So here are some cheery headlines to catch your eye:

US: Hospital ERs overwhelmed, one-day study finds (May 5)

A one-day snapshot of emergency room conditions at 34 U.S. hospitals shows they are all overwhelmed and none is prepared to handle a big event like a disaster or attack.

Bird flu pandemic risk just as real and probably growing (May 8)

Experts are warning that the risk of a human bird flu pandemic remains just as real and is in fact probably growing.

Doctors debate who would be allowed to die in pandemic (May 5)

Doctors know some patients needing lifesaving care won't get it in a flu pandemic or other disaster. The gut-wrenching dilemma will be deciding who to let die.

Together, they illustrate a dilemma. On the one hand, US hospitals are already strained, and can't really handle any more stress (see  Medical Crisis: The Shape Of Things To Come). On the other hand, any kind of major disaster, be it a Katrina-size storm or a pandemic, will add more patients and more demands to a medical system already maxed out, particularly when it comes to emergency departments and intensive care units (see Pandemic Challenges For Hospitals.) From the WaPo back in February:

The federal government's voluminous plans for dealing with pandemic flu do not adequately account for the overwhelming strain an outbreak would place on hospitals and public health systems trying to cope with millions of seriously ill Americans, some public health experts and local health officials say.

It's a problem. After all, from wildfires to tornadoes, natural disasters happen. So what does one do? A relatively new approach to major disasters after Katrina is to realistically appraise the numbers and try and figure out how hospitals can cope... see Hospital Surge, Exercises and Pandemics. And when they can't, well, at that point, when patients outnumber the available beds and equipment to take care of them, tough decisions need to be made.

...an influential group of physicians has drafted a grimly specific list of recommendations for which patients wouldn't be treated. They include the very elderly, seriously hurt trauma victims, severely burned patients and those with severe dementia.

The suggested list was compiled by a task force whose members come from prestigious universities, medical groups, the military and U.S. government agencies. They include the Department of Homeland Security, the Centers for Disease Control and Prevention and the Department of Health and Human Services.

The proposed guidelines are designed to be a blueprint for hospitals "so that everybody will be thinking in the same way" when pandemic flu or another widespread health-care disaster hits, said Dr. Asha Devereaux. She is a critical care specialist in San Diego and lead writer of the task force report.

For anyone interested in the details, the medical journal CHEST has made the task force report available (in several parts) for free.

Now, whenever we talk about hospital surge and rationing, there's bound to be people that get upset. But in reality, it's much better to talk about these things in advance rather than avoiding the topic, having no plan and having a disaster hit. And limited beds, limited supplies and limited personnel (shortages of space, staff and stuff) will force these unpleasant rationing choices upon us, like it or not. That's why California and New York have both looked at versions of this. In addition, the nature of infectious disease outbreaks, with the possibility of quarantine and isolation, have raised civil liberties issues of a different sort (see The ACLU, Pandemic Preparedness, and You).

So, step back and look at the big picture. The sheer size and scope of disasters require a completely different approach than medical 'business as usual', yet that means bringing in ethical and legal issues (e.g., rationing) that our political candidates like to avoid (except when they are accusing the other guy of advocating it). But don't let the politicians fool you. As illustrated in today's post, looking at rationing is now a mainstream part of evaluating hospital disaster care, and an arguably appropriate response to shortages.

The California Department of Public Health recently released the first comprehensive surge guidelines for health care during a catastrophic emergency.

The new "surge capacity guidelines"  - which authorities hope will serve as guidlines for hospitals nationwide, especially in the event of a pandemic - calls for letting older, sicker patients be allowed to die in order to save the lives of patients more likely to survive a catastrophic public health crisis.

By the way, this is a topic (health reform, disaster preparedness and the state of disrepair of public health infrastructure) the Presidential candidates need to address. At the same time, looking at "gut-wrenching dilemmas" needs to be done openly and with the input and participation of the public. You certainly don't want decisions like these to be made without you, do you?

American Presidential elections are about the future, and not the past. It's for that reason that the contrast between the junior senator from Illinois and the senior senator from Arizona is so fascinating.

The Republican National Committee is planning a $19.5 million advertising campaign to portray Mr. Obama, 46, as out of touch with the country and too inexperienced to be commander in chief, seeking to put him on the defensive before he can use his financial advantage against Mr. McCain, 71, party officials said.

"In 1984, Ronald Reagan said, ‘I’m not going to exploit for political purposes my opponent’s youth and inexperience,’ " said Frank Donatelli, the deputy chairman of the Republican National Committee. "Well, we are going to exploit Obama’s youth and inexperience."

On the Democratic side, Mr. Obama’s aides this week put finishing touches on advertisements intended to tether Mr. McCain to Mr. Bush and chip away at his image as a maverick, an identity that the aides said they found remained strong with voters.

"By November, every voter will know that McCain is offering a third Bush term," said Mr. Obama’s campaign manager, David Plouffe.

It isn't the age stuff (McCain at 72 would be the oldest President ever inaugurated, and as he put it himself, he's a man of "the twentieth century, my century"; Obama would be a year older than Bill Clinton was when Clinton took office.) It isn't character (McCain made it to the top the Republican way: he cheated on his first wife and married a Sugar Momma, who still finances his political ambitions; see McCain campaign violates own travel policy and the issue of Cindy McCain's tax returns.) No, it's none of that. It's the important stuff, issues in the real world that affect all of us. As David Gergen put it:

"The next president will inherit the most difficult agenda since the presidency of Franklin Roosevelt," he warned.

Gergen stressed that a continuation of current policies would likely result in the decline of America while Japan, China and India may become superpowers within the next few decades. Whether the U.S. will remain one is questionable, he said, especially if our policies remain static.

According to Gergen, America not only needs to change its policies, but revolutionize them. In addition, problems including two extensive wars, the education system and job growth require solving, not "sugar-coating."

It is in this regard that the contrast is so striking. So, let's look at the three issues Americans have identified as "most important" to them.

Iraq (statements from Foreign Affairs):

Obama:
To renew American leadership in the world, we must first bring the Iraq war to a responsible end and refocus our attention on the broader Middle East. Iraq was a diversion from the fight against the terrorists who struck us on 9/11, and incompetent prosecution of the war by America's civilian leaders compounded the strategic blunder of choosing to wage it in the first place. We have now lost over 3,300 American lives, and thousands more suffer wounds both seen and unseen.

McCain:
Whether success grows closer or more distant over the coming months, it is clear that Iraq will be a central issue for the next U.S. president. Democratic candidates have promised to withdraw U.S. troops and "end the war" by fiat, regardless of the consequences. To make such decisions based on the political winds at home, rather than on the realities in the theater, is to court disaster. The war in Iraq cannot be wished away, and it is a miscalculation of historic magnitude to believe that the consequences of failure will be limited to one administration or one party. This is an American war, and its outcome will touch every one of our citizens for years to come.

