Constitution does not forbid health care bill, says legal expert

The Supreme Court should affirm the constitutionality of the Affordable Care Act, contends Washington University in St. Louis law Professor Greg Magarian, JD, because the act fits comfortably within a proper understanding of the federal-state balance of power.

Magarian, a constitutional law expert, says the basic argument against the constitutionality of the health care bill is that some parts of the bill, most notably the requirement that people purchase health insurance, exceeds Congress’ power to regulate interstate commerce.

Magarian

“This argument has two levels to it,” he says. “The first has to do with precedent: the court over the past 15 years has found two congressional acts, one that banned possession of guns near schools, and another that created a civil cause of action for victims of rape and sexual assault, to exceed the Commerce Power.

“The second is related but has to do with first principles of constitutional law: allowing the federal government to do what it has done here simply encroaches too far on state power.”

Magarian says that the first level of the argument is fairly easy to get past.

“The two cases I referred to, United States v. Lopez and United States v. Morrison, involved narrow federal laws that the court found not to have anything to do with economic matters and thus not to have any bearing on interstate commerce,” he says.

“The health care bill obviously isn’t like that. Health care is an interstate market; health insurance is an interstate market,” Magarian says.

“This is, by its critics’ own account, a huge piece of legislation with broad sweep and enormous consequences. It simply isn’t anything like the laws struck down in Lopez and Morrison.”

According to Magarian, what is unusual about the health care bill is that it requires people to buy commercial insurance.

“The federal government has never really done this before,” he says. “State governments do it for auto insurance, so the argument goes that this is something that is appropriate for states to do, but not the federal government.

“That argument, however, doesn’t make logical sense. Purchasing insurance is commerce. I’m quite confident that, as a matter of constitutional law, the federal government could take over auto insurance regulation. That wouldn’t be very practical, but Congress could do it, because there’s nothing about a purchase mandate that exceeds the concept of ‘interstate commerce.’

“A purchase mandate may offend libertarians as a matter of individual rights; but of course that offense should apply just as strongly to state requirements that people purchase auto insurance.”

Magarian says that the argument that this bill simply goes too far in encroaching on state authority is a harder argument to resolve, because of course it’s completely relative.

“The important point here is that the Constitution doesn’t squarely answer the question of how far federal power can go,” he says.

“The Constitution enumerates the powers of Congress, but the most important of those enumerated powers, the power to regulate interstate commerce, has grown almost all-encompassing by its own terms. If you take the commerce power on its own terms, the health care bill passes constitutional muster easily, for the reasons I described above.

“But if instead you’re committed to the idea that the structure of the Constitution somehow implies specific limits on how we can construe the enumerated powers of Congress, then maybe this goes too far. This is ultimately a political argument, and it’s a political discussion that we need to have at critical moments.”

Magarian objects to the challengers’ argument that the Constitution clearly forbids the health care bill.

“That’s just unsustainable,” he says. “If the Supreme Court strikes down the health care bill, it will be a deeply political decision. I’m not saying that exceeds the Supreme Court’s power, but I think we need to acknowledge the political essence of the challenge if we’re going to have an honest discussion of it.

“I take the commerce power at face value, so I believe the court should reject the challenge and sustain the health care law without breaking a sweat.”

Why the Challenges to the Health-Care Law Are Wrong — And Right

http://blogs.wsj.com/law/2011/01/21/why-the-legal-challenges-to-the-health-care-law-are-wrong-and-right/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+wsj/law/feed+(WSJ.com:+Law+Blog)

JANUARY 21, 2011,

By Ashby Jones

In a provocative piece over at the National Law Journal, Wisconsin Law professor Andrew Coanstakes out a position that’s new to us: that both sides in the debate over the constitutionality of the Affordable Care Act are correct. And, at the same time, they’re both wrong.

(For background, click here for all of the LB coverage on the debate over the constitutionality of the law, arguably the signature domestic-policy achievement reached by the Obama administration.)

So what is Coan talking about? He explains, on the one hand, his assertion that both sides are right:

For courts to uphold the act would thus cast aside a cherished principle of American constitutional law — that the national government is one of limited powers, with everything else left to the states.

On the other hand, he writes:

For courts to invalidate the act would thus cast aside another bedrock principle of American constitutional law — that Congress has plenary power to regulate interstate commerce, including health insurance, and also wide flexibility in choosing how to carry that power into effect.

But both sides, he writes, are also wrong; wrong to deny the validity of their opponents’ arguments.

