- health care issues

jeanne's topics for discussion

My intent in redesigning this page is to break out the health care reform issue into topic areas, i.e., PPACA (the Patient Protection and Affordable Care Act); covering the uninsured and universal health care; quality; costs; and specific reforms like managing managed care, accounting for care, rationing care, and the like, and to sort the resources and discussion into topic areas for easier retrieval.


Patient Protection and Affordable Care Act

Let Sleeping Gorillas Lie: Setting the Benefit Rules Under PPACA

Quality Matters

Where Does the United States REALLY Rank Among Nations When it Comes to Health Care?

Does the U.S. have too few physicians, or too few primary care practitioners?

Cost Controls

Everything You Ever Wanted to Know About the PPACA Independent Payment Advisory Board But Were Afraid to Ask

Buried in PPACA (Obamacare) is a secret weapon to contain Medicare costs... the IPAB. Meet the group of House Democrats who want to destroy it.

The Independent Payment Advisory Board Under Fire: Can Its Opponents Succeed in Killing It?

Payment Changes and Reforms

Everything You Ever Wanted to Know About the PPACA Independent Payment Advisory Board But Were Afraid to Ask

Financing Changes, Taxes and Premiums

Means-Testing Medicare: The rich have been getting richer. Should they should pay more? Or get less?

The Budgetary Impact of the New Health Care Reform Law Over 10 Years and Beyond

Health Care is Now 17.6% of the Nation's Gross Domestic Product

U.S. Taxpayers are Over-Taxed... Not!  ...(when compared to other industrialized nations; we're just not getting what we pay for)...

PPACA Truths, Lies and Distortions

The Biggest and Baddest Lies about PPACA ("Obamacare")

Is PPACA a "Job-Killing, Budget-Busting Law?" Not According to the Facts.

 Repeal of PPACA is the REAL Job-Busting Action

Covering the Uninsured and Underinsured

Mini-Med ... and the Underinsured

Let's Just Allow the Buying of Health Insurance Across State Lines, That's the Ticket, Cheaper Insurance... NOT! Another Failed TeaParty/GOP Idea

Insurance Across State Lines: Sounds Good... on Paper ... But Consider the Real Impact ... And Besides it Does NOTHING to Solve Insurance Affordability and at Best Might Get Another 4 Million Insured... A Drop in the Bucket

The Nation's Uninsured (as seen by the Centers for Disease Control)

Gosh Darn All  Those Pesky Uninsured People...


Let's Kill Granny! Health Care Rationing For Me But Mostly You...

Changing How Health Care is Delivered

Too Many Doctors? Too Few Nurses!

Taming the Unicorn: Accounting for Accountable Care Organizations (ACOs)


... and after reviewing any of these "thoughts," you are offended or challenged... or maybe you just want to go into it a bit more, drop Jeanne an e-mail and open the dialog: jeanne.matthews@health-politics.

... and things only tangentially-related to health care ...

The Pope hates nuns because ...

1         France 66        Hungary 131       Honduras
2         Italy 67        Trinidad and Tobago 132       Burkina Faso
3         San Marino 68        Saint Lucia 133       Sao Tome and Principe
4         Andorra 69        Belize 134       Sudan
5         Malta 70        Turkey 135       Ghana
6         Singapore 71        Nicaragua 136       Tuvalu
7         Spain 72        Belarus 137       Ivory Coast
8         Oman 73        Lithuania 138       Haiti
9         Austria 74        St. Vincent- Grenadines 139       Gabon
10        Japan 75        Argentina 140       Kenya
11        Norway 76        Sri  Lanka 141       Marshall Islands
12        Portugal 77        Estonia 142       Kiribati
13        Monaco 78        Guatemala 143       Burundi
14        Greece 79        Ukraine 144       China
15        Iceland 80        Solomon Islands 145       Mongolia
16        Luxembourg 81        Algeria 146       Gambia
17        Netherlands 82        Palau 147       Maldives
18        United Kingdom 83        Jordan 148       Papua New Guinea
19        Ireland 84        Mauritius 149       Uganda
20        Switzerland 85        Grenada 150       Nepal
21        Belgium 86        Antigua-Barbuda 151       Kyrgystan
22        Colombia 87        Libya 152       Togo
23        Sweden 88        Bangladesh 153       Turkmenistan
24        Cyprus 89        Macedonia 154       Tajikistan
25        Germany 90        Bosnia-Herzegovina 155       Zimbabwe
26        Saudi Arabia 91        Lebanon 156       Tanzania
27        United Arab Emirates 92        Indonesia 157       Djibouti
28        Israel 93        Iran 158       Eritrea
29        Morocco 94        Bahamas 159       Madagascar
30        Canada 95        Panama 160       Vietnam
31        Finland 96        Fiji 161       Guinea
32        Australia 97        Benin 162       Mauritania
33        Chile 98        Nauru 163       Mali
34        Denmark 99        Romania 164       Cameroon
35        Dominica 100       Saint Kitts & Nevis 165       Laos
36        Costa Rica 101       Moldova 166       Congo
37     United States of America 102       Bulgaria 167       North Korea
38        Slovenia 103       Iraq 168       Namibia
39        Cuba 104       Armenia 169       Botswana
40        Brunei 105       Latvia 170       Niger
41        New Zealand 106       Yugoslavia 171       Equatorial Guinea
42        Bahrain 107       Cook Islands 172       Rwanda
43        Croatia 108       Syria 173       Afghanistan
44        Qatar 109       Azerbaijan 174       Cambodia
45        Kuwait 110       Suriname 175       South Africa
46        Barbados 111       Ecuador 176       Guinea-Bissau
47        Thailand 112       India 177       Swaziland
48        Czech Republic 113       Cape Verde 178       Chad
49        Malaysia 114       Georgia 179       Somalia
50        Poland 115       El Salvador 180       Ethiopia
51        Dominican Republic 116       Tonga 181       Angola
52        Tunisia 117       Uzbekistan 182       Zambia
53        Jamaica 118       Comoros 183       Lesotho
54        Venezuela 119       Samoa 184       Mozambique
55        Albania 120       Yemen 185       Malawi
56        Seychelles 121       Niue 186       Liberia
57        Paraguay 122       Pakistan 187       Nigeria
58        South     Korea 123       Micronesia 188       Dem. Rep. of Congo
59        Senegal 124       Bhutan 189       Cent. African Republic
60        Philippines 125       Brazil 190       Myanmar
61        Mexico 126       Bolivia  
62        Slovakia 127       Vanuatu  
63        Egypt 128       Guyana  
64        Kazakhstan 129       Peru  
65        Uruguay 130       Russia  
The Organisation for European Economic Cooperation (OEEC) was established in 1947 to run the US-financed Marshall Plan for reconstruction of a continent ravaged by war. By making individual governments recognise the interdependence of their economies, it paved the way for a new era of cooperation that was to change the face of Europe. Encouraged by its success and the prospect of carrying its work forward on a global stage, Canada and the US joined OEEC members in signing the new OECD Convention on 14 December 1960. 

The Organisation for Economic Co-operation and Development (OECD) was officially born on 30 September 1961, when the Convention entered into force.  Other countries joined in, starting with Japan in 1964. Today, 34 OECD member countries worldwide regularly turn to one another to identify problems, discuss and analyse them, and promote policies to solve them. The track record is striking. The US has seen its national wealth almost triple in the five decades since the OECD was created, calculated in terms of gross domestic product per head of population. Other OECD countries have seen similar, and in some cases even more spectacular, progress. 

So, too, have countries that a few decades ago were still only minor players on the world stage. China, India and Brazil have emerged as new economic giants. Most of the countries that formed part of the former Soviet bloc have either joined the OECD or adopted its standards and principles to achieve our common goals. Russia is negotiating to become a member of the OECD, and we now have close relations with Brazil, China, India, Indonesia and South Africa through our “enhanced engagement” programme. Together with them, the OECD brings around its table 40 countries that account for 80% of world trade and investment, giving it a pivotal role in addressing the challenges facing the world economy.

But there is one, new and VERY interesting ranking, this from the Gallup people, and using "survey" results obtained from "in person" interviews using standard statistical and polling mechanisms.  While "polling" is still not an exact science, its methodologies have improved significantly. The Gallup people have also introduced some "touchy-feely" aspects to their rating system... "thriving,"  "struggling," "suffering,"  In this survey the U.S. ranks considerably higher but still lags all of the Scandinavian countries and our English-speaking "sister" British-descendant nations, Australia, New Zealand and Canada, but ahead of continental Europe.

Gallup Global Wellbeing Index by Country 2010
Countries Ranked by % Thriving

Gallup’s global wellbeing metrics are the first comprehensive measure of the behavioral economics of gross national wellbeing, which lays the foundation for all other measures of a country’s economic strength. With ongoing research projects in more than 150 countries, Gallup is a leader in the collection and analysis of global data and measurements.

Gallup asks ordinary individuals for their thoughts and opinions on several topics, including economics, religion, migration, and wellbeing. Gallup’s data provide sound evidence on many issues that more than 98% of the world’s adult population faces.

The table shows life evaluation estimates of the percentage “thriving,” “struggling,” and “suffering” in countries and regions across the world. Gallup’s Thriving, Struggling, and Suffering indexes measure respondents’ perceptions of where they stand now and in the future. Based on the Cantril Self-Anchoring Striving Scale, Gallup measures life satisfaction by asking respondents to rate their present and future lives on a “ladder” scale with steps numbered from 0 to 10, where “0” indicates the worst possible life and “10” the best possible life. Individuals who rate their current lives a “7” or higher and their future an “8” or higher are considered thriving. Individuals are suffering if they report their current and future lives as a “4” or lower. All other individuals are considered struggling.

The table also includes daily wellbeing averages (0-10 scoring) based on responses to 10 items measuring daily experiences (feeling well-rested, being treated with respect, smiling/laughter, learning/interest, enjoyment, physical pain, worry, sadness, stress, and anger). Each daily experience is scored dichotomously with higher scores representing better days (more positive and less negative daily experience or affect).



1 Denmark 82 17 1 7.9
2 Finland 75 23 2 7.8
3 Norway 69 31 0 7.9
4 Sweden 68 30 2 7.9
5 Netherlands 68 32 1 7.7
6 Costa Rica 63 35 2 8.1
7 New Zealand 63 35 2 7.6
8 Canada 62 36 2 7.6
9 Israel 62 35 3 6.4
10 Australia 62 35 3 7.5
11 Switzerland 62 36 2 7.6
12 Panama 58 39 3 8.4
13 Brazil 58 40 2 7.5
14 United States 57 40 3 7.3
15 Austria 57 40 3 7.7
16 Belgium 56 41 3 7.3
17 United Kingdom 54 44 2 7.4
18 Mexico 52 43 5 7.7
19 Turkmenistan 52 47 1 7.5
20 United Arab Emirates 51 48 1 7.7
21 Venezuela 50 48 2 8.0
22 Ireland 49 49 2 7.5
23 Puerto Rico 47 45 8 7.6
24 Kuwait 47 50 3 7.0
25 Iceland 47 49 4 8.2
26 Colombia 46 47 7 7.7
27 Jamaica 46 49 5 7.7
28 Cyprus 45 50 5 6.6
29 Luxembourg 45 54 1 7.3
30 Trinidad and Tobago 44 51 5 7.9
31 Argentina 44 50 6 7.8
32 Belize 44 50 6 6.8
33 Germany 43 50 7 7.4
34 El Salvador 42 51 7 7.7
35 Chile 41 52 7 7.3
36 Uruguay 41 54 5 7.5
37 Qatar 41 58 1 6.8
38 Guatemala 40 50 10 7.7
39 Malta 40 48 12 6.6
40 Czech Republic 39 51 9 6.6
41 Italy 39 54 7 7.1
42 Honduras 37 49 14 7.5
43 Spain 36 58 6 7.0
44 Dominican Republic 35 54 11 7.3
45 France 35 60 6 7.0
46 Bolivia 34 59 7 7.0
47 Ecuador 34 52 15 7.6
48 Paraguay 32 59 9 8.3
49 Bahrain 32 45 23 7.0
50 Guyana 31 64 5 7.0
51 Greece 31 57 11 7.0
52 Nicaragua 30 53 17 7.4
53 Jordan 30 61 8 6.7
54 Belarus 29 59 12 6.5
55 Kosovo 29 65 6 6.2
56 South Korea 28 61 12 6.9
57 Poland 28 61 10 7.1
58 Saudi Arabia 27 69 3 6.7
59 Pakistan 27 50 23 6.2
60 Slovenia 27 57 16 6.8
61 Croatia 26 60 14 6.2
62 Montenegro 26 58 16 6.2
63 Malawi 25 64 10 8.0
64 Peru 25 65 11 7.2
65 Moldova 25 62 13 6.1
66 Lithuania 25 57 18 6.2
67 Libya* 24 68 8 6.0
68 Botswana* 24 65 11 7.3
69 Cuba* 24 66 11 6.7
70 Kazakhstan 22 72 6 7.2
71 Taiwan 22 64 14 7.5
72 Portugal 22 61 17 7.1
73 South Africa 21 71 8 7.3
74 Lebanon 21 64 15 6.3
75 Russia 21 57 22 7.0
76 Ukraine 21 53 26 6.6
77 Romania 21 56 23 6.6
78 Slovakia 21 60 19 6.5
79 Thailand 20 75 5 8.0
80 Bosnia+Herzegovina 20 59 20 6.2
81 Iran 19 66 14 6.3
82 Hong Kong 19 65 16 7.1
83 Singapore 19 75 6 6.9
84 Japan 19 69 12 7.4
85 Somaliland 18 77 5 7.1
86 Algeria 18 77 6 6.7
87 Nigeria 18 78 4 7.3
88 Uzbekistan 18 75 6 7.8
89 Indonesia 18 72 10 8.2
90 Estonia 17 62 21 6.8
91 Myanmar* 16 82 2 7.1
92 Bangladesh 16 71 13 6.9
93 Serbia 16 63 21 6.2
94 Malaysia 15 80 5 8.1
95 Philippines 15 68 18 7.2
96 Cameroon 14 77 9 7.0
97 Tunisia 14 77 9 6.8
98 Zambia 14 78 8 7.6
99 Yemen 14 62 24 6.3
100 Vietnam 14 76 10 6.9
101 Palestinian Territ. 14 70 15 5.8
102 Macedonia 14 54 32 6.8
103 Turkey 13 67 20 6.0
104 Kyrgyzstan 13 81 7 7.3
105 Azerbaijan 13 70 17 6.6
106 Hungary 13 53 34 6.9
107 Albania 13 67 19 5.6
108 Central African Rep. 12 75 13 6.4
109 Ethiopia 12 67 21 6.4
110 Namibia 11 79 10 8.1
111 Angola 11 81 8 6.8
112 Armenia 11 55 33 5.9
113 Iraq 11 71 18 5.2
114 Latvia 11 64 25 6.5
115 Mozambique 10 78 11 7.2
116 Egypt 10 71 19 6.1
117 Mauritania 10 83 7 7.2
118 Zimbabwe 10 73 17 7.3
119 Morocco 10 80 10 7.0
120 Sri Lanka 10 66 24 6.9
121 India 10 69 21 6.9
122 Syria 10 66 24 6.8
123 Georgia 10 56 35 6.2
124 Afghanistan 10 69 21 6.2
125 Kenya 9 78 13 7.5
126 Ghana 9 83 8 7.5
127 China 9 77 14 7.6
128 Congo (Brazzaville) 8 73 20 6.9
129 Guinea 8 89 3 7.1
130 Sudan 7 81 12 7.4
131 Djibouti 7 86 8 7.5
132 Madagascar 7 84 10 7.0
133 Nepal 7 82 11 7.4
134 Mongolia 7 81 12 7.0
135 Laos 7 89 4 7.1
136 Tajikistan 7 74 19 6.5
137 Uganda 6 71 23 6.8
138 Tanzania 6 70 24 7.5
139 Senegal 6 88 6 7.3
140 Bulgaria 6 58 36 6.5
141 Chad 5 88 7 7.1
142 Liberia 5 90 5 6.7
143 Mali 5 77 18 8.0
144 Ivory Coast 4 84 12 7.2
145 D R Congo 4 85 11 6.4
146 Benin 4 80 16 6.7
147 Haiti 4 60 35 6.2
148 Niger 3 86 11 7.9
149 Rwanda 3 75 22 7.8
150 Burkina Faso 3 71 26 6.5
151 Sierra Leone 3 74 23 6.3
152 Cambodia 3 75 22 7.6
153 Comoros 2 75 23 7.7
154 Burundi 2 58 40 7.5
155 Togo 1 67 31 5.0

