Ìý –1966: After a trip to the Columbia Point Health Center in Boston, which provided health care to low-income residents, the first-term senator introduces and helps pass legislation that adds $51 million to the Economic Opportunity Act for a national system of community health centers.

–1971: Kennedy becomes chairman of the Senate Health subcommittee and begins his long campaign for national health insurance.

— 1971: On Jan. 5, Kennedy co-sponsors a bill calling for a significant increase in funding for cancer research – providing a total of $1.2 billion over three years to the National Cancer Institute, more than what was proposed by the Nixon administration. A modified version of the bill is enacted Dec. 23, 1971.

–1971: Kennedy offers his national health-insurance plan. The “Health Security Act” calls for a universal single-payer plan financed through payroll taxes.

With support from organized labor and senior citizens, Kennedy holds hearings around the country and releases his report, “The Health Care Crisis in America,” which aims to garner support for his national insurance plan. President Richard M. Nixon, concerned about Democrats gaining advantages from the issue and a possible Kennedy campaign for president, later offers his own version of a bill, the National Health Insurance Partnership Act. It preserves private insurance but requires businesses to provide coverage to employees or make payments to a government-run fund. It also endorses the concept of health maintenance organizations.

“It’s really a partnership between the administration and insurance companies,” Kennedy says of the Nixon health plan. “It’s not a partnership between patients and doctors of this nation.” But Kennedy’s efforts on health insurance were pushed to the backburner by public concerns about the Vietnam War and later the Watergate scandal.

–1972: Working with other members of the Senate Select Committee on Nutrition and Human Needs, Kennedy helps secure authorization for a two-year pilot project for the Special Supplemental Nutrition Program for Women, Infants and Children, which provides food and health benefits to poor women who are pregnant and their children up to five years of age. In 1974 Kennedy fights to expand the program, and it is permanently authorized by the legislation.

–1973: Under pressure from doctors and other groups, the Nixon administration backs away from its proposal to expand HMO services, but Kennedy moves ahead on the issue. He sponsors the HMO Act of 1973, which is revised several times before it is eventually signed into law Dec. 29, 1973. The bill authorizes the spending of $375 million over five years to evaluate HMOs and requires employers with more than 25 employees to provide them with the option of a federally certified HMO where available. It also prevents states from restricting doctors who want to join HMOs.

–1973: Kennedy puts up “intense opposition” to the appointment of Caspar Weinberger as secretary of health education and welfare, according to a biography by Adam Clymer, a former New York Times reporter. Kennedy and other senators voice doubts about whether Weinberger can serve the interests of the poor, older Americans and uneducated people, but Weinberger is confirmed.

–1974: Kennedy teams up with Rep. Wilbur Mills, D-Ark., the head of the House Ways and Means Committee, to propose a compulsory national health insurance plan to be paid for by payroll taxes and general revenues. Kennedy’s aides secretly meet with Nixon administration officials but Kennedy and Nixon never agreed on a compromise. The Democrats’ plan is opposed by the American Medical Association and other groups. Kennedy tries unsuccessfully to revive the effort after Nixon resigns. Years later, Kennedy tells the Boston Globe that he may have missed an opportunity by not working closer with Nixon to find a consensus. Perhaps, he says, “We should have jumped on that.”

–1976: Although Democratic presidential candidate Jimmy Carter campaigns on the promise of a national health insurance program, Kennedy criticizes him for “intentionally [having] made his position on some issues indefinite and imprecise.”

–1977: Carter, concerned about the strength of the economy, moves away from national health insurance and proposes measures to contain expenses, such as hospital cost control. This prompts Kennedy in May at a United Auto Workers conference to lambast Carter for not setting a timetable to establish his health insurance program – a promise Carter made on the campaign trail. “Health reform is in danger of becoming the missing promise in the administration’s plans,” Kennedy says.

–1979: In March, Carter proposes phasing in a national health program, which he says will cost $10 billion to $15 billion, beginning in 1983. Kennedy quickly opposes the plan, calling Carter’s approach to health reform “piecemeal.” The administration shoots back that Kennedy’s proposal for a complete national health plan is too expensive. Kennedy later credits this disagreement as one of the influences on his decision to challenge Carter for the Democratic nomination for the president in 1980.

–1986: As part of what Kennedy calls “a fairly small step” to extend coverage to the country’s uninsured, he introduces legislation requiring employers to allow employees and others who lose group health coverage to purchase their employer-based insurance at their own expense for a fixed time period. It passes as part of the 1985 budget reconciliation bill. On April 7, President Ronald Reagan signs the Consolidated Omnibus Budget Reconciliation Act or COBRA, which was adopted as the name for Kennedy’s program.

–1987: Kennedy becomes the chairman of the Senate’s Labor and Human Resources Committee (later known as the Health, Education, Labor and Pensions Committee).

–1990: As chief co-sponsor, Kennedy joins forces with with Sen. Tom Harkin, D-Iowa, to drive the passage of the Americans with Disabilities Act, prohibiting discrimination based on disability.

–1990: Joined by Elizabeth Taylor, Kennedy and Sen. Orrin Hatch, R-Utah, hold a press conference on March 6 introducing a bill that eventually would be known as the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act to provide federal grants to improve care for individuals and families hit by HIV and AIDS. The measure passes later in the year and is signed by President George H.W. Bush on Aug. 18.