Coan compares the current conflict to one that emerged during the presidency of George Washington, when Congress passed legislation incorporating a national bank. The bank’s proponents claim the Constitution gives Congress the powers to tax and to borrow money, and, by extension, establish a national bank.

The bank’s opponents, on the other hand, argued that, in Coan’s words, “if Con­gress could incorporate a national bank merely out of convenience, what could it not do?”

At the end of the day, the Supreme Court upheld the bank, ruling implicitly that “Congress is usually in a better position than the courts to determine how to carry those powers into effect.” If the people really object to a piece of legislation, they can vote Congress out of office.

Coan concedes that the national bank situation may not be directly applicable to the health-care situation. And he doesn’t weigh in on one side or another.

Instead, his request is refreshingly modest:

If their decisions follow the lead of most commentators, both courts and the country will fail to appreciate the hard compromises that either result would entail. One bedrock constitutional principle or another must give way. It would make for wiser judicial decision-making — and a healthier democracy — if we began to wrestle with this openly now.

A healthy development

Posted: 24 Mar 2010 04:52 AM PDT

Something that President Barack Obama and I have in common:
Both our mothers died too young from disease. And to the end, both worried as much about their medical bills as they did about their medical treatments.
Obama wrote about his mother's plight in The Audacity of Hope. He spoke of it often on the campaign trail and in these last many months of debate. And yesterday, when became law, he spoke of his mother's plight again:

Today, I'm signing this reform bill into law on behalf of my mother, who argued with insurance companies even as she battled cancer in her final days.

Any child who's shared this experience knows the depth of emotion embedded in those few words, understands the source of the tenacity that has made health care reform a reality.

'This is the Civil Rights Act of the 21st century,'

Rep. James E. Clyburn (D-S.C.) said. He's one of many placing this legislation on par with some of America's best moments.
It's not perfect, not the truly universal safety net for which some hoped. It proclaims no right to health as many Democrats had done during the campaign.
Yet in freeing some families from the awful web of pre-existing condition clauses and COBRA cutoffs, in giving everyone access to health insurance, it is a formidable guarantee, in a country long chary of socioeconomic rights, of human security.
It does our mothers proud.

Deals to Restrain Generic Drugs Face a Ban in Health Care Bill

New York Times (NY)
January 13, 2010
Deals to Restrain Generic Drugs Face a Ban in Health Care Bill

NATASHA SINGER
A group of House lawmakers and the head of the Federal Trade Commission want Congress to include a provision in the health care legislation that they say could save American consumers several billion dollars a year on prescription drugs.

The group plans to ask Congress on Wednesday to block business deals in which they say makers of name-brand drugs directly or indirectly pay generic makers to delay competition from cheaper generic alternatives.

The House bill already includes such a ban. The Congressional Budget Office, considering only federal drug spending, has estimated that the House provision could save the government $1.8 billion in health costs over the next 10 years.

The Senate version does not include such a prohibition. But a group of nine Democrats, led by Herb Kohl of Wisconsin, signed a letter late last month to the majority leader, Harry Reid, urging that a ban be included in the final legislation.

An aide to Mr. Reid declined to comment. The Senate does not return from its holiday break until next week.

In recent years, critics say, deals between name-brand makers and generic makers have delayed the introduction of a range of generics including cancer drugs, antidepressants and prescription-strength antacids. The F.T.C. has estimated that such deals currently cost American consumers $3.5 billion a year.

''These are collusive, price-fixing deals,'' said Representative Chris Van Hollen, Democrat of Maryland, who is one of those urging Congress to ban the arrangements. ''It means the consumer pays a lot more for their pharmaceuticals.''

Opponents of the generic agreements -- maligned as ''pay for delay'' deals -- say they are standard industry practice and help prop up monopoly pricing.

Generics account for only about 22 percent of prescription drug spending in this country, although they represent nearly three-quarters of the prescriptions written, according to the research firm IMS Health. That means 78 percent of the nation's drug bill goes toward the 25 percent of prescriptions written for name-brand medicines.

But representatives of branded drug and generic makers said that settlements were a legitimate and expedient way to resolve expensive and time-consuming patent litigation.

Moreover, Kathleen Jaeger, the president of the Generic Pharmaceutical Association, an industry trade group, contested the term ''pay for delay.''

Settlements, she said, typically award the generic challenger the right to enter the market before a brand's patent is due to expire, giving consumers earlier access to affordable drugs. And compensation, she said, is often for legitimate side deals, like the generic company's supplying ingredients to the name-brand maker.

