This argument sounds logical until you look more closely. First, Anthem and its corporate parent, WellPoint, are enormously profitable. WellPoint’s profits rose to $2.7 billion last quarter. Even if you subtract one-time-only financial maneuvers, WellPoint is still fat and happy, which makes Anthem fat and happy. Everyone is fat and happy except Anthem’s policy holders, who are being skewered.

Anthem’s argument is even more questionable when you consider that Anthem has been among the most aggressive opponents of the healthcare bills passed by the House and Senate. If Anthem were sincere about why it’s raising its rates, it would be embracing the legislation. The Senate and House bills would add tens of millions of Americans to insurance pools -- thereby spreading the costs over more people and avoiding the very problem Anthem says is now forcing it to raise its rates so much.

Even more troubling is the fact that Anthem obviously believes it can raise its rates by as much as 39 percent without losing every one of its remaining customers with average or even somewhat above-average medical needs. The only way it could possibly raise its rates so high and expect to keep its customers would be if Anthem’s customers have no other choice. In other words, Anthem’s strategy makes sense only if Anthem faces little or no competition from other health insurers.

I wouldn’t be surprised if this were the case. Insurers, remember, are exempt from the federal antitrust laws. And WellPoint, Anthem’s parent, is the largest insurer in America.

Anthem is a microcosm of what ails our private for-profit health insurance system -- the most expensive in the world, whose costs are rising faster than anywhere in the world; a system rapidly becoming unaffordable to more and more Americans, in which insurers are rapidly consolidating into behemoths that have almost no competitors. And a system in which the biggest health insurers are lobbying like mad against reform because they like things just the way they are. They can squeeze the public and the public has no alternative but to pay up.

All this makes Anthem one of he best arguments for reform -- which is probably why the President mentioned Anthem yesterday when he emerged from what was billed as a "bipartisan" meeting to talk about healthcare and jobs.

Obama says he’s open to any new ideas from Republicans for how to control healthcare costs and expand coverage. The problem is Republicans don’t want to play this game. They don’t care about controlling costs or expanding coverage. They care only about taking back the House and/or the Senate next November. And they believe a means toward attaining this goal is to prevent Obama from achieving a victory on healthcare. The sooner the President accepts that undeniable fact -- and gets the House to pass the Senate’s bill, and then uses the reconciliation process (that requires only 51 votes in the Senate) to deal with any remaining irreconcilable differences between the House and Senate -- the better.

In the meantime, next chance I get I’m switching to another insurer -- if that makes any difference at all in what I pay or the service I get, which seems increasingly doubtful. I’m also joining any Tea Party of mad-as-hellers fed up with how Big Insurance, Big Pharma, Wall Street, and much of the rest of corporate America have taken over our democracy.

Republicans had just left the meeting and scoffed at the idea that the White House was actually interested in working with them. Take healthcare reform (cue the administration saying, "please"). "It's going to be very difficult to have bipartisan conversations with regard to a 2,700-page healthcare bill that the Democrat majority in the House and the Democrat majority in the Senate can't pass," House Minority Leader John Boehner told reporters. "Why are we going to talk about a bill that can't pass? It really is time to scrap the bill and start over." Senate Republican leader Mitch McConnell said more or less the same thing. "Why would they want to keep pushing something that the public is overwhelmingly against?" he asked. "The obvious answer is to put that measure on the shelf, start over."

A bipartisan summit on the issue is scheduled for two weeks from now, when Congress returns from its Presidents' Day break. And the GOP doesn't have high hopes for anything productive coming from itt. "It is becoming increasingly clear that the administration does not intend to reopen the legislative process -- they seem to just want to listen to what we have to say and move on," one senior GOP aide told Salon. "Fine. But you wasted an entire year doing exactly that. By taking that approach on healthcare, they drown out any efforts, post-stimulus, on jobs or any other of their priorities. And in the process, took a president with near-70 percent approval and drove him below 50. Nice work."