*Limited urban samples only.


Means-Testing Medicare: The rich have been getting richer. Should they should pay more? Or get less?

One of the more recent phenomenon’s of my advanced years has been how readily (and easily) I may change some of my most intense and deeply held political beliefs. I’ve already cited my change in philosophy regarding the percent of GDP spent on health care; now I am re-visiting Medicare means-testing.  It’s kind of like that old Samuel Clemens/Mark Twain adage, “When I was young, my father was the most stubborn, mule-headed, son-of-a-bitch, I had ever seen. But now that I am older, it’s amazing how much smarter he has gotten.”  But in my case, my personal mule-headedness may only date to my 50’s, and my smarter(ness) seems to have come in my late 60’s. <sigh>

Back before the turn of the century, I wrote (and spoke regularly) about the issue of means-testing Medicare, rejecting the concept as a sell-out to the original egalitarian principles of both Medicare and its big sister, Social Security.  These two benefit programs had become an integral part of the social contract that bound the nation together. Every citizen who met the minimum qualifications would be eligible; the bag-lady who sleeps over the grating outside Union Station in Washington DC would get them, Bill Gates would get them. The programs were completely egalitarian.


Way, way back in April 1999, in my regular monthly column in the Journal of the Healthcare Financial Management Association, I wrote about, "Changing the Medicare Social Contract"  I first began to discuss the potential for "means-testing Medicare. Back then, the driving issue was a GOP-majority report from one of the seemingly unlimited “Medicare commissions” that suggested something labeled: “premium support.”  Under a premium support model, Medicare would credit each eligible beneficiary with an equal allocation, an amount currently estimated to be 88 percent of the average per capita amount Medicare spends. Based on the then available 1998 expenditures, this amount would have been approximately $4,994 (88 percent of the $5,675 a year HCFA (now CM2) then said it was paying per beneficiary for Part A and Part B Medicare). Future Medicare allocations would have been adjusted yearly based on actual expenditures and budgetary decisions. Premium support advocates (mostly Republican) were seeking to "penalize" those who might choose a more expensive plan by reducing their 88 percent allocation while raising the allocation for lower-income individuals. In effect, under the plan, Medicare beneficiaries would be subject to means testing, thus transforming Medicare into a multitiered social benefits program with all of the trappings of a full-fledged welfare program.


Welfarizing Medicare (and Social Security)

Now welfare-like provisions have been creeping into Medicare and Social Security for some time. We have begun taxing the Social Security benefits of retirees with retirement incomes greater than $35,000 a year - in effect, taking back from the "wealthy" some of their "entitlement" to the full benefits of that program. Similarly, under Medicare, by subjecting every dollar of income to the Medicare tax with no increase in benefits, the wealthier have been paying more for their coverage for the past several years and effectively subsidizing poorer people who pay less. In 2003, with the passage of the Medicare Modernization Act (the law that gave us Medicare Part D, prescription drugs) we began the most direct means-testing of Medicare, increasing the monthly Medicare Part B premium for those with incomes over $80,000 a year.  At the time Democrats were unalterably opposed to this, holding fast to their egalitarian views. The prescription drug benefit provisions in the 2003 MMA (I prefer the acronym "NAIM") got all the attention but other changes to Medicare may end up having far more long term impact... mostly specifically the establishment of new Medicare Part C, the 2003 version of "premium support." For the first time, we tiered Medicare directly, with wealthier individuals paying higher monthly premiums, ranging from 20% to 100% more, on a rising scale. 

Democrats went postal at the time and the new law was passed without a single Democratic vote. The Democrats fought the "welfarization" of Medicare, fearing that in the long term, as merely another "welfare" program, the entitlement nature of the program would change forever, and with it, as the tides of time and change moved, would public support for the program.

But I am not the only one getting smarter in my old age, by 2010, in PPACA, Democrats had come virtually full circle on the means-testing issue and almost eagerly added a means test of their own, extending the GOP-driven rising scale of premiums for Medicare Part B to Medicare Part D. Will Medicare Part A be next?

As an interesting side fact, a survey showed that by 2008, that Democrats favored means-testing Medicare at a statistically higher rate than Republicans. You can draw your own conclusions about that, but egalitarian attitudes toward Medicare (and, presumably Social Security, would be appear to have died a slow and apparently not too painful Democratic mind-set death.

Changing the Social Contract

The egalitarian philosophy that was so much a part of Medicare in the beginning - that all Americans are entitled to receive Medicare simply because they are Americans -- is breaking down. Not that there's anything wrong with that. Social contracts can be changed as long as the American electorate understands and agrees to the change. But therein lies a very irritating rub, the Social Contract, is being changed secretly, incrementally without the understanding "advice and consent" of the people.

The idea of "privatizing" Medicare as pushed by today's TeaParty/GOPers should be a non-starter. They would essentially gut the entire program (albeit, as explained me by one of the "pool people" in my senior 55+ community in Arizona, "I know it would ultimately destroy Medicare, but it'll take them years to implement. By then I will be gone and won't worry about it.) She is an enthusiastic TeaParty/GOPer. But we do need to look at ways where means-testing may benefit not just the low to middle income beneficiaries of today, but those of tomorrow as well. We do need to couple any such mans-testing with major payment reforms and delivery changes.  Gosh for an old lady, I have a lot of work to do.

back to top

Is PPACA a "Job-Killing, Budget-Busting Law?" Not According to the Facts.

When it comes to truth in labeling, House Republicans are getting off to a poor start with their constantly repeated references to the new health care law as "job-killing."

The Facts:

  • Independent, nonpartisan experts project only a "small" or "minimal" impact on jobs, even before taking likely job gains in the health care and insurance industries into account.

  • The House Republican leadership, in a report issued January 6, badly misrepresents what the Congressional Budget Office has said about the law. In fact, CBO is among those saying the effect "will probably be small."

  • The GOP also cites a study projecting a 1.6 million job loss — but fails to mention that the study refers to a hypothetical employer mandate that is not part of the new law.

  • The same study cited by the GOP also predicts an offsetting gain of 890,000 jobs in hospitals, doctors’ offices and insurance companies — a factor not mentioned by the House leadership.

There’s little doubt that the new law will likely lead to somewhat fewer low-wage jobs. That’s mainly because of the law’s requirement that, generally, firms with more than 50 workers pay a penalty if they fail to provide health coverage for their workers. One leading health care expert, John Sheils of The Lewin Group, puts the loss at between 150,000 and 300,000 jobs, at or near the minimum wage. And Sheils says that relatively small loss would be partly offset by gains in the health care industry.


Attaching misleading labels to legislation is a well-worn tactic in Washington. Conservatives got rid of most of the estate tax after labeling it a "death tax," as though it taxed death instead of multimillion-dollar fortunes. And liberals once won passage of an "assault weapons ban" that didn’t really ban fully automatic military assault rifles, which were already illegal for civilians to own without a very-hard-to-get federal license. Now House Republicans are seeking to repeal what they call "Obamacare: A budget-busting, job-killing health care law." That’s the title of a study issued by the House Republican leadership January 6.

And the GOP is clearly pushing the "job-killer" claim. House Speaker John Boehner used the phrase "job-killing" to describe the health care law seven times on Thursday in a press conference that lasted less than 14 minutes — that’s once every 2 minutes. He also used the phrases "destroy jobs" and "destroying jobs" once each when talking about the law. Perhaps not surprisingly, the Republicans named their bill to repeal the health care law: "Repealing the Job-Killing Health Care Law Act."

But is the health care law really "job-killing" as claimed? That's just another case of exaggerated and misleading labeling.


To support its claim, the GOP report first cites the nonpartisan Congressional Budget Office — but the report badly misrepresents what CBO actually said.

House GOP Leadership, January 6: The health care law will cause significant job losses for the U.S. economy: the Congressional Budget Office has determined that the law will reduce the “amount of labor used in the economy by … roughly half a percent…,” an estimate that adds up to roughly 650,000 jobs lost.

In fact, CBO did not predict a 650,000 job loss. The Republican report cites a CBO report from August, which actually said that the economy will use less labor primarily because many people will choose to work less, or retire early, as a result of the new law.  What CBO projects is mostly a reduction in the supply of labor, which is not the same as a reduction in the supply of jobs.

CBO, August 2010: The Congressional Budget Office (CBO) estimates that the legislation, on net, will reduce the amount of labor used in the economy by a small amount—roughly half a percent—primarily by reducing the amount of labor that workers choose to supply.

CBO said one reason fewer people will choose to work is that many low-income people will have more money in their pockets as a result of the law expanding Medicaid and providing federal subsidies for many who buy insurance privately. "The expansion of Medicaid and the availability of subsidies through the exchanges will effectively increase beneficiaries’ financial resources," CBO said. "Those additional resources will encourage some people to work fewer hours or to withdraw from the labor market."

Another reason that people might work less is that the new law requires insurance companies to cover preexisting conditions, and also limits their ability to charge higher rates for older persons who buy policies for themselves. "As a result, some older workers will choose to retire earlier than they otherwise would," CBO said.

To be sure, some jobs will indeed be lost, CBO said. That’s because the new law requires many businesses to pay a penalty if they do not provide health insurance to their workers. That "will probably cause some employers to respond by hiring fewer low-wage workers," CBO said. But it also said these firms may hire more part-time or seasonal workers instead. CBO did not estimate the number of jobs likely to be affected either way.

In a more extensive look at the subject, CBO on July 14, 2009, said the effect of the employer mandate "would probably be small." The GOP report did not mention that.

Finally, CBO did not attempt to estimate the number of jobs likely to be gained in the health care and insurance industries. It has projected that the law will result in 32 million Americans gaining health insurance that they would not otherwise have, enabling them to buy more services from physicians and other health care providers. More about that later.

Others Estimate ‘Small,’ ‘Minimal’ Impact

The Lewin Group also has estimated a small impact on jobs as a result of the health care law. Senior Vice President John Sheils said Lewin’s analysis showed 150,000 to 300,000 jobs lost, all minimum wage or near minimum wage positions that would be lost permanently. That doesn’t account for increases in jobs in other sectors, mainly health care, that Sheils also expects but hasn’t quantified. All told, he estimates, a "small net job loss."

(TRUTH-IN-REPORTING: Lewin is a subsidiary of UnitedHealth Group, a huge for-profit health insurer) The reason that some low-wage workers are expected to lose jobs, as CBO also said, is that some employers who are faced with penalties will pass along those costs to workers in the form of lower wages or reduced benefits. For low-wage workers, their wages can’t be reduced below the minimum wage, so those firms would hire less, lay off workers or use more part-time employment.

Sheils notes that there will be distributional effects, as some sectors gain jobs and others lose them, but the people gaining employment aren’t necessarily the same who lost jobs. He says there’s "a potentially painful process here in changes in employment in some industries … versus others." Skilled workers are likely to benefit.In Nov 2009 the House was debating a health care bill with tougher requirements and penalties for employers than the law now has. Even under that bill, Elizabeth McGlynn, associate director of the health unit at RAND Corp., told us the effect on jobs "is likely to be quite minimal." McGlynn said: "Most large businesses already offer health insurance. And most small businesses are excluded from the mandate. So it’s relatively few firms that will be affected."

And small businesses — those with 50 or fewer employees — are likely to benefit under the law, Sheils says. "I think they actually could come out ahead," he says. "They don’t face the mandate and they could get a tax credit at least for a while for their health benefit. … It gives them an advantage in the marketplace," if they’re competing against larger firms.

Besides Sheils’ numbers and CBO’s estimate, no other nonpartisan figures on the law’s impact on jobs have been found. When Sheils was asked if he knew of others, he said no. He added that he thinks that a lot of economists believe the effect is small, and that’s why they’re not doing an analysis.

1.6 million lost jobs?

The second piece of evidence offered by the GOP report is a study by the National Federation of Independent Business, projecting a 1.6 million job loss. But here the GOP misrepresents the evidence again. The NFIB did not study the new law. Its report was based on a hypothetical employer mandate that bears little resemblance to what was actually passed — and it also projects a gain of hundreds of thousands of health care and insurance industry jobs.