''You can't sweep all the good, the pro-competitive, pro-consumer settlements out with the bad,'' Ms. Jaeger said in an interview on Monday.

Nevertheless Jon Leibowitz, the chairman of the Federal Trade Commission, argues that many settlement deals violate antitrust laws when they restrict generic entry and also involve compensation from the name-brand company to the generic maker.

''These sweetheart deals are being done on the backs of consumers,'' Mr. Leibowitz said in an interview. ''From the perspective of the Federal Trade Commission, these deals are one of the worst abuses across the board in health care and should be stopped.''

But, since 2005, several appellate courts have upheld some of the agreements, ruling that such settlements do not violate antitrust laws when they let the generic drug enter the market before the name-brand maker's patent is due to expire.

As a result, the F.T.C. is appealing to Congress to ban the compensated settlements altogether.

The settlement deals are an outgrowth of the Hatch-Waxman Act, a 1984 law intended to promote drug price competition by encouraging generic companies to challenge the patents on name-brand drugs.

Some name-brand drug patents, like those on the active pharmaceutical ingredient in a medication, may be strong and not vulnerable to challenge. But other patents, like those on the ingredient formula, may be weaker and more inviting to a generic challenger.

Under Hatch-Waxman, the first generic to challenge a name-brand drug's patent gains the exclusive right to sell its generic version for six months before other generic makers can enter the market. But Hatch-Waxman also gives drug makers who sue generic infringers an automatic 30-month stay of generic market entry so that litigation can proceed.

Rather than litigate cases to the end, though, many drug makers choose to settle with generic challengers. Sometimes, the parties negotiate an earlier market entry date for the generic, without the generic maker's receiving additional compensation.

But other agreements, the F.T.C. says, have restricted generic market entry and have involved compensation from drug makers to generic companies, either in the form of direct payments or in side deals in which drug makers agreed to pay generics to provide goods or services. The agency has sued some companies for such deals.

Even now, the F.T.C. is suing the drug company Cephalon, claiming that it illegally induced generic challengers to delay marketing generic versions of the stay-awake drug Provigil to protect the product, which had sales in the United States of about $925 million in 2008.

According to the F.T.C., in late 2005 and early 2006 the company reached settlements with four generic makers that had challenged a Provigil patent.

The generic companies agreed not to market a generic form of the drug until 2012, and Cephalon agreed to pay the challengers at least $238 million for 13 side deals involving services like ingredient supply, the F.T.C. said.

Gerald J. Pappert, Cephalon's general counsel, said on Tuesday that the company strongly disagreed with the F.T.C.'s characterizations of its agreements with generic makers. He said Cephalon had structured the settlements to be in full compliance with the law. Moreover, the agreements allowed generics to enter the market in 2012, three years earlier than the Provigil patent was due to expire, he said.

Drug companies entered into 19 settlement agreements in fiscal year 2009 that involved both delaying generic entry and compensation from the brand to the generic compared to no such agreements in fiscal year 2004, according to an F.T.C. report to be published on Wednesday. Settlement deals in which generic makers received compensation typically kept generics off the market for 17 months longer than deals without payments, the report says.

Not everyone outside the drug industry agrees that restricting the compensated generic settlements would necessarily benefit consumers.

Senator Orrin Hatch, the Utah Republican who was an author of the Hatch-Waxman law, has raised the possibility that, without the option of negotiated patent settlements, generic companies might be less likely to challenge drug patents, thus delaying generic availability.

In a letter last September to Senator Kohl, who had sponsored a stand-alone bill last year prohibiting the deals, Mr. Hatch wrote: ''Any generic entry prior to patent expiration gives consumers the choice of using generic drugs earlier than can be anticipated and provides savings to the health care system -- whether by agreement or final court decision.''

Detailing Obama's Health Care Dilemma

http://www.npr.org/watchingwashington/2009/07/obamas_detailed_dilemma_on_hea.html

watching washington with Ron Elving

When President Obama held a prime time news conference last week, he hoped to push along the revision of the nation's health care system. He wanted it passed in the House before it left for the August recess and to the brink of passage in the Senate.

Instead, the next 48 hours saw House leaders draw back from a planned floor vote while key committee negotiators in the Senate remained in disarray. Among the many reasons for this reversal, three stand out.

The first is the fundamentally disconnected process by which Congress makes laws, a process designed by founding fathers averse to centralized power. As longtime Republican congressman Barber Conable put it years ago, the government works just as intended, which is to say not very well.