That is why I support our continuing efforts to win in Iraq. It is also why I oppose a preemptive withdrawal strategy that has no Plan B for the aftermath of its inevitable failure and the greater problems that would ensue.

So who's right? Hint: not John McCain. Writing this month in Foreign Affairs, Steven Simon notes in The Price of the Surge (bolded mine):

Unfortunately, such claims misconstrue the causes of the recent fall in violence and, more important, ignore a fatal flaw in the strategy. The surge has changed the situation not by itself but only in conjunction with several other developments: the grim successes of ethnic cleansing, the tactical quiescence of the Shiite militias, and a series of deals between U.S. forces and Sunni tribes that constitute a new bottom-up approach to pacifying Iraq. The problem is that this strategy to reduce violence is not linked to any sustainable plan for building a viable Iraqi state. If anything, it has made such an outcome less likely, by stoking the revanchist fantasies of Sunni Arab tribes and pitting them against the central government and against one another. In other words, the recent short-term gains have come at the expense of the long-term goal of a stable, unitary Iraq.

Despite the current lull in violence, Washington needs to shift from a unilateral bottom-up surge strategy to a policy that promotes, rather than undermines, Iraq's cohesion. That means establishing an effective multilateral process to spur top-down political reconciliation among the major Iraqi factions. And that, in turn, means stating firmly and clearly that most U.S. forces will be withdrawn from Iraq within two or three years. Otherwise, a strategy adopted for near-term advantage by a frustrated administration will only increase the likelihood of long-term debacle.

Of course, McCain (the so-called military expert) hasn't been pinned down for a response about this, which qualifies as an example of Gergen's "sugar coating":

"So the Pentagon would maintain a team of 'military analysts' who reliably 'carry their water' -- yet who were presented as independent analysts by the television and cable networks. By feeding only those pro-Government sources key information and giving them access -- even before responding to the press -- only those handpicked analysts would be valuable to the networks, and that, in turn, would ensure that only pro-Government sources were heard from.

Hmmm... well, let's turn to another topic of import: health reform.

In a turnaround, where McCain was slightly edging the Dem cadidates previously, either Dem candidate would beat McCain today in the new LA Times/Bloomberg poll.

May 1-8, 2008 +/-3%
           May (Feb)

Clinton     47  (40)
McCain      38  (46)
Don't know  11   (9)

Obama       46  (42)
McCain      40  (44)
Don't know   9   (9)

LA Times:

"Although there is such infighting now between the two Democratic candidates, we are finding that both Democrats are beating McCain, and this could be attributed to the weakening of the economy," said Times Polling Director Susan Pinkus, who supervised the survey.

For example, among the 78% of voters who said they believe the economy has slid into a recession, 52% would vote for Obama, compared with 32% for McCain. A Clinton-McCain matchup showed nearly identical results.

The poll was based on telephone interviews with 2,208 adults nationwide -- 1,986 of them registered voters -- several days before and after Tuesday's primaries in Indiana and North Carolina, which Clinton and Obama split

We knew going in that McCain would be the most competitive of the GOP candidates, but that's not the same thing as winning the election. Fundamentals still matter, and the fundamentals will not be in the Republicans' favor this fall. Take a look at the graph.

McCain remains competitive because of his showing among older voters and independents -- constituencies both parties are vying to win. McCain leads Clinton among independents and is essentially tied with Obama.

Older voters and generational change will be a theme of the election, like it or not. So will independents, because no one wants to be a Republican. But as Chuck Todd astutely observed on primary day, NC looks more like the future than Pennsylvania. And when the question turns to policy, direction of the country, the economy, health care and Iraq, the senior senator from Arizona (R) is going to have his hands full convincing the country that his policies are not just more Bush, and that he can chart a path to the future that makes sense.

After all, the economy is not his strong suit, and he's a man of "the twentieth century, my century". McCain will win among voters who want to chart a path to the 20th Century... but if that's the case he makes, he'll lose the election.

The media narrative isn't always right, but it's always fascinating to watch. Because political reporters tend to be pack herd animals, once a narrative gets out there, it's tough to change. Yesterday, there was only one narrative: the Democratic race is over.

The consensus was swift and brutal. The tabloids had their own way of saying it (like the NY Post, which led the front page with "Toast!"). TIME has a cover offering an Obama victory pic. Broadcast media had their list, as captured by Jim Rutenberg in the NY Times (Pundits Declare the Race Over).

The moment came shortly after midnight Eastern time, captured in a devastatingly declarative statement from Tim Russert of NBC News: "We now know who the Democratic nominee’s going to be, and no one’s going to dispute it," he said on MSNBC. "Those closest to her will give her a hard-headed analysis, and if they lay it all out, they’ll say: ‘What is the rationale? What do we say to the undeclared super delegates tomorrow? Why do we tell them you’re staying in the race?’ And tonight, there’s no good answer for that.

Russert, btw, did an encore on Wednesday's evening news, using his whiteboard to go over the inexorable delegate math on the Nightly News (the astute Chuck Todd has been all over this), reiterating the idea that there was no way Clinton wins.

Yesterday afternoon, this AP story made its way onto the internet via the Houston Chronicle: Analysis: Democrats quietly send word to Clinton it's over. In the WaPo, Dan Balz did his own canvassing:

I sent a message to one of her most loyal supporters early Wednesday morning asking what are her realistic options? "She has only one option," he replied. "Gracefully exit and help unify the party to beat [John] McCain." How quickly, he was asked. "I would advise them to figure out how to do it as soon as this weekend," he replied.

Another veteran Democrat who has backed Clinton was equally pessimistic in his private assessment. "It's hard to see a path toward the twin goals of Hillary winning and the party uniting," he wrote. "Her strategy cannot be to destroy the village in order to save it. The superdelegate dam is about to break. Hillary losing [George] McGovern is like LBJ losing [former CBS News anchor Walter] Cronkite."

Several outlets started to dissect the Clinton superdelegates (this from The Hill):

"I, as you know, have great fondness and great respect for Sen. Clinton and I’m very loyal to her," [Dianne] Feinstein said. "Having said that, I’d like to talk with her and [get] her view on the rest of the race and what the strategy is.

Clinton, who eked out a win in Indiana Tuesday night but lost big to front-runner Sen. Barack Obama (Ill.) in North Carolina, has not responded to Feinstein’s phone call, the California senator said.

"I think the race is reaching the point now where there are negative dividends from it, in terms of strife within the party," Feinstein said. "I think we need to prevent that as much as we can."

Today, it'll be about grace, timing, pride and, inevitably, money. Already one can see the references to Planet Clinton ( a place far away from here where people think they can win) openly make their way into political discussions (I heard it on MSNBC yesterday; pundits hate it when the candidates defy the narrative.)