House GOP Leadership, January 6: A study by the National Federation of Independent Businesses (NFIB), the nation’s largest small business association, found that an employer mandate alone could lead to the elimination of 1.6 million jobs between 2009 and 2014, with 66 percent of those coming from small businesses.

That refers to a study by the NFIB’s Research Foundation. But that study was issued January 26, 2009 — well over a year before the new law was actually enacted. NFIB has not issued any study of what actually became law, and one of this study’s authors, Michael Chow, told us by e-mail that it has no present plans to do so.

The GOP report refers to the NFIB’s analysis as "independent," but it’s hardly a neutral source. The federation is currently backing repeal of the new law, and has historically been opposed to any requirement that businesses provide coverage for their workers. NFIB also cosponsored with the Chamber of Commerce an ad criticizing health care legislation in 2009.

More important, what the NFIB foundation studied was not what became law. It gave its estimate of the effect of a hypothetical employer mandate that would cover all businesses, and require that they pay at least half the insurance premiums for their workers.

NFIB Research Foundation, January 26, 2009: [T]he employer mandate would cause the economy to lose over 1.6 million jobs within the first five years of program implementation. Small firms would be most adversely affected by the mandate and account for approximately 66 percent of all jobs lost.

Even if that 1.6 million figure were accurate, it wouldn’t apply to the new law that was signed last March. The new law does not require all businesses to provide coverage. It exempts those with 50 or fewer workers. So the "small firms" that the NFIB study says would be "most adversely affected" by the imaginary mandate studied in 2009 will not be affected at all by the actual law. The 1.6 million figure is a gross exaggeration of the likely effect of the law, even using the NFIB’s study as a guide.

Looking closely at the study. It’s not possible to say precisely how big a job loss it would have predicted had the 50-worker exemption been factored in. It predicts that the mandate would cause 467,182 jobs to be lost in firms employing 19 or fewer workers, so the 1.6 million figure is high by at least that much. (See Table 6, page 17.) In addition, the study estimates that 420,600 jobs would be lost in firms employing from 20 to 99 workers, so some large but unknown share of those would also have to be subtracted, possibly reducing the figure to 1 million or less.

And although neither the NFIB nor the GOP leadership report mentions it, this is a gross figure, not a net figure. It fails to account for job gains brought about by the new law, a point already mentioned. And buried deep in the NFIB’s own report is evidence that those job gains could be substantial.

890,000 New Jobs?

Here’s what the NFIB report said about job gains, on page 20:

NFIB Research Foundation, January 26, 2009: The employer mandate would boost demand for healthcare goods and services, thereby increasing employment in healthcare-related sectors. The number of ambulatory healthcare professionals (physicians, dentists, and other healthcare practitioners) needed will increase by 330,000. An additional 327,000 staff will be required to work in hospitals. Some 157,000 more nurses (net of retirements) will be needed to staff doctors’ offices, outpatient clinics, and other provider locations. And payrolls at insurance companies will expand by 76,000 workers.

That comes to 890,000 new jobs.

Although the new law relies more on an individual mandate — requiring nearly everybody to obtain coverage on their own if their employers don’t provide it — the resulting increase in demand for health care services, prescription drugs and other goods would be the same. To repeat, CBO estimates that the law will result in 32 million additional persons with health coverage.

The NFIB study cautioned that some of those 890,000 new jobs might not be filled right away if the increased demand outstrips the health care system’s ability to meet it. But even so, it amounts to a sizeable offset to the jobs likely to be lost due to the employer mandate.

For the record, conservatives aren’t the only ones misrepresenting the law’s likely impact on jobs. The White House claimed in a blog post Jan. 7 that the law "could create more than 300,000 additional jobs" by "slowing the growth of health care costs." The liberal Center for American Progress said in a January 2010 report that "health care reform could increase the number of jobs in the United States by about 250,000 to 400,000 per year over the coming decade." But it remains to be seen whether the law will actually slow the growth of costs for employers and individuals, as the White House hopes it does.


So what about the "budget-busting" label that House Republicans are also trying to apply?

The Congressional Budget Office officially scored the new law as self-financing, projecting that it would actually reduce the deficit over the first 10 years — and beyond.  And so it should surprise nobody that CBO said Jan. 6 that repealing the new law, as Republicans propose, would increase the deficit. CBO’s latest figures project that repealing the new law will increase the deficit by a total of $230 billion over the next 10 years (through fiscal year 2021). So keeping it in place would help the budget, not bust it.

Republicans have a point, to this extent: The CBO is forced by law to rely on assumptions that may not turn out to be true, and which Medicare officials say probably won’t happen. The Medicare system’s chief actuary, Richard Foster, issued a report soon after passage of the law saying much of the projected savings "may be unrealistic," and that the law could cause 15 percent of hospitals to become unprofitable unless Congress eases up. "If these reductions were to prove unworkable within the 10-year period 2010-2019 (as appears probable for significant numbers of hospitals, skilled nursing facilities, and home health agencies), then the actual Medicare savings from these provisions would be less," Foster said.

If that happens, the law could well turn out to increase the deficit rather than trim it. But that remains to be seen.


Congressional Budget Office. "The Budget and Economic Outlook: An Update." Aug 2010.

Republican House leadership. "Obamacare: A Budget-Busting, Job-Killing Health Care Law." 6 Jan 2011.

Chow, Michael J. and Bruce D. Phillips. "Small Business Effects of a National Employer Healthcare Mandate." NFIB Research Foundation. 26 Jan 2009.

Sheils, John, senior vice president, The Lewin Group. Interview with 7 Jan 2011.

U.S. House. H.R. 2. Introduced 5 Jan 2011.

Congressional Budget Office. "Effects of Changes to the Health Insurance System on Labor Markets." 14 Jul 2009.

Novak, Viveca and Lori Robertson. "Health Care and the Economy." 17 Nov 2009.

"Small Business Looks to the New Congress to Repeal the Healthcare Law." NFIB website, accessed 7 Jan 2011.

Cutter, Stephanie. "Repealing the Affordable Care Act will Hurt the Economy." 7 Jan 2011.

House of Representatives Committee on the Budget, GOP staff. "The Budgetary Consequences of the President’s Health Care Overhaul." accessed 7 Jan 2011.

Congressional Budget Office. "Preliminary Analysis of H.R. 2, the Repealing the Job-Killing Health Care Law Act." 6 Jan 2011.

Foster, Richard. "Estimated Financial Effects of the ‘Patient Protection and Affordable Care Act,’ as Amended." Centers for Medicare and Medicaid Services. 22 Apr 2010.


back to top

Repeal of PPACA is the REAL Job-Busting Action

A Republican plan to sharply cut federal spending this year would destroy 700,000 jobs through 2012, according to an independent economic analysis was released on Monday, February 28, 2011

The report, by Moody's Analytics chief economist Mark Zandi, offers fresh ammunition to Democrats seeking block the Republican plan, which would terminate dozens of programs and slash federal appropriations by $61 billion over the next seven months.  Zandi, an architect of the 2009 stimulus package who has advised both political parties, predicts that the GOP package would reduce economic growth by 0.5 percentage points this year, and by 0.2 percentage points in 2012, resulting in 700,000 fewer jobs by the end of next year. His report comes on the heels of a similar analysis last week by the investment bank Goldman Sachs, which predicted that the Republican spending cuts would cause even greater damage to the economy, slowing growth by as much as 2 percentage points in the second and third quarters of this year.  Zandi also had bad news for liberal Democrats who are resisting sharp spending cuts: Bringing deficits down to sustainable levels will require more than a growing economy. Even if the economy recovers as expected, he writes, lawmakers will have to cut about $400 billion a year through the rest of this decade to narrow the gap between spending and revenue, and stop adding significantly to the national debt.



"Significant government spending restraint is vital, but given the still halting economic recovery, it would be counterproductive for that restraint to begin until the economy is creating enough jobs to bring down the still very high unemployment rate," Zandi writes. "Shutting the government down for any length of time would also be taking a big chance with the recovery, not only because of the disruption to government services, but also due to the potential hit to the fragile collective psyche."  

A partisan brawl is also brewing over the legal limit on government borrowing, currently set at $14.3 trillion. In his new report, Zandi predicts that the U.S. Treasury will be able to manage the government's finances under that cap only until June. With Republicans lining up against an increase, Zandi writes that the "threat of a serious policy misstep in the next several weeks and months" is serious.

back to top


The Biggest and Baddest Lies about PPACA ("Obamacare")

 I have been working on a compilation of the many lies and distortions about PPACA that have, in many cases become viral on the Internet. And while most of them are, to the rational mind at least blatantly and bold-facedly outright lies, their repetition, particularly by the likes of Glenn Beck, Rush Limbaugh, Sean Hannity and Bill O’Reilly have embedded them as apparent “truths” in the collective conscience of the Tea-Party and those who have fallen for the lie.

My list is not-comprehensive¸ and is still a work in progress. The list will be updated and expanded, but as of this haze-filled morning, here it is:

Lie #1 – “Obamacare will result in the largest tax hikes in the history of America. Ordinary taxpayers will see their taxes ‘skyrocket.’"  The liars who make this statement go even further, saying:  “The top income tax rate will rise from 35 to 39.6 percent.... The lowest rate will rise from 10 to 15 percent. All the rates in between will also rise. Itemized deductions and personal exemptions will again phase out, which has the same mathematical effect as higher marginal tax rates.” The liars base their conclusion on the scheduled expiration in 2011 of the 2001 and 2003 “Bush tax cuts” which a then Republican-controlled Congress established as a means of getting around Congressional rules on reporting the actual costs of any new legislation. By having the tax cuts “expire within 10 years” they did not have to account for the deficits these cuts created in the federal budget. The liars “assume” that Democrats will simply allow ALL the tax cuts to expire. The fact is that Democrats have repeatedly said that they want only the top end tax cuts, those on individuals earning more than $200,000 a year and couples earning more than $250,000, to expire. The tax cuts on lower incomes will be extended and made permanent. So, unless “ordinary” Americans is defined to include those earning in excess of $200,000 a year, the statement is a lie.

Lie #2 – “Obamacare has a second "wave" of tax increases taking effect January 1, 2011 that impact “ordinary” Americans.”  But this "wave" consists of three relatively minor tax changes that affect relatively few people.

·         The so-called "Obama Medicine Cabinet Tax" simply aligns rules governing health savings accounts (HSAs), Flexible Spending Arrangements (FSAs) and Health Reimbursement Arrangements (HRAs) with the tax rules that apply to deducting medical expenses generally. Under current law, taxpayers in general are not allowed to deduct the cost of non-prescription drugs as a medical expense. The only exception is for insulin. But those with HSAs, FSAs and HRAs were allowed to use pre-tax dollars to buy aspirin, over-the-counter cold and allergy medications, and other drugs available without a doctor’s prescription. The new "tax" simply says HSAs, FSAs and HRAs can’t be used to buy these medications -- except for insulin -- after December 31. This will affect a small proportion of taxpayers. For example, the health insurance industry says 10 million persons were covered by HSAs as of January of this year, roughly 3.2 percent of the population. For that relatively small group, the change does amount to a tax increase. It will bring in a total of $5 billion over the next 10 years.

·         The "HSA withdrawal tax hike" refers to a doubling of the current 10% penalty that must be paid on any HSA funds spent for something that’s not a qualified medical expenditure. This is expected to bring in $1.4 billion over 10 years.

·         The "special needs kids tax" refers to a cap of $2,500 that the new law places on spending from FSAs. The argument made is that "many" families with special needs children now use FSAs to pay tuition at private schools catering to special needs children, schools that Obama’s opponents say "can easily exceed $14,000 per year." Perhaps so.  IRS rules do allow use of FSA funds to pay for such expenses with pre-tax dollars. But the liars who make this statement offer no evidence of how many families might be taking advantage of this tax break currently. Indeed most employers offering FSA plans already limit the amount that can be set aside tax-free, to $2,500-$4,000. The claim is copied from the website of Americans for Tax Reform, but as ATR itself says: "For most people, the $2500 cap won’t be noticed." As ATR concedes, FSAs "tend to be used for things like small deductibles, co-payments, eyeglasses, over-the-counter medicines, and laser eye surgery." The amount deferred in the typical FSA is probably much less than $2,500 today, ATR says. The Congressional Budget Office expects the change will bring in $13 billion over 10 years, but says nothing about how much of that is likely to come from the pockets of parents of special needs children.

Without arguing for or against any of these three tax increases. I simply point out that, even taken together, they amount to less than $2 billion per year and, therefore, don’t constitute anything close to a "wave" of historically large tax increases taking effect next year.

Lie #3 – “Obamacare provides for armed IRS agents to enforce penalties.” This is a fantasy. Tea-Party lawmakers are claiming the law might require “as many as 16,500” new jobs in the IRS, a figure inflated by dubious assumptions. But the agency’s role will be mainly to hand out tax credits, not to enforce penalties. And the IRS won’t be sending armed agents to enforce the health care mandate, as falsely claimed by Texas Tea-Party Congresscritter Ron Paul. The law specifically waives any criminal penalties for those who both decline to obtain insurance coverage and refuse to pay the tax enacted to penalize lack of coverage.

Lie #4 – “Failure to purchase insurance will result in ‘jail time” for offenders.”  This is another bold-faced lie perpetuated over and over again by the laws’ opponents, and especially prevalent among Fox News commentators and guests. The Facts:  The law has a specific provision: "In the case of any failure by a taxpayer to timely pay any penalty imposed by this section, such taxpayer shall not be subject to any criminal prosecution or penalty with respect to such failure," which prohibits criminal prosecutions (and any possible “jail time.”  Fox News reluctantly and belatedly admitted this truth. But Fox News’ Bill O’Reilly, trying to defend himself and his network from this allegation, went so far as to suggest that “no one on Fox News had ever suggested that there would be jail time.” That statement was debunked by numerous news agencies citing more than 40 instances when Fox News commentators and guests lied about jail time, with at least 3 of these coming from Bill O’Reilly himself. See, for example:

Lie #5 – “The law set up a "private army" for Obama.” The facts: The liars who make this statement refer to a provision in the new law that establishes a Ready Reserve Corps of doctors and other health care workers who can be called upon in the case of a public health emergency. E-mails that call them "Hitler youth" and speculate that they may be administering "lethal injections" are thoroughly false and malicious.