Refining the workings of one-sixth of the national economy was never going to be easy. Trying to do it fast -- or what counts as fast in legislative terms -- lent the effort focus and force, but it also heightened the risk of sudden derailment.

The second reason the president was frustrated in this particular moment was of his own making. Allowing his legendary discipline to lapse, he let his own emotions show in reference to the arrest of his friend, Henry Louis Gates Jr., in Cambridge, Mass. When he said the police acted "stupidly" in the matter, he doomed his own hope that the next several news cycles would be about health care.

Indeed, once the news media had galloped off after the Gates story, momentum on health care shifted perceptibly on the Hill. The slim chance of passage in both chambers before August was gone.

Why do we in the media prefer a story about one racially-charged incident in Massachusetts to the president's most important domestic initiative? For the same reason that one Cambridge arrest was the talk of your workplace this week and health care was not.

Of course we all know that our health and our medical care and the cost and governance of both are more important than what two guys said to each other on a front porch last Sunday afternoon. But our grievances over race and class and identity and authority are far more immediate and deeply emotional. So whether we as news people are reflecting our audiences or ourselves, the result is much the same.

Beyond its visceral impact, the Gates story had the great appeal of human scale. You needed only a few seconds of information, or misinformation, to become engaged in it or upset about it. This sort of story makes great TV and inflames the blogosphere in a way no discussion of controlling structural health care costs in the out years ever will.

And that is the third reason the president was not able to seize the day this time. Everyone has a notion of what health is and what the medical system does, but delving into the particulars of either gets complicated. It requires attention and perseverance.

In his news conference of July 22, the president tried to keep the emphasis on the failures of the current system. He talked about those without care or without insurance. He talked about the runaway costs and the inevitable worsening of the crisis. Here his eloquence and intensity served him well. You could imagine people listening.

But when he responded to questions by dipping into the facts of the proposals he supports, he lost that personal connection. You could imagine people losing the thread, zoning out and reaching for the remote.

That is why advocates of change rend their garments when they hear opponents saying the president has not provided "enough detail." It is at least as possible that the degree of detail the president has tried to provide is in fact hobbling his effort to push the issue forward.

When Ronald Reagan signed a fundamental rewrite of the federal income tax in 1986, he blessed it for lowering the top marginal tax rate for individuals and eliminating "loopholes." He did not traffic in the trade-offs and countless adjustments that made the new mechanism work. He even denied it raised taxes on business, which it manifestly did.

We also have the memory of Bill Clinton's health care plan in 1994, a monument to detail that was understood by few (and loved by fewer). Obama's political situation does not allow him to float above the fray to a Reaganesque degree, but he does want to come down somewhere closer to that model than to the Clinton alternative.

What people usually mean when they ask for more detail is this: How will the changes affect me? Under all the different scenarios that might arise in my lifetime, what will happen? People don't want to be told simply to trust the government, and they obviously cannot be blamed for that.

Detailed information, in the end, is probably not the problem. If it were, the entire debate would be different. In this age of information-rich Web sites and search engines that find them in nanoseconds, those who really want more detail have more access to it than ever before. If the presentational style of the Congressional Budget Office is too forbidding, there are reader-friendly versions, partisan and non-partisan, all across the cyber-horizon.

In the end, the fine detail of any new program is never entirely clear until the program is place. That is true whether you are talking about changing employment rules or banning a substance or invading a foreign country. The political system produces a new direction, policymakers put it into law. Then a world of players, both in and out of government, co-create the new reality.

That is what will happen with the government and health care, if the president can get his top priority back on track in September

Will U.S. Move Toward European Capitalism?

http://www.npr.org/templates/story/story.php?storyId=111420898


by John Ydstie , August 3, 2009


The global financial storm has swept away millions of jobs and destroyed trillions of dollars in wealth, spawning calls for economic reform. The crisis originated in the United States — the result of careless lending, exotic financial products and lax regulation.

Daniel Yergin chronicled the global expansion of capitalism in a book and TV series titled The Commanding Heights. He says confidence in the capitalist system has been shaken by the financial crisis.

"We have not seen this kind of debate about the future of capitalism and market economies since the collapse of communism at the beginning of the 1990s," Yergin says.

While the U.S. style of lightly regulated, dynamic capitalism has been ascendant since then, Yergin says the pendulum is swinging back toward a less volatile (slower growing, more stable) European model, with more government involvement in the economy. Just look at President Obama's agenda, he says, and you see government being very assertive.

