Rudd's health policy
March 3rd, 2010 by Mark Bahnisch | Published in Federal Elections, Government, Health, Politics | 63 Comments
Kevin Rudd has released his health policy at the National Press Club.
Essentially, it encompasses a phased takeover of responsibility for activity based hospital funding by the Commonwealth, with 30% of GST revenue to be diverted directly to hospitals. Funding would flow to individual hospitals, with local authorities being funded to treat individual patients, and the establishment of national standards of care.
Primary health care will become the sole responsibility of the Commonwealth.
Politically, it buys the Commonwealth a possible fight with the largely unpopular state governments, and appears to short circuit the state health departments, leaving them with residual functions for the less glamorous administrative functions of hospital systems. It also incorporates the local focus Tony Abbott has championed, with flexibility for clincal and funding decisions to be made at hospital or regional level. The Commonwealth would become, in effect, a regulatory and activity based funding body, rather than ‘taking over’ hospitals, but the threat of a referendum remains.
Subsequent announcements between now and the election will focus on extra beds, doctor and nurse training, support for GPs, and the introduction of electronic patient record monitoring.
The AMA is supportive; the Coalition opposed.
Detail of the National Health and Hospitals Network Plan can be found here.
Update: Bernard Keane observes at The Stump that the plan comes with a snappy slogan – “funded nationally, run locally”.
Update: Melissa Sweet analyses the announcement at Croakey.
Update: The transcript of Kevin Rudd’s Q&A at the Press Club is now available here.
a) When will Australians realise that we actually have one of the world’s best health systems – especially for what we pay?
b) Why is it that people think administrators of different stripe will be somehow fundamentally difference?
Increase health outcomes = increase health funding. I don’t think this change is bad, per se, and I appreciate the wisdom of protecting health from state government vagaries and pressures, but will the federal pressures be better? I do not subscribe to the popular view of state-administrations as incompentent and blundering. They are – largely – making the best of a tough situation.
Part of the reason for the government’s is that it has spent too much effort developing the big fix at the expense of more limited, less spectacular action that would have allowed them to go into the next election with more tangible improvements.
For example,part of the problem with hospitals is that Howard allowed to do enough about the federal responsibility re nursing homes. As a result beds in hospitals are taken up by people who should be in nursing homes or other lower cost forms of care.
The proposed plan is unlikely to have much direct effect before the next election. Labor should be reviewing its priorities now to separate what action they can get in place before the election and what will have to be implemented after the election.
Some observations:
1) this proposal reduces – but won’t completely end – the “blame game”. Much more of the funding responsibility ends up with the federal government. In the case of allied services, the plan is for everything to be federally funded.
2) The proposal should mean less stuff delivered through hospitals and more through allied services. This is a good thing in principle, because it’s often cheaper and better to do stuff that way.
3) Let’s see what happens when the guilds get their teeth into it (as pointed out by Bernard Keane in today’s Crikey).
@1 – patrickg: the Commonwealth’s strength, bureaucratically, probably is in delivery of funding and regulation. As noted, there won’t be direct commonwealth responsibility for the administration and day to day management of hospitals.
In that sense, it’s potentially better than a takeover.
The other point to make is that Commonwealth responsibility for primary health care could be utilised to take the pressure off hospitals – particularly the effective substitution of emergency rooms for GPs, and the related problem of beds being used in place of aged care facilities.
Very much so, Mark.
The other thing to note, in a short-term political sense, is this is the power of incumbency at work. And the government has several more of these up its sleeve, notably the Henry tax review.
Yep!
It leaves Abbott’s health ‘policy’ looking very thin and threadbare, and his chorus of opposition to it should put pressure on him to come up with something substantive.
Good points, Mark. I suppose I was really railing against the portrayal of health and health issues in the media and public mind than the actual substance of this announcement itself.
Don’t want to get all Insiders, but I will be most interested to see how the Abbott Express responds actual policy from a government on the front foot. Saw headline in SMH to the effect of ‘Abbott lost in the wilderness’, referring to an escapade in NT. I thought, “yup”.
I suspect with silly talking points and naysaying, patrickg!
Update: Bernard Keane observes at The Stump that the plan comes with a snappy slogan – “funded nationally, run locally”.
Unsurprisingly ABC on-line manages to spin this as a negative for the government.
would these arrangements, once in place, make it easier to outsource management of public hospitals to private companies?