I'll leave it to others to talk about why the pundits suddenly realized what the blogs have been saying for weeks... Barack Obama will be the Democratic nominee, and it's about damn time to put his opponent, 71 year old John McCain, under the microscope and hold him accountable for his positions, his gaffes and his embrace of the worst President in polling history. But given the current narrative, that time is coming very soon.

I'm shaking my head watching the MSNBC pundits berate themselves for falling for the CW and thinking the Jeremiah Wright controversy (that they helped create and fuel) was bigger in their minds than it turned out to be in the minds of the voters. 56% of the latest CBS/NY Times respondents say the media spent too much time on the Wright issue.

We knew that. We knew it from reading the polling internals that said that Bush is a bigger problem for McCain than Wright is for Obama. And, come on, folks. Wright is a pastor. Bush is the current President of the United States and the worst president in the history of polling (see Bush's disapproval rating worst of any president in 70 years).

The 71 year old John McCain has had a free ride from the media for far too long. He doesn't know Shi'a from Sunni, doesn't know squat about the economy, and McCain represents the same ignorance and lack of attention to fundamentals represented by George W. Bush. In fact, McCain supports Bush on policy after policy, breaking from himself to do so.

And don't miss the fact that McCain, running virtually unopposed, can't nail down more than 80% of GOP primary voters in PA, NC and IN. They're voting for anyone but McCain.

Well, if you can't get sensible analysis on cable TV, come get it here. The fundamentals say that this is going to be a very rough year for John McCain. He's (very much) a Republican, he's a (very strong) Bush supporter, and he's wrong on the issues from the economy to Iraq to health care. The House and Senate races are going to be even worse for Republicans. So let's get back on track and cover the GOP train wreck that's coming. I can't wait for McCain to play defense for the Republican party. Personally, I don't think he's up to the job. And I'll warrant his fellow Republicans aren't loving the idea, either.

From the new CBS/NY Times poll, taken May 1-3 (full results,.pdf)

OBAMA’S HANDLING OF WRIGHT SITUATION (Among registered voters who have heard about Wright)

       All Voters   Dem Primary Voters
Approve      60%         68%
Disapprove   23          22

Half of voters think Obama’s comments on Wright were appropriate, but one in four voters (and slightly more Republicans) would have liked him to have gone further in his rejection.

OBAMA’S COMMENTS ON WRIGHT WERE...
(Among registered voters who have heard about Wright)
             All Voters    Dem Primary Voters
About right          52%    53%
Not critical enough  26     24
Too critical          6      9

Almost half – 47% - of voters see political motivation as the main reason behind Obama’s decision to renounce his minister. Fewer, 34% think the split came mainly because Obama disagreed with things Wright said.

The poll suggests that Wright had a bigger impact on Republicans than Democrats:

The general election is six months away, and most voters do not expect Wright’s impact to linger in their own minds. Only about one in ten say this will affect their November vote a lot. But more say it will matter to most people they know. The impact appears strongest among Republicans who are much less likely to vote for any Democrat.

And on the head to heads:

IF THE CANDIDATES WERE..., WHO WOULD YOU VOTE FOR? (Among registered voters)
          Now  4/30   4/3/08
Obama       51%  45%   47%
McCain      40   45    42
Undecided/DK 5    6     7

IF THE CANDIDATES WERE..., WHO WOULD YOU VOTE FOR? (Among registered voters)
          Now  4/30   4/3/2008
Clinton     53%  48%  48%
McCain      41   43   43
Undecided/DK 3    5    5

It's crystal clear the so-called "firestorm" was more in the minds of beltway bloviators (as well as conservative talking heads who have nothing else to talk about) than in the minds of the voters, some of whom would <gasp> never vote D in the first place. Others figure Obama was tested and passed.

In any case, Clinton and Obama both clean 71 year old Republican McCain's clock in this poll. So, media, can we talk about the issues now?

smintheus wrote yesterday about the 71 year old Republican candidate's attempted smear of Democratic proposals, evoking big government socialized medicine (in McCain's day, that meant something, but these days, it's just a marker of whether you are a Republican or a Democrat. And, of course, there's fewer and fewer Republicans every day.)

Earlier in the campaign Mr. McCain made the accusation more explicitly. "There will be efforts to have a single-payer big government solution by the Democrats," he said at a debate in Orlando, Fla., in October. "They’ve already espoused those causes. If you believe them, please take a trip to Canada or England before you decide to support such a thing."

And in August when he was interviewed by Charlie Rose on PBS, Mr. McCain said: "Look at what the Democrats’ proposal is. It’s a government-run, single-payer system like they have in Canada and like they have in England."

Mr. Rose interrupted: "But I beg to differ. They will say that it is not that at all."

Certainly it is not, even if many wish it would be. But what we have here is something that's a good deal simpler than it seems, but no one wants to talk about. The simple fact is that neither Republican nor Democratic proposals put a great deal of extra money into health reform. Because of that, the only way to enact any of the candidates' stated programs (in the unlikely event they actually go forward as is – something Congress will have a major say in) is to redistribute dollars, or to put it more bluntly, figure out who the winners and losers are.

In the McCain proposal, the winners are the insurance companies, and to a lesser extent, business. He'd like to allow more 'freedom' for the companies to sell their product with higher deductibles and catastrophic insurance but less in the middle, and somehow he'd like to borrow Bush's magic wand (the one that lowers oil prices) to make a high deductible plan more affordable to average Americans (and hope they don't really need the coverage or medicine). The funny thing is that McCain doesn't really understand his own proposal.

As a result, McCain's aides have been scrambling to come up with ways to satisfy those who want more coverage without violating what they call McCain's conservative principles on the issue.

There's more here about McCain and his plan, and more references here about all the plans.

In the Democratic proposal, increased coverage is the goal, though the cost of such a system to both consumers and taxpayers in unclear. Winners are those who can't afford insurance now, but what the end result will look like is murky. That's partly because there's a great disparity across the country between states like TX and CA with high uninsured, and states like MA with much lower percentages of uninsured, so winners and losers are not evenly distributed geographically.

So, trying to figure out winners and losers, here's some very helpful advice from the CEO of the Kaiser Foundation, Drew Altman:

In listening to candidates at a series of presidential candidate forums in our Barbara Jordan Conference Center and sifting through the hundreds of hours of speeches, debates, and documents by Presidential candidates about health policy we have compiled on the web, here are three critical differences between the parties that set the stage for the next health reform debate.

First, there is a basic difference on whether guaranteeing universal or nearly universal health insurance coverage should be the primary goal of health reform. Democrats consistently say it should be, though the leading candidates’ plans differ somewhat on how to get there and whose plan represents a better approach. Republicans do not have universal coverage as their overarching goal. They believe it requires too big a role for government to guarantee universal coverage and will cost too much to pay for it. Instead, they want to make coverage more available in the private marketplace and give people a tax break to help those who want it afford it. The top priority they emphasize is to create a more efficient, and in their view, more affordable private health insurance marketplace based on individual choice and competition. This, they believe will expand coverage, but guaranteeing coverage for all is not their main goal. This difference reflects the greater priority their base gives to controlling costs over expanding coverage, as documented repeatedly in the tracking polls that Molly Brodie, who heads our polling group, and her team conduct at the Foundation.