But the White House has been faster to fight back on attacks like that since the Massachusetts Senate special election, and Obama picked up that same message. "'Bipartisanship' can't be that I agree to all of the things that they believe in or want and they agree to none of the things I believe in or want, and that's the price of bipartisanship, right?" he said. The healthcare summit can't just be "political theater," the president said. And he made clear he still wants to push ahead. "The public has soured on the process that they saw over the past year," he said. "I think that actually contaminates how they view the substance of the bills."

In his last session with the press back in July,  a prime-time news conference that also focused on healthcare reform, Obama waded into the Henry Louis Gates Jr./ Cambridge police controversy, which led to the much-mocked beer summit -- perhaps explaining the lack of similar sessions these past seven months. But reporters have started grumbling lately, so Obama dropped in on an otherwise slow news day.

Obama also pushed for Congress to act fast on a jobs bill -- but the House has already gone on recess, thanks to the winter storms pummeling D.C. lately, and won't be able to vote on anything until the week of Feb. 22 at the earliest. In the end, the meeting Tuesday, and Obama's impromptu presser, aren't likely to do much to actually move legislation along. But the White House tone could help change voters' minds about who's to blame if it stalls.

UPDATE: Watch Obama's appearance here:

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As usual with this administration, the working strategy seems to be to give a little bit to everybody. Obama announced yesterday that he would call for a televised half-day bipartisan meeting at the White House to try to reach a breakthrough on healthcare. Echoing his State of the Union address and his "question time" with the House Republican caucus, the president said, "I want to come back and have a large meeting, Republicans and Democrats, to go through systematically all the best ideas that are out there and move it forward."

It’s not, of course, actually likely that the White House and congressional Democratic majorities are going to hear some revelatory and brilliant new proposal from the GOP -- especially when the Republicans, as a relatively tiny legislative minority, are insisting the president and majority meet their demands. Says Senate Minority Leader Mitch McConnell, R-Ky., "We know there are a number of issues with bipartisan support that we can start with when the 2,700-page bill is put on the shelf."

If the last eight months have shown anything systematically, it’s that there isn’t really any ground on which the parties can meet for compromise. Republicans are uninterested in letting Democrats pass a bill and claim success. McConnell’s point is clearly Republican orthodoxy; House Minority Leader John Boehner, R-Ohio, tells the New York Times almost exactly the same thing as his Senate counterpart. "The best way to start on real, bipartisan reform would be to scrap those bills and focus on the kind of step-by-step improvements that will lower health care costs and expand access."

For its part, the White House clearly has no intention of scrapping the bill and rebooting negotiations, not after watching Max Baucus and his "Gang of Six" fritter away a half a year in fruitless talks.

Clearly, this televised session idea would be some kind of kabuki theater. What’s happening here is a part of the administration’s ongoing effort to claim the center. The idea is that another on-air, face-to-face encounter will help the president to hold Republicans accountable with the public for abdicating shared responsibility for governing. They’ll be revealed for the do-nothing obstructionists they are.

But you have to think the GOP probably isn’t going to get caught off guard as it did with Obama’s "question time." Republican negotiators won’t just show up unprepared. They’ll do their homework, and they’ll have lots of proposals. You can bet that they will have ideas that sound perfectly good to the layperson but are actually completely infeasible in any compromise, for fairly complicated and wonky reasons. They won't suggest these ideas because they want the president to actually enact them; they'll just try to make him the one saying "no."

Obama and the Democrats want to go on TV to reveal the opposition as uninterested in genuine compromise. But really, it’s not hard to imagine how Republicans maneuver the Democrats into spending this half-day televised session rejecting all of the minority’s ideas. It sounds something like a replay, in miniature and on-air, of the whole painful process so far.

 

But there are some tensions between the White House and Senate Democrats, and behind closed doors, they're coming out. In a follow-up meeting, Sen. Al Franken, D-Minn., tore into David Axelrod, a senior advisor to Obama, about the president’s lack of leadership on healthcare. According to one Democratic aide quoted in the Huffington Post, the Minnesota senator said that "he really needed to know if the White House was going to lead." Apparently, Franken was not alone in his grievances. As one Democratic senator told Politico, "There was a lot of frustration in there."