–1992: Kennedy co-sponsors the Mammography Quality Standards Act, which seeks to ensure that all women have access to quality mammography by dealing with issues at screening facilities, including lack of oversight, inferior equipment and poorly trained staff. The law, which has been reauthorized several times, requires all facilities to be inspected, accredited by an FDA-approved group and certified by the FDA or the state.

–1996: Together with Sen. Nancy Landon Kassebaum, R-Kan., Kennedy co-sponsors the Health Insurance Portability and Accountability Act (HIPAA) to protect workers and their families who change jobs or lose employer-based health insurance from being locked out of health coverage or forced to wait for coverage due to pre-existing medical conditions. It also prohibits insurance from being cancelled because of illness. Also, for what the bill is now most well-known, HIPAA establishes provisions on medical confidentiality. President Bill Clinton signs the bill into law on Aug. 21, 1996.

–1997: Kennedy and Hatch announce plans to provide health insurance for millions of uninsured children through the State Children’s Health Insurance Program (SCHIP) and fund the program through an increase in cigarette taxes. Hatch says, “Some have referred to us as the odd couple of the United States Senate. I like to think of us as the dynamic duo.”

The legislation, although initially a victim to budget rules, passes and is signed by Clinton in August as part of the Balanced Budget Act. It provides money to the states to pay for health coverage for children who do not qualify for Medicaid but whose families cannot afford private insurance. Kennedy calls it “the most far-reaching step that Congress has ever taken to help the nation’s children, and the most far-reaching advance in health care since the enactment of Medicare and Medicaid a generation ago.”

–1998: Kennedy is one of 31 co-sponsors for the Patient Bill of Rights. Although this measure is not the first such bill to be introduced, it becomes the leading vehicle to address public anger toward managed care practices. The legislation aims to protect patients who are members of managed care plans from, among other things, being denied care for the purposes of cost-containment. It also opens the door for patients who are injured as the result of being denied care to sue health plans in state courts.

Later, a more sweeping measure advanced by Rep. Charles Norwood, R-Ga., a retired dentist, passes the House, but Senate GOP leaders hold off Democratic efforts to bring up the bill in that chamber before the close of the 105th Congress. In 1999, the Republican-controlled Senate approves a scaled-back measure while the House, in November, approves a Democratic-backed version. In 2000, after six months of House-Senate negotiations, the conference committee is unable to reach a final agreement.

–2001: Kennedy together with Sens. John McCain, R-Ariz., and John Edwards, D-N.C., introduce the Bipartisan Patient Protection Act, giving patients the right to sue health plans in state courts based on denied care. Although President George W. Bush vows to veto the bill, it passes the Senate 59-36 in June.

The House passes a modified GOP-backed measure that allows employers to protect themselves from liability, the result of a closed-door compromise made between Bush and Norwood, a long-time patients’ bill of rights leader. The compromise, Kennedy said, ”makes [the patients’ bill of] rights unenforceable.” Adding ”a right without a remedy is not an effective right.” A Senate-House conference never convenes to work out differences between the two chambers. Kennedy and the bill’s other primary sponsors continue attempts to reach agreement with the administration, but abandon these negotiations in 2002.

–August 2001: Kennedy and Hatch introduce the Rare Diseases Act. The legislation increases funding for the NIH Office of Rare Diseases and expands its work. It later splits into two different acts–the Rare Diseases Act and the Rare Diseases Orphan Product Development Act–which are signed into law by Bush in November 2002.

–2003: Kennedy backs Bush’s 2003 plan to add a prescription benefit to Medicare that came with a $400 billion price tag spread out over 10 years. But when Kennedy learns that the Medicare Prescription Drug and Modernization Act of 2003 would, for the first time, allow private HMOs to compete with Medicare for patients, Kennedy works to amend the bill, criticizing the proposal for Medicare competition as “an untried, untested, unworkable program.” His efforts ultimately prove futile and he opposes the final bill. The Medicare Prescription Drug and Modernization Act of 2003 passes Congress and is signed into law by Bush on Dec. 8, 2003.

Later, in an interview with the Boston Globe, Bill Novelli, chief executive of the AARP, which broke with Kennedy, a longtime ally, to endorse the Republican-backed bill, credits the prescription drug benefit to Kennedy. “I think the lesson he learned from the Nixon era is a lesson that history teaches us: You should not let the perfect be the enemy of the good,” he says. “The Medicare Modernization Act was certainly not perfect, but the idea was, get it done and improve it over the coming years.”

–2006: Kennedy and Sen. Charles Grassley, R-Iowa, secure passage of the Family Opportunity Act, which expands Medicaid coverage for children with special needs even if their parents earn more than the usual limit.

–2006: Kennedy, and Sen. Pete Domenici, R-N.M., work with mental health advocates, private insurers and industry on legislation to require private insurers to offer mental health benefits equivalent to traditional health benefits. The bill builds on 1996 legislation seeking to end restrictions on mental health coverage. The Senate approves the bill in September 2007 and the House in March 2008. After negotiations between the Senate and House, language supporting the combined plan is written into law as part of the economic stimulus bill. The effective date for most health plans to make the change is Jan. 1, 2010.

–May 20, 2008: Kennedy is diagnosed with a malignant glioma, a common, highly lethal form of brain tumor. He undergoes surgery and other treatments.

–July 9, 2008: Just a month after undergoing surgery for brain cancer, Kennedy makes a surprise appearance in the Senate, which gives Democrats enough votes to prevent a Republican filibuster that would have cut Medicare fees to doctors. “We got this victory because of Ted,” Sen. Max Baucus, D-Mont., tells the Los Angeles Times. The bill passes later that month after the Senate overrides President Bush’s veto.

