicare is another issue that’s been subjected to demagoguery and distortion during the course of this debate.

More than four decades ago, this nation stood up for the principle that after a lifetime of hard work, our seniors should not be left to struggle with a pile of medical bills in their later years. That is how Medicare was born. And it remains a sacred trust that must be passed down from one generation to the next. That is why not a dollar of the Medicare trust fund will be used to pay for this plan.

The only thing this plan would eliminate is the hundreds of billions of dollars in waste and fraud, as well as unwarranted subsidies in Medicare that go to insurance companies – subsidies that do everything to pad their profits and nothing to improve your care. And we will also create an independent commission of doctors and medical experts charged with identifying more waste in the years ahead.

These steps will ensure that you – America’s seniors – get the benefits you’ve been promised. They will ensure that Medicare is there for future generations. And we can use some of the savings to fill the gap in coverage that forces too many seniors to pay thousands of dollars a year out of their own pocket for prescription drugs. That’s what this plan will do for you. So don’t pay attention to those scary stories about how your benefits will be cut – especially since some of the same folks who are spreading these tall tales have fought against Medicare in the past, and just this year supported a budget that would have essentially turned Medicare into a privatized voucher program. That will never happen on my watch. I will protect Medicare.

Now, because Medicare is such a big part of the health care system, making the program more efficient can help usher in changes in the way we deliver health care that can reduce costs for everybody. We have long known that some places, like the Intermountain Healthcare in Utah or the Geisinger Health System in rural Pennsylvania, offer high-quality care at costs below average. The commission can help encourage the adoption of these common-sense best practices by doctors and medical professionals throughout the system – everything from reducing hospital infection rates to encouraging better coordination between teams of doctors.

Reducing the waste and inefficiency in Medicare and Medicaid will pay for most of this plan. Much of the rest would be paid for with revenues from the very same drug and insurance companies that stand to benefit from tens of millions of new customers. This reform will charge insurance companies a fee for their most expensive policies, which will encourage them to provide greater value for the money – an idea which has the support of Democratic and Republican experts. And according to these same experts, this modest change could help hold down the cost of health care for all of us in the long-run.

Finally, many in this chamber – particularly on the Republican side of the aisle – have long insisted that reforming our medical malpractice laws can help bring down the cost of health care. I don't believe malpractice reform is a silver bullet, but I have talked to enough doctors to know that defensive medicine may be contributing to unnecessary costs. So I am proposing that we move forward on a range of ideas about how to put patient safety first and let doctors focus on practicing medicine. I know that the Bush Administration considered authorizing demonstration projects in individual states to test these issues. It’s a good idea, and I am directing my Secretary of Health and Human Services to move forward on this initiative today.

Add it all up, and the plan I’m proposing will cost around $900 billion over ten years – less than we have spent on the Iraq and Afghanistan wars, and less than the tax cuts for the wealthiest few Americans that Congress passed at the beginning of the previous administration. Most of these costs will be paid for with money already being spent – but spent badly – in the existing health care system. The plan will not add to our deficit. The middle-class will realize greater security, not higher taxes. And if we are able to slow the growth of health care costs by just one-tenth of one percent each year, it will actually reduce the deficit by $4 trillion over the long term.

This is the plan I’m proposing. It’s a plan that incorporates ideas from many of the people in this room tonight – Democrats and Republicans. And I will continue to seek common ground in the weeks ahead. If you come to me with a serious set of proposals, I will be there to listen. My door is always open.

But know this: I will not waste time with those who have made the calculation that it’s better politics to kill this plan than improve it. I will not stand by while the special interests use the same old tactics to keep things exactly the way they are. If you misrepresent what’s in the plan, we will call you out. And I will not accept the status quo as a solution. Not this time. Not now.

Everyone in this room knows what will happen if we do nothing. Our deficit will grow. More families will go bankrupt. More businesses will close. More Americans will lose their coverage when they are sick and need it most. And more will die as a result. We know these things to be true.