Lie #6 -- “A government committee will decide what treatments you will receive."  The facts: The liars who make this statement refer to a provision in the new law that establishes a "private-public advisory committee" that will "recommend" what minimum benefits would have to be included in the basic insurance package that would meet the program’s “mandate” for coverage. There is nothing in the law that limits an individual from coverage of more extensive benefits nor is there a government panel which will review each individual’s treatments.

Lie #7 -- "Non-US citizens, illegal or not, will be provided with free healthcare services."   The facts: The liars who make this statement refer to a provision in the new law that prohibits discrimination in health care based on "personal characteristics." Another provision explicitly forbids "federal payment for undocumented aliens" and further prohibits undocumented individuals from even using their own money to pay for coverage through the insurance exchanges that will be created by the new law.

Lie #8 -- “Muslim Americans are exempt from the mandate to have health insurance.”  The law does say that some religious groups may be considered exempt from the requirement to have health insurance, and it uses the definition from 26 U.S. Code section 1402(g)(1), which defines the religious groups considered exempt from Social Security payroll taxes. Eligible sects must forbid any payout in the event of death, disability, old age or retirement, including Social Security and Medicare. They must also be approved by the Commissioner for Social Security. The law was originally designed to apply to the Old Order Amish, and we have yet to find any cases in which members of other religious groups were successfully able to claim exemption.  The Muslim faith does not forbid purchasing health insurance, and no Muslim group has ever been considered exempt under the definitions used in the health care law.

Lie #9 – “Under the new health care law, the elderly will be denied care when they have passed the age limit for treatment.”  The liars who make this statement are unable to cite any provision, any reference, or any speech, comment or off-the-record remark from any of the bill’s sponsors or supporters that justifies this conclusion.  Where can we start, there is absolutely nothing in the new law, not a sentence, not an inference, not a scintilla of evidence that “age” would be a standard for care or could become a standard of care. Some lies are more bold-faced than others. This is one of them.

Lie #10 – “A section about ‘Community-based Home Medical Services’ is actually a payoff to ACORN for its support of Obama."  The liars making this statement interpret any reference to the word "community" to be some kind of payoff for ACORN, a “community-organizing” group long vilified by President Obama’s opponents. ACORN does not provide medical  services, home or otherwise, and there is no connection, tangentially or otherwise.  In truth, “community-based home medical services” and the development of “community-based health centers” have been old pre-Tea Party takeover Republican proposals as an alternative to the more direct government provision of care. Three times in the eight years of President George W. Bush State of the Union speeches, Bush called for Congressional action on expanding “community-based health centers.” This just another good old pre-Tea Party takeover Republican idea, incorporated into the new law in an attempt to gain bipartisan-support, that has been turned on its head and is now evidence of Obama’s socialism.

Lie #11 – “Every person will be issued a National ID Healthcard.” The liars who make this claim refer to a provision that government standards for electronic medical transactions "may include utilization of a machine-readable health plan beneficiary identification card,” to show eligibility for services. Insurance companies typically issue such cards already, but if such a standard were issued the cards would need to be in a standard form readable by computers. The word “may” is used to permit such a standard, but it does not require one. There is no mention of any “National ID Healthcard” anywhere in the bill.

Lie #12 -- "The Obama Health and Human Services Department is planning to compile a federal health record on all U.S. citizens by 2014," including "each individual’s Body Mass Index." The Facts: The liars who make this claim refer to a provision in the new law that directs the establishment of an “electronic health record” (EHR) by 2014. Other liars about the bill have cited this same provision for all sorts of potentially malevolent and nefarious actions by government.  Let’s set the record straight: the broader use of electronic “health information technology” (HIT) has been a goal of both the private health care industry, which formed a trade group the “Association for Electronic Health Care Transactions” (AFEHCT) in 1993 and the government, which established the quasi-government-private sector “Workgroup on Electronic Data Interchange” (WEDi) in 1991. This was the original brainchild of Missouri pre-Tea Party takeover Republican Senator Christopher Bond in 1989 and was a major part of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Some estimates say that better use of HIT could result in savings of up to 30% of the health care dollar. Computerizing medical records has long been a goal of policymakers across the ideological spectrum. The idea is to shift from paper-based records to electronic ones, so that doctors can access information about patients more quickly and easily and make better clinical decisions as a result. Supporters hope that electronic medical records will reduce the frequency of medical errors, unnecessary diagnostic tests and inappropriate treatments. They also hope that, in the long term, streamlining record-keeping could bring down the rapidly escalating cost of health care.  As noted, the effort did not begin with President Barack Obama.  At the earliest President George H.W. Bush called for more work in this area in 1991. In 2004, his son, President George W. Bush issued an executive order creating incentives for the adoption of information technology by 2014, to be spearheaded by a new federal official, the national coordinator for Health Information Technology. Under Obama, Congress passed his economic stimulus package in February 2009. The stimulus included several items designed to promote health information technology, including $19 billion over four years to fund electronic infrastructure improvements and the widespread adoption of electronic health records by providers, typically through higher Medicare and Medicaid reimbursements for doctors who use electronic medical records effectively. The Office of the National Coordinator for Health Information Technology describes the Nationwide Health Information Network as a "network of networks." Please note this is not a single database residing at, say, a federal agency. It's more accurately viewed as a network to link many separate databases where records already exist, such as regional databases or medical offices, along with efforts to establish common technical standards so that these far-flung repositories of data can exchange information as needed. So will an intrusive government will have access to your private medical information? The short answer is: No. This is just another great old pre-Tea Party takeover Republican idea that has gone bad because it was embraced by Democrats and President Obama. Just say NO to anything President Obama says.

Lie #13 -- The federal government will have direct, real-time access to all individual bank accounts for electronic funds transfer.” The Facts: The liars who make this claim refer to a provision that aims to simplify electronic payments for health services, the same sort of electronic payments that already are common for such things as utility bills or mortgage payments. The bill calls for the secretary of Health and Human Services to set standards for electronic administrative transactions that would "enable electronic funds transfers, in order to allow automated reconciliation with the related health care payment and remittance advice." There is no mention of "individual bank accounts" nor of any new government authority over them. Also, the section does not say that electronic payments from consumers is required. Also, this section of the law simply expands on the 1996 Health Insurance Portability and Accountability Act (HIPAA) which was originally proposed by President George H.W. Bush in 1991 and which was passed by a GOP-controlled Congress in 1996 and expanded by Republicans in 2004 and 2006.  Just another good old pre-Tea Party takeover Republican-idea gone bad simply because Democrats also support it. The Republican/Tea-Party “NO-machine” gone amok.

Lie #14 –Taxpayers will subsidize all union retiree and community organizer health plans (read: SEIU, UAW and ACORN).” The liars who make this claim refer to a provision that would set up a new federal reinsurance plan to benefit retirees and spouses covered by any employer plan, not just those run by labor unions or nonprofit groups. Specifically, it covers “retirees and . . . spouses, surviving spouses and dependents of such retirees” who are covered by “employment-based plans” that provide health benefits. It’s open to any “group health benefits plan that . . . is maintained by one or more employers, former employers or employee associations,” as well as voluntary employees’ beneficiary associations . Furthermore, the aim of the fund is to cut premiums, co-pays and deductibles for the retirees. Payment “shall not be used to reduce the costs of an employer.” Since this provision went into effect, thousands of corporations, including some of the nation’s largest employers, have applied for coverage.

Lie #15 – “All private healthcare plans must conform to government rules to participate in a Healthcare Exchange.”  The liars who make this claim are trying to draw negative inferences from a provision in the new law setting up new state and regional  Health Insurance Exchanges through which individuals and employers may choose from a variety of private insurance plans, much like the system that now covers millions of federal workers. Any private insurance plans offered through this exchange must meet new federal standards. For example, such plans can’t deny coverage for preexisting medical conditions.

Lie #16 – “All private healthcare plans must participate in the Health care Exchange (i.e., total government control of private plans.)”   This is yet another “good” old pre-Tea Party takeover Republican idea gone bad because Democrats “stole” it.  Health Exchanges have long  been operational in two US states, Utah and Massachusetts. Under the Utah Health Exchange, operational for over 10 years and established by a Republican-controlled legislature and endorsed by Republican governors and local business owners, most Utahans get their health coverage through the Exchange which assures basic standards and operational mandates. In Massachusetts, the state’s “Connector” was and is an integral part of the “Romneycare” plan mandating coverage for every state resident.  Under the Obama version, no insurance company is required to sell plans through an exchange if it doesn’t want to. Any employer may choose to buy coverage elsewhere. In fact, the vast majority of employers will still be buying private plans through the normal marketplace, because only employers with 100 or fewer employees are even allowed to buy through an exchange in the first year. It won’t be until 2017, that the exchanges will be open to all employers.

Lie #17 – “Members of Congress have exempted themselves from coverage under the law.” Au contraire, Contrary to all rumors suggesting that members of Congress are NOT covered by the new law, the law specifically requires that members of Congress MUST buy their coverage through an Exchange.  Quote: "The only health plans that the Federal Government may make available to Members of Congress and congressional staff with respect to their service as a Member of Congress or congressional staff shall be health plans that are — (I) created under this Act (or an amendment made by this Act); or (II) offered through an Exchange established under this Act (or an amendment made by this Act)."

Lie #18 – “The new law cover Viagra for convicted sex offenders.” The facts: There’s no change from current law. Convicts who are not in prison can purchase whatever health plan they’d like and some plans could cover erectile-dysfunction drugs. The Congressional Research Service said that there was nothing in the new law that would "require health plans to limit the type of benefits that can be offered based on the plan beneficiary’s prior criminal convictions." This mini-controversy erupted when Republicans introduced a string of amendments in a final effort to obstruct passage of the reconciliation bill. Republican Sen. Coburn of Oklahoma proposed the amendment to bar sex offenders from getting health plans that covered such drugs with federal money through the state-based exchanges. Democratic Sen. Max Baucus of Montana called the amendment "a crass political stunt." And it failed by a 57-42 vote.

AND THE BIGGEST, BADDEST LIE ABOUT PPACA OF ALL: “It will “kill granny” (and impose health care rationing) -- Trust me on this, I’m a lawyer… just like his Democratic predecessor in the presidency, Bill Clinton, who was somewhat successful at reaching across the aisle, President Barack Obama has not hesitated to “steal” a good old pre-Tea Party Republican ideal and turn it to good (political) use. Republicans (without a single Democratic vote) passed the “Medicare Modernization Act of 2003.” Buried in that 717-page law were provisions for CM2 to begin the process of determining the “comparative effectiveness” of various health care services. The current health care plans simply build on that initial step… but oops, that’s where Sarah Palin’s “death panels” and “killing granny” became an issue.

The GOP-passed 2003 Medicare Modernization Act (better known for establishing the Part D drug program) had lots of buried secrets, not the least of which was new funding for AHRQ and a plan to begin several demonstration projects with a goal of better identifying:

         “the appropriate use of best practice guidelines by providers and services by beneficiaries”

         The “reduced scientific uncertainty” in the delivery of care through the examination of variations in the utilization and *allocation of services, and outcomes measurement and research

         achieving the *efficient allocation of resources

         “the financial effects on the health care marketplace of altering the incentives for care delivery and changing the *allocation of resources”

(* Trust me on this, I’m a lawyer, “allocation of resources” = “rationing”)

The little agency that could. Buried in the backwater reaches of the U.S. Public Health Service is the Agency for Healthcare Research and Quality (AHRQ), charged with developing the future “cookbook of health care.”

CM2 has already embarked on an effort to define many of the elements of effective health care, that is what works and what doesn’t, using much of the work product of AHRQ.

“In the future, we will only pay for what works and not for what doesn’t work.”

President George W. Bush, September 17, 2006



back to top


The budgetary impact of the new health care reform law over 10 years and beyond.

Considerable debate has focused on the ACTUAL effects the recently enacted health reform legislation (PPACA) would have on the federal budget. TeaParty/Republicans, led by their new majority leader, Eric Cantor, have been particularly vocal in reinforcing their demand that the new law be repealed IN ITS ENTIRETY. Democrats have countered citing the reports from both the nonpartisan Congressional Budget Office (CBO) and the bipartisan Joint Committee on Taxation (JCT).

Let's begin by reviewing the budget estimates done by CBO and the staff of the Joint Committee on Taxation (JCT):

In combination, the initial legislation and the subsequent reconciliation act that modified it will generate changes in direct spending and revenue that will reduce federal deficits by $143 billion during the 2010-2019 period.

The legislation will change the size of the federal budget by increasing outlays by $411 billion and revenues by $525 billion over the next 10 years (excluding the provisions of the reconciliation act related to education, which will reduce spending by about $19 billion over that period). The legislation will increase the federal budgetary commitment to health care (the sum of net federal outlays for health programs and tax preferences for health care) by $390 billion over the next 10 years. The legislation will reduce federal deficits during the decade beyond the 10-year budget window relative to those projected under current law—with a total effect in a broad range around one-half percent of GDP.

But are these assumptions valid? Eric Cantor of the TeaParty/GOP says: "About the budget implications, I think most people understand that the CBO did the job it was asked to do by the then-Democrat majority, and it was really comparing apples to oranges. It talked about 10 years' worth of tax hikes and six years' worth of benefits. Everyone knows beyond the 10-year window, this bill has the potential to bankrupt this federal government as well as the states." We can conclude then, if Congresscritter Cantor is correct, that the CBO is not the non-partisan body we have been led to believe and is simply another partisan hack group, which we should be free to ignore any time its conclusions threaten our pre-conceived notions.

Aw shucks, before we go that far, let's look at some of Mr. Cantor's objections:

He has asserted that CBO and JCT have misestimated ("misunderestimated?)  the effects of the changes in law, particularly underestimating the costs of the program subsidies to low and middle income families.

But, if you look at the tables and the statistics relied upon by the CBO and JCT, you can see that they have chosen some fairly expansive numbers, reflecting the middle of the distribution of possible outcomes based on some pretty careful analysis and using clearly professional judgment, drawing upon relevant research by other experts. Of course, their estimates are just that, "estimates," and  the effects of comprehensive health care reforms at this early stage are clearly very uncertain. Actual outcomes will surely differ from the CBO and JCT estimates in one direction or another, but to insist that the TeaParty/GOP estimates are the only ones that are correct and that the other side's are a crock of you know what, is disingenuous at best. (For the record, we should note that Democrats have criticized the CBO estimates as being "too low" and "not fairly estimating the larger impact the new law will have on budgetary savings). Looking at the CBO and JCT estimates seems the safest middle ground.