Ìý— 2008: Kennedy, weakened by cancer treatment, addresses the Democratic National Convention in Denver Aug. 25, pushing the party to continue his efforts on reform. “For me this is a season of hope — new hope for a justice and fair prosperity for the many, and not just for the few — new hope,” he says. “And this is the cause of my life — new hope that we will break the old gridlock and guarantee that every American — north, south, east, west, young, old — will have decent, quality health care as a fundamental right and not a privilege.”

–2009: On June 9, Kennedy submits the Affordable Health Choices Act, and although Kennedy is sidelined fighting his cancer and not able to participate, the measure passes in his Senate Health, Education, Labor and Pensions Committee as part of the larger Capitol Hill effort on health reform. However, the Senate Finance Committee is expected to significantly alter the bill. In July, Kennedy, along with long-time speechwriter and friend Robert Shrum, published an article in outlining his personal and political experiences with health issues over the years and describing his vision for reform.Ìý He wrote: “For four decades I have carried this cause-from the floor of the United States Senate to every part of this country. It has never been merely a question of policy; it goes to the heart of my belief in a just society.”

target=”_blank”>portable electrocardiogram machine

, trumpeting the new product’s ability to help patients wherever they might need it.

But the most interesting thing about the MAC 800 is not where it can go, but where it came from: China.

Chinese engineers funded by GE Healthcare helped develop the machine for sale in China. Although initially tailored to local needs, the MAC 800 has found a new market – the United States, where hospitals with community programs can easily take it on the road to treat patients.

The company is betting that other products originally created for the developing world ultimately also can be useful here. GE is tapping into the increasingly popular idea that medical innovation should be a global two-way street in which the West benefits from the resourcefulness and frugality poorer nations apply to health problems. The idea isn’t new, but it’s gaining traction, beyond the creation of products and technology, as public health experts rethink ways to prevent disease and deliver care.

Health care in the developing world holds several “general lessons for richer countries,” Nigel Crisp, a former permanent secretary of Britain’s Department of Health, observed in a recent . “Unconstrained by our history, [developing countries] train people differently, create new sorts of organisations, involve families and communities and concentrate more on promoting health rather than on just tackling disease.”

With interest in international health expanding, this type of thinking is likely to become more common. A 2009 survey by the Consortium of Universities for Global Health found that enrollment in global health courses had doubled since 2006. This rapid growth is changing the way people think about health care abroad, says Dr. Michael Merson, director of the Duke Global Health Institute. “I think the old days of development where the rich helped the poor, for the most part have passed,” he says. “I think we go into this with a true sense of shared partnership.”

The Roots Of ‘Kangaroo Care’  

While some experts doubt the U.S. is really ready to embrace lessons from abroad, there is a growing number of examples. They run the gamut from basic to high-tech – including an electronic medical records program in use in more than 20 countries.

The Boston-based Prevention and Access to Care and Treatment project, which serves HIV/AIDS patients, is modeled on a community health worker program pioneered in Haiti. Since the late 1990s, the project has sought out the most difficult-to-treat HIV patients: those who fail in conventional programs because of factors such as mental illness and poverty. The program reports good results and has been sharing its methods with the New York City health department and hospitals with similar programs.

“,” an approach developed in Colombia, is another example. With a major shortage of incubators, doctors advised mothers to cradle preterm babies in a sling. They did so well that it changed what had been the conventional approach in the U.S., which encouraged only limited human contact while newborns were in incubators.

Merson participated in what became one of the best known illustrations of a borrowed idea. During the 1970s he was in Bangladesh working with other doctors to treat an outbreak of cholera, an acute infectious disease whose symptoms include severe diarrhea. The team made extensive use of a cheaper, simpler treatment for diarrhea, which can result in life-threatening dehydration, and it is now the recommended standard for care worldwide.

“It took a while for pediatricians to use here,” Merson says, “but now we have products like Pedialyte and other kinds of oral rehydration fluids that are used to treat kids.”

These days, it’s increasingly common to find experts without medical backgrounds collaborating on health-related projects for developing countries. One example is OpenMRS, an open-source electronic medical record system that started in 2004 as a collaboration between the Boston-based nonprofit Partners in Health and the Regenstrief Institute, an informatics and health care research organization in Indianapolis. Both programs use the system to manage projects in the developing world. It’s especially critical for hospitals that track large numbers of HIV-positive patients, says William Tierney, an informatics expert at Regenstrief.

Without electronic information, “How do you know when patients aren’t coming in, so you can go out and chase them down to enhance adherence to the drug?” Tierney asks.

Rwanda, Tanzania and Peru are among the countries where the program has caught on. Since the software platform is open source it can be customized by anyone and tailored to specific programs, which would be more challenging with bigger commercial systems. Now it is being used at Indiana University’s School of Medicine – where Tierney is a professor – as well as at sites in Maryland, Boston and Los Angeles.

‘What Can The U.S. Learn From Ghana?’

Students now in school might lead a new wave of innovation. Anjali Sastry, a global health delivery and system dynamics researcher who lectures at the MIT Sloan School of Management, says her MBA students are increasingly using what they learn to experiment with different models for care delivery. “Ghana tried a national health insurance system, for instance,” she says. “What can the U.S. learn from Ghana?”

