The passage of the health insurance legislation has two overriding positive effects: it brings more clarity to the health insurance issue and it demonstrates the President's ability to govern.

The legislation also affirms that Americans should not face financial ruin from being unable to afford health insurance. It also makes good progress on prevention, on increasing the supply of health care professionals, on eliminating the flawed "doughnut hole" in the Medicare prescription drug system, and on beginning to address the long term care crisis. These are the good elements of this legislation.

As health insurance system restructuring, the legislation has deep flaws that must be addressed in subsequent legislation. We cannot guarantee coverage, prevent people from being subject to pre-existing condition exclusions, and prohibit insurers from canceling policies for those who become ill during the policy period without significantly increasing costs for all policyholders unless we cause healthy uninsured people to buy insurance, reduce what we pay health care providers, or levy more taxes on people to pay for increased subsidies.

The penalties for healthy people refusing to buy insurance are far too low and do not take effect for several years. Reducing payments to doctors and hospitals either drives them out of the system or causes them to drop Medicaid patients. Raising taxes on everyone to pay for these increased costs worsens our economic situation.

One situation illustrates my point: in the 8th Ward of Washington D.C., there is a severe shortage of specialists, including one urologist for a large population. Most people have health insurance or Medicaid. After this legislation passes, there will be even more people with insurance, but still a severe physician shortage. We have more work to do before our health care system is viable. Health insurance affordability does not produce health care access.

Looking back over the past year of health-care legislation, I would make the following observations:
• The Obama Administration made remarkable progress on health information technology, prevention and wellness and health-care quality in the February 2009, stimulus legislation.
• Although the House and Senate health-care reform bills were not bipartisan and some of the compromises were not particularly good ones, I am pleased that the Senate discarded the public option, the logic for which was never compelling.
• Relative to what the bills attempted to accomplish, the goal of enabling universal health insurance would be achieved. However, there are some structural flaws in the design of the insurance systems that, if not corrected, will put our country at serious financial risk.
• Structural health-care payment and delivery reform could avoid a financial crisis, but it is not clear that any level of government has the political will to tackle these issues, and they were addressed in these bills. Raising taxes to fund health insurance will cripple the economy, and cutting Medicare payments in our existing flawed system will simply drive doctors and other providers out of the system, which will create shortages. At this stage, it is unclear how we will create universal insurance that is affordable and financially sustainable.
• I commend Senators Harkin and Dodd and their colleagues for some excellent work on prevention and wellness. I also believe that the foundation has been laid for supporting more community health centers, a vital tool for health care delivery. Nevertheless, the good pieces of the legislation are relatively under-developed nuggets, not full-blown health care transformation solutions.

Politically, this legislation went as far as Congress could probably go, but much remains to be done.

Compromises are inevitable in any complex piece of legislation. Those that address the unique needs of particular communities and increase the degree to which the legislation meets its fundamental goals are good compromises. Those unrelated to the purpose of the legislation turn the legislative process into a power game in which the strong prey upon the weak.

The decisions to drop the public option and the Medicare eligibility of 55-64 year olds were sensible. Once the Senate required insurers to cover everyone who applied, prohibited coverage limitations based on pre-existing conditions, provided subsidies for those who could not afford insurance, and created national exchanges to insure competition, the primary reasons for having a public option or for expanding Medicare melt away.

I liked the tanning salon tax, because salons probably increase the risk of skin cancer. I was disappointed that the Senate deleted the cosmetic surgery tax. Many plastic surgeons game the insurance system and Medicare by coding cosmetic surgery as reimbursable reconstructive surgery. While some cosmetic surgeries have medical and psychological benefits, the health benefit of others is marginal at best, and risky at worst. Anything that forces a more thoughtful decision on such surgeries would have been beneficial.

I am disappointed that the legislation did not more aggressively address health-care access, quality, and cost issues. As a piece of legislation designed to make health insurance universal, it is relatively good. However, the ultimate problem with mandatory universal health insurance remains how to pay for it without creating other problems. The penalty for young, healthy people who choose not to get insurance is too low, and the subsidy for the older, less healthy people is too generous. If either the House or Senate legislation gets enacted, we will have serious financial problems we will eventually have to address.

