HHS Presser on New Value-Based Hospital Reimbursement

FOR IMMEDIATE RELEASE Contact: HHS Press Office

Friday, April 29, 2011 (202) 690-6343

CMS Public Affairs

(202) 690-6145

Administration Implements Affordable Care Act Provision to Improve Care, Lower Costs

Value-Based Purchasing Will Reward Hospitals Based on Quality of Care for Patients

The Department of Health and Human Services (HHS) today launched a new initiative which will reward hospitals for the quality of care they provide to people with Medicare and help reduce health care costs. Authorized by the Affordable Care Act, the Hospital Value-Based Purchasing program marks the beginning of an historic change in how Medicare pays health care providers and facilities—for the first time, 3,500 hospitals across the country will be paid for inpatient acute care services based on care quality, not just the quantity of the services they provide.

This initiative helps support the goals of the Partnership for Patients, a new public-private partnership that will help improve the quality, safety and affordability of health care for all Americans. The Partnership for Patients has the potential over the next three years to save 60,000 lives and save up to $35 billion in U.S. health care costs, including up to $10 billion for Medicare. Over the next ten years, the Partnership for Patients could reduce costs to Medicare by about $50 billion and result in billions more in Medicaid savings.

“Changing the way we pay hospitals will improve the quality of care for seniors and save money for all of us,” said HHS Secretary Kathleen Sebelius. “Under this initiative, Medicare will reward hospitals that provide high-quality care and keep their patients healthy. It’s an important part of our work to improve the health of our nation and drive down costs. As hospitals work to improve their performance on these measures, all patients – not just Medicare patients – will benefit.”

In FY 2013, an estimated $850 million will be allocated to hospitals based on their overall performance on a set of quality measures that have been shown to improve clinical processes of care and patient satisfaction. This funding will be taken from what Medicare otherwise would have spent, and the size of the fund will gradually increase over time, resulting in a shift from payments based on volume to payments based on performance.

“Medicare is in a unique position to reward hospitals for improving the quality of care they provide,” said Centers for Medicare & Medicaid (CMS) Administrator Donald Berwick, M.D. “Under this new initiative, we will reward hospitals for delivering high-quality care, treating their patients with respect and compassion, and ensuring they have the opportunity to participate in decisions about their treatment.”

Some of these measures will assess whether hospitals:

· Ensure that patients who may have had a heart attack receive care within 90 minutes;

· Provide care within a 24-hour window to surgery patients to prevent blood clots;

· Communicate discharge instructions to heart failure patients; and

· Ensure hospital facilities are clean and well maintained.

The measures to determine quality in the Hospital Value-Based Purchasing Program focus on how closely hospitals follow best clinical practices and how well hospitals enhance patients’ experiences of care. When hospitals follow these types of proven best practices, patients receive higher quality care and see better outcomes. And helping patients heal without complication can improve health and ultimately reduce health care costs. For example, ensuring heart failure patients receive clear instructions when they are discharged on their medications and other follow-up activities reduces the likelihood that they will suffer a preventable complication that would require them to be readmitted to the hospital.

The better a hospital does on its quality measures, the greater the reward it will receive from Medicare. The measures selected for the Hospital Value-Based Purchasing program in FY 2013 have been endorsed by national bodies of experts, including the National Quality Forum. Hospitals have been reporting on quality measures through the Hospital Inpatient Quality Reporting Program since 2004, and that information is posted on the Hospital Compare website. For a complete list of quality measures, visit www.HealthCare.gov/news/factsheets/valuebasedpurchasing04292011b.html.

In the future, CMS plans to add additional measures that focus on improved patient outcomes and prevention of hospital-acquired conditions. Measures that have reached very high compliance scores would likely be replaced, continuing to raise the quality bar.

The Hospital Value-Based Purchasing initiative is just one part of a wide-ranging effort by the Obama Administration to improve the quality of health care for all Americans, using important new tools provided by the Affordable Care Act. The Partnership for Patients is bringing together hospitals, doctors, nurses, pharmacists, employers, unions, and state and federal government committed to keeping patients from getting injured or sicker in the health care system and improving transitions between care settings. CMS will invest up to $1 billion to help drive these changes. In addition, proposed rules allowing Medicare to pay new Accountable Care Organizations (ACOs) to improve coordination of patient care are also expected to result in better care and lower costs.

For a fact sheet on the Hospital Value-Based Purchasing program, visit www.HealthCare.gov/news/factsheets/valuebasedpurchasing04292011a.html. To learn more about Hospital Value-based Purchasing, please visit www.cms.gov/HospitalQualityInits.

The final rule establishing the program was placed on display at the Federal Register today, and can be found online at: http://www.cms.gov/HospitalQualityInits.

More technical information about the final rule, including the measures CMS has included in the program, as well as CMS’ scoring methodology, is included in a Fact Sheet posted on our Web page at: http://www.cms.gov/apps/media/fact_sheets.asp.

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The Hunger Strike That Wasn't

I have had a very serious conversation with my doctor about whether I can fast for 30 days. He's strongly advised me against it. He feels that what I read, which makes it sound pretty safe if you fast for only 30 days and you drink water and take salt really applies to healthy people. He's concerned about even taking all of my medicine without any food in my stomach and the harm that might cause. Of course, this is why he's a doctor and I'm not.

I want you to understand where my desperation comes from, though, because it's important. A few months ago, I lost an insurance appeal for a 20 year old girl with complex regional pain syndrome. She's been all over the world for treatments -- German, Austria, Mexico -- and tried everything, including some pretty crazy things. She finally found a doctor in Philadelphia who tried IVIg and it worked. This young girl all of a sudden had a life. She could go to college. She could do crafts. She could have something of a life. But her insurance company wouldn't pay for IVIg for CRPS. We did an external appeal to a 3 doctor panel. This was the most monumental insurance appeal I've ever filed. There were over 1000 pages of medical records and lots and lots of medical research, and a 23 page appeal letter. One of the three doctors said of course, since she's tried everything else, and since we know this works, she should get the IVIg. But the other two said there was insufficient evidence to show that IVIg was better than the standard options. I swear, that's what they said. There were 1000 pages of evidence that IVIg worked and nothing else did. There are no standard options, and whatever options there are were tried. Losing that appeal devastated me. If I can't win that case for that young girl, what am I really doing?

Fast forward to this week. We got an email from a man with chronic inflammatory demyelinating polyneuropathy. He works and earns $200 per week -- too much for Medicaid. He has no health insurance. He's in terrible pain, and at times, he can't speak. He needs medical care. We spent a day and a half making phone calls and finally found a clinic that would get him in quickly, although it's an insufficient solution since he can't get to a specialist and he can't get the drug he needs, for which there is no patient assistance program. He lives in the shadows, and we're the first people who've even tried to help him. And our help is far less than he deserves.

When the World Health Organization came out with its statement yesterday that chronic illness is now the leading cause of death in the world and most major papers -- NY Times, Wall St. Journal, USA Today -- didn't even cover it, I went into a sort of panic mode. These people are desperate. They need medical care. Yet, budgets are being cut, and the safety net is eroding quickly. Everything bad that happens in the health care world is blamed on health reform, which everybody knows is only a first step, and since it's not even fully implemented yet, it's wrong to give up on it and declare it a failure because health care costs continue to rise. Yes, we need to do more. But we need people to get covered now, as quickly as possible. Health reform implementation is 2.5 years away, but we have to hang onto it because, with Medicaid expansion and subsidies, the man with CIDP will have coverage. It's still a long way off, but I understand that implementation of any major change would take time, and so we have to hang in. But I'm so scared that our society -- fueled by a bunch of radicals on the right who have no concern for facts -- will give up on it before it even takes full effect.