Dr. Jaspal Sandhu, a global health designer and researcher with an engineering background, is among those asking such questions. In 2004, Sandhu and two other researchers traveled to Tamil Nadu state in India to closely examine the workings of Aurolad, an affiliate of Aravind Eye Care System, which developed an intraocular lens that significantly reduced the cost of cataract surgery in India. Today, Aurolab exports the lenses to 120 countries, including Canada, Denmark and Israel, though not the U.S.

It’s not just the lenses that interest Sandhu, a consultant who has worked with the World Bank, Microsoft and other clients. It’s the way the Aravind system works. This includes the use of health workers rather than doctors for certain basic procedures-one of a handful of strategies that could promote “lower costs and shorter waiting periods,” he says.

Not every expert is as optimistic. , an assistant professor at Columbia University’s Mailman School of Public Health, says  in the U.S., “hyper-technologization of everything” leads to rejection of simple solutions in favor of “the stuff that has some incredibly overly technical basis.”

“I think there are a ton of lessons that can be applied in primary care and at community health centers from countries like Rwanda,” says Ruxin, who runs a health and poverty program in that country. “But I haven’t sensed that the United States is ready for that.”

GE Healthcare, a believer, is investing $3 billion over six years in its “Healthymagination” initiative to create low-cost, high-quality products worldwide. It aims to use “reverse innovation,” the same development process that produced the MAC 800. GE learned a hard lesson prior to the initiative. “Quite frankly, when we develop stuff in the U.S. and try to make it available for lower-cost markets, it just doesn’t work,” says Melanie Varin, GE’s general manager of marketing for diagnostic cardiology. Products created that way tend to be too expensive for those markets and are unable to capture “the mindset of the local user.”

That experience led GE to pursue its current approach, which is outlined in an October 2009 , coauthored by GE’s CEO, Jeffrey R. Immelt. “Once products have proven themselves in emerging markets,” the article says, “they must be taken global.”

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“Are You Covered?”

Now a new study examines data from several health systems and highlights the role of health care quality in the midst of the current U.S. debate, which is often focused on improving access.

The , which was conducted by Elizabeth Docteur and Robert Berenson and released in August by the Urban Institute, compared U.S. treatment outcomes and other quality indicators with that of at least 30 developed countries, including Australia, France and the United Kingdom.

Docteur, an independent health policy and research analyst, said she and Berenson wanted to see whether the scientific literature supported the idea that American medicine really is best – a notion often “bandied about in the health reform debate.” They examined health care system research conducted during the past 10 to 15 years and found there was “no hard evidence” that U.S. health care quality stands out across the board. They did find that the U.S. had high scores in some specific treatment areas, such as cancer care. However, it didn’t do as well when compared to other nations at handling preventive care or treatment for acute conditions, including heart disease and hip fractures.

Perhaps one of the study’s most unexpected findings-depending on your political point of view -is that the quality of health care in Canada tends to be higher than in the U.S. The researchers looked at 10 statistically adjusted studies of broad populations and found that five favored care in Canada. The U.S. came out better in two. Three were inconclusive. Docteur points out the universal coverage in Canada helps to ensure that Canadians receive the care they need throughout their lives. “I think the main point is that our study showed quite clearly that it is not the case that the U.S. is dominating Canada in terms of quality of care,” she said.

“The findings are not a surprise to policy wonks,” saidÌýBruce Siegel, a quality expert and professor at The George Washington University’s School of Public Health and Health Services. Siegel-who was not involved in the study but said the authors used “the best information out there for comparison”-thinks their findings have the potential to be a “myth buster.”

Docteur said she hopes that her findings will draw more attention to quality issues, which have been a “bit of a sleeper” in the current debate. The research made it clear that although it’s necessary to find a way to cover more people to improve the country’s health system, “just solving the problem of the uninsured is not going to be enough.” She said she would like to see the debate reframed from a discussion on quality being at risk to a dialogue considering what the best performers are doing.

In the context of the current health system overhaul, he said, governors are most concerned with the prospect of a major expansion of Medicaid, which would pose a “tremendous financial liability” to states. Reforms to the state-administered program can only be accomplished “in partnership” with the federal government, which shares the costs of Medicaid with the states, he added.

With that in mind, Douglas said governors need more details about theÌývariousÌýproposals to determine the actual impact they would have on their states. Regarding the overhaul proposal released Wednesday by Senate Finance Committee Chairman Max Baucus, D-Mont., Douglas said the parts of the measure that deal with insurance reforms and exchanges “still need work,” but that overall the bill is “headed down a path that seems workable.”

He also warned that, although reform is “critical for the stretched budgets of state governments,” legislation that fails to respect these fiscal realities will force states to further eat into other vital programs, such as education. “Unlike the federal government,” he said, “states can’t print money. We have to balance our books.” Reform efforts, he added, also need “to respect that no one size fits all at the state level.”

Douglas appeared Thursday at the National Press Club in Washington, D.C., at an event launching a year-long (.pdf) to help governors reduce health care costs and expand coverage. He said he has talked with House leadership and several senators on the Finance Committee’s “Gang of Six” who have been negotiating on a health reform proposal.

During his talk, Douglas said his “greatest concern” is that the Washington health reform discourse is too focused on the current payment structure, which he says is the “wrong end” of the problem. “No matter who pays, healthcare costs are on track to bankrupt the country.”

The focus should be on improvements to the healthcare delivery system. “True reform really needs to get at the cost drivers,” he said.