"You know, Washington, D.C., is not only the political capital of the United States, it's the financial capital, it's the auto capital, it's the energy capital, it's the health capital of the United States," he says. "So I think people recognized that the game is here — here in Washington."


What Role For Government?

Obama has said: "I don't want to run auto companies. I don't want to run banks."
He has made it clear that he sees much of the recent government involvement in the economy as temporary: "I refuse to let these companies become permanent wards of the state, kept afloat on an endless supply of taxpayer money."

Princeton professor and former Federal Reserve vice chairman Alan Blinder takes the president at his word. He believes Obama really doesn't want the government to run companies like GM or Citigroup.

"It's in some real sense un-American; it's not the way we do things in the United States," he says. "You know, this really isn't France — as you can tell by sampling the food (?) — so I'm not so worried about that. It's definitionally true: We now have in America a bigger socialist sector, if you want to call it that, than we've had in a very long time — maybe ever. But the government definitely wants to get out of these businesses."

In the end, Blinder thinks it's doubtful that the U.S. will move very far in the direction of the European economic model.

Barry Eichengreen of the University of California, Berkeley agrees. But he thinks the current financial crisis suggests the U.S. needs to be more open to other ideas.

"The United States has no monopoly on how best to organize a market economy," he says.

Eichengreen, who recently published a book on European economies, says Europeans obviously do things differently, with a larger role for government, more regulation and a more generous social safety net that provides workers greater security.

"And yet they have been able to grow in terms of living standards as successfully as we have for the last 15 or 20 years," he says.


What Does The European Model Offer?

So what would it mean for Americans if the U.S. economy became more like Europe's — especially with a bigger social safety net?

Well, Allegra Milan has experienced the difference. She grew up in New York but fell in love with a German student. Milan followed her boyfriend, Florian Dussler, back to Germany. They settled in Dusseldorf, where Milan got a job teaching at an international school. And they had a baby, Adrian, five months ago.

Milan found having a baby in Germany quite different from what she'd observed in the U.S. First of all, her public health plan paid virtually all the cost. That included the cost of a midwife, who helped her prepare for Adrian's birth and then visited her at home for seven weeks afterward.

"And when she'd come, she'd check on my healing from the delivery, and she'd check on Adrian's weight and how he was growing and just talk with me," Milan says. "So, I felt very, very supported as a new mother here, whereas I don't think I would have had the same kind of support in the U.S."

Dussler, who works for a software company, says there's something else the government provides that Americans might find even more surprising.

"We get a so-called payment for Adrian called Kindergeld, which is child money, literally translated," he says. "It's 164 euros per month." That's about $232. And on top of that, Allegra gets paid about two-thirds of her annual teacher's salary for a full year after Adrian's birth while she stays home to care for him.

There's A Downside, Too

Of course, the price for these social supports and other benefits — such as a free college education and generous unemployment payments — is steep.

"Almost half of my salary goes to my combined taxes, including the contribution I make to my health care," Milan says.

And even with taxes at that level, the generous benefits are becoming unsustainable. As the German population ages, there aren't enough workers to pay taxes into the system. That's partly why Germany is subsidizing child birth: The country needs more babies like Adrian who will grow up to be workers.

While Milan and Dussler appreciate the security and support provided by the European model and think it's worth the taxes they pay, they also think it has some problems. Dussler says he wishes it were more dynamic.

"It needs to be easier to found your company," he says. "It needs to be easier to employ people. Many companies don't exist in Germany because you have such harsh employment rule[s]."


Converging U.S., European Models?


Kevin Hassett, an economist at the American Enterprise Institute, a conservative Washington think tank, agrees. And he says that, actually, many European governments have been loosening their grip on their economies during the past couple of decades.

"They've moved much more towards having an economy that looks like an American, or a traditionally American economy," he says.

Hassett believes that will continue. But as a result of the financial crisis, he also sees the U.S. moving in Europe's direction and the two models converging.

"I'm not saying that that's what I would do if I were dictator, but I think that it's clear that's the path that seems to be emerging," he says.

Hassett is right — Europe has been moving toward the U.S. model in some areas, says Ken Rogoff, a former chief economist at the International Monetary Fund. But now, he says, the big shift will come in the U.S.

"I think the United States is clearly going through a sea change to become more like Europe," he says.

The Potential For Higher Taxes

Rogoff, now a Harvard professor, warns that Americans need to understand there will be consequences. He says a move toward European-style capitalism, with its more generous social safety net and tighter regulation, will mean higher taxes — and not just for the wealthy.