And then there's health reform implementation and the gains the insurance industry is making as they pressure the feds to do less than is needed. I'm particularly involved in the appeals regulations. It's killing me -- it's causing physical pain -- to listen to the Department of Labor say that self-funded plans don't want to have to do external appeals, and to actually buy into some of their ridiculously petty concerns.

And even when health reform is fully implemented, I will still lose insurance appeals that never should be lost. Whatever was in the minds of those two doctors when they said there was no evidence that IVIg was better than standard therapies is just perverse -- but it's also pervasive.

People are quietly dying. They have invisible illnesses, so they face disbelief and a lack of support and understanding. They are addicted to pain meds, and then the feds crack down on prescribing pain meds, and doctors just abandon them. Family and friends abandon them. Heck -- I don't have any social life because just leaving the house is so difficult for me, and since so few people get it, people don't come to see me -- they want me to meet them for dinner, which is something I just can't do. But they don't believe me. They don't get it.

This is a heck of a life and there are millions of us suffering like this. I see it. I feel it intensely. And I don't know how to change it. I don't know what it's going to take. Must we have sick people dying alone in sparse apartments where they've been warehoused without care or attention? Must we just let that happen, as it does every day, invisibly? How do we make the invisible visible? How do I get people to care?

If I figure out an answer, I will let you know. Until I do, I am in agony over the treatment of sick people, some of whom get less attention and caring than our family pets. If you have ideas, please tell me. Maybe, if enough of us came together, we could make a difference.

Can all of you please help me to make some noise, to tell this story, to make the invisible visible? Can you tell me how I can do more, do better?

We are collectively very powerful. Together, we can lift people up out of the darkness and demand that, if nothing else, Americans see the consequences of the choices they have made to ignore people with invisible chronic illnesses. Please, please help me. Jennifer

Finally Friday Edition

I have to do this quickly because I'm missing the wedding of the century!!! But first, the news.

Healthcare costs continue to grow in the US at a rate that exceeds that in other countries. This is not about health insurance premiums. This is not about health reform. This is about how we deliver health care, how much money providers are allowed to make, and the fact that many other countries have universal health care, so the system is far more regulated. But for our higher cost, we do not get the best value; quality lags far behind. This clearly has to change.

Now some Dems are threatening to vote against raising the debt ceiling without serious concessions on the debt and budget. Never mind that it would ruin the global economy if we defaulted on our debt.

Town hall meetings are still lively, as the public tells the GOP not to end Medicare as we know it. Lots of ads are going up on the airways, as well.

There will be a new payment system for hospitals in Medicare, and it will be based, in part, on how patients rate the level of care and services they got. There will be cuts in Medicare to nursing homes, as well, in part to make up for what the feds say was an overpayment this year.

Meanwhile, the GOP is demanding to know how much money the IRS is getting as part of health reform. But the military now will provide health care coverage to dependents up to age 26.

Aetna is scaling back rate hikes. I like Aetna better every day!

The FDA was supposed to define "gluten free" for food labeling 3 years ago, and they're still working on it.

Sleep. We need it. We don't get enough of it. That has to change.

Emergency rooms continue to be busy treating people with nowhere else to go.

And that's today's news. Now, let's go see Kate's dress! Have a great day! Jennifer

Hunger Strike

I am planning a hunger strike for chronic illness. The planning will take some time -- there's no point in doing it if I don't get any publicity -- but I can't stand how invisible we are any more.

From today's LA Times:

Chronic illnesses like cancer, heart disease and diabetes have reached global epidemic proportions and now cause more deaths than all other diseases combined, the World Health Organization (WHO) said on Wednesday.

In its first worldwide report on so-called non-communicable diseases, or NCDs, the United Nations health body said the conditions caused more than half of all deaths in 2008 and pose a greater threat than infectious diseases such as malaria, HIV and tuberculosis (TB) -- even in many poorer countries.

"The rise of chronic noncommunicable diseases presents an enormous challenge," WHO Director-General Dr Margaret Chan, who launched the report at a meeting in Moscow, said in a statement.

"For some countries, it is no exaggeration to describe the situation as an impending disaster; a disaster for health, for society, and most of all for national economies," she said.

NCDs, which include heart disease, lung diseases, cancer and diabetes, accounted for 36 million, or 63 percent, of the 57 million deaths worldwide in 2008.

And this story appeared ONLY in the LA Times. What the hell is wrong with us as a society when we care so little for our sick? I can't stand it any more. Jennifer

P.S. -- Just to be totally clear, I am not trying to commit suicide. If you drink water and take salt during a fast, you can go for a good 60 days -- people have gone way longer, and the length of time you'll be able to handle is longer the more body weight you have on you, which means I could easily go 60 days. But I think I would shoot for 30 days. Hopefully, that would be long enough to make my point.

I just wanted to be clear that I'm not doing this without researching, without medical approval, and familial approval. J

Thursday Themes

And here's today's news round-up:

The World Health Organization warns of the enormous burden of chronic illness. Chronic illnesses have reached epidemic proportions and are the leading cause of death -- more than HIV, malaria, tuberculosis -- and all across the globe.

On the budget, Speaker Boehner appears to be softening in his support for the Ryan budget that would eliminate Medicare and Medicaid as we know them. Senator Reid says he'll hold a vote on the Ryan plan in the Senate, forcing GOP to go on record in support of ending Medicare/Medicaid. And the GOP make a new argument in favor of the Ryan plan -- it's just like health reform!!! Well, not so much. But lobbyists are still out there criticizing health reform. And the GOP are facing stiff disagreement about their Medicare plan. And the Dems have jumped on this as an issue that may help them in 2012. A liberal policy group, the Center for Economic and Policy Research, says the GOP plan would increase health care costs by $34 trillion.

But for me, here's the really scary story. The GOP are planning to link sweeping financial cuts to the increase of the debt ceiling, forcing Dems and the President to agree to huge cuts or risk defaulting on our debt, which could cause a global economic crisis. Either the Dems agree to do something awful like eliminate Medicare as we know it, or they refuse to cave and we default on our debt. This is my opinion: The GOP should not hold us hostage over something as critical as the debt ceiling.

California passed a law allowing the State to stop insurers from raising rates unfairly. Other states are considering similar moves.

Florida moves Medicaid into HMOs to save money. It hasn't saved money in other states -- indeed, it's cost money here in Connecticut -- but states are desperate for fiscal relief. I just wish they could look around the country and see that privatization is not the answer.

If you want to be happy, avoid your cell phone, make a donation to charity (I know a good one) and elect your boss. A new movement with a website called actionforhappiness.org modeled on the teachings of the Dalai Lama.

Merck is pitching a Hep-C drug to the FDA. This would be amazing.

A new checklist may help diagnose autism in babies as early as 1 year old.

And that's it for this morning. Have a great day! Jennifer

Jonathan Cohn: When Seniors Had No Insurance

Once upon a time, Jonathan Cohn reminds us, there was no health insurance for seniors. If you don't remember what it was like before Medicare, then read Jonathan's piece -- as always, insightful and illuminating. Jennifer

Hump Day Headlines

The theory is that if we make it past Wednesday, we're home free. So hang in today and here's the news:

The GOP is facing a public angry about a budget proposal that attacks Medicare and Medicaid. Some are screening questions, and others are making a fast get-away. There are many who resist cutting programs for kids, too. Some Dems are softening, too -- Barney Frank is ready to talk tort reform and higher copays.