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Ìý –1966: After a trip to the Columbia Point Health Center in Boston, which provided health care to low-income residents, the first-term senator introduces and helps pass legislation that adds $51 million to the Economic Opportunity Act for a national system of community health centers.

–1971: Kennedy becomes chairman of the Senate Health subcommittee and begins his long campaign for national health insurance.

— 1971: On Jan. 5, Kennedy co-sponsors a bill calling for a significant increase in funding for cancer research – providing a total of $1.2 billion over three years to the National Cancer Institute, more than what was proposed by the Nixon administration. A modified version of the bill is enacted Dec. 23, 1971.

–1971: Kennedy offers his national health-insurance plan. The “Health Security Act” calls for a universal single-payer plan financed through payroll taxes.

With support from organized labor and senior citizens, Kennedy holds hearings around the country and releases his report, “The Health Care Crisis in America,” which aims to garner support for his national insurance plan. President Richard M. Nixon, concerned about Democrats gaining advantages from the issue and a possible Kennedy campaign for president, later offers his own version of a bill, the National Health Insurance Partnership Act. It preserves private insurance but requires businesses to provide coverage to employees or make payments to a government-run fund. It also endorses the concept of health maintenance organizations.

“It’s really a partnership between the administration and insurance companies,” Kennedy says of the Nixon health plan. “It’s not a partnership between patients and doctors of this nation.” But Kennedy’s efforts on health insurance were pushed to the backburner by public concerns about the Vietnam War and later the Watergate scandal.

–1972: Working with other members of the Senate Select Committee on Nutrition and Human Needs, Kennedy helps secure authorization for a two-year pilot project for the Special Supplemental Nutrition Program for Women, Infants and Children, which provides food and health benefits to poor women who are pregnant and their children up to five years of age. In 1974 Kennedy fights to expand the program, and it is permanently authorized by the legislation.

–1973: Under pressure from doctors and other groups, the Nixon administration backs away from its proposal to expand HMO services, but Kennedy moves ahead on the issue. He sponsors the HMO Act of 1973, which is revised several times before it is eventually signed into law Dec. 29, 1973. The bill authorizes the spending of $375 million over five years to evaluate HMOs and requires employers with more than 25 employees to provide them with the option of a federally certified HMO where available. It also prevents states from restricting doctors who want to join HMOs.

–1973: Kennedy puts up “intense opposition” to the appointment of Caspar Weinberger as secretary of health education and welfare, according to a biography by Adam Clymer, a former New York Times reporter. Kennedy and other senators voice doubts about whether Weinberger can serve the interests of the poor, older Americans and uneducated people, but Weinberger is confirmed.

–1974: Kennedy teams up with Rep. Wilbur Mills, D-Ark., the head of the House Ways and Means Committee, to propose a compulsory national health insurance plan to be paid for by payroll taxes and general revenues. Kennedy’s aides secretly meet with Nixon administration officials but Kennedy and Nixon never agreed on a compromise. The Democrats’ plan is opposed by the American Medical Association and other groups. Kennedy tries unsuccessfully to revive the effort after Nixon resigns. Years later, Kennedy tells the Boston Globe that he may have missed an opportunity by not working closer with Nixon to find a consensus. Perhaps, he says, “We should have jumped on that.”

–1976: Although Democratic presidential candidate Jimmy Carter campaigns on the promise of a national health insurance program, Kennedy criticizes him for “intentionally [having] made his position on some issues indefinite and imprecise.”

–1977: Carter, concerned about the strength of the economy, moves away from national health insurance and proposes measures to contain expenses, such as hospital cost control. This prompts Kennedy in May at a United Auto Workers conference to lambast Carter for not setting a timetable to establish his health insurance program – a promise Carter made on the campaign trail. “Health reform is in danger of becoming the missing promise in the administration’s plans,” Kennedy says.

–1979: In March, Carter proposes phasing in a national health program, which he says will cost $10 billion to $15 billion, beginning in 1983. Kennedy quickly opposes the plan, calling Carter’s approach to health reform “piecemeal.” The administration shoots back that Kennedy’s proposal for a complete national health plan is too expensive. Kennedy later credits this disagreement as one of the influences on his decision to challenge Carter for the Democratic nomination for the president in 1980.

–1986: As part of what Kennedy calls “a fairly small step” to extend coverage to the country’s uninsured, he introduces legislation requiring employers to allow employees and others who lose group health coverage to purchase their employer-based insurance at their own expense for a fixed time period. It passes as part of the 1985 budget reconciliation bill. On April 7, President Ronald Reagan signs the Consolidated Omnibus Budget Reconciliation Act or COBRA, which was adopted as the name for Kennedy’s program.

–1987: Kennedy becomes the chairman of the Senate’s Labor and Human Resources Committee (later known as the Health, Education, Labor and Pensions Committee).

–1990: As chief co-sponsor, Kennedy joins forces with with Sen. Tom Harkin, D-Iowa, to drive the passage of the Americans with Disabilities Act, prohibiting discrimination based on disability.

–1990: Joined by Elizabeth Taylor, Kennedy and Sen. Orrin Hatch, R-Utah, hold a press conference on March 6 introducing a bill that eventually would be known as the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act to provide federal grants to improve care for individuals and families hit by HIV and AIDS. The measure passes later in the year and is signed by President George H.W. Bush on Aug. 18.