Good idea in theory, but Id much prefer a straight out division of whether health is a federal or state responsibility.
Pollie of both parties, both state and federal, have used health as a stick with which to beat each other.
I dont care which it is, make it either all State, or all federal, this compromise will see state health departments keep running the same (with quite a few unnecessary back room staff/office workers) numbers of staff, plus an enlargement of a Canberra bureaucracy.
More management….wonderful.
The other negative I can see (and Ill use WA as an example) is the GST cuts will be a gimmie for State pollies.
WA had its GST take reduced to around 7% this year, if our Premier wants too (and he will), he will sell it as “Look Federal Lab have cut us to only 5.9% of the GST, bitch,moan whinge”.
I think its a compromise to far, Rudd might have been better off biting the bullet and taking direct control, this will leave him open to “oh look the Bureaucrat has announced a new bureaucracy, and new bureaucratic processes to meet a real world problem, just like fuelwatch/grocerywatch etc”… Regardless of whether that’s fair criticism or not.
That’s not necessarily so, Mole. As I said, it doesn’t involve another layer of management from the Commonwealth, just delivery of activity based funding within a regulatory framework. If anything, the thrust is a decentralisation of decision making, and an increased role for clinical decisions rather than managerialist beancounting.
To me, a direct takeover would have been the worst outcome – does anyone imagine that a whole stack of brand new people would suddenly appear to manage hospitals? It would just be the same state health departments and authorities under a commonwealth minister.
I also think that it would have been quite politically disastrous at the moment – ‘Canberra can’t run stuff on the ground’ has just had a big kick along from the various environment department debacles. Nor do I think that day to day management of 7000+ hospitals from Canberra is sensible.
I can’t see a fight with the states as being anything other than a plus for Rudd – they’re hardly well liked on the whole! National objectives delivered locally vs. state selfishness and parochialism is not a bad political line…
Just a reminder for those w/ short memories:
Medibank was the name given to Australia’s system of universal health insurance when it was first created by Gough Whitlam’s Australian Labor Party government in 1975.
Medibank started on schedule, on 1 July 1975. In nine months, the Health Insurance Commission had increased its staff from 22 to 3500, opened 81 offices, installed 31 minicomputers, 633 terminals and 10 medium-sized computers linked by land-lines to the central computer, and registered and issued health insurance cards to 90% of the Australian population.
Despite this hostile response to its introduction, Medibank/Medicare was supported by subsequent governments and has become a key feature of Australia’s public policy landscape.
Medicare
On 1 February 1984 Medicare was established by the Hawke Government. The major changes introduced by the Fraser Government were largely rejected by the Hawke Labor Government, which returned to the original Medibank model. Although the financing arrangements were different, and there was a name change from Medibank to Medicare, little else differed from the original. Medicare as we know it came into operation on 1 February 1984, following the passage in September 1983 of the Health Legislation Amendment Act 1983, including amendments to the Health Insurance Act 1973, the National Health Act 1953 and the Health Insurance Commission Act 1973.
(wikipedia)
The Labor Party has helped bring Australians, using the words of Bill Hayden way back in those early, courageous maiden voyage days, the ‘most equitable and efficient means of providing health insurance coverage for all Australians’.
I reckon the Rudd government’s plans are just another step in improving health services in an equitable manner…and mending some of the financing problems caused by Tony Abbott as Health Minister & the Howard government’s obsession w/ propping up the private system at the expense of the public system.
Whilst the Rudd plan still respects the essential role of private hospitals.
N’
“I suspect with silly talking points and naysaying, patrickg!”
There is that, but also…(note how he thinks he is already P.M. in comment about Holt)
http://www.abc.net.au/news/stories/2010/03/03/2835167.htm?section=justin
Mark
“If anything, the thrust is a decentralisation of decision making..”
Yup I realise thats the aim, but I think its a bit foolish to hope it will lead to any reduction in State or Federal managerial staffing numbers. I will bet you London to a brick, that federal departments having anything to do with health will grow like topsy in the next couple of years.
Update: Melissa Sweet analyses the announcement at Croakey.
@17 – Dunno, Mole. Depends on how seriously Tanner can hold back government spending.
This is a political smoke screen so Rudd can retreat from his promise to reform or take over the health system.