Cantor and the TeaParty/GOP have also asserted that the CBO and JCT budget estimates hide or misrepresent certain effects of the law, such as its impact on future discretionary spending, its effect on the government’s ability to pay Medicare benefits, and its effects on the economy, suggesting that these impact will be far greater that suggested.

The CBO and JCT estimates focus on direct spending and revenues because those are the figures that are relevant to the "pay-as-you-go rules" that govern House spending legislation. PAYGO is the acronym for House budget rules first adopted during the Newt Gingrich/GOP years (post 1994) which were essentially abandoned during the George W. Bush "borrow and spend" years and restored in 2006 when the Democrats regained control of the House by a narrow 6-vote margin.  PAYGO rules require that any new spending be offset either by new taxes or by cuts in spending elsewhere. To go around PAYGO, the House would have had to pass additional legislation excepting the spending. In the case of PPACA, the new taxes and spending offsets were considered neutral and thus additional legislation was not required. The additional spending suggested by Cantor and the TeaParty/GOP, that the costs of implementing the new law, and the costs of maintain physician reimbursement at non-BBA levels, should have invoked PAYGO and thus demand repeal of the law, fall flat.  (1) Administrative costs have never been considered under PAYGO and were routinely exempted during years of Republican control of the House, and (2) the costs of maintaining physician Medicare reimbursement at higher than the rates under the 1997 Balanced Budget Act, are NOT the costs of PPACA. They are costs of a separate piece of legislation and, if a problem for the TeaParty/GOP, they need to be addressed separately. As the CBO said, those effects will occur without any additional legislative action and regardless of PPACA.

o    Additionally, the legislation will improve the cash flow in the Hospital Insurance trust fund (that is, Part A of Medicare) by more than $400 billion over 10 years. Higher balances in the fund will give the government the legal authority to pay Medicare benefits longer.

Cantor and his TeaParty/GOP cohorts argue that CBO and JCT 10-year estimates of total federal budget reduction are flat out wrong and have asserted that the law will be changed in the future in ways that will make deficits worse.

In fact, CBO’s cost estimate noted that the legislation maintains and puts into effect a number of policies that might be difficult to sustain over a long period of time. For example, the legislation reduces the growth rate of Medicare spending (per beneficiary, adjusting for overall inflation) from about 4 percent per year for the past two decades to about 2 percent per year for the next two decades. It is unclear whether such a reduction can be achieved, and, if so, whether it would be through greater efficiencies in the delivery of health care or through reductions in access to care or the quality of care. The legislation also indexes exchange subsidies at a lower rate after 2018, and it establishes a tax on insurance plans with relatively high premiums in 2018 and (beginning in 2020) indexes the tax thresholds to general inflation.

[As another historical note, one need only look at the passage of Medicare in 1965. Lyndon Johnson gave away the farm in order to get that law passed in the first place. Cost-plus reimbursement to hospitals, "usual and customary" payments to physicians and other providers. Opponents then made many of the same arguments they are making today; "costs estimates were too low, it would bankrupt the country, benefits are not being paid for, we can't afford it."  Face facts, the 2010 version of PPACA will not be the 2010 version just as the 1965 version of Medicare was not the 1975 version (P.L. 92-603 was passed in 1972 changing much of the law), or the 1985 version (DRGs had replaced cost+ and RB-RVS replaced usual and customary), or the 2011 version. Amendments will be enacted, circumstances will demand changes, our laws are living instruments that adapt, modify and reflect as the nation changes.]

That's all well and good -- but it's not true. Take Cantor's TeaParty/GOP core point: The health-care reform bill includes "10 years' worth of tax hikes and six years' worth of benefits." There's nothing philosophical about this statement. It can be checked with a simple look at the spending tables the Congressional Budget Office published in their analysis of the bill. And when you look at those tables, Cantor's statement falls apart:

Roughly speaking, new spending is what counts as "benefits." Those are the lines shooting up. New taxes are the lighter blue part of bars pointing down. In years one, two, and three, new benefits are larger than or matched with new taxes. In year four, that's not true, but the difference is fairly small. And in the six years after that, even Cantor admits the benefits match or overwhelm the taxes.

Comparing 10 years of saving and working with six years of spending is not comparing apples to oranges. Parents will routinely work harder (revenue increases) and save more (spending cuts) for decades in order to help their children pay for college. That's 18 years of raising revenues and cutting costs in return for four years of spending on benefits. An accountant wouldn't look at that and say he couldn't assess the wisdom of the decision because it's apples-to-oranges. An accountant would happily note that that's how you pay for things when you're being responsible. Cantor's party might be out of practice on that, given the way they paid -- or, to be more specific, didn't pay -- for the Medicare Prescription Drug Benefit, but it doesn't make it any less true.

As for the period "beyond the 10-year window," the Congressional Budget Office -- which is now comparing "apples to apples," as the law is delivering full benefits for all 10 of the next 10 years -- says the law saves vastly more money in its second decade: "The legislation will reduce federal deficits during the decade beyond the 10-year budget window relative to those projected under current law—with a total effect in a broad range around one-half percent of GDP." That's in the neighborhood of a trillion dollars.

What's important about Cantor's argument is not that he's wrong. It's why he's saying something he knows to be wrong. There are plenty of reasons to oppose the health-care reform bill. You might not want to spend that money insuring people, or you might not think the legislation goes far enough in reforming the system. But as a matter of arithmetic, using the math that Congress always uses, the bill saves money. It cuts enough spending and raises enough taxes to more than pay for itself, both in the first 10 years and in the second 10 years. In fact, Democrats added that second metric, which is not typically a hoop that legislation has to jump through, in order to specifically allay concerns that the legislation would backload its costs. Instead, as CBO said, it ramps up its savings.

But Cantor and the TeaParty/GOP know full well that the bill is unpopular largely because people think it increases the deficit. Polls have shown that only 15 percent of Americans know that CBO said it will reduce the deficit. If, in the repeal fight, it becomes widely understood that the bill reduces the deficit, it will become more popular. So it's crucial, as the repeal effort goes forward, for TeaParty/Republicans to become much more brazen in falsely asserting that the bill doesn't really reduce the deficit, and that even if the CBO does say it reduces the deficit, that they're saying that because they've been tricked somehow. But CBO wasn't tricked. If it were, Cantor, who has a staff dedicated to figuring these things out, would have a better argument than the one he's offering.


Everything You Ever Wanted to Know About the PPACA Independent Payment Advisory Board But Were Afraid to Ask

The Patient Protection and Affordable Care Act established a 15-member IPAB to extend Medicare solvency and reduce spending growth through the use of a spending target system and fast-track legislative approval process.

By April 30 of each year—beginning in 2013—the Centers for Medicare & Medicaid Services (CMS) Actuary's Office will project whether Medicare's per-capita spending growth rate in the following two years will exceed a targeted rate. Initially, the targeted rate of spending growth will be based on the projected five-year average percentage increase in the Consumer Price Index for all urban consumers and the Consumer Price Index for all urban consumers for medical care.

Beginning in 2019, the target will be set at the nominal gross domestic product per capita + 1.0 percent. If future Medicare spending is expected to exceed the targets, the IPAB will propose recommendations to Congress and the president to reduce the growth rate. The IPAB's first set of recommendations would be proposed on Jan. 15, 2014.

Spending rate reductions will be established at:

0.5 percent in 2015

1.0 percent in 2016

1.25 percent in 2017

1.5 percent in 2018 and beyond

If Congress fails to pass legislation by Aug. 15 each year to achieve the required savings through other policy changes, the IPAB's recommendations will automatically take effect. The IPAB is prohibited from submitting proposals that would ration care, increase revenues, change benefits, modify eligibility, increase Medicare beneficiary cost-sharing (including Parts A and B premiums), or change the beneficiary premium percentage or low-income subsidies under Part D. Hospitals and hospice will not be subject to cost reductions proposed by the IPAB from 2015 through 2019. Clinical labs would be exempt for one year.

Beginning July 1, 2014, the IPAB must also submit an annual report providing information on system-wide health care costs, patient access to care, utilization and quality of care that allows comparison by region, types of services, types of providers, and payers—both private insurers and Medicare. By Jan. 1, 2015, and at least every other year thereafter, the IPAB will submit recommendations to slow the growth in national health care expenditures while preserving or enhancing quality of care. These recommendations could be those that: (1) the secretary of Health and Human Services (HHS) and other federal agencies could implement administratively; (2) may require federal legislation to be implemented; (3) may require state or local government legislation to be implemented; or (4) private entities can voluntarily implement.

Fast-track Legislative Process

By Jan. 15 of each year, beginning in 2014, the IPAB must submit a proposal to Congress and the president for achieving Medicare savings targets in the following year.

If the IPAB fails to submit a proposal to Congress and the president by Jan. 15, the HHS secretary must submit a proposal for meeting the savings targets to the president and the Medicare Payment Advisory Commission (MedPAC) by Jan. 25 of that same year. The president must submit the secretary's proposal to Congress within two days.

The House and Senate Majority Leader or their designee must introduce the IPAB proposal the same day it is received (or on the first day the chamber is in session). If the proposal is not introduced within five days, any senator or representative can introduce it.

The proposal must be referred to the Senate Finance Committee and the House Ways and Means and House Energy and Commerce Committees.

By April 1, the committees of jurisdiction are to complete their consideration of the proposal. Any committee that fails to meet that deadline will be discharged from further consideration.

Congress cannot consider any bill or amendment that does not meet the IPAB targets or that would repeal or change the fast-track congressional consideration process without a three-fifths vote (60) in the Senate. Non-germane amendments are not permitted.

The HHS secretary must implement the IPAB proposal on Aug. 15 of the year in which the proposal is submitted. Recommendations regarding the physician fee schedule would take effect on Jan. 1 the following year. If Congress does not pass the proposal before Aug. 15, or if the president vetoes the proposal as passed by Congress, the original IPAB recommendations would take effect. (All policy changes affecting physicians that are not part of the physician fee schedule will be addressed in the regulatory process and will take effect as soon as practicable.)

IPAB Board Members

The IPAB members are to include:

Fifteen members appointed by the president, by and with the advice and consent of the Senate; in selecting individuals for nominations for appointments to the board, the president shall consult with: (i) the majority leader of the Senate concerning the appointment of three members; (ii) the speaker of the House of Representatives concerning the appointment of three members; (iii) the minority leader of the Senate concerning the appointment of three members; and (iv) the minority leader of the House of Representatives concerning the appointment of three members

The HHS secretary, the administrator of CMS, and the administrator of the Health Resources and Services Administration (all of whom will serve ex officio as nonvoting members of the Board)

Qualifications/requirements for IPAB members:

Appointed members of the IPAB will include individuals with national recognition for their expertise in health finance and economics, actuarial science, health facility management, health plans and integrated delivery systems, health facilities reimbursement, allopathic and osteopathic physicians, other providers of health services, and other related fields who provide a mix of professionals, broad geographic representation, and balance between urban and rural areas.

IPAB members must include (but not be limited to) physicians and other health professionals, experts in the area of pharmaco-economics or prescription drug benefit programs, employers, third-party payers, individuals skilled in the conduct and interpretation of biomedical, health services, and health economics research, and expertise in outcomes and effectiveness research and technology assessment. Members must also include individuals representing consumers and the elderly.

Individuals who are directly involved in providing or managing the delivery of Medicare items and services may not constitute a majority of IPAB's membership.

The president must establish a system for public disclosure by IPAB members of any financial and other potential conflicts of interest.

No IPAB member may be engaged in any other business, vocation or employment


back to top

Let's Just Allow the Buying of Health Insurance Across State Lines, That's the Ticket, Cheaper Insurance... NOT! Another Failed TeaParty/GOP Idea

Recent TeaParty/GOP proposals about buying health insurance across state lines have sent many of us scrambling to check policies, and wondering whether such changes might mean it’s time to find a new insurer. After all, wouldn’t such a change open up the market and make it possible to get cheaper coverage?

Unfortunately, it’s by no means certain that such a change would be largely beneficial. In fact, it’s actually possible that the end result might be more expensive insurance overall, and that over time, more Americans would find health insurance too expensive.

So what does selling coverage across state lines actually mean? Simply that an insurer could sell their product to any person in any state. Theoretically, this would mean consumers have a much greater range of insurers from which to choose, meaning increased competition and lower premium costs. However, there are some wider implications.

The fact is, such a change may end up benefiting only those who are young, fit, and healthy – people who are low-risk in the eyes of insurers, and who can have their pick of policies. Anyone who is moderate or high risk will eventually find that getting affordable insurance, or perhaps even any insurance at all, becomes much harder.

This may seem counter-intuitive. After all, surely opening up the market will mean everyone has a better shot at getting affordable insurance. The problem is, however, to an insurance company risk is still risk. The perceived risk of an individual who is fifty years old, overweight, and a smoker won’t decrease just because that individual can buy insurance anywhere in the country.

And if an insurance company can offer cheap premiums to entice low-risk people from all over the country, they’re that much less likely to continue offering any type of insurance to higher-risk individuals.

What this means is, it’s more likely that insurers will be encouraged to underwrite more and more aggressively, with cheaper premiums for those who qualify as low-risk. But those cheaper policies will provide increasingly skimpy coverage, meaning that people who prefer more comprehensive policies – as well as high-risk individuals – will find fewer companies are willing to offer the insurance they need.

Does this mean across-state-lines insurance can’t work? Not necessarily, but more thought is needed to produce a workable solution. Federal regulation of insurance companies might be a good start – and in fact, if insurance companies are allowed to sell across state lines, this might seem to be the most appropriate and logical solution.

Insurance Across State Lines: Sounds Good... on Paper ... But Consider the Real Impact ... And Besides it Does NOTHING to Solve Insurance Affordability and at Best Might Get Another 4 Million Insured... A Drop in the Bucket

The Kaiser Family Foundation has issued a “white paper” (reproduced below) on the issue of buying health insurance across state lines, a key element in the new GOP “Pledge To America,” the Republican plan to unravel much of the Obama administrations policies, especially the new Patient Protection and Affordable Care Act (”PPACA”). I have interposed a few “just between you and me” comments on the Kaiser white paper.