"Certainly, the administration and the Democrats talk about raising all the money from the wealthy," he says. "But I think the empirical evidence shows that's not likely to begin to pay for everything, and the tax hikes are going to have to be much broader."


Given what the administration is contemplating on health care, the environment and other initiatives, Rogoff estimates taxes could rise by 25 to 50 percent. And he argues there's no question that higher taxes would slow U.S. growth and raise unemployment closer to European levels. While Rogoff says he might personally tolerate that in exchange for European-style social benefits, it's not clear that most Americans would.

Costs and Compassion

http://www.nytimes.com/2009/07/24/opinion/24krugman.html?_r=1

Op-Ed Columnist, Costs and Compassion, By PAUL KRUGMAN, Published: July 23, 2009

The talking heads on cable TV panned President Obama’s Wednesday press conference. You see, he didn’t offer a lot of folksy anecdotes.

Shame on them. The health care system is in crisis. The fate of America’s middle class hangs in the balance. And there on our TVs was a president with an impressive command of the issues, who truly understands the stakes.

Mr. Obama was especially good when he talked about controlling medical costs. And there’s a crucial lesson there — namely, that when it comes to reforming health care, compassion and cost-effectiveness go hand in hand.

To see what I mean, compare what Mr. Obama has said and done about health care with the statements and actions of his predecessor.

President Bush, you may remember, was notably unconcerned with the plight of the uninsured.

I mean, people have access to health care in America,” he once remarked. “After all, you just go to an emergency room.”

Meanwhile, Mr. Bush claimed to be against excessive government expenditure. So what did he do to rein in the cost of Medicare, the biggest single item driving federal spending?

Nothing. In fact, the 2003 Medicare Modernization Act drove costs up both by preventing bargaining over drug prices and by locking in subsidies to insurance companies.

Now President Obama is trying to provide every American with access to health insurance — and he’s also doing more to control health care costs than any previous president.

I don’t know how many people understand the significance of Mr. Obama’s proposal to give MedPAC, the expert advisory board to Medicare, real power. But it’s a major step toward reducing the useless spending — the proliferation of procedures with no medical benefits — that bloats American health care costs.

And both the Obama administration and Congressional Democrats have also been emphasizing the importance of “comparative effectiveness research” — seeing which medical procedures actually work.

So the Obama administration’s commitment to health care for all goes along with an unprecedented willingness to get serious about spending health care dollars wisely. And that’s part of a broader pattern.

Many health care experts believe that one main reason we spend far more on health than any other advanced nation, without better health outcomes, is the fee-for-service system in which hospitals and doctors are paid for procedures, not results. As the president said Wednesday, this creates an incentive for health providers to do more tests, more operations, and so on, whether or not these procedures actually help patients.

So where in America is there serious consideration of moving away from fee-for-service to a more comprehensive, integrated approach to health care? The answer is: Massachusetts — which introduced a health-care plan three years ago that was, in some respects, a dress rehearsal for national health reform, and is now looking for ways to help control costs.

Why does meaningful action on medical costs go along with compassion? One answer is that compassion means not closing your eyes to the human consequences of rising costs. When health insurance premiums doubled during the Bush years, our health care system “controlled costs” by dropping coverage for many workers — but as far as the Bush administration was concerned, that wasn’t a problem. If you believe in universal coverage, on the other hand, it is a problem, and demands a solution.

Beyond that, I’d suggest that would-be health reformers won’t have the moral authority to confront our system’s inefficiency unless they’re also prepared to end its cruelty. If President Bush had tried to rein in Medicare spending, he would have been accused, with considerable justice, of cutting benefits so that he could give the wealthy even more tax cuts. President Obama, by contrast, can link Medicare reform with the goal of protecting less fortunate Americans and making the middle class more secure.

As a practical, political matter, then, controlling health care costs and expanding health care access aren’t opposing alternatives — you have to do both, or neither.

At one point in his remarks Mr. Obama talked about a red pill and a blue pill. I suspect, though I’m not sure, that he was alluding to the scene in the movie “The Matrix” in which one pill brings ignorance and the other knowledge.

Well, in the case of health care, one pill means continuing on our current path — a path along which health care premiums will continue to soar, the number of uninsured Americans will skyrocket and Medicare costs will break the federal budget. The other pill means reforming our system, guaranteeing health care for all Americans at the same time we make medicine more cost-effective.

Which pill would you choose?