Meanwhile, the Treasury Department is preparing the worst case scenario, if the debt limit isn't raised.

Some states are moving to Medicaid managed care as a way to cut spending. In Connecticut, we tried managed care and it didn't work, so now we're on to primary care case management, which also has saved money in other states.

The feds are developing a checklist that will help patients remember to take their medicine.

Support groups are aimed at increasing the mortality rate among Blacks. And here's an interesting one that I don't understand -- Blacks with cancer are more likely to drain their bank account to stay alive as long as possible.

Should a drug manufacturer be able to buy your drug utilization records and use it to market to doctors? The Supreme Court will decide, but from the arguments yesterday, it looks like they're going to allow this "data mining."

Communities teaching kids how not to be fat.

And that's it today. Have a great day. Jennifer

Tuesday's Tidbits

You know I'm not feeling well if I blow off the blog for a day. Hopefully, I can do better today.

The Supreme Court has decided not to fast-track the health reform litigation -- and Justice Kagan voted, which means she won't recuse herself. Great news. Here's more.

Speaker Boehner says there may not be a vote on the debt ceiling if he doesn't get some of what he wants out of the deal. So get this. The GOP would topple the world's economy if they don't get what they want. Totally irresponsible.

The head of Medicaid and Medicare says GOP Paul's plan is rationing. It is becoming a uniting force for the left.

Under health reform, preventive care - including colonosocopies -- are free UNLESS yours turns into more than a routine screening. If the doctor removes a polyp, for example, all bets are off.

Med students turning away from primary care -- which will create a shortage where doctors are really needed.

States are starting to plan their exchanges, their marketplace for purchasing insurance. Here are our comments. The feds hope Connecticut plays a leading role.

Do you follow your doctor's instructions on taking your meds?

A push to develop drugs for deadly rare diseases. This will include expedited consideration of off-label uses.

Christian ministries share health care expenses. Until someone gets really sick and then they have no help and no insurance.

Gabrielle Giffords will attend the space launch on Friday.

If a blind person all of a sudden could see, would they recognize by sight what they'd only previously recognized by touch?

What do you hope to get from your doctor?

The saga of a medical mystery. Interesting.

Have a great day! Jennifer

Late Monday

The Supreme Court has denied the Virginia Attorney General's reqest fast track the health reform lawsuit.

A family doctor would like to retire -- but he can't even give away his practice, and he can't leave his patients. The disappearing family doctor.. Jennifer

Finally Friday Edition

Another TGIF, wishing my life away from one Friday to the next. Oh, well. Here's the news:

Paul Ryan is home in his district, having offered the country a plan that would eliminate Medicare as we know it. His constituents aren't all that happy with him. Indeed, lots of GOP members are confronting opposition to their handling of the debt. That seems predictable. Indeed, I have to wonder who -- other than the private insurance companies, who would get all the seniors with their vouchers -- they thought would like this plan. Ezra Klein points out that it violates all of the principles the GOP held dear when we were debating health reform. Still, the GOP is trying to sell their plan as the only plan that will save Medicare. Save it while ending it? I don't think so. Indeed, even Newt Gingrich opposes it!

But nothing has me as scared as the debate over raising the debt ceiling. What concessions will the GOP demand in order to keep our country out of default and financial ruin?

Meanwhile, the President's task force on deficit reduction is off to a rocky start. And the so-called "gang of six" bipartisan members of Congress is still adamant that there will not be tax increases.

Here's a cautionary tale of trying to buy individual insurance. It's a whole lot more difficult than it ought to be. And the writer is healthy. If she had pre-existing conditions, she'd have been that much worse off.

Gabrielle Giffords's staff is advocating for treatment of brain injuries -- an issue they've come to know too much about.

Interesting piece by Paul Krugman -- reacting to referring to medical patients as "consumers." I always called our clients patients until maybe the last six months or so, when I've been around other advocates calling them consumers, and I thought maybe that was more appropriate since I'm not a doctor. But Krugman argues that it devalues the doctor-patient relationship. Interesting. He also makes some important points about the proposals to curb Medicare costs. A worthwhile read.

Twenty-five states now ban smoking in public places and the CDC predicts that all 50 states will have done so by 2020.

And that's today's outlook. Have a great day. Jennifer

Thursday Themes

Big meeting today on Exchanges, about as wonky a subject as there is! But first, the news:

President Obama criticized the GOP deficit reduction plan during a town hall meeting at and on Facebook yesterday. The LA Times also blasts the plan as burdening the neediest and the sickest. Here's what they say about the President's plan.

But here's what has me scared, big time. The GOP is stepping up its demands on the debt limit. America will hit its debt limit some time in the next couple of months, the experts say. If we don't increase the debt limit, we default in our debt, which could lead to an economic crisis that goes beyond anything we've seen. But the GOP won't vote to increase the debt limit unless they get some major concessions. Will they really play a game of chicken when the stakes are so high? I'm not the only one who's worried -- Wall Street knows that a default would kill the economy, so they are lobbying hard for increasing the debt limit.

The Obama Administration is urging graduating college students to learn about their health insurance options; in most cases, that means joining their parents' policy.

In a fascinating discovery, scientists now believe that, in addition to there being 4 distinct blood types, there also are 3 distinct bacterial types or enterotypes. This may lead to being able to determine what drugs will work best for someone and so on.

And here in Connecticut, the parties have reached a deal on the SustiNet plan, allowing municipalities and some nonprofits to buy into the state employee health plan, but not opening the plan to the public ... at least for now. I don't think we can call this a victory since the plan won't be open to the uninsured, and the whole point of SustiNet was universal coverage -- but I suppose a first step is better than none.

And that's pretty much it -- a slow news day. Have a great day! Jennifer

Hump Day Headlines

Good morning! Here's the news:

As President Obama travels to talk to Americans about debt reduction, a poll shows that Americans disfavor cuts to Medicare and Medicaid, but favor increasing taxes on the wealthy. Meanwhile, the GOP has decided to send only two representatives to meet with VP Biden to negotiate a debt reduction plan, Eric Cantor and John Kyl. The White House had requested 8 total GOPers -- 4 from the House and 4 from the Senate. And they're sending policy guys, not budget crunchers. Dems haven't done much better, sending only 4 instead of 8, and also sending their policy guys. Doesn't appear to be off to a very good start. However, some say this is the right way to start towards a bipartisan solution.

The Medicare Independent Payment Advisory Board -- which President Obama believes can help stem Medicare costs -- will make recommendations about things that can be cut, and their cuts will take effect unless Congress blocks them. This idea is considered "rationing" by some. Others feel it usurps Congress's role. If I have a choice between a voucher that will pay for some of my insurance premium or a slightly thinner Medicare as we know it, I'll stick with traditional Medicare any day. I suspect the criticism has to do with things like a proposal to reduce Medicare acute hospital payments by 0.5%. Too many members of Congress have too many ties to industry.

The Department of Health and Human Services says it will hold itself accountable for health care disparities among racial and ethnic minorities. This is hugely important. Read this interview with the person responsible. And here's a piece about a meeting to address disparities that took place right here in Connecticut.

Some members of Congress want broker commissions reclassified. As you know, under health reform, insurers must spend 80 or 85% of premium dollars on health care, which meant brokers' commissions were part of the 20% administrative costs. But there's a bill in Congress that would shift commissions to the health care part of the balance, increasing premiums and contributing to the deficit, as explained by our esteemed friend, Tim Jost.