Altman rightly suggests focusing on the fundamental differences between the D and R plans, including the McCain's suggested move away from employer-based care, because that's what the discussion should be in the fall:

...there is also a fundamental difference in what the two sides see as the basic purpose of health insurance. Democrats favor comprehensive insurance with front-end protection, which in their view encourages more preventive care and protects people better from financial costs of an illness. Republicans generally promote plans with high deductibles on the front end and catastrophic protection on the back end, coupled with tax-preferred savings accounts people would use to pay for routine care. They believe this will encourage people to become more prudent consumers of health care and use less health care overall.  Whether high deductible health plans with savings accounts are a forward-looking reform that will introduce market incentives and lower costs as advocates claim, or represent skimpier insurance surrounded by market rhetoric as critics believe, is an important question to debate and study as these new forms of insurance enter the marketplace. My purpose here is to characterize differences, not to referee these debates. There is no question, however, that the difference between the parties on the very nature and purpose of health insurance is a fundamental one that needs to be elucidated for voters.

Altman has further observations that can be found here. And, for a more blunt view of what's going on in the health debate, check out this half hour video from Henry J Aaron (Brookings) and Stuart Butler (Heritage) debating the uninsurance/underinsurance issue. Wonky, but very good. Aaron notes the winner-loser issue up front, and Butler talk about the limits <gasp> of the market (not bad from a conservative). He says "markets themselves cannot guarantee affordable and available access everywhere", and he's right. But he also brings up issues of rationing as an inevitable consequence. Both agree that state innovation (with Federal support) is key, which is exactly the opposite of Bush and McCain's attitude towards SCHIP.

McCain: Bush right to veto kids health insurance expansion

This is an issue that will be even more prominent come November, so take the time to study up a bit on how to define the issue. It seems that McCain is already trying to do that, and part of the reason is that he knows he loses on the universal coverage issue (see McCain rejects calls for universal health coverage), and because of his pre-existing cancer diagnosis, looks like a hypocrite to boot. And don't get me started on what recession means to all of the above. Check this out:

Almost Four In 10 Report Serious Financial Burden Caused By Medical Bills; 7 Percent Say Someone In Their Household Got Married So They or Their Spouse Could Get Health Benefits

Health reform is a problem that's not going away.

DemFromCT's Health Care Discussion Links can be found here.

Not everyone reads the NY Times, but today's the day to do so. Via Al Giordano, I caught this fascinating story and graph by Charles Blow, who published an important graph and analysis of NY Times/CBS poll data (Clinton's goes back to 2005 while Obama's goes back to Jan 2007.)

The question is this: Have white Democrats soured on Obama? Apparently not. Although his unfavorable rating from the group is up five percentage points since last summer in polls conducted by The New York Times and CBS News, his favorable rating is up just as much.

On the other hand, black Democrats’ opinion of Hillary Clinton has deteriorated substantially (her favorable rating among them is down 36 percentage points over the same period).

While a favorable opinion doesn’t necessarily translate into a vote, this should still give the Clintons (and the superdelegates) pause. Electability cuts both ways.

It's tough to summarize this better than Al Giordano:

So, to sum up: Look at the damn graphs. You can see that Clinton is in a staggering free-fall among African-American voters, her favorability is down 36 points while 17 percent view her more negatively than before, while Obama’s favorable and negative ratings among whites have paired at five point increases. You can even see the small dip - about two percentage points - in his popularity among whites that can be attributed to the news cycles about his ex-pastor, and see that it has leveled out and is now on a straight horizontal line (meanwhile, Clinton’s numbers among blacks continue on an extreme downward precipice). The greater context is that even including Obama’s slight dip, he’s more popular today among white voters than he ever was prior to February.

Not since Ronald Reagan has an American presidential candidate withstood such an assault in the media and seen his popularity not hurt by it, but, rather, galvanized by it. That’s what is meant, in politics, by the term "Teflon."

Those facts won’t stop many media (and Internet) talking heads from continuing - whether out of gullibility or intentional dishonesty - to prop up the "white voters" narrative, but it ought to inoculate you, kind reader, from believing it.

I have been writing for some time that the polling hasn't moved much despite the bloviating from broadcast media, especially. In that, it reminds me of Iraq. It seems some opinions have simply already been made, and while the talking heads may get palpitations over a minor issue, the voters don't care because they see the big picture.

Your/our job as political junkies is to understand what's going on, and just because the so-called pundits don't always do their job is no reason for us to avoid doing ours. This remains a fundamentally difficult election for Republicans, and the media's zest for Democratic conflict stories doesn't change that one bit.

In January, George W Bush was at 31% approval, and the wrong right track number was 19%. And guess what?

Bush — not Wright or Bill Clinton — is voters' main concern

A new NBC/WSJ poll finds between them, Barack Obama is at 46%, Clinton 43% And while 32% are saying Rev. Wright a major concern, ties to Bush for McCain make 43% say it's a major concern. And, by the way, the head-to heads have barely changed (for example, in March it was 44-42 Obama-McCain). They've barely changed in any of the polls.

So, the gasbags can blather all they want about Rev. Wright.

According to the poll, 73 percent of respondents disapprove of Bush’s handling of the economy and 81 percent believe the United States is in a recession.

Oh, and don't miss:

What is your preference for the outcome of this year's congressional elections––a Congress controlled by Republicans or a Congress controlled by Democrats?

Republican-controlled Congress ......34

Democrat-controlled Congress ........49

Hmmm. I think Stu Rothenberg was right... "For McCain, This Could Be as Good As It's Going to Get". While the Democratic primary approaches end-game, the bread-and butter questions about the economy, Iraq and health care are going to take center stage. That's what Americans want to talk about, along with how unpopular this Republican President is. And when they talk about the issues, 71 year old Republican John McCain (and other Republicans running as well) lose.

Update [2008-4-30 19:25:58 by DemFromCT]: NYT/CBS:

The weakening economy appears likely to play a critical role in the campaign, the poll found. The issue showed up in personal ways: As food and gas prices soar, more Americans say they are having a hard time saving or buying extras. Thirty-eight percent said they could do so in February, just 27 percent in the latest poll.

President Bush continues to get low marks on his overall job performance, with just 21 percent approving of his handling of the economy. Given those ratings, Mr. McCain faces a political challenge in establishing his own identity: About half of all voters say they expect him to continue Mr. Bush’s policies if elected, while another 2 in 10 say he will have policies that are even more conservative...

The underlying political landscape continues to favor the Democrats, despite their current divisions. Over all, 52 percent of adults said they had a favorable opinion of the Democratic Party, compared with 33 percent who felt positively about the Republican Party.