–1992: Kennedy co-sponsors the Mammography Quality Standards Act, which seeks to ensure that all women have access to quality mammography by dealing with issues at screening facilities, including lack of oversight, inferior equipment and poorly trained staff. The law, which has been reauthorized several times, requires all facilities to be inspected, accredited by an FDA-approved group and certified by the FDA or the state.

–1996: Together with Sen. Nancy Landon Kassebaum, R-Kan., Kennedy co-sponsors the Health Insurance Portability and Accountability Act (HIPAA) to protect workers and their families who change jobs or lose employer-based health insurance from being locked out of health coverage or forced to wait for coverage due to pre-existing medical conditions. It also prohibits insurance from being cancelled because of illness. Also, for what the bill is now most well-known, HIPAA establishes provisions on medical confidentiality. President Bill Clinton signs the bill into law on Aug. 21, 1996.

–1997: Kennedy and Hatch announce plans to provide health insurance for millions of uninsured children through the State Children’s Health Insurance Program (SCHIP) and fund the program through an increase in cigarette taxes. Hatch says, “Some have referred to us as the odd couple of the United States Senate. I like to think of us as the dynamic duo.”

The legislation, although initially a victim to budget rules, passes and is signed by Clinton in August as part of the Balanced Budget Act. It provides money to the states to pay for health coverage for children who do not qualify for Medicaid but whose families cannot afford private insurance. Kennedy calls it “the most far-reaching step that Congress has ever taken to help the nation’s children, and the most far-reaching advance in health care since the enactment of Medicare and Medicaid a generation ago.”

–1998: Kennedy is one of 31 co-sponsors for the Patient Bill of Rights. Although this measure is not the first such bill to be introduced, it becomes the leading vehicle to address public anger toward managed care practices. The legislation aims to protect patients who are members of managed care plans from, among other things, being denied care for the purposes of cost-containment. It also opens the door for patients who are injured as the result of being denied care to sue health plans in state courts.

Later, a more sweeping measure advanced by Rep. Charles Norwood, R-Ga., a retired dentist, passes the House, but Senate GOP leaders hold off Democratic efforts to bring up the bill in that chamber before the close of the 105th Congress. In 1999, the Republican-controlled Senate approves a scaled-back measure while the House, in November, approves a Democratic-backed version. In 2000, after six months of House-Senate negotiations, the conference committee is unable to reach a final agreement.

–2001: Kennedy together with Sens. John McCain, R-Ariz., and John Edwards, D-N.C., introduce the Bipartisan Patient Protection Act, giving patients the right to sue health plans in state courts based on denied care. Although President George W. Bush vows to veto the bill, it passes the Senate 59-36 in June.

The House passes a modified GOP-backed measure that allows employers to protect themselves from liability, the result of a closed-door compromise made between Bush and Norwood, a long-time patients’ bill of rights leader. The compromise, Kennedy said, ”makes [the patients’ bill of] rights unenforceable.” Adding ”a right without a remedy is not an effective right.” A Senate-House conference never convenes to work out differences between the two chambers. Kennedy and the bill’s other primary sponsors continue attempts to reach agreement with the administration, but abandon these negotiations in 2002.

–August 2001: Kennedy and Hatch introduce the Rare Diseases Act. The legislation increases funding for the NIH Office of Rare Diseases and expands its work. It later splits into two different acts–the Rare Diseases Act and the Rare Diseases Orphan Product Development Act–which are signed into law by Bush in November 2002.

–2003: Kennedy backs Bush’s 2003 plan to add a prescription benefit to Medicare that came with a $400 billion price tag spread out over 10 years. But when Kennedy learns that the Medicare Prescription Drug and Modernization Act of 2003 would, for the first time, allow private HMOs to compete with Medicare for patients, Kennedy works to amend the bill, criticizing the proposal for Medicare competition as “an untried, untested, unworkable program.” His efforts ultimately prove futile and he opposes the final bill. The Medicare Prescription Drug and Modernization Act of 2003 passes Congress and is signed into law by Bush on Dec. 8, 2003.

Later, in an interview with the Boston Globe, Bill Novelli, chief executive of the AARP, which broke with Kennedy, a longtime ally, to endorse the Republican-backed bill, credits the prescription drug benefit to Kennedy. “I think the lesson he learned from the Nixon era is a lesson that history teaches us: You should not let the perfect be the enemy of the good,” he says. “The Medicare Modernization Act was certainly not perfect, but the idea was, get it done and improve it over the coming years.”

–2006: Kennedy and Sen. Charles Grassley, R-Iowa, secure passage of the Family Opportunity Act, which expands Medicaid coverage for children with special needs even if their parents earn more than the usual limit.

–2006: Kennedy, and Sen. Pete Domenici, R-N.M., work with mental health advocates, private insurers and industry on legislation to require private insurers to offer mental health benefits equivalent to traditional health benefits. The bill builds on 1996 legislation seeking to end restrictions on mental health coverage. The Senate approves the bill in September 2007 and the House in March 2008. After negotiations between the Senate and House, language supporting the combined plan is written into law as part of the economic stimulus bill. The effective date for most health plans to make the change is Jan. 1, 2010.

–May 20, 2008: Kennedy is diagnosed with a malignant glioma, a common, highly lethal form of brain tumor. He undergoes surgery and other treatments.

–July 9, 2008: Just a month after undergoing surgery for brain cancer, Kennedy makes a surprise appearance in the Senate, which gives Democrats enough votes to prevent a Republican filibuster that would have cut Medicare fees to doctors. “We got this victory because of Ted,” Sen. Max Baucus, D-Mont., tells the Los Angeles Times. The bill passes later that month after the Senate overrides President Bush’s veto.