We've seen the down-side to doctors refusing to treat chronic pain adequately, but here's the other side of it -- the harm painkillers can do. So the federal government is getting involved to curb the use of opioids. The "drug czar" says doctors should be trained specially before prescribing these drugs. And the FDA is stepping up its oversight of pain meds, requiring manufacturers to provide educational materials. I suspect that means it will be harder for chronic pain patients to obtain relief. It's quite a quandry. There are people who are in agony and need pain meds, and people who abuse them. Where's the right balance?

And that's where I'll leave you today -- striving for balance. Have a great day. Jennifer

Health Insurance Exchanges

As you know, under health reform, each State is supposed to create a new marketplace where consumers can shop for insurance. These marketplaces are called Exchanges under the law. This may sound simple enough -- design a website, make it interactive so people can pull up the policies that best suit them, and make that information available to consumers. Not so fast.

There are so many questions involved in how a State wants to design its Exchange. For example, is it good for the Exchanges to list all available plans, or should they weed some out, perhaps negotiate better premiums even, and show you your best options? Should the individual market and small market be combined or separate? What are the best ways to make sure that only sick people, who can't get insurance outside the Exchange due to pre-existing conditions, don't all flock to the Exchange, driving up prices inside the Exchange, with the healthy people paying less outside the Exchange (called "adverse selection")?

The Connecticut Office of Policy and Management asked some of the consumer advocates in the State for our thoughts, and we gathered them here. As you can see, they are detailed and a bit complicated, but if you're interested in seeing our approach and recommendations, there you go. There will be a meeting on May 3 to discuss these ideas further. So if you have some thoughts, please let me know.

Unless you're inclined to curse out health reform or President Obama, in which case I'd love it if you kept it to yourself. Jennifer

P.S. -- NOTE that OPM will be conducting a series of public forums to hear what you think about how the Exchange should be designed. They are as follows:

• April 25 at 6:30 p.m. in Danbury City Hall, 155 Deer Hill Ave.;
• April 27 at 6:30 in the New London Public Library, 63 Huntington St.;
• May 5 at 7 p.m. in New Haven City Hall, 165 Church St.;
• May 9 at 6 p.m. in Downtown Hartford Public Library, 500 Main St.;
• May 17 at 6:30 p.m. at Windham Middle School, 123 Quarry St.

Urgent Call for Help

Subject: URGENT: living donor needed for liver transplant

Dear Friends,

Our very close friend in Chicago, Joanie, has been very sick for a very long time and is now in desperate need of a liver transplant. The healthy liver for the transplant must come from a living donor. The process involves taking a small portion of the living donor's healthy liver, removing the damaged liver and replacing it with the donated healthy liver piece. Since the liver is an organ that rejuvenates itself in a short period of time, both people should have a full healthy liver within a few weeks.

We are reaching out to everyone we know to ask for help to save Joanie's life and can pay the donor $500 plus all medical expenses.

The requirements to be a donor for Joanie's liver transplant are itemized below.

The donor must be:

Age: Between 18-55

Health: Excellent

Blood Type: O (positive or negative)

Place of Surgery: Northwestern Memorial Hospital

Donor would provide a piece of their liver. Liver would begin to rejuvenate itself, it would start to do this in about 2 weeks after surgery.

Donor would be in hospital approx. 3-4 days.

Candidates need to contact Lori Clark, RN (Transplant Nurse Coordinator - Kovler Organ Transplant Center) (312) 695-0870

If you are able, (or know of anyone who is able) to help save Joanie's life by meeting the above requirements and donating a small portion of your liver, please contact Lori Clark, RN as stated above. Ms. Clark will be able to discuss the details of the procedure and answer your questions.

We all love Joanie very much are doing everything we can to find a donor in time. Please forward this to everyone you know because someone out there can be Joanie's life saver!

Thank you very much,

Tuesday Tidbits

Despite a lovely case of asthmatic bronchitis, here I am, your trusty news gatherer, ready to take on another day:

Vice President Biden will be presiding over a deficit reduction panel to negotiate a plan, but as of right now, no Republicans plan to attend. Meanwhile, analysis of Rep Ryan's GOP 2012 budget shows ... a lot of unclarity. Although he says it repeals the health reform law, apparently it only repeals the parts the GOP doesn't like. For example, the GOP decried cuts to Medicare under health reform (which weren't really cuts), but now they've incorporated them -- and want to go further.

Since the next big fight -- which somehow will involve health reform, Medicare and Medicaid even if they all seem totally irrelevant -- will be raising the debt ceiling. So I thought a good place to start would be what is the debt ceiling and why it's a huge deal. There's already a threat of downgrading US debt issued yesterday by Standard & Poor's. Just the threat sent stock prices tumbling.

Organ donors have a pre-existing condition for insurance purposes. Yup -- that's right -- give away an organ and you can't get health insurance. Nice.

A new RAND study shows that high deductible plans don't discourage people from getting the care they need -- although I have to tell you, not only is this wrong anecdotally, but among the 1513 people who took our chronic illness survey, there were a lot of people skipping medical care, regardless of the amount of their deductible.

Patients with Do Not Resuscitate orders are more likely to die after surgery.

There are new guidelines for the diagnosis of Alzheimer's disease. The idea is to diagnose early. It does appear that certain other conditions -- mostly vascular -- does contribute to Alzheimer's.

There's a short supply of a leukemia drug -- scary. We also need to do better with palliative care at the end of life.

CVS pays $17.5 million to settle allegation that they charged Medicaid patients in Florida and elsewhere too much.

Font size doesn't help you learn, but font type does. Interesting read.

And to my Jewish friends, happy Pesach. Have a great day. Jennifer

Monday Moaning

No, it's not Monday. It can't be. Or can it? Oh, boy. Here's the news:

The President is taking his deficit reduction plan on the road. But the next big battle is about raising the debt ceiling, without which we default on our loans, destroying not only our economy, but the world economy. Some say this would be catastrophic. What does this have to do with health care? The GOP plan to kill Medicare and Medicaid whenever they can. Of course, the GOP screamed that health reform would cut back on Medicare -- but now they want to do a lot more cutting. Treasury Secretary Geitner says the GOP has promised to vote to raise the debt ceiling without attaching a lot of poison pills. But GOP budget chief Paul Ryan says they want concessions for voting to increase the debt limits. We'll see. Here's a good point and counterpoint.

Sen Sherrod Brown opposes cuts to graduate medical education at children's hospitals.

A free dental clinic draws capacity crowd, there's such a huge need.

Handoffs in the hospital -- how patients fare a the change of shifts.

Will hypnosis give you a better chance to care for your illness?

And that's the early news. Have a great day! Jennifer

Then Again, You Really Should Read This, Too!

The ever brilliant Jonathan Cohn has written a piece analyzing the Ryan deficit reduction plan. He concludes:

In short, the Republican vision for health care reform, as expressed by Ryan, is to limit federal spending on medical care, at levels far below what we spend today, and then let individuals make the best of the situation. By contrast, the health law calls for more gradual, more shared sacrifice by everybody involved with health care -- with a focus on promoting efficiency so that lower spending needn't result in lesser care. That's not only a more realistic approach to controlling costs. It's also a more humane one.

I agree. Jennifer

If I Could Get You to Read One Thing....

Nobel prize winning economist and NY Times columnist Paul Krugman explains what's wrong with GOP budget czar Paul Ryan's deficit reduction plan, and what's right about President Obama's. He takes on the fallacies of privatization, Rep. Ryan's mathematical errors, and the fact that the GOP plan won't reduce the debt because it calls for $2.9 trillion in tax CUTS.

So lower taxes on the wealthy and corporations, give people a voucher to buy insurance instead of Medicare, turn Medicaid into a system of block grants ... that's the GOP plan.