The Democratic Party was viewed as better able to handle the economy, more likely share the respondent’s moral values, more likely to improve the health care system and more likely to make the right decisions about the war in Iraq. The Republicans, however, maintained their advantaged in ensuring that American military defenses were strong.

[UPDATE II] From WSJ:

Only 27% of voters have positive views of Republicans, according to the latest Wall Street Journal/NBC News poll, the lowest level for either party in the survey's nearly two-decade history.

Come to think of it, nothing's ever my fault. Jimmy Baker taught me that years ago. What was I thinking? Always blame someone else for anything that I do wrong. Hey, I know! Congress! It's Congress' fault. Yeah, that's it! The press will eat it up.

AP:

President Bush put politics ahead of the facts Tuesday as he sought to blame Congress for high energy prices, saying foreign suppliers are pumping just about all the oil they can and accusing lawmakers of blocking new refineries.

Bush renewed his call for drilling in an Arctic wildlife refuge, but his own Energy Department says that would have little impact on gasoline prices.

Hmmm. Better blame them for the economy a little more directly. But I can't use the "R" word... the country can't handle it. Come to think of it, McCain can't either. Jeez, that guy knows knows less about the economy than I do.

NY Times:

In declining to embrace the word "recession," Mr. Bush said that many Americans were just beginning to receive their tax rebate checks as part of an $168 billion stimulus program, and that it would be some time before the effects of those checks on the economy were clear.

As for rising energy prices, including the eye-popping cost of filling up the gasoline tank, Mr. Bush said that "if there was a magic wand to wave, I'd be waving it, of course."

Once again, he chided Congress for not approving exploration for oil and gas in the Arctic National Wildlife Refuge, which he said could be done in an environmentally safe way, and for not sharing his belief in "clean, safe nuclear power."

Hey, I think it's working. Isn't it?

First Read:

The numbers? Only 21% approve of President Bush's job in handling the economy -- his lowest number ever as president on that question.

Also, a whopping 81% believe the US is currently in a recession.

Phew. Definitely it's working. Hey, maybe NBC will do my job approval tomorrow.

Man, I love being the President. You can get away with anything.

Kos will have a Pennsylvania prediction thread later this morning, but since I come from a state that's already voted, I will spare you the arrogance of demanding the primary be over already (that will come after the votes are counted).

I still find myself firmly in the camp of "Democratic voting? Good!" as thousands of new voters get motivated to register Democratic, turning states ever bluer. I see the lazy media dragging out their "Democratic fratricide" and "unnamed Democratic officials worry about primary" themes and stories. But having been around for a while, I can tell you there's an infinite number of Democratic officials worried about something, and they are always willing to speak to the press about it. They usually live in DC, conveniently for the newspapers, and they don't know squat about what's going on outside the beltway (think George Will lecturing the country about the evils of elitism, or David Broder on the appeal of Mike Bloomberg, Joe Lieberman, and other third party centrists).

One thing seems quite evident prior to getting the vote totals: while Obama has a floor, McCain and Cinton have ceilings, and they've already hit them. This isn't just my idea. Two of the sharper professional analysts have come to live in the same neighborhood. While noting that things can always change in the general election, check out Charlie Cook writing about Obama's chemisty:

This unusual combination created the equivalent in Democratic politics of nitroglycerin. It has already overpowered all but Clinton and is pushing its beneficiary closer and closer to the nomination, despite the inherent advantages that she began with. Obama’s chemistry experiment seems to defy all the normal rules of nomination politics. Could it continue working for him in a general election? That’s a 50-50 proposition, but it certainly would contribute to one of the oddest configurations that the two major parties have offered voters in our lifetimes.

More blunt about Bush's most ardent courtier, Stu Rothenberg says it all in the headline:

For McCain, This Could Be as Good As It's Going to Get

Cook and Rothenberg, seasoned professionals, know enough to look to November for the real story and not waste time on the crap that ABC tried to peddle at their debate (just check polling on national priorities to know what questions to ask, fellas... it's really not that hard). Meanwhile, in the WaPo Dan Balz writes about Beyond Pa., a Weakened Clinton, which is why beyond today there's really no race any more. For that reason, there will be no North Carolina debate.

The North Carolina Democratic Party said Monday that the forum in that state, scheduled for next Sunday night, had been canceled. Mr. Obama had not committed to the date. The cancellation comes as a disappointment for CBS, which had offered the candidates prime air time after the newsmagazine "60 Minutes" for the debate. Katie Couric, the anchor of the "CBS Evening News," would have moderated the debate.

The cancellation was because of political considerations by both candidates, said Paul Friedman, a senior vice president at CBS News.

Hmmm. There was a terrific debate at Yearly Kos moderated by Joan McCarter and Matt Bai, far more substantive than the one on ABC, and the CBS debate has been canceled. Welcome to the future of media (and see you at Netroots Nation).

In the meantime, given that it's primary day in PA, let's simply advise you to ignore the leaked exit polls early in the day, and settle in for a day of politics and democracy (small d). It's been a long time coming, but the end of the Bush era is in sight. And it will be covered, substantively, on the internets.

The State Children’s Health Insurance Program (SCHIP) was passed in 1997 by bipartisan agreement.

Why SCHIP?

   SCHIP was enacted at a time when the number and rate of uninsured children were growing rapidly, especially among those just above the poverty threshold— too poor to purchase private coverage but not poor enough to qualify for Medicaid. Recognition of the large number of uninsured children eligible for Medicaid but not enrolled was also mounting. When Congress launched SCHIP as part of the Balanced Budget Act of 1997, it gave states considerable flexibility in designing programs to expand coverage for uninsured low-income children. They could expand coverage through Medicaid (M-SCHIP), create a separate child health program (S-SCHIP), or combine the two approaches. SCHIP represented the largest expansion of publicly sponsored health insurance coverage since Medicare and Medicaid were created in the mid-1960s.¹

It's been a remarkably successful program. Naturally, its very success made it a target for the Bush administration.    

• SCHIP helps poor kids; SCHIP expansion helps millions more
• The reason to oppose SCHIP expansion was ideological and had more to do with the structure of how the government would function than any reason suggested by Republicans
• The House Republicans, being a regional party, used the higher cost of living in the North to hide the lower benefits available in the South²

After a contentious battle, a Presidential veto was barely sustained by House Republicans despite heavy bipartisan lobbying.

Bush couldn't eliminate SCHIP, and could barely stave off expanding the program (blocking expansion is bad policy in a shaky economy), so states like NY with high costs of living and compassion about its citizens tried to expand the program locally. The Bush administration said no, enacting executive regulations to block adding kids at the state level.

The measure does not address an SCHIP policy directive announced in August by CMS that states must enroll 95% of children in families with incomes up to 250% of the federal poverty level before expanding eligibility, The Hill reports. Acting CMS Administrator Kerry Weems said that the Bush administration would not require states to disenroll children from the program despite the requirement. House Energy and Commerce Committee Chair John Dingell (D-Mich.) said that Weems' statement contradicts the policy, adding, "Perhaps CMS officials are reading their directive differently than the rest of us."...