The promise at the last election was that either reform happened or the Federal Government would take it over – full stop. Now he is moving the goal posts because his government has achieved bugger all and he won’t keep the promise.
The funding model is still a dog’s breakfast – split between state and health. There still is going to be blame gaming about who is funding what.
From a WA perspective – we are already being fiscally raped by the Eastern States. Cutting our already meagre share of the GST is not going to fly over here.
I would imagine joe2 this is just another Abbott DISTRACTION & attention-seeking tactic. I put nothing past the man. Too much of a coincidence methinks…this lost in bush stuff. Good for newspaper headlines and grabbin’ media & public attention tho.
I’m more interested in REAL policy announcements…hearing about the future of our Health departments rather than worrying about a child-like attention-seeker who comes from the Howard administration school of fear-mongering & “anything goes” in order to distract from essential public information….or hook-in the public.
I imagine it gives us a pretty good indication of Abbott’s leadership style. WAR & CRUSADES here…penny pinching from public services there…add some Serfchoices…and BREAD & BUDGIE SMUGGLING CIRCUSES to keep the public & media hypnotised & generally unquerying.
Been there, done that. W/ the morning walker.
I reckon Rudd was pretty gracious in showing concern & applauding Abbott’s trip to “the red centre” considering question time during his important National Press Club address on the future of healthcare was interrupted by some dopey statement & query related to Abbott’s latest stunt.
I’ll trust Federal Labor on initiating & implementing further “equitable healthcare” steps anyday over a leader of the Liberal Party who seems more pre-occupied w/ transforming himself into a plastic action figure than demonstrating the seriousness, consistency & wide thinking necessary to become PM of a complex nation.
N’
So we’re going to trade the experienced state administrators with a whole-of-state focus for a bunch of inexperienced medicos determined to secure the best local outcomes and bugger anybody else.
I was involved in a review of a hospital a few years back which included discussions with many of the doctors. All of them whinged passionately about what a mess the hospital was falling into. Unfortunately, there was virtually no common ground between them and health statistics refuted most of their complaints. So now we’re going to set up boards full of these administrative lightweights to run hospitals. Expect incompetence. Expect unreasonable duplication of services. Expect rorting. Expect health costs to rise. Expect Rudd to get some short term mileage out of this.
Jenny @ 22, you say:
Are these the same experienced state administrators responsible for the:
?
So what is your solution then? Or is it case of “talk first, think later”.
PS You’re not Peter Dutton’s Press Secretary are you?
Razor @ 20 There’s a pretty good article in the West of Monday 01/10 by Shane Wright which makes nonsense of your comments on the GST carve-up as well as those
of Colin Barnett whose comments on this are at odds with those of State Treasurer Troy Buswell.
To say that ‘From a WA perspective – we are already being fiscally raped by the Eastern States. Cutting our already meagre share of the GST is not going to fly over here’ is absolute nonsense. If you’re going by Colin Barnett’s reported statements on this I suggest even he would not claim WA’s share of the national GST take was ‘meagre’. He’s just been doing a bit of anti-Fed grandstanding which could smoke screen his own budget problems, largely caused by the Royalties for Regions deal with the Nats here.
Anyway it’s not the Federal Government itself, but the independent Commonwealth Grants Commission which apportions the GST to the various states. It’s done on an agreed formula, not based on population, but on an ability to raise revenue. There are issues amongst the various states on even that criterion and this year Troy Buswell along with the Queensland Treasurer made some headway in changing that methodology and returned home last week with some changes which increased WA’s GST share by some $23m, about which he was very pleased.
Kevin Rudd had no part in those negotations, adopting a hands-off policy from whatever is agreed to by CGC, as was proper.
Interestingly I can’t find this article on the West website. Some possibilities…It hasn’t been archived? I’m not a good searcher? Or it’s just gorn….Whatever, I have the print article to my left hand here.
Oops – 01/03/10 is the date of Shane Wright article in the West Australian.
Patricia – you are a much stronger person than I am. I am unable to bring myself to read anything but the comics and the footy (and even barely that) in the West.
Oh, and I know that the Grants commision is independent and agreed formula yada yada yada – but it is a hell of a good line to throw around and I enjoy doing it.
Cheers
Looks to me like Rudd (where was Roxon today?) is going to end the blame game by turning hospitals into fundholding trusts as in the UK. The Commonwealth will give every hospital the same X dollars per patient and then when the money runs out Rudd can say “don’t come to us, you got the same as everyone else, put your house in order”. Hospitals will then start rationing services and we’ll end up with health services becoming a postcode-related lottery.