But don't believe me. Read. Jennifer

Finally Friday Edition

With no rest last week-end and a wicked cold this week, I could not be gladder that it's Friday. Here's the news:

The 2011 budget deal passed yesterday, although many Dems and conservative GOP voted against it. The cuts that will occur this year are relatively small, which explains the conservative opposition. Next comes raising the debt ceiling; some Republicans are saying they won't vote for it unless there are huge cuts to Medicare and Medicaid at the same time. This is going to get ugly.

The House also voted to defund Planned Parenthood and health reform, although those won't pass the Senate. The Senate has already rejected the health reform defunding and also Planned Parenthood defunding. The GOP hopes these votes will haunt Dem Senators in 2012.

Today, the House will vote on Representative Ryan's draconian debt reduction measure, that would end Medicare and Medicaid as we know them. The President has put forward a different plan that includes tax increases for the wealthy. But Medicare is going to see some changes, it appears.

Finally, the repeal of the 1099 bookkeeping problem has been signed by the President. Glad we finally got that out of the way.

The Department of Health and Human Services has laid out several flexibility options for the states in administering their Medicaid plans -- changes that can be made without converting Medicaid to block grants.

Some big name Dems have started a new health advocacy group Know Your Care to help support a progressive health care agenda -- with big money behind them.

Catherine Zeta Jones has acknowledged she suffers from bipolar disorder, sparking more public awareness of this difficult chronic illness.

And that, my friends, is it for now. Have a great day! Jennifer

Deadline Approaching: Call Your Members of Congress

Tomorrow, the House of Representatives will vote on the deficit-reduction plan proposed by Representative Ryan of Wisconsin. As you know -- as indicated by the many links to the many articles I've posted about this in the past few days -- Representative Ryan's plan would:

1. Eliminate Medicare as we know it, instead providing seniors with a voucher that they can use to purchase private insurance. If the voucher doesn't cover the full cost, the consumer has to come up with money. And then there are deductibles and copays and coinsurance, all of which will be far more expensive for consumers than Medicare as we know it.

2. Eliminate Medicaid as we know it, instead providing states with block grants to use however they will. That means that there's a limit on what states can expect to receive from the federal government, no matter how sick people get and how much their health care costs.

If you are poor, a senior, or if you are disabled, this will affect YOU.

The House will vote tomorrow, and they probably will pass the proposal. But that's a far cry from a done deal; it still has to get past the Senate and the President, who has vowed to veto it if it reaches his desk.

So what you have to say matters. Don't assume that your member of Congress is safe -- or that there's no hope of changing their views. You have a right to be heard, so speak up.

To reach your member of Congress, call 1-888-876-6242.

If you don't know who your Senator is, look here. If you don't know who your Representative is, look here.

Say NO to ending Medicare and Medicaid as we know them. There are other ways to cut the debt (like ending the Bush tax cuts on the wealthy, as one example). Tell Congress not to do it on the backs of the poor, the middle class, and seniors.

Thanks. Jennifer

Thursday Themes

I've already posted the full text of the President's speech, so when people lie about what he said, you can read it for yourself. So here's the news:

There is growing dissent about the compromise brokered by the President last Friday night for the rest of 2011. Tea Partiers are unhappy because the cuts weren't more, and Speaker Boehner is turning somersaults to try to keep a fragile coalition of support for the vote, which should happen some time today. The details of the deal are out, and there are surprises. The cuts are only about $365 million for this year, not the $38.5 billion that was touted. Political watchers will keep an eye on today's vote and see who defects on both sides of the aisle.

And the 2012 GOP budget that trashes Medicare and Medicaid is up against some opposition, too. The President's plan stands in stark opposition, and signals the start of what will be a long fight. The President's framework includes spending cuts, but also revenue enhancers as he digs in his heels and says he will not extend the Bush tax cuts for the rich again. Here are some of the Congressional reactions. He would make changes to Medicare and Medicaid, but would not gut them like the GOP would. There would be a stronger independent Medicare board to try to control spending, and a different payment formula for Medicaid. Some liberals think he shouldn't change Medicaid. But for the most part, the President's plan is favored by Dems. It does seem that Medicare will be at the center of this battle. Here's a good comparison of all of the deficit reduction plans. The GOP says the President's plan is too partisan -- as if the GOP plan is not?

Meanwhile House GOP voted to repeal part of health reform, the Prevention and Public Health Fund. The President says he'll veto it if it passes the Senate. The GOP says it's a "slush fund" that the Secretary of HHS can spend however she likes. Dems says it's a critical part of health reform that expands access to preventive care and creates health care sector jobs.

There are 2 million stillbirths every year, and that number could be cut in half if all pregnant women had good health care.

In good news, a study finds a drop in deadly VA hospital errors.

It's good for the baby if you exercise when pregnant.

And that's this morning's news round-up. Have a great day! Jennifer

Transcript of the President's Speech

The White House has requested that we widely disseminate this, so here you go:

THE WHITE HOUSE
Office of the Press Secretary
__________________________________________________________________________________________________
For Immediate Release April 13, 2011

REMARKS BY THE PRESIDENT
ON FISCAL POLICY

George Washington University
Washington, D.C.

1:48 P.M. EDT

THE PRESIDENT: Thank you very much. (Applause.) Please have a seat. Please have a seat, everyone.

It is wonderful to be back at GW. I want you to know that one of the reasons that I worked so hard with Democrats and Republicans to keep the government open was so that I could show up here today. I wanted to make sure that all of you had one more excuse to skip class. (Laughter.) You’re welcome. (Laughter.)

I want to give a special thanks to Steven Knapp, the president of GW. I just saw him -- where is he? There he is right there. (Applause.)

We've got a lot of distinguished guests here -- a couple of people I want to acknowledge. First of all, my outstanding Vice President, Joe Biden, is here. (Applause.) Our Secretary of the Treasury, Tim Geithner, is in the house. (Applause.) Jack Lew, the Director of the Office of Mangement and Budget. (Applause.) Gene Sperling, Chair of the National Economic Council, is here. (Applause.) Members of our bipartisan Fiscal Commission are here, including the two outstanding chairs -- Erskine Bowles and Alan Simpson -- are here. (Applause.)

And we have a number of members of Congress here today. I'm grateful for all of you taking the time to attend.

What we’ve been debating here in Washington over the last few weeks will affect the lives of the students here and families all across America in potentially profound ways. This debate over budgets and deficits is about more than just numbers on a page; it’s about more than just cutting and spending. It’s about the kind of future that we want. It’s about the kind of country that we believe in. And that’s what I want to spend some time talking about today.

From our first days as a nation, we have put our faith in free markets and free enterprise as the engine of America’s wealth and prosperity. More than citizens of any other country, we are rugged individualists, a self-reliant people with a healthy skepticism of too much government.

But there’s always been another thread running through our history -– a belief that we’re all connected, and that there are some things we can only do together, as a nation. We believe, in the words of our first Republican President, Abraham Lincoln, that through government, we should do together what we cannot do as well for ourselves.

And so we’ve built a strong military to keep us secure, and public schools and universities to educate our citizens. We’ve laid down railroads and highways to facilitate travel and commerce. We’ve supported the work of scientists and researchers whose discoveries have saved lives, unleashed repeated technological revolutions, and led to countless new jobs and entire new industries. Each of us has benefitted from these investments, and we’re a more prosperous country as a result.
Part of this American belief that we’re all connected also expresses itself in a conviction that each one of us deserves some basic measure of security and dignity. We recognize that no matter how responsibly we live our lives, hard times or bad luck, a crippling illness or a layoff may strike any one of us. “There but for the grace of God go I,” we say to ourselves. And so we contribute to programs like Medicare and Social Security, which guarantee us health care and a measure of basic income after a lifetime of hard work; unemployment insurance, which protects us against unexpected job loss; and Medicaid, which provides care for millions of seniors in nursing homes, poor children, those with disabilities. We’re a better country because of these commitments. I’ll go further. We would not be a great country without those commitments.