Ìý— 2008: Kennedy, weakened by cancer treatment, addresses the Democratic National Convention in Denver Aug. 25, pushing the party to continue his efforts on reform. “For me this is a season of hope — new hope for a justice and fair prosperity for the many, and not just for the few — new hope,” he says. “And this is the cause of my life — new hope that we will break the old gridlock and guarantee that every American — north, south, east, west, young, old — will have decent, quality health care as a fundamental right and not a privilege.”

–2009: On June 9, Kennedy submits the Affordable Health Choices Act, and although Kennedy is sidelined fighting his cancer and not able to participate, the measure passes in his Senate Health, Education, Labor and Pensions Committee as part of the larger Capitol Hill effort on health reform. However, the Senate Finance Committee is expected to significantly alter the bill. In July, Kennedy, along with long-time speechwriter and friend Robert Shrum, published an article in outlining his personal and political experiences with health issues over the years and describing his vision for reform.Ìý He wrote: “For four decades I have carried this cause-from the floor of the United States Senate to every part of this country. It has never been merely a question of policy; it goes to the heart of my belief in a just society.”

target=”_blank”>portable electrocardiogram machine

, trumpeting the new product’s ability to help patients wherever they might need it.

But the most interesting thing about the MAC 800 is not where it can go, but where it came from: China.

Chinese engineers funded by GE Healthcare helped develop the machine for sale in China. Although initially tailored to local needs, the MAC 800 has found a new market – the United States, where hospitals with community programs can easily take it on the road to treat patients.

The company is betting that other products originally created for the developing world ultimately also can be useful here. GE is tapping into the increasingly popular idea that medical innovation should be a global two-way street in which the West benefits from the resourcefulness and frugality poorer nations apply to health problems. The idea isn’t new, but it’s gaining traction, beyond the creation of products and technology, as public health experts rethink ways to prevent disease and deliver care.

Health care in the developing world holds several “general lessons for richer countries,” Nigel Crisp, a former permanent secretary of Britain’s Department of Health, observed in a recent . “Unconstrained by our history, [developing countries] train people differently, create new sorts of organisations, involve families and communities and concentrate more on promoting health rather than on just tackling disease.”

With interest in international health expanding, this type of thinking is likely to become more common. A 2009 survey by the Consortium of Universities for Global Health found that enrollment in global health courses had doubled since 2006. This rapid growth is changing the way people think about health care abroad, says Dr. Michael Merson, director of the Duke Global Health Institute. “I think the old days of development where the rich helped the poor, for the most part have passed,” he says. “I think we go into this with a true sense of shared partnership.”

The Roots Of ‘Kangaroo Care’  

While some experts doubt the U.S. is really ready to embrace lessons from abroad, there is a growing number of examples. They run the gamut from basic to high-tech – including an electronic medical records program in use in more than 20 countries.

The Boston-based Prevention and Access to Care and Treatment project, which serves HIV/AIDS patients, is modeled on a community health worker program pioneered in Haiti. Since the late 1990s, the project has sought out the most difficult-to-treat HIV patients: those who fail in conventional programs because of factors such as mental illness and poverty. The program reports good results and has been sharing its methods with the New York City health department and hospitals with similar programs.

“,” an approach developed in Colombia, is another example. With a major shortage of incubators, doctors advised mothers to cradle preterm babies in a sling. They did so well that it changed what had been the conventional approach in the U.S., which encouraged only limited human contact while newborns were in incubators.

Merson participated in what became one of the best known illustrations of a borrowed idea. During the 1970s he was in Bangladesh working with other doctors to treat an outbreak of cholera, an acute infectious disease whose symptoms include severe diarrhea. The team made extensive use of a cheaper, simpler treatment for diarrhea, which can result in life-threatening dehydration, and it is now the recommended standard for care worldwide.

“It took a while for pediatricians to use here,” Merson says, “but now we have products like Pedialyte and other kinds of oral rehydration fluids that are used to treat kids.”

These days, it’s increasingly common to find experts without medical backgrounds collaborating on health-related projects for developing countries. One example is OpenMRS, an open-source electronic medical record system that started in 2004 as a collaboration between the Boston-based nonprofit Partners in Health and the Regenstrief Institute, an informatics and health care research organization in Indianapolis. Both programs use the system to manage projects in the developing world. It’s especially critical for hospitals that track large numbers of HIV-positive patients, says William Tierney, an informatics expert at Regenstrief.

Without electronic information, “How do you know when patients aren’t coming in, so you can go out and chase them down to enhance adherence to the drug?” Tierney asks.

Rwanda, Tanzania and Peru are among the countries where the program has caught on. Since the software platform is open source it can be customized by anyone and tailored to specific programs, which would be more challenging with bigger commercial systems. Now it is being used at Indiana University’s School of Medicine – where Tierney is a professor – as well as at sites in Maryland, Boston and Los Angeles.

‘What Can The U.S. Learn From Ghana?’

Students now in school might lead a new wave of innovation. Anjali Sastry, a global health delivery and system dynamics researcher who lectures at the MIT Sloan School of Management, says her MBA students are increasingly using what they learn to experiment with different models for care delivery. “Ghana tried a national health insurance system, for instance,” she says. “What can the U.S. learn from Ghana?”