[Rahm] Emanuel said SCHIP will be addressed this summer, when the new rules take effect. He said, "What we can't resolve, the American people will resolve in November," adding, "This will be the first thing a Democratic president will get done. We don't need March '09" (Johnson, CongressDaily, 12/19).³

And that's where it stands, with a summer fight expected, and fall campaigning on the issue a certainty (and Republicans up and down the ticket are expected to pay a price for vetoing the popular program's expansion). John McCain stood, as always, with George W. Bush on policy.

McCain: Bush right to veto kids health insurance expansion

So, with that background, we find this morning that yet again the Rule of Law is just another casualty of Bush ideology.

The Bush administration violated federal law last year when it restricted states’ ability to provide health insurance to children of middle-income families, and its new policy is therefore unenforceable, lawyers from the Government Accountability Office said Friday.

The ruling strengthens the hand of at least 22 states, including New York and New Jersey, that already provide such coverage or want to do so. And it significantly reduces the chance that the new policy can be put into effect before President Bush leaves office in nine months.

At issue is the future of the State Children’s Health Insurance Program, financed jointly by the federal government and the states. Congress last year twice passed bills to expand the popular program, and Mr. Bush vetoed both.

State officials of both parties say the policy, set forth in a letter to state health officials on Aug. 17, has stymied their efforts to cover more children at a time when the number of uninsured is rising and more families are experiencing economic hardship.

Not only is this unconscionable, Bush policy on SCHIP has been fully supported by Bush clone John McSame. John McCain is no maverick. He's a Bush third term disaster in waiting. On what Bush policy, from torture to health care to Iraq does he offer change?

The political press, with its miserable failure to cover issues in this campaign, needs to stop bringing him coffee and start covering the issues. Start asking him where he stands in SCHIP, and why. Does he support the Rule of Law or does he not? This is what Americans care about, not whether he wears a lapel pin.

SCHIP coverage archives can be found here.

Good news for Obama, bad news for Clinton. This time, there's a poll seems a tad outside the margin of error. Newsweek says:

The survey of 1,209 registered voters found that Obama now leads Clinton by nearly 20 points, or 54 percent to 35 percent, among registered Democrats and those who lean Democratic nationwide. The previous Newsweek poll, conducted in March after Clinton's big primary wins in Ohio and Texas, showed the two Democrats locked in a statistical tie (45 percent for Obama to 44 percent for Clinton). The new poll puts Obama ahead among women as well as men, and voters aged 60 and older as well as younger voters. (For the complete poll data, click here).

One of the more devastating results for Clinton was that a majority of all registered voters now see her as dishonest and untrustworthy. According to the poll, just four in 10 (41 percent) registered voters view the New York senator as honest and trustworthy, while 51 percent think the opposite. This compares with solid majorities of voters who see Obama and McCain as honest and trustworthy (both polled 61 percent).

The ABC debacle changed no minds:

Stacy DiAngelo of Princeton Survey Research Associates, which did the April 16-17 polling, says that of the registered voters who were surveyed 517 were interviewed after the debate and 692 before. She added that the views of those surveyed remained largely constant.

Oh, and did you know McCain is seen by voters as old?

The poll pointed up a trouble sign for McCain as well, which is that no one's forgotten how old he is. While voters have mixed opinions about whether Obama's race will do more to help or hurt his chances of being elected president (20 percent vs. 22 percent, respectively), and Clinton's gender is only somewhat more likely to be seen as a hindrance than a help (27 percent vs. 20 percent), McCain's age may be the biggest vulnerability of all in the eyes of the voters. Nearly four in 10 (36 percent) think the Arizona senator's age—at 71, he would be the oldest president ever to assume office for the first time—will hurt his chances of winning.

In the (meaningless at this stage) head to heads, Obama and Clinton both beat McCain, each by 4 (it's a registered voters poll, btw, MoE +/-3.)

More to come before next Tuesday, but there's no obvious movement to Clinton in the polls. And, the ABC debacle had little to do with how people will vote. All things being equal, Tuesday is getting more interesting than ever.

Read Part I from March 26 here, wherein the economic news and Democratic registration are cited as fundamentals that the Republicans and Iraq war booster John McCain will need to battle against, while McCain hugs Bush to death. These fundamentals are so much more important than meaningless head-to-head polls this early out.

And the latest from ABC/WaPo is, if anything, worse for the GOP.

The public's ratings of the national economy continue to sour, with assessments deteriorating faster than at any point in Washington Post-ABC News polling. Views on the Iraq war have also turned more negative, with six in 10 now rejecting the notion that the United States needs to win there to effectively battle terrorism.

The economy and the Iraq war are the top two issues on voters' minds, according to the new Post-ABC poll, and worsening opinions of both may dampen GOP hopes for the November elections.

Nine in 10 Americans now give the economy a negative rating, with a majority saying it is in "poor" shape, the most to say so in more than 15 years. And the sense that things are bad has spread swiftly. The percentage who hold a negative view of the economy is up 33 points over the past year, and the percentage who rate the economy "poor" has increased 13 points in the past two months. That is the quickest 60-day decline since The Post and ABC started asking the question, in 1985.

Views of the Iraq war have dipped as well. Now, more than six in 10 say that the conflict is not integral to the success of U.S. anti-terrorism efforts. That is the most people to reject what is one of the Bush administration's central contentions and a core part of presumed GOP presidential nominee John McCain's stand on the issue.[my bold]

A bit more on Iraq:

On several measures, the poll finds Republicans inching away from support for the war. Among them, a sense that progress in Iraq has stalled has increased 13 points from early March, and the percentages who prefer withdrawing troops over risking more casualties (30 percent) and who think that the battle against terrorism can be a success without victory in Iraq (39 percent) are each at new highs.

The percentages of Democrats and independents advocating withdrawal and seeing Iraq as distinct from the U.S. terrorism fight are also at or near high marks. And three-quarters of Democrats and nearly six in 10 independents do not see significant progress in Iraq.

Remember, for all the bloviating about "the surge is working", Americans have viewed Iraq as a mistaken venture for months verging on years (this poll had "not worth it" at 58% in Jan '07), and half the country strongly disapproves of Republican leader Bush. The issue is what to do about it, and anything that highlights the fools and knaves who got us there is a strong reminder of what's at stake in this election (hello, ABC News? Pay attention to your own poll!)

The Bush economy is going to strangle McCain while Iraq stabs him in the heart, and that's true for downticket Republicans as well. People who read too much into today's polling have to understand that politics isn't stagnant, and we are not locked into anything in April of an election year before the Democrats have a formal nominee.

Oh, I'm sorry. I do apologize. The difference between political coverage on the blogs compared to the broadcast media is downright embarrassing. Now let's get back to the important questions, like what's Barack's favorite tree and Hillary's pick for campaign song.