According to Kaiser: “When Republican House leaders recently unveiled their 'Pledge To America,' they revived an idea long popular with conservatives: legislation that would allow consumers to buy health insurance across state lines so that residents of a state with expensive health plans could find cheaper options elsewhere.  …”

Just between you and me…cool idea if it weren’t for all the fraud artists and fly-by-night operators out there who are already preying on the uninsured, people with pre-existing conditions and more critically the UNDERINSURED. Weak state insurance laws and enforcement would open a floodgate for abuse. More on this later…

Advocates of the Republican proposal -- including some insurers and small business groups -- say it would give the more than 17 million Americans who buy individual coverage a greater choice of plans and the possibility of lower prices.  When they were writing the new health law, Democrats said they heard the GOP and they included a way to sell insurance across state boundaries. They put in language allowing states to establish "health care choice compacts." But Republicans say that the compacts won't bring the same benefits.  …”

Just between you and me…They don’t explain why or how this would happen, they simply assert the allegation unsupported…

“Consumer advocacy groups are part of the political back-and-forth, arguing that such provisions would erode many state protections, leave policyholders with inadequate coverage and could actually lead to higher premiums for some people.

With the issue back in the news, here’s a short primer:

What currently restricts insurers from selling policies outside of their home states?

Insurers are allowed to sell policies only in states where they are licensed to do business. Most insurers obtain licenses in multiple states. States have different laws regulating benefits, consumer protections and financial and solvency requirements. Even before the federal health law was passed, states could have opted to set up compacts for health insurance. But they did not.

What do advocates say are the main advantages of the Republican plan to allow insurers to sell across state lines?

The individual health insurance market is dominated in many states by just a handful of companies, so this provision would allow consumers to shop broadly for cheaper policies, supporters say.

"You shouldn't limit people to products in the states they live in or make them move to get the insurance they want," Tom Miller, a resident fellow at the American Enterprise Institute said.

J.P. Wieske, the executive director of the Council for Affordable Insurance, which represents companies selling individual health insurance, said replacing the compacts with a GOP proposal would simplify operations for insurers. In addition, it will improve conditions "in a number of states that have ruined their market" by rigidly regulating policies. That has left consumers with higher rates and less competition, he said.

Just between you and me… Oops, there they go again. Regulation is always bad, and everyone knows that de-regulation has worked so well to save money for everyone… NOT! Tell that to Americans paying off the costs of de-regulating the nation’s banking and financial industries. Under the Pledge to America, the GOP apparently wants to do the same for the health insurance industry that it did for banking and finance.

“The Republican plan is hoping ‘to help turn those states into more competitive marketplaces,’ he added. ‘They haven't been able to do it on their own.’

Why is there skepticism about the Republican concept?

"It's not the concept that is the problem. Quite the contrary, it's a fine idea," said Ron Pollack, founding executive director of Families USA, a consumer health care advocacy group. But he expressed concern about efforts to de-regulate the market. "The real underlying issue is that Republicans and others who created this do not want to create adequate standards for the sale of health care." That would result in policies that "perpetuate the practices that have harmed consumers," he said.

If insurers can sell beyond state lines, the concern is that consumers would be attracted to the least comprehensive policies because they would be cheapest - some call it "a race to the bottom." For example, someone could buy a policy in a state that doesn't mandate coverage of diabetic supplies and then the consumer could be stuck with higher bills.

In addition, insurers selling across state lines might market policies to younger, healthier individuals. That could leave the insurance pool with older and sicker individuals, who would face ever-rising rates -- or face being turned down -- because their insurers would have fewer healthy people to spread risk.

That would "undermine insurance regulation in states doing serious regulation," said Linda Blumberg, a senior fellow at the Urban Institute's Health Policy Center.  "It would be destructive to those state efforts."

There are also fears that consumers dealing with out-of-state companies would have difficulties resolving disputes. And, since health costs vary geographically, insurance purchased in one state might not cover as much of the cost of care in a more expensive state.

The federal health law backers say that it allows the advantages of cross-border sales while still protecting consumers. "I think we're going to see a whole lot more choice available for consumers under the new law," said Pollack.

How would the new "state compacts" work?

The new health law allows states to form insurance compacts but does not require that they do. States joining a compact, however, would be required to pass legislation authorizing that decision. States could begin the process starting Jan. 1, 2016.

Many of the details for the compacts will depend on federal regulations that have not been written yet, but plans in the compact must meet the new federal minimum requirements set in the health law and would be governed by the laws of the state in which the policies are "issued or written."

Setting up a compact would be complex since states would likely have to settle a number of questions about regulation and consumer safeguards, said Blumberg. Because of those types of bureaucratic issues and because many of the concerns about getting adequate health coverage are alleviated by the new federal law, she said, "I don't think much of this is going to happen."

The law also requires that the Office of Personnel Management, which oversees health benefits for federal employees, contract with insurers to offer at least two multi-state plans. They would be offered through the health insurance "exchanges" - marketplaces being set up in 2014 to provide individual and small market coverage. The multi-state plans would be priced locally. According to the law, these plans would have to meet the same requirements as other plans in the exchanges. States could add more benefits to the plans, although the states would have to bear the costs.

Why are Republicans critical of how Democrats handled the issue?

Conservatives say that the high minimum standard to which all plans must adhere in the health law works against consumer choice and that the GOP's market-based system would allow growth of innovative plans that meet consumers' needs.

The Republican proposal "is a serious, honest concept that is worth doing, if you don't promise the moon," said AEI’s Miller. He acknowledged that any such effort would need a framework to ensure consumer protections, solvency standards and accountability but he believes those measures would not be as restrictive as the provisions now in the federal health law.

He says that other industries that were once strictly state-based, such as banking, have worked well with interstate competition. "It doesn't mean you're not regulated," he said. "You'll have better competition," and still have safeguards.


 ...  "Everyone" knows that Obama's health care plan will end up rationing health care in American, right? ... NOT!

The "rationing" argument is perhaps the most insidious lie being spread about PPACA. PPACA has simply built on a really good, original Republican idea ... "comparative effectiveness" ... the only problem is that now that Obama and the Democrats have embraced it, the idea had to be defeated. A good idea gone bad... for one reason and one reason only ... politics! ...

The GOP-passed 2003 Medicare Modernization Act (better known for establishing the Part D drug program... and passed by a GOP-controlled Congress without a single Democratic vote, in the dead of night, using an esoteric parliamentary procedure known as "reconciliation" and signed by a Republican president) had lots of buried secrets, not the least of which was new funding for a little government agency known as the Agency for Health Review and Quality (AHRQ) and a plan to begin several demonstration projects with a goal of better identifying…

... the appropriate use of “best practice guidelines by providers and services by beneficiaries”

The “reduced scientific uncertainty” in the delivery of care through the examination of variations in the utilization and *allocation of services, and outcomes measurement and research”

achieving the “*efficient allocation of resources”

“the financial effects on the health care marketplace of altering the incentives for care delivery and changing the *allocation of resources”

Trust me on this, I am a lawyer... "allocation of resources” (efficiently or otherwise) is just a neat little legalistic comfort word for "rationing" ... in the future said George W. Bush, "we will only pay for what works not for what doesn't." 

That's right, I said GEORGE W. BUSH!

"In the future, we will only pay for what works and not for what doesn’t work.”

President George W. Bush, September 17, 2006

HIPAA facilitates the collection of data and thus the ability of planners and payers to ration health care intelligently.

Future of US Health Care: “Rationing” … by any other name

AHRQ: The little agency that could: Buried in the backwater reaches of the U.S. Public Health Service is the Agency for Healthcare Research and Quality (AHRQ),  charged with developing the future “cookbook of health care.”

CM2 has already embarked on an effort to define many of the elements of effective health care, that is what works and what doesn’t, using much of the work product of AHRQ.

Worthless Lives Under the British NHS

“People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.”

Investors Business Daily, August 11, 2009

Apparently, Investor’s Business Daily doesn’t have access to the Internets... A quick stop at Wikipedia would have told them that Hawking is British, lives in Britain, and has lived to the age of 67 there, and was diagnosed with ALS under, and treated by the National Health Service for his entire adult life. They must have just been fooled by his voice synthesizer's American accent.

"I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived."

Stephen Hawking, at a press conference after being awarded the USA’s highest civilian award, the Presidential medal of Freedom, August 12, 2009.

How Efficient Allocation of Resources (i.e., “Rationing”) Would Actually Work

Collect all-population, all-patient, all-payer data  (including care processes, clinical outcomes, patient experiences, and costs while enabling benchmarking and monitoring of changes)

Assess health outcomes (e.g., percent diabetes under control; cancer survival rates)

Post web comparison of insurance choices, costs and benefits, experiences; include share of premium for administrative/overhead/profit  (complete national transparency with capacity for state or geographic analysis and benchmarks and designed so states could add, build with more detailed data where available)

And someday… actually start paying only for what works and not for what doesn’t


In the U.K., the National Heath Service (the nationalized health program) has instituted a National Institute for Health and Clinical Excellence (NICE).

NICE has used cost calculations per "quality adjusted life-year (QALY)" saved as an index for what NHS will or will not cover.  Anything that costs more than Ł30,000 British pounds (about $54,000 U.S.) per QALY saved can only be covered after undergoing a further extensive cost-benefit analysis.


The quality-adjusted life year (QALY) is a measure of disease burden, including both the quality and the quantity of life lived. It is used in assessing the value for money in a medical intervention.

The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, e,g., if the patient would lose a limb, or be blind or have to use a wheelchair, then the extra life-years are given a value between 0 and 1.

Among the leading U.S. developers of QALYs in health care decision-making AND PAYMENT approval... private commercial insurance companies.



back to top

Too Many Doctors? Too Few Nurses!

Jeanne's Note: In 1995, I wrote an article for the magazine then called "Computers in Health Care." In it I made one of my famous (infamous???) prescient (but clearly delayed) predictions, saying that 20 years in the future (then 2015) the nation would need only about 450,000 physicians (presently we have about 800,00),  Almost all of these would be highly-trained specialists. Most primary care, routine, preventive, well-baby, normal pregnancy care would be provided by legion of very highly trained and educated "physician extenders." (I still have problems with the terms "physician assistant" but less so with  "nurse practitioner" which by their very nature imply limitations.)  These would be I said well-educated (Masters Degree+), well-trained (1-2 years internships and residencies), well-compensated (my suggestion in 1995 dollars was around $100k/year), professionals. ... And of course, the article resulted in enormous amounts of "hate mail" primarily from physicians.

My vision, given my Michigan and particularly Detroit auto industry childhood growing up background was of "CAD-CAM." CAD-CAM was then the "hot" new things for the auto industry which was "guaranteed" to make the Big 3 auto companies more profitable and more successful in competing with their German and Japanese competitors (the South Koreans weren't yet that big of force). CAD-CAM: "computer assisted design/computer assisted manufacture" was to save the U.S. auto industry. Well we all know how well that worked out <sigh>. My CAD-CAM stood for something different: computer-assisted diagnosis/computer-assisted medicine. My vision: a million or more of these primary care providing professionals, meeting America's primary care needs in inner cities and rural communities, in suburbs and retirement communities using automation and computer tools to assist in providing primary and preventative care.

A new report released on October 5, 2010 may give nurses with advanced degrees a potent weapon in their perennial battle to get the authority to practice without a doctor's oversight.  The Institute of Medicine report says nurses should take on a larger and more independent role in providing health care in America, something many doctors have repeatedly opposed, citing potential safety concerns. It calls for states and the federal government to remove barriers that restrict what care advanced practice nurses ... those with a master's degree ... provide and includes many examples of nurses taking on bigger responsibilities. "A qualified health care professional is a terrible thing to waste," Cheryll Jones, a pediatric nurse practitioner in Ottumwa, Iowa, told the authors. The report calls for elimination of "regulatory and institutional obstacles" including limits on nurses "scope of practice" ... which are state rules about what care people who are not physicians can provide.

The findings come from the Committee on the Robert Wood Johnson Foundation Initiative on the Future of Nursing, a collaboration among nurses, doctors, health care business leaders and academics that studied the issue for two years. While the report addresses a ongoing battle being played across state legislatures, it's not clear if the new report will have any impact on those battles. The panel is planning a meeting next month to discuss ways to implement its recommendations.

The new federal health care law provides more funding for nursing education and nurse-led clinics, but this study could also propel the nurses' argument for more authority to deliver care independently from physicians.

"We cannot get significant improvements in the quality of health care or coverage unless nurses are front and center in the health care system ... in leadership, in education and training, and in the design of the new health care system," said Donna Shalala, a former Health and Human Services secretary and chair of the IOM's committee on the future of nursing. "We can't be fighting with each other if we really are going to have a high quality system that we can afford."

For years advanced practice nurses ... as well as a host of other caregivers such as chiropractors and physical therapists ... have butted heads with doctors over "scope of practice" considerations. Doctors maintain that even with an advanced degree, these nurses do not have the same education that physicians get in medical school and residency programs and that patient safety could be compromised. They are also wary that their practices could see significant patient losses if the nurses were allowed to practice more independently.

In its recommendations, the committee said Medicare and Medicaid should reimburse advanced practice nurses the same as a physician for providing the same care. "When you do the same job you ought to be paid the same," Shalala said.

Also, the report calls for nurses to be allowed to admit patients to the hospital or to a hospice and for the Federal Trade Commission and the Department of Justice to review existing scope of practice provisions for "anticompetitive" practices.

The Obama administration has signaled its commitment to increasing the number of primary care providers, including nurses. Late last month the Department of Health and Human Services announced $320 million in
grants to strengthen the health care workforce. The grants include $31 million to 26 nursing schools to increase full-time enrollment in primary care nurse practitioner and nurse midwife programs and $14.8 million for nurse-managed health clinics. In addition, Peter Buerhaus, a registered nurse, heads the newly formed National Health Care Workforce Commission, which was set up under the new law to advise lawmakers on how to change the health care workforce to better fit America's needs.

Experts predict that more physicians, nurses and other medical professionals will be needed to care for the 32 million additional Americans who will get coverage beginning in 2014 under the sweeping health care law. Nurses' groups say that they can help ease a physician shortage. Last week, the Association of American Medical Colleges said in a
report that in 2015, there will be a shortage of nearly 63,000 doctors across all specialties in America. 

