Anyone who doubted whether Barack Obama would keep health carereform front and center on his legislative agenda due to hisunderstandable preoccupation with our broader economic crisis waslikely proven wrong today, as the president-elect introduced theformer Senate majority leader, Tom Daschle, not only as hissecretary of health and human services, but also as director of anew White House Office of Health Reform, where he will be the leadarchitect in crafting ways to expand coverage and controlcosts.

Details remain sketchy, especially about how Mr. Obama will financean expansion of health care coverage for those 45-to-50 million nowuninsured. In response to a reporter's question, he emphasized theneed to cut costs first–for example, by allowing Medicare tonegotiate with drug companies for better prescription prices, aswell as eliminating subsidies for Medicare HMOs, and bringing thepaper-intensive medical industry into the computer age.

But when Mr. Daschle spoke, there were far more controversialissues raised.

As reported in The New York Times, “Mr. Daschle wants toestablish a Federal Health Board–an independent entity like theFederal Reserve,” which would “make coverage decisions for federalhealth programs.” He said the board would reduce or deny paymentfor new drugs and procedures that arent as effective as currentones. (For the full Times article, click here.)

That's political land mine number one, as the powerful makers ofdrugs and medical devices battle to protect their turf. You alsohave to wonder about the negative impact this might have on medicalcare innovation, if manufacturers decide it's not worth spendinghundreds of millions of dollars to develop new drugs or devices ifa federal board will decide it's not worth paying for.

Political land mine number two is the question of whether UncleSam should launch a federal health insurance plan to compete withprivate carriers. Backers say private insurers will hold downpremiums if faced with such non-profit competition, but the Timesnoted that critics contend “a government plan would have unfairadvantages and could drive private insurers from the market.” Mightthat be the long-term intent of the Obama administration?

Political land mind number three is Mr. Daschle's stated intentto break the myth that this is the best health care system in theworld,” instead describing it as islands of excellence in a sea ofmediocrity,” with care determined by how much money you have, andyour eligibility for coverage determined by your prior medicalhistory, leaving many out in the cold.

When people complain about the Canadian system, this is thefocus of their critique–that critical procedures are either deniedor delayed, while in the U.S. people (at least the insured) getquicker and more comprehensive care. Even Michael Moore, in his“Sicko” documentary, conceded that we might all have to wait longerfor care if everyone is insured, since one way to ration care issimply to exclude a huge segment of the population–not exactlyfair, especially if it's your life or health on the line.

Political land mine number four, of course, is expectedopposition from the powerful health insurance lobby. Mr. Daschlemade it clear he is under no illusions about what he is up against,expecting an all-out war to defeat reform by the healthcareindustry, including insurers.

Mr. Daschle blasted insurers specifically in the Times articlefor underwriting strategies that exclude or charge the highestrates to people who need the coverage the most–citing those withpreexisting conditions.

Of course, the Times article concluded, “insurers recentlyoffered to accept all applicants, regardless of any pre-existingmedical conditions–if the government required everyone to havecoverage.”

Will the Obama administration call the industry's bluff and dojust that?

Fasten your seat belts, folks, because it's going to be a bumpyride after Jan. 20, 2009!