It's not unknown, or even unusual, but sometimes cable and print political pundits (especially the ones paid to espouse GOP or conservative points of view) latch on to a meaningless story to fill air time and print space.

Perhaps they read too much Drudge and not enough economic reports. Perhaps they don't pay attention to Iraq. In any case, this 'bitter' nonsense falls in that category. As multiple commentators have said, Obama should just have said "pissed off" and moved on (because if you look at the wrong track numbers and Bush's job ratings,  people are pissed off). But whatever the reason, the headline writers don't even pay attention to their own subject matter experts:

Will 'elitist' label stick to Obama?

...Dr. James Twitchell, an author, University of Florida English professor and commentator on American culture, said the whole elitism back-and-forth is "self-serving nonsense," pointing specifically to the similarities in the Democratic contenders' stories...

"The issue comes down to two things. One is -- do you let your opponent brand you as elite -- in which case you are in a lot of trouble in American politics? And the second is do you convey clearly to people that you understand them and the world they live in and the problems they face?" he said.

"In the case of Barack Obama, my guess is this isn't going to stick terribly well because he does such a good job of connecting with people that the elitist charge is going to be a harder one to make people feel.

Chris Cillizza, in trying to figure out the depth of the story made a comment the other day:

Polls: Polling holds the key to understanding which direction this story is headed. Everyone in the political world is waiting expectantly for some good data from states --Pennsylvania, Indiana and North Carolina in particular -- and national polls that ask voters what their impressions were of Obama's words. (Quinnipiac University will be out with Pennsylvania numbers tomorrow although it's not clear how much of the poll was in the field prior to Obama's comments were made public.) Until then, the political class and punditry (including, sigh, the Fix) is flying blind.

If a series of polls come out in Pennsylvania that show Clinton with a far wider lead over Obama than she enjoyed the last few weeks, it will further drive the idea that this is a seminal moment in the campaign and questions will start to be asked about whether the Illinois Senator can weather the storm.

On the other hand, if polls come out in the next week that show little (or no) movement in Pennsylvania and elsewhere, all of this will quickly be relegated to the dustbin of history as much sound and fury signifying nothing.

Well, polls are out and there's little (or no) movement in Pennsylvania. Clinton has a static 8 point lead (more or less), down from 20, and what are the pundits and gasbags going to latch on to next?

Have you ever participated in a school fire drill? If you have, you've been part of a live disaster exercise. And like fire drills, the health system (including hospitals and public health) need to run their own drills to see what works and what needs to be done better so as to be better able to handle a natural disaster like the California wildfires or a pandemic. We ran an interesting drill last weekend to practice how my local area would respond to an influenza pandemic.

Part of the the health reform task is to make sure that natural disasters such as hurricanes, wildfires and (yes) influenza pandemics can be approached and mitigated by improving medical and public health infrastructure. One way to do this is to examine and improve the ability of hospitals to care for an excess number of patients for at least short periods of time. However, this can lead to concern about playing the fear card, and overdoing response. Despite those concerns, there's need to plan for surge.

California has led the way, with careful definitions:

A healthcare surge is proclaimed in a local jurisdiction when an authorized local official, such as a local health officer or other appropriate designee,3 using professional judgment determines, subsequent to a significant emergency or circumstances, that the healthcare delivery system has been impacted, resulting in an excess in demand over capacity in hospitals, long-term care facilities, community care clinics, public health departments, other primary and secondary care providers, resources and/or emergency medical services. The local health official uses the situation assessment information provided from the healthcare delivery system partners to determine overall local jurisdiction/Operational Area medical and health status.

Healthcare surge is not the frequent emergency department overcrowding experienced by healthcare facilities (for example, Friday/Saturday night emergencies). It is also not a local casualty emergency that might overcrowd nearby facilities but have little to no impact on the overall healthcare delivery system.

As defined above, a healthcare surge will directly impact a provider's ability to acquire and manage resources under their normal procedures.

This means that during times of stress to the system, usual standards of care will need to be switched to what's called 'essential care', the provision of which will mean different standards than what the public is used to.

An influenza pandemic is an example of the type of natural disaster that would require health care surge. As an update of where we are at with H5N1 and bird flu, try this piece from the Times (UK):

It is now five years since the present outbreak of H5N1 avian flu first infected people. Though 379 people have since contracted the virus, of whom 239 have died, it has yet to start a pandemic.

As its name suggests, bird flu remains predominantly an avian disease. While it is very dangerous to humans who catch it, this has happened only rarely, after close contact with infected birds.

This week, however, brought some alarming news. Writing in The Lancet, a Chinese medical team confirmed that a 52-year-old man who contracted H5N1 in Jiangsu province last December almost certainly caught it from his 24-year-old son, who died. It is the best-documented case of human-to-human transmission to date.

That is important because, if this virus is going to start a pandemic, it must first acquire the ability to move readily from person to person. Not enough people are ever going to catch it from birds to constitute a global threat. The Chinese case, like a previous suspected human-to-human incident in Thailand, has thus raised fears that H5N1 might be mutating in worrying fashion, and it was duly reported around the world.

The details of the Lancet study, however, are less troubling than they at first appear. This investigation of this cluster of infections, indeed, is somewhat reassuring because of what it shows has not happened.

It has not become easier to catch, and human-to-human (H2H) transmission remains rare - but not unknown. Similar H2H spread was also documented in Pakistan last year, in a case that involved a family member traveling to the United States. But whether the next pandemic is H5N1 or some other virus, pandemics are inevitable. Since it's not a matter of "if", but "when", planning has to occur to cover the areas where we will be short. In other words, since 20-30% of the public will be ill, pandemics will cause the health system to run short of staff, space and stuff... the exact things that surge tries to alleviate.

There's only one problem... no matter how hard you try, you'll still run short. And for that reason, even creative solutions will need to be coupled with unpleasantry in the form of rationing. Whether it's rationing of space or of resources, triage of pateints will be an inevitable consequence of too many ill and not enough resources.

More on the flip...

The NY Times today covers the ineffectiveness of a group run by former WH officials designed to bolster conservative causes and back President Bush. The press is so enamored of supposedly independent conservative extensions of the WH (without understanding that astroturf isn't grassroots) that they expected for example, Fred Thompson (remember him?) to have a huge internet presence, and that Bush's popularity would take more than a broder bounce to oblivion.

Bush Job Approval at 28%, Lowest of His Administration
Only Nixon and Truman have had lower job approval ratings

The problems of Freedom's Watch are the problems of the Republican Party. How this story should have been written:

The conservative group Freedom’s Watch [Republican Party], headlined by two former senior White House officials, had been expected to be a deep-pocketed juggernaut in this year’s presidential election, heralded by supporters on the right as an aggressive counterweight to MoveOn.org, George Soros and the like...