Obama has long been criticized for his lack of leadership on healthcare -- first by liberal commentators and more recently by leading progressive members of the House, including Rep. Anthony Weiner, D-N.Y. The argument stems from frustration that the President hasn't done enough to garner public enthusiasm for reform. Franken and his fellow Democrats in the Senate, however, have been reluctant to blame the White House for their healthcare woes.

Obama’s latest comments on healthcare reform don’t seem to indicate that he'll be getting more personally involved anytime soon. At a fundraiser Thursday night, the President voiced concern about whether a bill would pass at all, and suggested that the onus lay on Congress to get something done:

So there’s a lot of information out there that people understandably are concerned about. And that’s why I think it’s very important for us to have a methodical, open process over the next several weeks, and then let’s go ahead and make a decision.

And it may be that — you know, if Congress decides — if Congress decides we’re not going to do it, even after all the facts are laid out, all the options are clear, then the American people can make a judgment as to whether this Congress has done the right thing for them or not. And that’s how democracy works. There will be elections coming up and they’ll be able to make a determination and register their concerns one way or the other during election time.

Gawande's third book, "The Checklist Manifesto: How to Get Things Right," explores how doctors and other professionals, overwhelmed with the complexity of their work, have become more likely to fail. Gawande's proposed solution is simple and inexpensive, if not terribly sexy: a checklist. Sound too mundane? Keep in mind that Gawande proved, in conjunction with the World Health Organization, that doctors and surgical teams who use checklists save lives.

I arranged to meet Gawande on a crisp, clear Wednesday afternoon in downtown San Francisco while he was on book tour. The doctor arrived a few minutes early, so instead of looking out for him, I had my head buried in Paul Starr's "The Social Transformation of American Medicine," and my iPod headphones on. It was Gawande who got in the first question.

"What are you listening to?" he asked.

LCD Soundsystem, I told him, as we shook hands. Like me, Gawande is an alternative music fiend. Later he pulled out his own iPod, suggesting Bon Iver and a Scottish Band called Frightened Rabbit, whom he recently saw in a bar in Boston with 30 other people. "Maybe it's the surgeon in me, but many of their songs involve someone who has been either maimed or dismembered," he said. And later, we both agreed that Radiohead still ruled the day, and that as amazing as the Flaming Lips are, "Embryonic" wouldn't fly in the operating room, where Gawande famously plays music while he operates. But before that, we talked about how he influenced "Grey's Anatomy," his simple suggestion for fixing a sprawling problem and, of course, the ongoing debate about healthcare reform. (Note to readers: This interview took place a week before the election in Massachusetts.)

If you had to make a checklist of, say, three killer items that reform must address, what would they be?

First, it has to offer coverage for the population. We have to eliminate families going bankrupt because of healthcare bills. The second thing is not killing the deficit. The third has to do with delivering reform -- being able to begin providing opportunities for change that would begin phasing away from fee-for-service medicine.

Will this bill change what you saw in McAllen?

One of the things I saw was how fragmented and disorganized care was. Doctors are paid for doing things piecemeal rather than knitting care together in some meaningful way. And further, they were pursuing that as a business objective. The doctors were caught between maximizing the needs of their business and the needs of their patients.

I think the incentives in this bill will begin to provide opportunities for people who want to change that culture. The key moment that matters most is when the doctor -- who has control of 90 percent of spending -- sits down with the patient and has to make a decision about the right thing to do, and whether [doctors] are equipped to make the decisions that avoid wasted and unnecessary care.

But the entire success or failure of this reform package will depend on what we do in communities. If there's one community that manages not just to bend the curve but actually lowers costs and raises quality, then it will become the metric for reform. Then we need to determine how to implant them.

Let's talk more about that moment when a doctor is sitting down with his or her patient trying to decide what to do. When doctors are paid to do more, and patients often expect more, how are we going to make it so that doctors are doing the right thing? As we both know, that isn't always ordering more tests, drugs or procedures. Consider the recent outrage over the breast cancer screening guidelines, which recommended fewer mammograms. 