“This is a political smoke screen so Rudd can retreat from his promise to reform or take over the health system.”
A smoke screen made up of a very important and major piece of reform to hide the fact that Rudd doesn’t want to make any reforms?
Efficiency? Does that equal kicking you out of hospital before you’ve completely recovered. (I’m biased. The death factory in Armidale isn’t too bad.)
It’s an ‘efficient price’, Paul, meaning that the Commonwealth determines the cost of a procedure, and hospitals attempt to provide the service for the price.
Tyro – no, that is not what I said at all. Rudd promised either reform or a takeover at the last election. The expectation created was that this would occur in the current term of government. He didn’t promise to come up with a proposal to argue with the states about and then take to the following election for voter approval.
Mark @ 31,
What happens to the patient if the service to the patient can only be provided by the hospital at more than that ‘efficient price’?
Mr Burns @33 – rationing – otherwise known as waiting lists.
Razor, surely it would only be a “smokescreen” if he was trying to hide something.
I would have thought Rudd has been quite out there that the thing has been delayed.
Fair enough, given most of his other promises have have been, or will be, fulfilled in this term.
And not a bad record given the economic circumstances and a totally obstructionist opposition.
@34 – No, the point is to shorten waiting lists.
I posted a link to the report for a reason. Please refer to that, as opposed to speculation. Or, if you prefer to discuss something without taking the time to inform yourself on it, that’s your choice.
Update: The transcript of Kevin Rudd’s Q&A at the Press Club is now available here.
Looks to me like Rudd (where was Roxon today?) is going to end the blame game by turning hospitals into fundholding trusts as in the UK. The Commonwealth will give every hospital the same X dollars per patient and then when the money runs out Rudd can say “don’t come to us, you got the same as everyone else, put your house in order”. Hospitals will then start rationing services and we’ll end up with health services becoming a postcode-related lottery
Well, in a bit more detail, the real problem in the UK is that the central govt has pushed the standards too high for the funding they provide (I don’t mean just too high!), in that they have prescribed very specific outcome targets. The local trusts then spend their limited funds (rock) on achieving the specifics targets set out by the govt (hard place). Micro-managed rubbish outcomes prevail.
Furthermore, funding in the UK is a mess, as much of a patient’s hospital funding flows through their GP: You are registered with the NHS through your GP, and if you end up needing any health care, the funds are channelled through your GPs account. Opportunity for chance for graft much?
Plus, just to make it a real shit-storm, local out-patient and community care is often operated by different trusts to the local hospitals. And the areas they manage don’t match, meaning a hospital trust might have to deal with more than one community care trust, and vice versa. And services that operate across both trusts in a single area, that might be in offices next door to each other, may each be funded by the different trusts, making resource sharing a complete cluster-fark … I could go on.
I don’t see this ridiculous patch-work of overlapping funding and administrative accountabilities coming out of the Labor’s health policy – the NHS’s mess not something you can design.
Fair crack of the whip, Razor, we did have a global financial crisis in the middle – which Rudd and the reserve basically got us out of scot-free, remember that?
I thought Rudd did pretty well in that Q&A, but crikey, some of the questions!
Shockingly ignorant some of them, and blisteringly bias; the Oz should be ashamed of itself: “who will hire, appoint, fire, what will be their accountability? Will you just stack them with mates, Labor hacks and union bosses?”
Matthew Franklin from the Australian, you, sir, are a dickhead.
Karen Middleton is a waste of space, and if Matthew Riley from 7 had half a wit he would be twice as smart as he is now. Ditto for that idiot asking about Tony Abbott. I mean honestly, when “journalists” from the Hun and the Tele are asking better questions than you, you’re really in trouble.
Mark, I like it, but where does it stop … I mean what are the states for?? will this be more accountable, probably not ….. will it be funded well (let’s see in 20 years). There is no reason that schools can’t be run like this and indeed they could be via vouchers for public schools. If it’s good enough for th goose …
Rudd’s stuffed.
He’s either got to get the state premiers to vote themselves out of existence (or begin to), or win a referendum at the same time as a federal election without bipartisan support. If he does it, it will be a amazing feat, but that is unlikely.
