1. Ted Marmor responds to Uwe Reinhardt's comment on patients' rights legislation: Prof. Theodore R. Marmor (1st response): After the Patient's Bill of Rights fight (which was supposedly going to be easy), the task is even harder and the odds of big change in health insurance coverage in the U.S. are slight. That seems to me accurate as analysis and thereby helpful to those concerned about using their reform energy sensibly. However, I do not think Uwe Reinhardt's remark is either accurate or helpful. It is not accurate in the sense that he has no grounds for claiming that, were we not debating the patients' bill of rights, we would be having legislative battles over the three very important topics he names. There are few political analyses that would support this concept of diversion. Instead, the patients' bill of rights fight illustrates two very important features of healthcare policy disputes in America. One is that broad coalitions of sometimes strange bedfellows are important for defeating concentrated groups like the health insurance industry. That is one of the points of Bob Pear's analysis of how surprised the industry was by the concentration of political energy on the attack side. That in turn reflected the electoral appeal of acting on behalf of the millions of Americans angry about health insurance practices of the past decade. It does no political good at all for reform efforts to ridicule the steps that are taken if a) they are in the right direction and b) they do not have large political opportunity costs. Second, the question arises of opportunity costs of incremental steps that do not either solve huge problems. In fact, the question now is precisely "what's next" now that some of the outrages of so-called managed care practice have been identified and signals given to firms to watch out for foolish choices. And the answer to that question is obvious: Medicare and prescription drugs, the uninsured, and only much later, medical errors. The notion that legislation can solve the medical error problem in any reasonable time scale is questionable. But we can do a lot about the other two topics if there is a shift in the political composition of the Congress. We have had a century of failed efforts to legislate national health insurance in the US and it surely is time to be careful about misplaced clarity concerning next steps. What one can say for sure is that universal health insurance is not likely to happen in one step unless there is a large shift in the ideological composition of Congress. Absent that, one step at a time is right as long as the steps build on one another and expose the next step to take. I think that is the significance of the patients' bill of rights controversy. Ted Marmor and Jon Oberlander have addressed the strategic issues facing health care reform in "The Path to Universal Health Insurance", chapter 4 of R.L.Borosage and R.Hickey, eds., THE NEXT AGENDA, (Connecticut, Westview Press, 2001). Theodore R. Marmor, Professor of Public Policy & Management, Professor of Political Science, Yale University School of Management ** 2.  Saul Friedman responds to Ted Marmor: I think you're missing what has been happening in the Congress. When last you spoke at AARP, I think, you told us Medicare was safe. That was during the Clinton years when Medicare continued to retreat...I have been covering the Congress for a long time..What's in the wind, if you will talk to anyone who deals with the issue in Washington, is the dismantling of Medicare...You believe that the array of forces that got senate passage of the Patients' bill is a sign of great change coming...Wrong! It's only a sign that the Congress will do only what they have to do and divert us and themselves from what needs to be done...And what needs to be done is not to tame the HMO, but deal once and for all with the need to expand Medicare, as Angell says...AARP no longer advocates, but bargains. Unfortunately, with this very ideological leadership among House and Senate Republicans, the only bargain they seek is the dismantling of public insurance. Saul Friedman, columnist, "Gray Matters" - Newsday ** 3.  Ted Marmor responds to Saul Friedman: I really do not think I am missing what is happening in Congress, though we might disagree about how to interpret it. I have been warning anyone who would listen for the past two years about the dangers of the Breaux/Thomas approach to Medicare 'reform' and the new edition of The Politics of Medicare takes the same task. And, in any event, Medicare has been able to withstand a lot of attack precisely because it has a political structure that mobilizes beneficiaries, though to a lesser degree than social security retirement benefits. Second, I am not at all surprised that the Republicans have an anti-Medicare stealth plan in mind--a kind of MyLai view: save Medicare by destroying it. That is what I have been attacking. But it does not follow that one should mock the patients' bill of rights because of the above. It simply is logically and politically separate and requires analysis to sort out. I agree with you about the Republican aims but disagree that Medicare is going to be gutted. The danger is more that it will be hurt by seemingly small changes. You are rightly angry with threats, but have, in my view, not looked at what both I and Ellen Shaffer are saying about the political consequences of a win on the narrower legal issue and what that highlights. Theodore R. Marmor, Professor of Public Policy & Management, Professor of Political Science, Yale University School of Management On to fourth response. Back to PBOR discussion guide