If we think of having to do it through Washington rules, we'll fail. Instead, it’s important that a doctor and patient [relationship] is part of a system of care that makes doing the right thing easier. For example, we’ve had tremendous growth in the number of CT scans we order, and it’s partly out of the belief that more can’t be a bad thing, even though they cost a lot and expose people to a lot of radiation. But also, the radiologists get paid for doing more scans, and there’s no incentive to moderate it. At my hospital, we decided to tackle this, because we got incentive from insurers to give it a try. Our solution, instead of having a committee or an insurance administrator decide, was to have an electronic system that required you to talk to the radiologist about your decision [to do a CT scan] when your reason fell outside of the established guidelines. The result is that we are below our 2005 ordering numbers while others have been rising.

That result didn’t happen by rationing. The radiologists were instructed not to deny a scan. Rather, it happened by one doctor talking to another doctor, comparing notes and deciding what the right thing to do was. 

You're talking about what happens between doctors, but what about the American health consumer? If I come to you and say I have a headache, and I tell you my friend down the street went to another hospital and had a head CT the same day, I'm going to expect and may even demand the same from you. How do you fix that?

I think that has to do with how we talk to patients, and to learn to have those conversations. Most of medical care is totally invisible to us, and just being able to see what a community does can have an effect by itself. The gray zone is usually not a patient pushing -- it’s how we deal with our discomfort about what we know and don’t know. It’s about reaching the point where the better investment is to consult with a colleague, or about asking the patient to come back in four weeks to recheck him or her.

But there are other tools. I was fascinated by one that pediatricians now are using to deal with antibiotic resistance and ear infections. Before, a parent might come all that way to see the doctor and expect something. Now [since studies show that most ear infections resolve without antibiotics], they write a safety net prescription for ear pain -- go ahead and fill this in 48 hours if it’s not getting better. As much as it sounds like these dumb little tools, how they help manage that social interaction is a chance for some real innovation.

In your New Yorker article, there is a moment that struck me, as a doctor. You were having dinner with a group of doctors from McAllen, and you told them just how costly the care there was. They didn't seem to have a clue about that. So how is it that we know how good a doctor we actually are -- and how do patients also figure that out? 

I think this is something that has been totally overlooked in reform. The National Center for Health Statistics is going to have to be equipped to produce that data, like we do for agriculture, and for economic needs like unemployment. The Medicare data we have now is only there because an academic center -- Dartmouth -- put it together, but that data is three years old. I haven't seen the real goods, which is pulling data from all insurers regardless of where a person is receiving care and putting it together with clinical information. How many operations are done in my country, and how many ended up with a disability or death because of it? How many people had a heart attack, and how did they fare in the hospital? We have that data on maternal and infant mortality, but that’s about it. The fact that we have no idea about how our health systems are doing now versus, say, two years ago -- that flabbergasts me. 

By the end of the book, I talk about how we’re obsessed with components in medicine: Do I have the best medicine, do I have the best doctor? The reality is that a doctor embedded in one system may get different results than if he or she were embedded in a different one. Some studies have started to show doctors getting different results when they work in more than one hospital. I think it’s much more critical for patients to see how good a system can be. Because care requires a whole chain of events.

So why in the world would you write a book about checklists, of all things?

What we're grappling with in reform or public health is immense complexity. We do 50 million operations a year in the U.S., with 150,000 deaths within 30 days. Five hundred thousand people are disabled, and half of those are avoidable. When we think about how we grapple with complexity, we've been using two solutions: super-specialization and technology. These haven't been good enough. When I looked at how other worlds like aviation and construction grapple with complexity, I found checklists.

But checklists are also an admission of fallibility. It's an admission that individuals aren't the only thing that matter, that chains of people and processes matter. Further, it's an admission that we can't handle the complexity that's coming at us. And I think that's the case across lots of walks of life.