Now, for much of the last century, our nation found a way to afford these investments and priorities with the taxes paid by its citizens. As a country that values fairness, wealthier individuals have traditionally borne a greater share of this burden than the middle class or those less fortunate. Everybody pays, but the wealthier have borne a little more. This is not because we begrudge those who’ve done well -– we rightly celebrate their success. Instead, it’s a basic reflection of our belief that those who’ve benefited most from our way of life can afford to give back a little bit more. Moreover, this belief hasn’t hindered the success of those at the top of the income scale. They continue to do better and better with each passing year.

Now, at certain times -– particularly during war or recession -– our nation has had to borrow money to pay for some of our priorities. And as most families understand, a little credit card debt isn’t going to hurt if it’s temporary.

But as far back as the 1980s, America started amassing debt at more alarming levels, and our leaders began to realize that a larger challenge was on the horizon. They knew that eventually, the Baby Boom generation would retire, which meant a much bigger portion of our citizens would be relying on programs like Medicare, Social Security, and possibly Medicaid. Like parents with young children who know they have to start saving for the college years, America had to start borrowing less and saving more to prepare for the retirement of an entire generation.

To meet this challenge, our leaders came together three times during the 1990s to reduce our nation’s deficit -- three times. They forged historic agreements that required tough decisions made by the first President Bush, then made by President Clinton, by Democratic Congresses and by a Republican Congress. All three agreements asked for shared responsibility and shared sacrifice. But they largely protected the middle class; they largely protected our commitment to seniors; they protected our key investments in our future.

As a result of these bipartisan efforts, America’s finances were in great shape by the year 2000. We went from deficit to surplus. America was actually on track to becoming completely debt free, and we were prepared for the retirement of the Baby Boomers.

But after Democrats and Republicans committed to fiscal discipline during the 1990s, we lost our way in the decade that followed. We increased spending dramatically for two wars and an expensive prescription drug program -– but we didn’t pay for any of this new spending. Instead, we made the problem worse with trillions of dollars in unpaid-for tax cuts -– tax cuts that went to every millionaire and billionaire in the country; tax cuts that will force us to borrow an average of $500 billion every year over the next decade.

To give you an idea of how much damage this caused to our nation’s checkbook, consider this: In the last decade, if we had simply found a way to pay for the tax cuts and the prescription drug benefit, our deficit would currently be at low historical levels in the coming years.

But that’s not what happened. And so, by the time I took office, we once again found ourselves deeply in debt and unprepared for a Baby Boom retirement that is now starting to take place. When I took office, our projected deficit, annually, was more than $1 trillion. On top of that, we faced a terrible financial crisis and a recession that, like most recessions, led us to temporarily borrow even more.

In this case, we took a series of emergency steps that saved millions of jobs, kept credit flowing, and provided working families extra money in their pocket. It was absolutely the right thing to do, but these steps were expensive, and added to our deficits in the short term.

So that’s how our fiscal challenge was created. That’s how we got here. And now that our economic recovery is gaining strength, Democrats and Republicans must come together and restore the fiscal responsibility that served us so well in the 1990s. We have to live within our means. We have to reduce our deficit, and we have to get back on a path that will allow us to pay down our debt. And we have to do it in a way that protects the recovery, protects the investments we need to grow, create jobs, and helps us win the future.

Now, before I get into how we can achieve this goal, some of you, particularly the younger people here -- you don't qualify, Joe. (Laughter.) Some of you might be wondering, “Why is this so important? Why does this matter to me?”

Well, here’s why. Even after our economy recovers, our government will still be on track to spend more money than it takes in throughout this decade and beyond. That means we’ll have to keep borrowing more from countries like China. That means more of your tax dollars each year will go towards paying off the interest on all the loans that we keep taking out. By the end of this decade, the interest that we owe on our debt could rise to nearly $1 trillion. Think about that. That's the interest -- just the interest payments.

Then, as the Baby Boomers start to retire in greater numbers and health care costs continue to rise, the situation will get even worse. By 2025, the amount of taxes we currently pay will only be enough to finance our health care programs -- Medicare and Medicaid -- Social Security, and the interest we owe on our debt. That’s it. Every other national priority -– education, transportation, even our national security -– will have to be paid for with borrowed money.

Now, ultimately, all this rising debt will cost us jobs and damage our economy. It will prevent us from making the investments we need to win the future. We won’t be able to afford good schools, new research, or the repair of roads -– all the things that create new jobs and businesses here in America. Businesses will be less likely to invest and open shop in a country that seems unwilling or unable to balance its books. And if our creditors start worrying that we may be unable to pay back our debts, that could drive up interest rates for everybody who borrows money -– making it harder for businesses to expand and hire, or families to take out a mortgage.

Here’s the good news: That doesn’t have to be our future. That doesn’t have to be the country that we leave our children. We can solve this problem. We came together as Democrats and Republicans to meet this challenge before; we can do it again.

But that starts by being honest about what’s causing our deficit. You see, most Americans tend to dislike government spending in the abstract, but like the stuff that it buys. Most of us, regardless of party affiliation, believe that we should have a strong military and a strong defense. Most Americans believe we should invest in education and medical research. Most Americans think we should protect commitments like Social Security and Medicare. And without even looking at a poll, my finely honed political instincts tell me that almost nobody believes they should be paying higher taxes. (Laughter.)

So because all this spending is popular with both Republicans and Democrats alike, and because nobody wants to pay higher taxes, politicians are often eager to feed the impression that solving the problem is just a matter of eliminating waste and abuse. You’ll hear that phrase a lot. “We just need to eliminate waste and abuse.” The implication is that tackling the deficit issue won’t require tough choices. Or politicians suggest that we can somehow close our entire deficit by eliminating things like foreign aid, even though foreign aid makes up about 1 percent of our entire federal budget.

So here’s the truth. Around two-thirds of our budget -- two-thirds -- is spent on Medicare, Medicaid, Social Security, and national security. Two-thirds. Programs like unemployment
insurance, student loans, veterans’ benefits, and tax credits for working families take up another 20 percent. What’s left, after interest on the debt, is just 12 percent for everything else. That’s 12 percent for all of our national priorities -- education, clean energy, medical research, transportation, our national parks, food safety, keeping our air and water clean -- you name it -- all of that accounts for 12 percent of our budget.

Now, up till now, the debate here in Washington, the cuts proposed by a lot of folks in Washington, have focused exclusively on that 12 percent. But cuts to that 12 percent alone won’t solve the problem. So any serious plan to tackle our deficit will require us to put everything on the table, and take on excess spending wherever it exists in the budget.

A serious plan doesn’t require us to balance our budget overnight –- in fact, economists think that with the economy just starting to grow again, we need a phased-in approach –- but it does require tough decisions and support from our leaders in both parties now. Above all, it will require us to choose a vision of the America we want to see five years, 10 years, 20 years down the road.

Now, to their credit, one vision has been presented and championed by Republicans in the House of Representatives and embraced by several of their party’s presidential candidates. It’s a plan that aims to reduce our deficit by $4 trillion over the next 10 years, and one that addresses the challenge of Medicare and Medicaid in the years after that.