That is why we cannot fail. Because there are too many Americans counting on us to succeed – the ones who suffer silently, and the ones who shared their stories with us at town hall meetings, in emails, and in letters.

I received one of those letters a few days ago. It was from our beloved friend and colleague, Ted Kennedy. He had written it back in May, shortly after he was told that his illness was terminal. He asked that it be delivered upon his death.

In it, he spoke about what a happy time his last months were, thanks to the love and support of family and friends, his wife, Vicki, and his children, who are here tonight . And he expressed confidence that this would be the year that health care reform – “that great unfinished business of our society,” he called it – would finally pass. He repeated the truth that health care is decisive for our future prosperity, but he also reminded me that “it concerns more than material things.” “What we face,” he wrote, “is above all a moral issue; at stake are not just the details of policy, but fundamental principles of social justice and the character of our country.”

I’ve thought about that phrase quite a bit in recent days – the character of our country. One of the unique and wonderful things about America has always been our self-reliance, our rugged individualism, our fierce defense of freedom and our healthy skepticism of government. And figuring out the appropriate size and role of government has always been a source of rigorous and sometimes angry debate.

For some of Ted Kennedy’s critics, his brand of liberalism represented an affront to American liberty. In their mind, his passion for universal health care was nothing more than a passion for big government.

But those of us who knew Teddy and worked with him here – people of both parties – know that what drove him was something more. His friend, Orrin Hatch, knows that. They worked together to provide children with health insurance. His friend John McCain knows that. They worked together on a Patient’s Bill of Rights. His friend Chuck Grassley knows that. They worked together to provide health care to children with disabilities.

On issues like these, Ted Kennedy’s passion was born not of some rigid ideology, but of his own experience. It was the experience of having two children stricken with cancer. He never forgot the sheer terror and helplessness that any parent feels when a child is badly sick; and he was able to imagine what it must be like for those without insurance; what it would be like to have to say to a wife or a child or an aging parent – there is something that could make you better, but I just can’t afford it.

That large-heartedness – that concern and regard for the plight of others – is not a partisan feeling. It is not a Republican or a Democratic feeling. It, too, is part of the American character. Our ability to stand in other people’s shoes. A recognition that we are all in this together; that when fortune turns against one of us, others are there to lend a helping hand. A belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgement that sometimes government has to step in to help deliver on that promise.

This has always been the history of our progress. In 1933, when over half of our seniors could not support themselves and millions had seen their savings wiped away, there were those who argued that Social Security would lead to socialism. But the men and women of Congress stood fast, and we are all the better for it. In 1965, when some argued that Medicare represented a government takeover of health care, members of Congress, Democrats and Republicans, did not back down. They joined together so that all of us could enter our golden years with some basic peace of mind.

You see, our predecessors understood that government could not, and should not, solve every problem. They understood that there are instances when the gains in security from government action are not worth the added constraints on our freedom. But they also understood that the danger of too much government is matched by the perils of too little; that without the leavening hand of wise policy, markets can crash, monopolies can stifle competition, and the vulnerable can be exploited. And they knew that when any government measure, no matter how carefully crafted or beneficial, is subject to scorn; when any efforts to help people in need are attacked as un-American; when facts and reason are thrown overboard and only timidity passes for wisdom, and we can no longer even engage in a civil conversation with each other over the things that truly matter – that at that point we don’t merely lose our capacity to solve big challenges. We lose something essential about ourselves.

What was true then remains true today. I understand how difficult this health care debate has been. I know that many in this country are deeply skeptical that government is looking out for them. I understand that the politically safe move would be to kick the can further down the road – to defer reform one more year, or one more election, or one more term.

But that’s not what the moment calls for. That’s not what we came here to do. We did not come to fear the future. We came here to shape it. I still believe we can act even when it’s hard. I still believe we can replace acrimony with civility, and gridlock with progress. I still believe we can do great things, and that here and now we will meet history’s test.