The controversy over the U.S. Preventive Services Task Force guideline that mammograms not be administered to women under 50 years old reminds us that we have to move toward more personalized analyses of what is needed for individuals. If a woman has a family history or other factors which suggest that she is at higher risk of having breast cancer, then she would need to get a mammogram much earlier.

Unfortunately, the legal and regulatory framework under which we operate puts the entire burden on the patient and an overworked doctor to flag the information that would indicate that she is at higher risk. For example, the ability of an employer administering a self-insured health care program or an insurance company providing private insurance coverage to gather family history information that would enable them to encourage a woman to get a mammogram before age 50 has been shut down by recently issued privacy regulations called the Genetic Information Non-Discrimination Act ("GINA") regulations, that will prohibit even asking the question about family history in a health risk assessment. This regulation correctly prohibits discrimination against someone based on genetic information or family medical history, but it is written so broadly that it also prohibits more generous benefits, such as financial incentives, in favor of someone at higher risk, when the benefit is designed to be more generous to women who need a mammogram more.

Lawmakers try to make broad rules like the U.S. Preventive Services Task Force guidelines or the GINA regulations when our health risks are highly personalized and probably unique to virtually each individual. The government has to move away from broad rules to tools that help design a system that allows care to be custom designed, based on more complete knowledge of the patient.

The single biggest issue with both the Senate and the House health-care reform bills is that neither meaningfully and comprehensively attacks either the drivers of higher cost and mediocre quality in our current health-care system. I strongly support an amendment to current Section 3502 in the Senate amendment to House Bill 3590, which would beef up the creation and spread of patient-centered coordinated care models for Medicare, Federal Employee Health Benefit Plan, and federal-established health insurance exchange patients.

The current Senate bill contemplates a grant program for the creation of community-based health teams to support primary care physicians, but it lacks several critical components:

• A mechanism for drawing on appropriated funding to get it done nationwide;
• A direction to Congress and HHS to make this available to all Medicare participants within a specified time frame;
• A requirement that a coordinated community care team use an integrated, interoperable electronic health record; and
• A decision to expand this concept beyond Medicare to the Federal Employee Health Benefits Plan.

The reason this type of amendment is so critical is that too much of the Senate and House focus has been on expanding insurance access and affordability and finding ways to pay for it. We need to find ways to reduce hospital readmissions and costs arising from poor care coordination, and to increase the use of modern technology tools that will reduce cost and improve care.

The Senate and House bills are too timid at this stage in attacking cost and quality issues. Without this kind of amendment, we will see more insured people being piled into an already dysfunctional system.

Some of the relatively low-cost, high-return ways to improve health and reduce health care cost increases are relatively unglamorous and do not involve big government programs. For example, at Pitney Bowes, we reduced the rate of seasonal influenza and other infectious diseases by having an aggressive outreach on seasonal immunizations and on hand-washing and other hygiene-focused practices, such as more frequent cleaning of surfaces on which viruses or bacteria reside and spread. The rate of hospital-acquired infections, which cost our health care system dearly, could be reduced significantly if all hospitals focused similarly on infectious disease prevention.

Another relatively low-cost area of focus, which pays both significant short and long term dividends, is more aggressive outreach on prenatal counseling and lifestyle modification. Today, government programs are predominantly focused on the medical interaction required close to the time the mother delivers. However, the real benefit of prenatal counseling is at much earlier points in the pregnancy, at points during which an intervention can reduce the incidence of low birth-weight, premature babies. At Pitney Bowes, we used a program called Great Expectations, which provided financial incentives to get expectant mothers to participate, and we achieved lower incidence of premature births.

Any investment in getting children and adolescents to adopt better living habits pays back handsomely. For example, increasing the price of tobacco products by 10 percent reduces the percentage of teenagers who start smoking by 4 percent as a number of studies summarized in 2004 by Professor John Taurus of the University of Illinois at Chicago shows.

We have to refocus our efforts on improving health, as opposed solely to increasing insurance access. If we do not solve the health and health care access problems, and only give everyone an insurance card, we are effectively rearranging the deck chairs on the Titanic.

You can't please all the people all the time. There are no simple solutions. This is a compromise situation. But is giving up on millions of Americans the answer?