Dr. Rebecca J. Patchin, a former nurse who is now anesthesiologist and member of the American Medical Association’s Board of Trustees, said that physicians must be involved to help protect patients. "We think that care in the operating room or care in the office is best done with physician involvement and oversight," Patchin said. "Due to that additional training that they have … when or if a complication occurs they are better equipped to handle it."

The battle is being waged across the country. Colorado, for instance, recently became the 16th state
to allow nurse anesthetists to work without a doctor's oversight. In Michigan, nurses are pushing for legislators there to allow advanced practice nurses to prescribe drugs. Other fights over scope of practice for registered nurses loom in Kentucky, North Carolina, Iowa and Minnesota.

But, Dr. Alexander Hannenberg, president of the American Society of Anesthesiologists, said the clashes between nurses and doctors scare the public. "It's exactly what people worry about when they worry about what health reform will bring," he said. "Patients and voters say ''f you're talking about taking the docs out of my health care, I want no part of it.'"

Taming the Unicorn: Accounting for Accountable Care Organizations...

From California Healthline:

Spotting a Unicorn: ACOs Inch Closer to Reality

Almost everyone can describe a unicorn -- but has anyone actually seen one?

The mythical beast is an apt analogy for the emerging "accountable care organization" model, according to a cautionary note from Mark Smith, president and CEO of the California HealthCare Foundation. CHCF publishes California Healthline.

Health care providers are rushing to create new structures that could eventually qualify as ACOs, putting them in line for added reimbursements under health reform. But are these actually ACOs? Federal agencies haven't finished defining the model, and regulators have yet to bless these new alliances.

As a result, there's another word that could describe some would-be ACOs: illegal. If providers aren't careful, their new networks may violate current laws restricting provider competition. Essentially, the pace of changes wrought by health reform has outstripped a 14-year-old legal framework.

Providers Likely in Clear for Now, but Face Outstanding Legal Questions

Most providers trying to set up ACOs are probably in the clear, Modern Healthcare notes. Hospitals are generally using existing safe harbors, like direct physician employment and the Federal Trade Commission-sanctioned Clinical Integration model, to craft accountable care alliances.

The government's open intention to encourage creative structures, in hopes of unearthing new cost-cutting strategies, also could absolve progressive organizations from prosecution. Jon Leibowitz, FTC chair, told the American Medical Association in June that if providers "join together to improve patient care and lower costs, not only will we leave you alone, we'll applaud you."

After all, the ACO model was at the heart of the health reform goal of more-coordinated care at lower cost. The concept isn't new. Encouraging hospital-physician alliances to coordinate care builds off years of research, failed projects by care providers themselves and the government's own efforts to spark clinical and financial integration.

What is new is that CMS is clearly willing to "reimburs[e] integrated providers for providing a broad base of care to patients," according to John Liethen, a health law attorney with Dorsey & Whitney.

Through the Shared Savings Program, Medicare will reward ACOs for reducing total cost of care for an assigned population of patients. This reimbursement concept will initially be voluntary, but is meant to eventually encompass the entire Medicare population. Having providers experiment with different models serves CMS' purposes.

However, that hasn't stopped health care stakeholders from grappling with significant legal concerns. How will regulators interpret physician payments given anti-kickback statutes? Will these new ACOs violate existing anti-trust rules? And what will ACOs look like in California, given corporate practice of medicine laws that prevent hospitals from directly employing physicians?

Agencies Slowly Move Forward

After months of these questions, some answers may be on the horizon.

FTC, CMS and the HHS Office of Inspector General next week will host an all-day open workshop designed to foster conversation and address potential changes to ease ACO development under current law. The workshop has drawn dozens of key health care stakeholders, and many participants already have filed comments ahead of the session. For example, the American Hospital Association submitted questions asking for federal guidance on anti-trust, Stark and civil monetary penalty laws.

One reason that federal guidance has been slow to come is that regulators "are doing much the same thing as providers: They are scrambling to understand a changing landscape as it morphs around them," Modern Healthcare reports. Susan DeSanti, a director at FTC, notes that next week's session will allow the agencies to collaboratively prepare for situations where one regulator -- say, CMS -- might deem a provider worthy of ACO incentive payments, while FTC submits an anti-trust complaint to the same provider.

Meanwhile, numerous trade groups and pilot projects continue to move the ACO discussion forward. The California Association of Physician Groups will convene a national conference on ACOs in late October. CMS will release guidelines for its flagship ACO demonstration in December. Still, many hospitals and physicians have elected to wait to form or join an ACO until the model is better defined or regulators switch course.

Interim Strategies Rely on Safe Harbors

Barring further guidance, providers that are moving ahead with ACOs essentially have two options to stay on the right side of anti-trust law: Turn to hospital-physician employment or FTC's Clinical Integration model.

Of course, California hospitals and health systems -- governed by strict corporate practice of medicine laws -- can't directly employ physicians. Similarly restrictive laws may also constrain the model's potential application in states like Texas and Illinois. According to Don Ammon, former CEO of Adventist Health, "for ACOs to work ... legislative reform would have to occur" in California.

However, many of California's independent physician associations might meet the financial risk test that would allow them to joint contract without violating anti-trust law, as they exclusively operate under capitation arrangements, Liethen of Dorsey & Whitney points out. Beyond anti-trust, California's unique experience with managed care could give state providers a leg up on attempting the model.

More broadly, Liethen notes that "the path to ACOs runs through the FTC." Notably, the commission's sanctioned Clinical Integration model relies on organizations engaging in active evaluation and modification of physician practice patterns and cooperating with them to cut costs and boost quality. Charles Wright, a partner with Davis Wright Tremaine, adds that providers "can exist comfortably within the existing antitrust laws even without financial risk sharing, if they are sufficiently integrated clinically."

Here's a look at what else is making news in health reform.

Health Reform Rollout

  • Last week, President Obama convened a meeting with more than two dozen people in the backyard of a family's home outside of Washington, D.C., to discuss the benefits of the federal health reform law (Stolberg, New York Times, 9/22). Obama delivered a brief speech, during which he highlighted new health insurance industry regulations that took effect on Sept. 23. The president also asked guests to share how they hope to benefit from the health reform law (Aizenman/Kornblut, Washington Post, 9/23).
  • Last week, the Government Accountability Office announced the appointment of 19 members to the board of the not-for-profit Patient-Centered Outcomes Research Institute, which was created under the federal health reform law. PCORI is designed to research the best medical treatments for patients. The board members serve staggered six-year terms and can be reappointed once (Pecquet, "Healthwatch," The Hill, 9/23).
  • CMS officials are not content to wait until Medicaid eligibility significantly expands in 2014 and are trying to boost program enrollment now, according to CMS Director Cindy Mann. Mann said at a public meeting of the new Medicaid and CHIP Payment and Access Commission that the agency is breaking out of the mindset that there will always be an "eligible but unenrolled" population for Medicaid and CHIP. She said the agency's "new paradigm" suggests that "eligibility equals enrollment" (Reichard, CQ HealthBeat, 9/24).
  • Fewer residents than expected have enrolled in the high-risk health insurance pools created in each state under the federal health reform law. The pools are designed to serve people with pre-existing conditions who have not had health insurance for at least six months. Enrollment began in some states on July 1, but others have just recently begun accepting applications. Officials say that some states have had fewer than 100 applicants for their high-risk pools, despite estimates that hundreds of thousands of residents could qualify for the programs (Adams, CQ HealthBeat, 9/24).
  • The federal health reform law includes a little-noticed provision that allocates $9 million annually for four years, starting in 2010, for programs to increase awareness about the risk of breast cancer in women ages 15 through 44. Under the health reform provision, CDC is charged with creating educational campaigns focusing on breast cancer in younger women and encouraging healthy habits that promote prevention and early detection. Groups that support young women with breast cancer are eligible for grants under the provision. The law also directs NIH to develop new screening and early-detection tests and prevention methods for younger populations (Andrews, Washington Post, 9/27).

Gearing Up for Midterm Elections

  • Last week, Republicans released their "Pledge to America," a 21-page document detailing how they would limit the size of government -- in part by repealing and replacing the federal health reform law -- if they win a majority in the midterm elections (Kane/Bacon, Washington Post, 9/23). The pledge states that the GOP would replace the current overhaul with smaller measures, such as ones to limit malpractice lawsuits against physicians and  enroll individuals with chronic health conditions in state-run high-risk insurance pools (Bacon, Washington Post, 9/23).
  • Despite speculation that Democrats are avoiding the subject of the federal health reform law during campaigning for midterm elections, several House Democrats are putting the overhaul at the forefront of their campaigns. Several Democrats, including Reps. Shelly Berkley (D-Nev.) and Dina Titus (D-Nev.), are scheduling speeches alongside HHS Secretary Kathleen Sebelius to address provisions in the so-called "Patient's Bill of Rights" that took effect last week. In addition, some House Democrats are airing television advertisements and writing opinion pieces in their local newspapers to show their support of the law (Haberkorn, Politico, 9/27).

In Public Opinion

  • More than half of U.S. residents incorrectly believe the federal health reform law will raise their income taxes and about one-quarter think the overhaul includes so-called "death panels," according to a recent Associated Press survey. Among survey respondents who identified as Republicans, accurate knowledge of the law mattered little in their overall opposition to it. Among Democrats and independents, the poll found that respondents who were more knowledgeable about the overhaul were more likely to be in favor of it (Alonso-Zaldivar/Tompson, AP/Miami Herald, 9/22).
  • Another recent Associated Press poll found that many U.S. residents believe the federal health care reform law did not accomplish enough. The poll -- conducted by Stanford University and funded by the Robert Wood Johnson Foundation -- found that 30% of Americans favor the overhaul, 40% oppose it and 30% remain neutral. Four in 10 poll respondents said that the health reform did not do enough, regardless of their stance on the law. Meanwhile, one in five said that the government has no place being involved in health care (Alonso-Zaldivar, AP/Atlanta Journal-Constitution, 9/26).

Eye on the Insurance Industry

  • Insurers are scrambling to adjust after the first provisions of the federal health reform law took effect last week. Some companies are reducing administrative staff to lower overhead costs, investing in technology upgrades and training employees to expect a surge in customer inquiries. In addition, some insurers are altering their business models to deal with the new rules. According to some health experts, the adjustments required under the health care overhaul could put some insurers at risk of going out of business (Abelson, New York Times, 9/22).
  • Many insurers are facing the prospect of spending tens of millions of dollars to overhaul their coverage plans and reconfigure their technological systems as they work to comply with newly effective provisions of the health reform law. The reform law now requires insurers to fully cover the cost of any preventive service, waive policyholders' annual and lifetime spending limits and accept all children, even those with pre-existing conditions. In addition, some insurers likely will cut costs to comply with new medical-loss ratio rules (Sturdevant, Hartford Courant, 9/24).

Read more:

A proposal outlining the Obama administration's preferred ground rules for new accountable care organizations should be out within a month, says Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services.  And Berwick signaled that he may fund other experiments in coordination of care through the new Center for Medicare and Medicaid Innovation.

The health care law, PPACA, (PL 111-148, PL 111-152) called for CM2 officials to fund a limited number of so-called accountable care organizations (ACOs), which are groups of health care providers who agree to be accountable for the quality, cost, and care of Medicare recipients. The ACOs could take a variety of forms, such as networks of physicians or partnerships between hospitals and physicians. These new groups would test out the concept by agreeing to care for at least 5,000 people for three years or longer. If an ACO saved money, then the medical providers who are part of the group would share in the savings.  Berwick declined to spell out what the proposed rule on ACOs will say, but he acknowledged that federal officials will have to sort through complicated and contentious issues. "It's going to be tough," Berwick said.

Among the potential questions that Berwick foresees:

  • How will the quality of care for patients be measured? As Berwick noted, if measurements are too stringent, then fewer providers will be interested in participating.

  • How will antitrust laws be relaxed so that providers can cooperate without being accused of monopolistic behavior?

  • What kind of financial risk will providers have to assume in order to form an ACO?

  • How can CM2 officials make sure that the ACOs don't cherry-pick and recruit the healthiest patients to be part of a group, leaving sicker patients out of the network?

  • How will patients be assigned to an ACO? Berwick said that the "law presumes choice," but it doesn't spell out the details of how seniors can join or be assigned to an ACO.

When different medical groups join together, how can providers make sure that they're protecting patients' privacy?

How can small practices get the capital to operate an ACO?

Berwick warned that he is looking for proposals that will represent significant shifts in how patient care is coordinated so that providers are really collaborating in a new way that respects patients' preferences.  "Parties will be out there who will wish to repackage the status quo. I don't think that will be enough," he said. "We're going to have to find a way to deliver care better. That means change."

As Berwick searches for the best models of coordinated care, the innovation center may separately fund what he called "pioneering" organizations that began working on such efforts without waiting for health law rules governing ACOs to be written. Groups funded by the innovation center aren't expected to have to adhere to the new ACO regulations.

Officials with the innovation center—which has been operating for two months and funded four major grants so far—are in the midst of a 60-day strategic planning process. Federal officials are coming up with a list of the type of projects that they want to support through federal financing. In remarks to reporters after the Brookings briefing, Berwick gushed about the structure of the innovation center, saying that it "allows us to move faster" than officials can by using the rulemaking process and can "invite reforms of exploration that wouldn't be possible" otherwise.



UPDATE: June 23, 2011: The Obama administration has announced that it will shutting down a program that had provided "Mini-Med" exemptions from the new health care law for many employers and labor unions offering bare-bones insurance coverage to workers. No more applications will be accepted after September 22, federal health officials said. Steven B. Larsen, director of the federal Center for Consumer Information and Insurance Oversight, said employers and labor unions had until that date to seek exemptions or request the extension of waivers already granted. The new health care law generally requires employers to provide at least $750,000 in coverage to each person in their health insurance plans this year. Many restaurants, retailers and small businesses do not meet the standard. Some provide "mini-med" coverage with annual limits that may be as low as $10,000.

Consider what it would be like to have a health insurance plan that capped annual benefits at $2,000. For any medical care costing more than that, you would have to pay out of pocket.  Examples of care that costs more than $2,000 — and often a lot more — include virtually any cancer treatment, any heart surgery, a year’s worth of diabetes treatment and care for many broken bones. Even a single M.R.I. exam can cost more than $2,000. A typical hospital stay runs thousands of dollars more.

So does this insurance plan sound like part of the solution for the country’s health care system — or part of the problem?