Most likely result – Rudd wins the election, loses the referendum, has no legitimacy, PM Gillard by July 2011.
To me it’s a simple issue. It ain’t broke so don’t fix it. The statistics show that across Australia both emergency medicine and elective surgery are achieving or close to achieving national health standards. This is despite rising salaries in the health sector and reducing Commonwealth revenues. Unfortunately the MSM have been whinging so relentlessly for so long that it seems most everyone believes our public hospitals are falling apart. Far from it – if they were any better, if waiting lists were any shorter, private hospitals would cease to exist and then we really would have a problem. And when did it become commonsense to create hundreds of competing bureaucracies.
The key issue here, particularly for mental health, is clinical governance. The public needs to know what practices, methods and clinical procedures are being used that can produce the best outcomes, within, cost and resource constraints. Health care today is more and more a multi-disciplinary issue, requiring new ways for practitioners to work together to deliver cost effective health care.
Its not necessarily an issue of more money and resources as putting more money into inefficient and ineffective practices is only going to produce more of it and burn more money. This has been the approach taken with mental health and it has failed miserably.
The Australian developed Flinders Model of health care is an example of an approach that is aimed at addressing this very issue.
I.T systems that focus on mostly automating records collection and retrieval will deliver partial benefits unless they also help with assisting new multi-disciplinary work practices and allow patients to have more control over their own records and their own health care.
But Jenny @ 43, back @ 22 you said you had participated in a “review” during which time the doctors “whinged passionately about what a mess the hospital was falling into”.
Now you say “it ain’t broke” and you see the current state of affairs as acceptable?
But what about considerations for the future? The essence of the reform package on Health is to facilitate the infrastructure to cope with the future challenges.
You’ve presented an extremely short-sighted solution.
I’ll say it again: are you sure you’re not Peter Dutton’s press secretary?
Jenny, it may not be broke now, but it’s broke in the long term. Literally.
As the report points out, the costs of healthcare are rising faster than state government revenues, and all the taxing powers are with the Commonwealth.
So something has to be done. That may just involve the Commonwealth handing the states more money. You could, theoretically, fix it by handing taxation powers back to the states. But, given that there is already a mishmash of cost-shifting between the state and commonwealth governments in health, the most logical thing is head towards the Commonwealth paying for the lot.
‘Jenny’s’ just got the latest talking point by fax from News Ltd/ABC/Coalition headquarters, which will be repeated ad-nauseum from here on to the election.
So the health system that until yesterday was in catastrophic decline, is now in great shape and there is no need for the do nothing Rudd government to er…do anything.
It’s going to be a difficult year ahead.
adrian @ 47, it’s just as well that Rudd suddenly doesn’t need to do anything because, as we’ve been told ad nauseam, he’s all talk and no action.
Self-fulfilling prophesies ‘R’ us!
While I don’t want to betray the real identity of our posters, “Jenny” is almost certainly not a Liberal troll, and furthermore is likely to have some first-hand knowledge of some of these issues.
The Krudd spin machine is masterful.
The GST is a tax for the states – all the revenue is meant to go to the states.
Krudd now proses to take 30% of the GST and put that into health and then define that as Federal Funding, not State funding.
It is no different to my wife going shoe shopping – what’s mine is mine and what’s yours is mine.
A load of bullshit razor.
Things change. if it was introduced as a tax for the states does that mean it should remain forever so?
If the Feds fund part of what was state’s responsibility it makes perfect sense to direct the money that the states would have received back to the Commonwealth to fund these new responsibilies.
You are really scraping the bottom of the barrel here, but nothing new in that I suppose.
razor, the point of the GST was not to give the states a pot of gold which would go into their general revenue – it was to give them access to a growth tax which would enable services (such as health) to continue to be funded given greater demand for them. Given that the cost of running hospitals is growing at 7% a year, much greater than the cost of goods and services which is the basis of the GST revenue, something has to give, and the projections are that hospitals will eat up a very large proportion of state and territory budgets within a couple of decades. So it’s more than appropriate that the Commonwealth does ensure that an appropriate proportion of GST will go directly to health, and as announced, this won’t be the total of the Commonwealth provision. A large part of the point of direct Commonwealth responsibility for hospital provision is cost containment.
Someone has to pay for public health. Perhaps Tony Abbott envisages local boards holding lamington drives?