These are both worthy goals. They’re worthy goals for us to achieve. But the way this plan achieves those goals would lead to a fundamentally different America than the one we’ve known certainly in my lifetime. In fact, I think it would be fundamentally different than what we’ve known throughout our history.

A 70 percent cut in clean energy. A 25 percent cut in education. A 30 percent cut in transportation. Cuts in college Pell Grants that will grow to more than $1,000 per year. That’s the proposal. These aren’t the kind of cuts you make when you’re trying to get rid of some waste or find extra savings in the budget. These aren’t the kinds of cuts that the Fiscal Commission proposed. These are the kinds of cuts that tell us we can’t afford the America that I believe in and I think you believe in.

I believe it paints a vision of our future that is deeply pessimistic. It’s a vision that says if our roads crumble and our bridges collapse, we can’t afford to fix them. If there are bright young Americans who have the drive and the will but not the money to go to college, we can’t afford to send them.

Go to China and you’ll see businesses opening research labs and solar facilities. South Korean children are outpacing our kids in math and science. They’re scrambling to figure out how they put more money into education. Brazil is investing billions in new infrastructure and can run half their cars not on high-priced gasoline, but on biofuels. And yet, we are presented with a vision that says the American people, the United States of America -– the greatest nation on Earth -– can’t afford any of this.

It’s a vision that says America can’t afford to keep the promise we’ve made to care for our seniors. It says that 10 years from now, if you’re a 65-year-old who’s eligible for Medicare, you should have to pay nearly $6,400 more than you would today. It says instead of guaranteed health care, you will get a voucher. And if that voucher isn’t worth enough to buy the insurance that’s available in the open marketplace, well, tough luck -– you’re on your own. Put simply, it ends Medicare as we know it.

It’s a vision that says up to 50 million Americans have to lose their health insurance in order for us to reduce the deficit. Who are these 50 million Americans? Many are somebody’s grandparents -- may be one of yours -- who wouldn’t be able to afford nursing home care without Medicaid. Many are poor children. Some are middle-class families who have children with autism or Down’s syndrome. Some of these kids with disabilities are -- the disabilities are so severe that they require 24-hour care. These are the Americans we’d be telling to fend for themselves.

And worst of all, this is a vision that says even though Americans can’t afford to invest in education at current levels, or clean energy, even though we can’t afford to maintain our commitment on Medicare and Medicaid, we can somehow afford more than $1 trillion in new tax breaks for the wealthy. Think about that.

In the last decade, the average income of the bottom 90 percent of all working Americans actually declined. Meanwhile, the top 1 percent saw their income rise by an average of more than a quarter of a million dollars each. That’s who needs to pay less taxes?

They want to give people like me a $200,000 tax cut that’s paid for by asking 33 seniors each to pay $6,000 more in health costs. That’s not right. And it’s not going to happen as long as I’m President. (Applause.)

This vision is less about reducing the deficit than it is about changing the basic social compact in America. Ronald Reagan’s own budget director said, there’s nothing “serious” or “courageous” about this plan. There’s nothing serious about a plan that claims to reduce the deficit by spending a trillion dollars on tax cuts for millionaires and billionaires. And I don't think there’s anything courageous about asking for sacrifice from those who can least afford it and don’t have any clout on Capitol Hill. That's not a vision of the America I know.

The America I know is generous and compassionate. It’s a land of opportunity and optimism. Yes, we take responsibility for ourselves, but we also take responsibility for each other; for the country we want and the future that we share. We’re a nation that built a railroad across a continent and brought light to communities shrouded in darkness. We sent a generation to college on the GI Bill and we saved millions of seniors from poverty with Social Security and Medicare. We have led the world in scientific research and technological breakthroughs that have transformed millions of lives. That’s who we are. This is the America that I know. We don’t have to choose between a future of spiraling debt and one where we forfeit our investment in our people and our country.

To meet our fiscal challenge, we will need to make reforms. We will all need to make sacrifices. But we do not have to sacrifice the America we believe in. And as long as I’m President, we won’t.

So today, I’m proposing a more balanced approach to achieve $4 trillion in deficit reduction over 12 years. It’s an approach that borrows from the recommendations of the bipartisan Fiscal Commission that I appointed last year, and it builds on the roughly $1 trillion in deficit reduction I already proposed in my 2012 budget. It’s an approach that puts every kind of spending on the table -- but one that protects the middle class, our promise to seniors, and our investments in the future.

The first step in our approach is to keep annual domestic spending low by building on the savings that both parties agreed to last week. That step alone will save us about $750 billion over 12 years. We will make the tough cuts necessary to achieve these savings, including in programs that I care deeply about, but I will not sacrifice the core investments that we need to grow and create jobs. We will invest in medical research. We will invest in clean energy technology. We will invest in new roads and airports and broadband access. We will invest in education. We will invest in job training. We will do what we need to do to compete, and we will win the future.

The second step in our approach is to find additional savings in our defense budget. Now, as Commander-in-Chief, I have no greater responsibility than protecting our national security, and I will never accept cuts that compromise our ability to defend our homeland or America’s interests around the world. But as the Chairman of the Joint Chiefs, Admiral Mullen, has said, the greatest long-term threat to America’s national security is America’s debt. So just as we must find more savings in domestic programs, we must do the same in defense. And we can do that while still keeping ourselves safe.

Over the last two years, Secretary Bob Gates has courageously taken on wasteful spending, saving $400 billion in current and future spending. I believe we can do that again. We need to not only eliminate waste and improve efficiency and effectiveness, but we’re going to have to conduct a fundamental review of America’s missions, capabilities, and our role in a changing world. I intend to work with Secretary Gates and the Joint Chiefs on this review, and I will make specific decisions about spending after it’s complete.

The third step in our approach is to further reduce health care spending in our budget. Now, here, the difference with the House Republican plan could not be clearer. Their plan essentially lowers the government’s health care bills by asking seniors and poor families to pay them instead. Our approach lowers the government’s health care bills by reducing the cost of health care itself.

Already, the reforms we passed in the health care law will reduce our deficit by $1 trillion. My approach would build on these reforms. We will reduce wasteful subsidies and erroneous payments. We will cut spending on prescription drugs by using Medicare’s purchasing power to drive greater efficiency and speed generic brands of medicine onto the market. We will work with governors of both parties to demand more efficiency and accountability from Medicaid.

We will change the way we pay for health care -– not by the procedure or the number of days spent in a hospital, but with new incentives for doctors and hospitals to prevent injuries and improve results. And we will slow the growth of Medicare costs by strengthening an independent commission of doctors, nurses, medical experts and consumers who will look at all the evidence and recommend the best ways to reduce unnecessary spending while protecting access to the services that seniors need.

Now, we believe the reforms we’ve proposed to strengthen Medicare and Medicaid will enable us to keep these commitments to our citizens while saving us $500 billion by 2023, and an additional $1 trillion in the decade after that. But if we’re wrong, and Medicare costs rise faster than we expect, then this approach will give the independent commission the authority to make additional savings by further improving Medicare.

But let me be absolutely clear: I will preserve these health care programs as a promise we make to each other in this society. I will not allow Medicare to become a voucher program that leaves seniors at the mercy of the insurance industry, with a shrinking benefit to pay for rising costs. I will not tell families with children who have disabilities that they have to fend for themselves. We will reform these programs, but we will not abandon the fundamental commitment this country has kept for generations.

That includes, by the way, our commitment to Social Security. While Social Security is not the cause of our deficit, it faces real long-term challenges in a country that’s growing older. As I said in the State of the Union, both parties should work together now to strengthen Social Security for future generations. But we have to do it without putting at risk current retirees, or the most vulnerable, or people with disabilities; without slashing benefits for future generations; and without subjecting Americans’ guaranteed retirement income to the whims of the stock market. And it can be done.