Dr. Jaspal Sandhu, a global health designer and researcher with an engineering background, is among those asking such questions. In 2004, Sandhu and two other researchers traveled to Tamil Nadu state in India to closely examine the workings of Aurolad, an affiliate of Aravind Eye Care System, which developed an intraocular lens that significantly reduced the cost of cataract surgery in India. Today, Aurolab exports the lenses to 120 countries, including Canada, Denmark and Israel, though not the U.S.

It’s not just the lenses that interest Sandhu, a consultant who has worked with the World Bank, Microsoft and other clients. It’s the way the Aravind system works. This includes the use of health workers rather than doctors for certain basic procedures-one of a handful of strategies that could promote “lower costs and shorter waiting periods,” he says.

Not every expert is as optimistic. , an assistant professor at Columbia University’s Mailman School of Public Health, says  in the U.S., “hyper-technologization of everything” leads to rejection of simple solutions in favor of “the stuff that has some incredibly overly technical basis.”

“I think there are a ton of lessons that can be applied in primary care and at community health centers from countries like Rwanda,” says Ruxin, who runs a health and poverty program in that country. “But I haven’t sensed that the United States is ready for that.”

GE Healthcare, a believer, is investing $3 billion over six years in its “Healthymagination” initiative to create low-cost, high-quality products worldwide. It aims to use “reverse innovation,” the same development process that produced the MAC 800. GE learned a hard lesson prior to the initiative. “Quite frankly, when we develop stuff in the U.S. and try to make it available for lower-cost markets, it just doesn’t work,” says Melanie Varin, GE’s general manager of marketing for diagnostic cardiology. Products created that way tend to be too expensive for those markets and are unable to capture “the mindset of the local user.”

That experience led GE to pursue its current approach, which is outlined in an October 2009 , coauthored by GE’s CEO, Jeffrey R. Immelt. “Once products have proven themselves in emerging markets,” the article says, “they must be taken global.”

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“Are You Covered?”

Now a new study examines data from several health systems and highlights the role of health care quality in the midst of the current U.S. debate, which is often focused on improving access.

The , which was conducted by Elizabeth Docteur and Robert Berenson and released in August by the Urban Institute, compared U.S. treatment outcomes and other quality indicators with that of at least 30 developed countries, including Australia, France and the United Kingdom.

Docteur, an independent health policy and research analyst, said she and Berenson wanted to see whether the scientific literature supported the idea that American medicine really is best – a notion often “bandied about in the health reform debate.” They examined health care system research conducted during the past 10 to 15 years and found there was “no hard evidence” that U.S. health care quality stands out across the board. They did find that the U.S. had high scores in some specific treatment areas, such as cancer care. However, it didn’t do as well when compared to other nations at handling preventive care or treatment for acute conditions, including heart disease and hip fractures.

Perhaps one of the study’s most unexpected findings-depending on your political point of view -is that the quality of health care in Canada tends to be higher than in the U.S. The researchers looked at 10 statistically adjusted studies of broad populations and found that five favored care in Canada. The U.S. came out better in two. Three were inconclusive. Docteur points out the universal coverage in Canada helps to ensure that Canadians receive the care they need throughout their lives. “I think the main point is that our study showed quite clearly that it is not the case that the U.S. is dominating Canada in terms of quality of care,” she said.

“The findings are not a surprise to policy wonks,” saidÌýBruce Siegel, a quality expert and professor at The George Washington University’s School of Public Health and Health Services. Siegel-who was not involved in the study but said the authors used “the best information out there for comparison”-thinks their findings have the potential to be a “myth buster.”

Docteur said she hopes that her findings will draw more attention to quality issues, which have been a “bit of a sleeper” in the current debate. The research made it clear that although it’s necessary to find a way to cover more people to improve the country’s health system, “just solving the problem of the uninsured is not going to be enough.” She said she would like to see the debate reframed from a discussion on quality being at risk to a dialogue considering what the best performers are doing.

In the context of the current health system overhaul, he said, governors are most concerned with the prospect of a major expansion of Medicaid, which would pose a “tremendous financial liability” to states. Reforms to the state-administered program can only be accomplished “in partnership” with the federal government, which shares the costs of Medicaid with the states, he added.

With that in mind, Douglas said governors need more details about theÌývariousÌýproposals to determine the actual impact they would have on their states. Regarding the overhaul proposal released Wednesday by Senate Finance Committee Chairman Max Baucus, D-Mont., Douglas said the parts of the measure that deal with insurance reforms and exchanges “still need work,” but that overall the bill is “headed down a path that seems workable.”

He also warned that, although reform is “critical for the stretched budgets of state governments,” legislation that fails to respect these fiscal realities will force states to further eat into other vital programs, such as education. “Unlike the federal government,” he said, “states can’t print money. We have to balance our books.” Reform efforts, he added, also need “to respect that no one size fits all at the state level.”

Douglas appeared Thursday at the National Press Club in Washington, D.C., at an event launching a year-long (.pdf) to help governors reduce health care costs and expand coverage. He said he has talked with House leadership and several senators on the Finance Committee’s “Gang of Six” who have been negotiating on a health reform proposal.

During his talk, Douglas said his “greatest concern” is that the Washington health reform discourse is too focused on the current payment structure, which he says is the “wrong end” of the problem. “No matter who pays, healthcare costs are on track to bankrupt the country.”

The focus should be on improvements to the healthcare delivery system. “True reform really needs to get at the cost drivers,” he said.

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