Because that is who we are. That is our calling. That is our character. Thank you, God Bless You, and may God Bless the United States of America.

##

Our nation faces two extremely serious and interconnected problems, i.e., a health care crisis and an economic crisis.

Neither problem can be resolved without simultaneously addressing the other. Without comprehensive health system reform, the exponentially rising costs of health care will bankrupt the Nation, businesses of all sizes, families and individuals. We cannot afford to do nothing. The status quo simply is not an option.

He should then say:

The magnitude of these crises was daunting seven months ago and they remain so today. However, with the help of many, the campaign to enact major health system reform this year has already made history. Our nation’s health care system reform agenda has advanced further this year than any such effort since Teddy Roosevelt’s effort 100 years ago. Failure to complete the job now and to do so in a comprehensive but fiscally responsible manner would be a disservice to all Americans.

The problem with Uwe Reinhardt’s advice is that the president has absolutely no plan to control costs. He never has had one. Last summer’s campaign rhetoric promised all gain and no pain thru preventive medicine, EMRs, etc. Now that those ideas have been blown out of the water by the CBO, everyone is waiting for some new idea. None has been forthcoming. To the contrary. The CBO says that all versions of Obama Care on Capitol Hill will increase health care spending. Independent analysts agree.

So I second Uwe’s suggestion that the president should tell the American people what will happen if we do nothing. But then he should say that all the bills Congress has produced so far will only make the problem worse. He should say that if Congress cannot come up with anything better, doing nothing is to be preferred.

From Nancy Brown, CEO of the American Heart Association

We hope the President can break through the rhetoric and return the debate to a discussion of the fundamental issues and challenges in health care that almost everyone agrees must be addressed. The debate must shift back to the urgent needs of individuals – the uninsured, the underinsured, heart disease and stroke patients and others with chronic disease who do not have access to affordable, quality care. Their stories are getting lost in the rhetoric. Each day, more families are losing their homes because of crushing medical debt. We cannot forget about these individuals who are struggling on a daily basis to meet their health care needs and those of their loved ones. They’re now looking at what is going on in Washington with diminishing hope and optimism that their circumstances will change at all for the better. It’s time for Congress to get back to work on health care reform because the situation is not getting any better as more people lose jobs and health benefits in this economy. Senators on both sides of the aisle have now spent nine months attempting to reach an agreement on health care reform, and we hope they can do so very soon. In any event, it’s time to move forward on areas where there is common ground such as coverage for individuals with pre-existing conditions, subsidies for low and middle-income families and capping out-of-pocket costs to help families avoid medical bankruptcy. There’s clearly too much at stake to slow the momentum for reform.

Senator John McCain’s health plan would have insured just as many people as Barack Obama aims to insure – and at no additional cost to the Treasury. It would have substantially lowered health care costs and may have increased quality as well. On the demand side, it would have created new incentives for patients to shop for care, based on price and quality. On the supply side, it would have created a national market for insurance. The financing mechanism was more progressive than anything that has been proposed on the Democrat side of the aisle.

Barack Obama should have praised these sensible ideas and promised to work with both parties to enact some or all of them. Instead, he spent several hundred million dollars demagoguing them. In their place, he proposed a Rube Goldberg reform that cannot possibly work. What is now called “Obama Care” will increase costs, probably reduce quality, and (after spending more than $1 trillion) may not even increase access to care.

So what should Obama say on Wednesday night?

How about, “I was wrong.”?

The President’s overarching aim in the speech should be to present to the Congress and to the American people a realistic – and I emphasize “realistic” – picture of the situation in which American health care finds itself. It should be a sober speech, without rhetorical flourishes.

According to the Milliman Medical Index, total health spending for the typical non-elderly, privately insured American family has grown at an annual compound rate in excess of 8 percent throughout this decade.