For millennia, we didn't know why we got ill. Now, there are more than 13,000 diagnoses, 6,000 drugs and 4,000 procedures. Back when the main problem was ignorance, people gave doctors leeway. If you succeeded, you were a miracle worker. And if you failed, well, what could you do? But if you fail nowadays, it's because you didn't deliver on existing knowledge. That's infuriating. What do you mean my mom is in the ICU with an infection because someone didn't wash their hands? What do you mean that the bomber got on the plane to Detroit when there were three pieces of information someone couldn't put together? Checklists can help get at that kind of failure.

Why are people resistant to the idea, and why is it so hard to bring change to the culture of medicine?

A checklist feels like a judgment on who we are in a way that a drug doesn't, and I think there's a deep resistance to that. Also there's a reality -- because a drug costs money, prescribing it means revenue for somebody, while a checklist is free.

Also, we think what it means to be effective is to have it all in your head, to make the right move in the right moment and do it with our gut instinct. It took a long time to change aviation from a culture in which you were just great because you knew what you were doing to one in which, no matter how good you were, you weren't great until you used the checklist. And then you see a kind of joy in the discipline of it.

Besides a checklist, what is it going to take for future doctors to be successful?

Culturally, the shift from individuals to teams, and equipping physicians to lead teams that execute very complex things. Also, how to be a member of a team where you may not be the leader. There’s a couple of lessons given to pilots before they get on a plane. One is that their brain is fallible, and if you don't recognize that, you’re going to die and take some people with you. The second is that pilots get drilled and taken through simulations for complex planes in which you're part of a group. The first time you probably dealt with a major high-stress, chaotic situation was during a code as an intern your first week on call. That’s crazy. I think we ought to import the pilot training into what we do. I’m also fascinated by one experiment at the University of Nevada Reno, where they’ve combined parts of the medical and nursing school -- and co-teaching parts of classes so that both groups have the same language and know each other from the very beginning.

Your fellow New Yorker writer Malcolm Gladwell wrote a book called "Blink," which is essentially about how we make split decisions and judgments. Checklists seem the very opposite of that. Is your book the anti-"Blink"?

[laughs] In the second half of "Blink," Gladwell talks about the Diallo shooting, where the police put 44 bullets in a guy who was just sitting on his porch in New York. So I think he understands the cautionary nature of gut instinct. What he was interested in was how experts achieve the great gut instinct -- to look at a CT scan and see the tumor, or look at an EKG and see the heart attack without having to take the pieces apart. You need that intuitive capability, but you also need preparation upfront, which involves a check on what you're doing. You need to think about, as a group, what could go wrong, and are we prepared for it? Is everything available so when that moment happens and you need that intuitive capability, you're primed as much as you can be.

I understand your first book, "Complications," became the inspiration for "Grey's Anatomy."

It's a sore point. "Grey's Anatomy" was actually called "Complications" when they made the pilot. Every chapter in the book gets used as an episode. They have the blushing patient, the 23-year-old with the flesh-eating bacteria. But they didn't acknowledge it, and I didn't want to battle it. Mostly, I was flattered that they took an interest.

Now, the really flattering thing was a guy named Teddy Blanks, who made an EP called "Complications" based on stories from the book. He also wrote and recorded a song called "The Itch" based on my New Yorker article. That was one of the most gratifying things to me, to feel like people made a connection at that level. I sent him my book and he actually made a whole series of songs -- he's morbidly fascinated by medical things -- and included a cover of the Frank Black song "Headache."

And the checklist made it onto "ER" as well?

I worked with them on that episode, as a vehicle to help people understand what it's about. There's a four-minute scene with Benton fighting with another surgeon who wouldn't use the checklist and wanted to throw him out. And the checklist saves Carter's life. That was much more about the cultural differences in medicine. It was a huge part of our work. It was shown in hospitals here and abroad which were adopting the checklist.

You've been practicing for such a short time, yet you've done so much. When, someday, they put your picture up at Harvard, what do you want them to say about you?

I don't know. My teams once asked me what our mission statement is. All I could come up with is to do cool stuff that lasts. That's all I got.