But after a splashy debut last summer, in which it spent $15 million in a nationwide advertising blitz supporting President Bush’s troop escalation in Iraq, the group [GOP] has been mostly quiet, beset by internal problems that have paralyzed it and raised questions about what kind of role, if any, it will actually play this fall...

Behind the scenes, however, Freedom’s Watch [the GOP] has been plagued by gridlock and infighting, leaving it struggling for direction, according to several Republican operatives familiar with the organization who were granted anonymity so they could be candid about the group’s problems.

This group is as independent of Bush as McCain and the rest of the GOP are... which is to say, not at all:

Q: "What about grants for sex education in the United States? Should they include instructions about using contraceptives? Or should it be Bush’s policy, which is just abstinence?"

  Mr. McCain: (Long pause) "Ahhh. I think I support the president’s policy."

Can you say albatross?

In any case, don't forget Freedom's Watch can still do slime damage under the radar. It's more likely to go for negative impact, since there's so little positive for Republicans to run on. In so many ways, Freedom's Watch is a metaphor of the modern GOP.

You gotta love this headline (unless you're a Republican).

McCain camp working out healthcare details
Aides struggle to sort out his promises

Aides struggle to sort out his promises? Oy. See, he's got a problem. His proposals don't make much sense.

When Senator John McCain unveiled his healthcare proposal last fall, a journalist asked whether the Arizona senator's battle against skin cancer would make him sympathetic to the idea of requiring that insurance companies provide coverage to people with preexisting conditions.

McCain flatly rejected the idea. "That would be mandating what the free enterprise system does," McCain said.

McCain's response highlights the challenge he faces as he prepares to try to sell his healthcare plan in the fall campaign. He says the country must provide access to healthcare for all our citizens, and that "we need to help people who need it." But McCain also wants to shrink government's role in healthcare and doesn't want to impose regulations on insurance companies.

As a result, McCain's aides have been scrambling to come up with ways to satisfy those who want more coverage without violating what they call McCain's conservative principles on the issue.

And therein lies McCain's problem. You can't move toward more coverage without violating McCain's conservative principles.

McCain, for example, has spoken in general terms about how he might help people with preexisting conditions. He has said he favors what he calls a "special provision including additional trust funds for Medicaid payments." The comment left even some of his aides unsure of his meaning. Medicaid funds are generally used to help lower-income Americans.

Lately, some of McCain's aides have said he might try to divert some Medicaid funds into a program that would help people with preexisting conditions, but his advisers can't yet say how such a program would work or how many people would be covered.

"These are real questions, and I think there will be answers, and there better be, but they are not there yet," said McCain adviser Thomas P. Miller, a resident fellow at the American Enterprise Institute. "A lot more remains to be hammered out."

See, McCain doesn't really know a lot about complicated things like Sunni vs Shi'a or condoms and HIV, and he sure as hell doesn't understand his own health care proposals. Interestingly, in this case, neither does his aides.

In a nutshell, the McCain plan focuses much more on cost than access. Similar to Bush, McCain wants to move the burden of insurance from employers to individuals, and let the market work it out. This analysis comes from the Health Care Policy and Marketplace Review, where Bob Laszewski has asked tough questions of all the candidate plans:

However, the real question is, will McCain's plan give people enough to be able to afford health insurance? With the average cost of employer-provided family health insurance at $12,000 a year, a $5,000 tax credit will often come up way short—especially for higher age people and those who don't have the benefit of an employer contribution. High deductibles and HSA plans will help but families who don't have employer contributions should be prepared to pay at least a few thousand extra dollars.

And to further expand the part about the McCain tax credit:

If McCain were to be successful in moving the system from the employer to the individual with his individual tax credit proposals, the employer arguably would have a smaller incentive to continue providing these benefits. Many employers might simply say, "Here's the money I was paying—go find your own coverage." It may just be easier for the employer to drop the coverage and give the employee the cash value of the health benefits.

The employer would also have the new advantage of having the difference in wages go up each year by the wage rate while the employee saw his health care costs rise at the rate of health care inflation—which has averaged two to three times more.

McCain does not have a mandate to buy insurance for individuals or employers. So, people can still opt to go without coverage.

Again, the big question is how does McCain see his individual health insurance market working. How will he deal with age rating, medical underwriting, and pre-existing conditions? If McCain does not develop an individual health insurance market everyone can access, no matter how old or how sick they are, his plan will fall way short. He needs to detail his "risk adjustment bonus" scheme for older and higher cost families.

One of the intriguing things about the McCain proposal is that it gets more points for cost containment (or, if you prefer, cost-shifting) than for availability (no way is it universal), thus the reviewer correctly assumes

Senator McCain's health care proposal is one that will appeal to conservative Republican voters as well as centrists.

That's because health care costs are just as important to voters as access – if you're a Republican. Of course, there's not as many of those these days, so that puts McCain at a disadvantage.

In any case, we're brought back to McCain's stumbling on pre-existing conditions, and as this Kaiser summary notes, also brings us to Ron Wyden's S. 334 Healthy Americans Act , which mandates enrollment (a few exemptions for religious reasons or "has insurance already") in a state private plan that entices people away from employer-based coverage. This Oregonian editorial discusses the relationship between Wyden's plan and the Democratic candidate's position, emphasizing the appeal of expanded coverage (which McCain's lacks).

If we can duck the Bosnian sniper fire at Hillary Clinton, and dodge the wayward bowling balls Barack Obama let loose in Pennsylvania, there were some things this campaign was supposed to be about. Actually, one in particular.

And as the race approaches Oregon, it's reaching a good place to discuss it.

Turn your head, cough and say, "health care."

And a reminder from here in CT as to the "whys" of health care reform:

Three Connecticut residents die every week because they don't have health insurance and cannot afford to see doctors for regular checkups, screenings and other preventive care, according to a new report released Thursday.

The study by Families USA, a nonprofit health care consumers group, says such care is important for catching diseases at an early stage and greatly increases the chances for survival.

In 2006, about 209,000 of the 1.9 million people in Connecticut between the ages of 25 and 64 didn't have health insurance, and about 150 of them died that year because they lacked coverage, the report says.

Connecticut Democratic U.S. Reps. Rosa DeLauro, Joe Courtney and Chris Murphy say the study is more evidence that Congress needs to stop dragging its feet on health insurance issues and make coverage more accessible and affordable.

So, in the end, McCain stumbles on the pre-existing condition/access piece (there are other bills pending to address that from Steve Kagen and Joe Courtney), while Clinton and Obama will be pushed to discuss mandates (or lack of same) and cost containment. The Presidential candidates aren't promising affordable, increased access reform because it's tough to have both. But according to the numbers (graph from Kaiser.edu), the 'more accessible' is going to need to be at least as prominent as the 'more affordable', and therefore McCain's position on pre-existing conditions is not tenable and will not last, regardless of how his aides try to dig him out of the hole he's in.

graph from kaiseredu.org