The Senate Finance Committee bill would achieve coverage for 94 percent of us, which is indeed a substantial improvement from the current 83 percent. And without a doubt, that 94 percent is a hard-won achievement for those crafting the bill, given the strong views and conflicting priorities in Congress, let alone the Committee.

Committee members have worked for weeks with the certain knowledge that regardless of their efforts and compromises, someone's not going to get what they want. Many of us are going to think the final package is too expensive. Others will say it didn't do enough to fix the inequities in a broken health care system. Some won't be satisfied unless health care is free to all.

I get it. It's a tough situation and they're doing their best.

But I refuse to believe that the best we can do still leaves millions and millions of Americans behind. Final legislation must get closer to the principle that led us to embark on reform in the first place: in this nation, it is unacceptable that people suffer and die because they can't afford to go to the doctor.

Today's vote is a huge and helpful step for America's families, and it is truly historic. Never before has the Senate Finance Committee adopted meaningful health insurance reform. Never before have all five congressional committees with jurisdiction over health care adopted measures designed to make high-quality, affordable health coverage available for America's families. And never before have we reached the point that both the Senate and House are poised to debate and adopt health insurance reform. These are clear signals that passage of health insurance reform is virtually inevitable this year -- and it couldn't happen too soon.

The Senate Finance Committee bill is complex and touches upon many subjects of significant interest to specific stakeholders. As a person who built and refined an employer-based health care program, and who feels passionately about health-care delivery and payment reform, as well as promotion of public health, I feel there is much to like in the bill, as well as some troubling provisions.

I support the idea of universal, affordable coverage, but feel that the $750 penalty for those not purchasing insurance is too low, and will have the unintended effect of causing far more sicker and older people to seek insurance and more healthy young people to pay an insufficiently low penalty in lieu of insurance.

I like the many efforts to address payment and delivery reform, and quality improvement. As a recently retired CEO of a large, self-insured employer, I like the increased plan design flexibility the bill creates, and do not object strongly to the idea of a "Cadillac plan" tax. However, the bill reduces significantly the tax benefit of flexible spending accounts, a vital health care planning tool, and it needs refinement in defining what it considers a "Cadillac plan."

I like the idea that the bill is taking a fresh look at many obsolete and costly state insurance mandates, and that it will create additional affordable choices for consumers. However, I believe that the additional fees charged to health insurers will simply get passed on to consumers and work against the goals of the bill.

I hope that Title III, Subtitle A of the Senate Health, Education, Labor and Pension Committee bill that provided for a National Prevention, Health Promotion, and Public Health Council survive, because, ultimately, improving overall health is essential to "bending the cost curve."

I support taxes on "Cadillac" plans as long as we adjust the cost for plans that enroll a higher percentage of less-healthy patients. Research shows that a richer plan does not produce better health or health care.

The "Cadillac" plans typically have bad plan designs that provide 100 percent reimbursement for hospitalizations and outpatient surgeries, and close to 100 percent reimbursement for expensive and overused diagnostic tests. When plan participants are paying little or nothing for the most expensive components of care, they have no incentive to manage their health or the quality of their care. They also are less likely to adhere to chronic disease treatment plans because they implicitly know that their hospitalization is completely covered.

It is inconvenient and challenging for many people to change their behaviors to better manage their health or diseases. There has to be some degree of cost sharing for the most expensive and technologically-intensive treatment to get them to alter their behaviors.

By contrast, those plans that align the plan participants and payers by giving incentives for high-quality care and healthy patient behaviors should be rewarded. In those plans, because there are cost-sharing arrangements and differences in premiums and payments to providers, there are opportunities to affect both doctor and patient behavior for the better.

For example, we should give discounts for patients with chronic diseases like Type 2 diabetes who do everything they are supposed to do to maintain or improve their health, since we know that Type 2 diabetics can actually improve their condition. We should use workplace-based clinics that deliver convenient, lower-cost care, and an exceptionally high degree of employee satisfaction. We should aggressively promote preventive screenings that save on health care costs.

As I saw at Pitney Bowes, an intelligently-designed health plan produces better health and health care at a significantly lower cost than these "Cadillac" plans.