@ 50
Well, perhaps the tide is turning Razor. The track record of the States as regards to Health – and in particular a reform plan for the future – is poor, and what we see now is a Commonwealth that seeks to arrest that trend.
As we’ve heard, the implementation of the reforms will be no easy feat: it will take some balls.
Incidentally, you could follow a similar strategy with your prodigal wife.
I am not going shoe shopping for my wife.
She won’t wear stilettoes.
The argument about whether this is apropriate appropriation of GSt revenues us going to need to be won by Krudd if he has any chance of getting this over the line.
It appears that you think I am against reform of the health system. That is not true. I understand the problems. It is however reasonable to point out flaws in the proposl from the Krudd government.
I am actually all for getting rid of the States, Local government in its’ current form and the Senate and having a Federal Government and Regional Governments. Health is a universal right with equal standards for all Australians and funded and administered Federally. The current barney between SA and the NT over dialysis is evidence of the stupidity of the current arrangements.
The scheme could be started as long as there is one state willing to forgo GST money in return for accepting the new system. If it works well in one state, state governments will be under heavy pressure to join up.
However, if I were a state premier I would not agree to sign up unless the commonwealth took over a 100% of the funding. A scheme that has the states paying for anything above the “efficient price” would be a nightmare, particularly given that the efficient price is set by the feds, not the states. Mixed funding on the proposed basis would lift the blame game to unprecedented levels.
In the meantime, people will be judging this government on what they actually do before the next election. Schemes that will only have an effect after the next election won’t really count.
I agree that there’s a problem with the current funding model. Currently it’s too easy for the C’wealth to reduce real funding then criticise the states for diminution of service.
But my problem is with the proposed new management model which replaces a small number of experienced managers with a larger number of inexperienced ones, each with a strong local bias. An illustration: shortly before the last fed election, Tasmania made the hard but correct call to take away some services from the Mersey hospital since they were replicated 50 km up the road. Can you envisage a community based management group making such a call, or being motivated by anything other than the need to protect its ‘patch’?
Of course it’s theoretically possible to put in place performance standards to overcome the self interest of community managers, but that’s a recipe for rorting and unintended adverse consequences. An example: national standard waiting times for elective surgery vary according to the urgency classification of the procedure. But that urgency classification is highly subjective, varies widely between states and consequently invalidates cross jurisdictional comparisons of waiting times. I see a time coming when procedures to correct life threatening heart conditions are classified as ‘3’ to make the stats look better and attract more funding. Of course, that can happen now, and to a small extent does, but it’s a lot easier to keep your eye on seven state or territory administrations than on hundreds of hospitals.
P.S. thanks for your support, Robert. I don’t think I’m a troll either. I get wearied by the growing tendency towards factless debate. E.g., the media treats Garrett as guilty but never does get around to explaining precisely what he did wrong. E.g., the media treats the hospital system as being in crisis but never does get around to providing a statistics-based argument (instead it will tell you that somebody in NSW had a baby in a toilet – which proves nothing). I understand that it isn’t practical for the MSM to do a full review of each issue before publication, but at the same time I find the ‘group think’ certainty infuriating, particularly because so many people seem to unquestioningly take the fish and chip wrap as gospel.
John D @ 56
Surely that cannot be correct: piecemeal health reform? It would have to be a ‘one-in-all-in’ scenario otherwise what is the point of the reform agenda?!
Surprised that the Coalition hasn’t raised a fear campaign about “Death Panels”, as in the U.S.
“Oh we are very sorry about your Granny, but the officials in Canberra have decided that continued treatment would not be cost-effective.
Euthanasia will proceed in 5 minutes.”
I’m not generally a supporter of Rudd but at this early stage the health outline looks like something that might improve services in practice. Case mix funding has worked pretty well in Victoria despite some worries and most of the independent health experts I’ve heard have sounded optimistic.
Not the least of the problems we have in the system has been duplication. Beyonf A&E and some of the other basic services, some outpatient care and so forth why does each district have to supply everything one could want in health? Some rationalisation of specialist services would seem to make sense.
Rob @58: We have a better chance of achieving real health reform if the program stats in states who think it is a good idea and then extending the program once it has been demonstrated to be a good idea. We are far less likely to get health reform if it can’t start until all the states agree or a referendum succeeds.
CMMC @ 59 – that will be next week.
@ 61
You know it’s called fundamental reform for a reason … it’s not try before you buy