The fourth step in our approach is to reduce spending in the tax code, so-called tax expenditures. In December, I agreed to extend the tax cuts for the wealthiest Americans because it was the only way I could prevent a tax hike on middle-class Americans. But we cannot afford $1 trillion worth of tax cuts for every millionaire and billionaire in our society. We can’t afford it. And I refuse to renew them again.

Beyond that, the tax code is also loaded up with spending on things like itemized deductions. And while I agree with the goals of many of these deductions, from homeownership to charitable giving, we can’t ignore the fact that they provide millionaires an average tax break of $75,000 but do nothing for the typical middle-class family that doesn’t itemize. So my budget calls for limiting itemized deductions for the wealthiest 2 percent of Americans -- a reform that would reduce the deficit by $320 billion over 10 years.

But to reduce the deficit, I believe we should go further. And that’s why I’m calling on Congress to reform our individual tax code so that it is fair and simple -- so that the amount of taxes you pay isn’t determined by what kind of accountant you can afford.

I believe reform should protect the middle class, promote economic growth, and build on the fiscal commission’s model of reducing tax expenditures so that there’s enough savings to both lower rates and lower the deficit. And as I called for in the State of the Union, we should reform our corporate tax code as well, to make our businesses and our economy more competitive.

So this is my approach to reduce the deficit by $4 trillion over the next 12 years. It’s an approach that achieves about $2 trillion in spending cuts across the budget. It will lower our interest payments on the debt by $1 trillion. It calls for tax reform to cut about $1 trillion in tax expenditures -- spending in the tax code. And it achieves these goals while protecting the middle class, protecting our commitment to seniors, and protecting our investments in the future.

Now, in the coming years, if the recovery speeds up and our economy grows faster than our current projections, we can make even greater progress than I’ve pledged here. But just to hold Washington -- and to hold me --- accountable and make sure that the debt burden continues to decline, my plan includes a debt failsafe. If, by 2014, our debt is not projected to fall as a share of the economy -– if we haven’t hit our targets, if Congress has failed to act -– then my plan will require us to come together and make up the additional savings with more spending cuts and more spending reductions in the tax code. That should be an incentive for us to act boldly now, instead of kicking our problems further down the road.

So this is our vision for America -– this is my vision for America -- a vision where we live within our means while still investing in our future; where everyone makes sacrifices but no one bears all the burden; where we provide a basic measure of security for our citizens and we provide rising opportunity for our children.

There will be those who vigorously disagree with my approach. I can guarantee that as well. (Laughter.) Some will argue we should not even consider ever -- ever -- raising taxes, even if only on the wealthiest Americans. It’s just an article of faith to them. I say that at a time when the tax burden on the wealthy is at its lowest level in half a century, the most fortunate among us can afford to pay a little more. I don’t need another tax cut. Warren Buffett doesn’t need another tax cut. Not if we have to pay for it by making seniors pay more for Medicare. Or by cutting kids from Head Start. Or by taking away college scholarships that I wouldn’t be here without and that some of you would not be here without.

And here’s the thing: I believe that most wealthy Americans would agree with me. They want to give back to their country, a country that’s done so much for them. It’s just Washington hasn’t asked them to.

Others will say that we shouldn’t even talk about cutting spending until the economy is fully recovered. These are mostly folks in my party. I’m sympathetic to this view -- which is one of the reasons I supported the payroll tax cuts we passed in December. It’s also why we have to use a scalpel and not a machete to reduce the deficit, so that we can keep making the investments that create jobs. But doing nothing on the deficit is just not an option. Our debt has grown so large that we could do real damage to the economy if we don’t begin a process now to get our fiscal house in order.

Finally, there are those who believe we shouldn’t make any reforms to Medicare, Medicaid, or Social Security, out of fear that any talk of change to these programs will immediately usher in the sort of steps that the House Republicans have proposed. And I understand those fears. But I guarantee that if we don’t make any changes at all, we won’t be able to keep our commitment to a retiring generation that will live longer and will face higher health care costs than those who came before.

Indeed, to those in my own party, I say that if we truly believe in a progressive vision of our society, we have an obligation to prove that we can afford our commitments. If we believe the government can make a difference in people’s lives, we have the obligation to prove that it works -– by making government smarter, and leaner and more effective.

Of course, there are those who simply say there’s no way we can come together at all and agree on a solution to this challenge. They’ll say the politics of this city are just too broken; the choices are just too hard; the parties are just too far apart. And after a few years on this job, I have some sympathy for this view. (Laughter.)

But I also know that we’ve come together before and met big challenges. Ronald Reagan and Tip O’Neill came together to save Social Security for future generations. The first President Bush and a Democratic Congress came together to reduce the deficit. President Clinton and a Republican Congress battled each other ferociously, disagreed on just about everything, but they still found a way to balance the budget. And in the last few months, both parties have come together to pass historic tax relief and spending cuts.

And I know there are Republicans and Democrats in Congress who want to see a balanced approach to deficit reduction. And even those Republicans I disagree with most strongly I believe are sincere about wanting to do right by their country. We may disagree on our visions, but I truly believe they want to do the right thing.

So I believe we can, and must, come together again. This morning, I met with Democratic and Republican leaders in Congress to discuss the approach that I laid out today. And in early May, the Vice President will begin regular meetings with leaders in both parties with the aim of reaching a final agreement on a plan to reduce the deficit and get it done by the end of June.

I don’t expect the details in any final agreement to look exactly like the approach I laid out today. This a democracy; that’s not how things work. I’m eager to hear other ideas from all ends of the political spectrum. And though I’m sure the criticism of what I’ve said here today will be fierce in some quarters, and my critique of the House Republican approach has been strong, Americans deserve and will demand that we all make an effort to bridge our differences and find common ground.

This larger debate that we’re having -- this larger debate about the size and the role of government -- it has been with us since our founding days. And during moments of great challenge and change, like the one that we’re living through now, the debate gets sharper and it gets more vigorous. That’s not a bad thing. In fact, it’s a good thing. As a country that prizes both our individual freedom and our obligations to one another, this is one of the most important debates that we can have.

But no matter what we argue, no matter where we stand, we’ve always held certain beliefs as Americans. We believe that in order to preserve our own freedoms and pursue our own happiness, we can’t just think about ourselves. We have to think about the country that made these liberties possible. We have to think about our fellow citizens with whom we share a community. And we have to think about what’s required to preserve the American Dream for future generations.

This sense of responsibility -- to each other and to our country -- this isn’t a partisan feeling. It isn’t a Democratic or a Republican idea. It’s patriotism.

The other day I received a letter from a man in Florida. He started off by telling me he didn’t vote for me and he hasn’t always agreed with me. But even though he’s worried about our economy and the state of our politics -- here’s what he said -- he said, “I still believe. I believe in that great country that my grandfather told me about. I believe that somewhere lost in this quagmire of petty bickering on every news station, the ‘American Dream’ is still alive…We need to use our dollars here rebuilding, refurbishing and restoring all that our ancestors struggled to create and maintain… We as a people must do this together, no matter the color of the state one comes from or the side of the aisle one might sit on.”

“I still believe.” I still believe as well. And I know that if we can come together and uphold our responsibilities to one another and to this larger enterprise that is America, we will keep the dream of our founding alive -- in our time; and we will pass it on to our children. We will pass on to our children a country that we believe in.

Thank you. God bless you, and may God bless the United States of America. (Applause.)

END 2:31 P.M. EDT