By contrast, wages and salaries in the U.S. have grown at an average annual compound rate of only about 3 percent in the past decade and a half. At the moment, they grow at an even lower rate, if at all. And the fraction of Americans who are employed has been falling for most of this decade.

It is simple arithmetic that, if these trends continue for another decade – as they very well might -- more and more American middle- and lower-income families will be priced out of American health insurance and health care.

The President could convey all of that information in a minute or two with one simple H. Ross Perot style visual.

Next, the President should say: “If you want to live in an America in which no American needing health care is barred from that care for want of ability to pay and in which no American family, having received health care, goes into financial distress over medical bills, then clearly we must help families in the bottom half of the income distribution [show of graph of that distribution] gain access to adequate health insurance and health care. And that will require sizeable additional government subsidies for these families.”

The President then might say that he and his allies on the Hill are now thinking of subsidies to the tune of about $1 trillion over the next decade during which, however, our nation should enjoy a GDP of about $170 trillion and total health spending even in the absence of better insurance coverage is now projected to be $35 trillion.

The $1 trillion figure is useful, because it is actually less than the close to $1.2 trillion that President Bush’s MMA ’03 is now projected to add to the US federal deficit during the period 2010-2019. It will be recalled that Bush and his Republican Congress did not even think of financing that new entitlement to the elderly. They simply deficit-financed it. The President is entitled to start off with that baseline.

President Obama might then say that he does not wish to be as fiscally irresponsible as were President Bush and his Congress in 2003. Instead, he will try as hard as he can to put in place financing for the $1 trillion or so of subsidies he envisages under his health reform.

Part of that financing will have to come from new taxes, whose nature is yet being discussed. [Or he could be specific. I’d prefer as one source a general, earmarked “health insurance tax” on retail-sales of, say, half a percent.]

The other part of the financing will have to come from greater economies in the use of federal funds already being spent in the system.

If I were the President, I would get a little nasty here and point out the intellectual disarray among his critics – especially the editorial page of the Wall Street Journal.

Part of their chorus is that Medicare spending is out of control and unsustainable. But whenever any measure is proposed to reign in Medicare spending – even just zeroing in on the huge geographic spending variations well known to all – there are from these same critics outcries of rationing health care for the elderly, underpaying doctors and hospitals and stifling innovation. I believe the President needs to address these critics sharply. They are not being responsible.

But he should also point that that there seems a virtual consensus now that America spend too much on health care without commensurate results. The fact, though, is that, it will take at least the better part of the decade to attack this problem – to really bend the cost curve down significantly, as the current jargon goes.

One reason why this task is so hard is that it is technically difficult. For example, we do not yet fully understand what drives these geographic spending variations. The reform of how we pay providers of health care also is technically daunting – especially moving from fee-for-service payment to bundled payments per episode of illness

The other reason why cost control, is difficult is that every dollar health spending is someone else’s health care income, which means that cutting health spending will trigger a tenacious trench warfare with the affected interest groups seeking to protect their incomes. The fight with these interest groups over healthy spending must be won in the long run; but it is beyond the power of one legislative period and anyone who thinks otherwise must be dreaming. The President should be clear about that.

Finally, some folks need anger-management consulting to get through life. The President needs the obverse consulting services, certainly for this speech.

First: We’ve come too far – we can do this! The President must detail how much agreement there is already – how far we’ve come. The major stake holders are being helpful. His attitude should convey both humility on the complexity and an air of inevitability on the necessity.

Second: We are in this together! He must demonstrate that he understands people’s concerns. That includes pointing out that everyone of us has a story about our or a friend or family member’s health care story – including searching for an affordable plan.

Third: Yes we can afford to do HCR! We can’t afford not to do it! Pay for it three ways: (1) fraud and abuse savings - put an end to ripping off the system; (2) efficiency – pay for good outcomes; (3) we need to take personal responsibility for ourselves and our families – eat right, exercise, and don’t smoke.

All this said with EMOTION and PASSION. He must be upbeat and positive.