A $2,000 plan happens to be one of the main plans that McDonald’s offers its employees. It became big news last week, when The Wall Street Journal reported that the company was worried the plan would run afoul of a provision in the new health care law. In response to the provision, McDonald’s threatened to drop the coverage altogether, until the Obama administration signaled it would grant some exemptions.

This episode was only the latest disruption that the health law seems to be causing. Also last week, the Principal Financial Group said it was getting out of the health insurance business, while other insurers have said they might stop offering certain types of coverage. With each new disruption come loud claims — some from insurance executives — that the health overhaul is damaging American health care.

On the surface, these claims can sound credible. But when you dig a little deeper, you often discover the same lesson that the McDonald’s case provides: the real problem was the status quo.

American families spend almost twice as much on health care — through premiums, paycheck deductions and out-of-pocket expenses — as families in any other country. In exchange, we receive top-notch specialty care in many areas. Yet on the whole, we do not get much better care than countries that spend far less.

We don’t live as long as people in Canada, Japan, most of Western Europe or even relatively poor Jordan. Misdiagnosis is common. Medical errors occur more often than in some other countries. Unique to the developed world, millions of people have no health insurance, and millions more, like many fast-food workers, are underinsured.

In choosing their health reform plan, President Obama and the Democrats eschewed radical changes, for better or worse, and instead tried to minimize the disruptions to the current system. Sometimes, Mr. Obama went so far as to suggest there would be no disruptions, saying that people could keep their current plan if they liked it. But that’s not quite right. It is not possible to change a system as huge, and as hugely flawed, as ours without some disruptions.

McDonald’s offers its hourly workers two different health care plans, which are known as “mini-med” plans. In one, workers can pay about $730 a year for benefits of up to $2,000. In the other, they can pay about $1,660 a year for benefits of up to $10,000, The Journal reported.

In a memo to federal regulators, McDonald’s executives argued that their version of health insurance “positively impacts” the almost 30,000 workers who are covered. And that’s true. A plan with a $2,000 or $10,000 cap can cover some modest health problems and is better than being uninsured.

But should the litmus test for American health care really be better than nothing?

Mini-med plans force people to drain their savings accounts for dozens of common medical problems. They also force hospitals to let some bills go unpaid, which drives up costs for everyone else.

Senator Charles Grassley, Republican of Iowa, has previously criticized AARP for marketing similarly limited plans to its members. “It’s not better than nothing,” Mr. Grassley argued, “to encourage people to buy something described as ‘health security’ when there’s no basic protection against high medical costs.”

Dr. Aaron Carroll, an Indiana University pediatrics professor who studies health policy, says of mini-med plans: “They’re great if you’re healthy, because you feel like you’re covered. But if you ever need them, they’re so skimpy, they provide very little.” Gary Claxton of the Kaiser Family Foundation adds, “They really just shouldn’t be considered health insurance.”

The plans’ skimpiness is the main reason they ran into legal jeopardy. Under the new law, most plans must spend at least 85 percent of their revenue on medical care, rather than administrative overhead. The McDonald’s plans aren’t generous enough to clear the hurdle.

At the same time, it’s probably unrealistic to expect McDonald’s to give workers decent health insurance. Many of those workers make less than $20,000 a year. A typical family insurance plan would raise their total compensation by more than half, destroying the McDonald’s business model.

The workers, for their part, cannot afford to buy insurance in the so-called individual market. Plans are even more expensive in that market, because it is dominated by people who desperately need insurance — which is to say, sick people.

This is where health reform comes in. It tried to solve the problem by creating what policy experts call a three-legged stool.

First, people will be required to buy insurance, to spread costs among the sick and the healthy. Second, insurers will be prohibited from cherry-picking only the healthiest customers, again to spread costs. Finally, the government will give subsidies to people, like McDonald’s workers, who can’t afford insurance on their own.

Germany, the Netherlands and Switzerland all use a system along these lines to cover everyone, largely through the private sector, for less money per person than this country spends.

The recent disruptions in our health insurance market are partly a result of the fact that the stool’s three legs were not built on the same timetable. Some of the insurance regulations, like the one on overhead costs, are starting to take effect. But the new markets for health insurance, known as exchanges, won’t be up and running until 2014. This timetable has its problems, and the Obama administration will probably need to grant some more temporary exemptions.

In 2014, however, the choice for McDonald’s workers will no longer be between a bad policy and no policy. Through the exchanges, they will be able to buy a real health insurance plan — one that covers cancer, heart attacks, surgeries, M.R.I.’s and hospital stays. Dr. Carroll notes that many families will end up paying less than they are now paying out of pocket and will get more access to care, too.

For insurance companies, these changes won’t be quite so positive. They will no longer be able to sell plans that devote 30 percent of revenue to salaries for their workers. They will not be allowed to compete over which company can come up with the most ingenious ways to say no to the sick. Their benefits and prices will become more public, thanks to the exchanges.

The health care overhaul that passed Congress is far from ideal, as I have written many times in this space. But it does represent progress.

The fact that it is beginning to disrupt the status quo — that some insurance policies will eventually be eliminated and some inefficient insurers will have to leave the market altogether — is all the proof we need.



back to top


U.S. Taxpayers are Over-Taxed... Not!

 Source: OECD

back to top

50.7 Million “officially” uninsured in 2009
(9.5M of them are children)
2009 Families USA Report: "90 Million Uninsured at Some Time During 2007-20079 


2007 Consumers Report Estimate: 
60+ Million "Underinsured"

which if you do the math, means that 40% of Americans with no or inadequate health insurance… 


But Never Fear, the Answer is Simple:

- GEORGE W. BUSH, Cleveland, Ohio, August, 2007
29 Industrialized Nations, 28 With NHI ... these other nations mostly developed their National Health Insurance systems in the post-Great Depression, post WW-II era; the U.S. came up with an alternative, "get a job, get health insurance," they went hand-in-hand. And it worked, for the most part, for 50 years or so.
EMTALA-Driven Uncompensated Care/Emergency Room Crisis ... what we don't have is a system of paying for it. Medicare participating hospitals and physicians under the EMTALA mandate are absorbing upwards of $145 billion -- yeas, I said BILLION -- in annual transferred costs to pay for covering the uninsured showing up in our hospital emergency rooms and clinics seeking care. This is an "invisible" tax that we are all paying for higher and far less efficient or effective health care through higher premiums on our health insurance and higher local taxes used to run public hospitals.
37th Ranking in World ... wow, this means some second and third tier nations in the world rank ahead of us. And don't deceive yourself, as John McCain does when he says that we have the best health care in the world, we don't, It stinks, especially given the money we pay for what we get. This is a national embarrassment!
15.9% GDP ... no other nations save Luxembourg and Switzerland spend more than 12%. I used to think this was OK. I told myself that I would rather live in a nation that spent 16% of its GDP on health care rather than in a nation that spent 16% on invisible bombers and tanks that couldn't shoot straight. Then I saw what was happening to America's industrial might. Our auto, steel and other heavy manufacturing industries, the backbone of America's economy and strength. They were losing the competitive markets to their European and Asian competitors. In countries where health care costs were considered part of the social contract, and where health care accounts for less than 10% of GDP, the American auto industry, its steel plants and its other manufacturing centers were losing out. Lee Iacocca was president of Chrysler Corporation back in 1993-94 when the first Clinton health plan was on the table. He came to DC regularly to testify before those task forces that were meeting to plot out the plan. "If you think my cars suck," he said. (Well, he didn't use those words exactly, but that was his message.) "If you think my cars suck, recognize that it costs me more than $1200 per car MORE than my German and Japanese competitors for the health care insurance for the workers and retirees of Chrysler Corporation than they pay. I have to cut $1200 out of the plastics and the steel just to be able to play on an even pricing field with my competitors." America is losing its competitive edge in large part because of the enormous costs of its health care delivery system. And we are getting crappola.
Movement Away From Employment-Based Coverage ... fewer than 60% of American companies now offer their employees health insurance, down from over 75% in 1990. Predictions are that it will be less than 50% by 2012.

back to top

Back, way before the turn of the century, when I was young and even more stupid than I am today, I used to think that I would much prefer to live in a society that spent 20% of its income on health care than one that spent 20% on invisible bombers and tanks that couldn’t shoot straight.  But over the years, I began to realize that spending that much under a system where employers bore a major portion of the costs wasn’t getting us anywhere very fast.

If you’re old enough, take yourself back to 1993-94, when health care was estimated to be taking up 14% of our domestic economy, and the great debate that was taking place over the proposed Clinton plan, affectionately labeled as “Hillarycare” by its opponents.  Lee Iacocca was then president of Chrysler Corporation and he came to Washington, not so much in support of the Clinton proposal, as to try to tell Congress the problem rising health care costs was posing for the American manufacturing industry.

Mr. Iacocca told the august members of that body that if Americans thought his Chrysler cars sucked (he didn't actually use that word, but that's what he meant), they had to realize that for every care he built, he was paying the workers and the company's retirees $1200 more than his German, Japanese and Korean competitors. That meant that he had to cut $1200 from the design work, the steel and the plastics used to build that car, just to play on a level price field with his competitors. And Chrysler was losing that game.

So what did we do about it? We threw the Democrats out of office in the 1994 elections, killed the reform effort and put Newt Gingrich and his de-regulating Republicans into office with their Contract on America.  By 2007, more and more American manufacturing companies were feeling the pinch of having to compete against foreign competitors in lands where health care was treated as a societal cost, borne across the board for the good of that society, and not the specific cost of any individual or company.  General Motors executives came to Washington begging for relief, estimating that the price differential over employee health insurance had reached $1900+ per car. Steel and other heavy industry manufacturers, paying higher and higher employee health premiums, couldn't compete with foreign producers. Appliance and furniture manufacturing was going overseas. Almost all light assembly work was long gone and heavy industries were moving production across the border.  And while, other economic factors contributed, a significant portion of the blame laid at the foot of growing health insurance costs. Health care was now 17.6% of the nation's economic market.

The Reagan-era initiated drive to re-regulate, accelerated by Newt and his cohorts, and embraced by George W. Bush, had spun out of control. Greed and a new banking system that rewarded short term paper profits over long term growth and stability had won out... and the economic house of cards had begun to tumble.  With jobs gone and the middle class decimated, the wealthy now enjoyed an unprecedented (and unwarranted) share of America's largesse.

But whoa, we elected Barack Obama in 2008 with the promise of changes. Surely things could be righted.  Well, no.

20 months into office, a stubborn Republican minority in the Senate had blocked virtually every reform initiated by Obama using an antiquated (and non-Constitutional) filibuster rule. What watered down recovery legislation that could be passed did was slow the economic descent and slowly. so very slowly, begin the process of turning the economic ship of state to its proper course.  The one shining light (and even that didn't go far enough) was the passage of the Patient Protection and Affordability Care Act in March 2010 ("PPACA").  Finally, we had a plan to reform the US health Care system, moving the nation toward a more universal system of coverage and benefits; a plan that would begin to hold down the annual double-digit increase in health care costs and bring some sanity to the U.S. health care marketplace. It was as Vice President Biden so eloquently put it at the signing of the new law: "a big [bleeping] deal!"

Admittedly, the Democrats did use a few parliamentary tricks to maneuver the law threw and around the GOP's obstinacy, and compromises were struck that threatened to reduce the potential impact and longer term effectiveness of the new law, but the deed was done. Or so we thought...

Using many of the same tactics that had derailed the Clinton health plan in 1994, a new Republican party emerged, the TeaParty/GOP. Fueled by millions in newly "legalized" corporate PAC funds following a 5-4 Supreme Court decision in Citizens United v. Federal Election Commission, 130 S.Ct. 876, January 10, 2010, and armed with ignorance, the new TeaParty/GOP went on a crusade of lies and misrepresentations about PPACA. Derisively labeling it as "Obamacare," the TeaParty/GOP invented arguments against the law out of whole cloth, "death panels," "Obama's private army," "government takeover of health care," "bureaucrats controlling your health care."  Using the Internet, lying and factually-challenged e-mails went viral one after another. Democrats congresscritters were confronted, and in some cases physically assaulted, in their home districts when they tried to explain the actual provision of the new law. Truth meant nothing.  Moderate Republicans faced a similar challenge and one after another, they fell in primaries to the new TeaParty/GOPers.  By the November election, it was 1994 all over again, out went the Democrats and in came the TeaParty/GOP and the well-tanned, well-rested Newt Gingrich wanna-be clone, John Boehner. Their #1 promise, repeal "Obamacare." It was déjŕ vu all over again.

At this point, we can only hope we won't see the same disasters, economic, political and international, the last time we went through this. <sigh>

Buried in PPACA (Obamacare) is a secret weapon to contain Medicare costs... the IPAB. Meet the group of House Democrats who want to destroy it.

When Wisconsin Housecritter Paul Ryan let loose the bombshell of his TeaParty/Republican budget proposal in early April, the pressure in Washington immediately began to mount for President Obama to come back with a response. Hailed as a “bold” and “courageous” attempt to reckon with the mounting deficit, Ryan’s plan scored instant points for its willingness to grapple with Medicare, the greatest long-term driver of government deficits and debt. Of course, behind the much-hyped “boldness” came an all-too-familiar Republican attack on a government program. Ryan proposed phasing out Medicare and replacing it with a privatized system of vouchers that would, according to the Congressional Budget Office, have seniors paying two-thirds the cost of their care, while also cutting taxes on the wealthy and repealing the Patient Protection and Affordable Care Act of 2010. But a gauntlet had been thrown down: Obama would have to come forward with a better idea.

And so the president did, in a widely watched speech eight days later at George Washington University. With Ryan himself sitting in the front row, Obama excoriated the Republican’s proposal and offered a full-throated defense of programs like Medicare, Medicaid, and the social safety net as a whole. “We’re a better country because of these commitments,” Obama said. “I’ll go further—we would not be a great country without those commitments.”

When it came time to offer his substantive answer to Ryan and the deficit, Obama pointed to the Patient Protection and Affordable Care Act itself, whose reforms, he reminded the crowd, were projected to save the federal government $1 trillion on their own. Then, as a new deficit-control measure, Obama proposed expanding the powers of a crucial but little-understood entity established by the health care bill. “We will slow the growth of Medicare costs,” Obama said, “by strengthening an independent commission of doctors, nurses, medical experts, and consumers who will look at all the evidence and recommend the best ways to reduce unnecessary spending while protecting access to the services that seniors need.” He was referring to something called the Independent Payment Advisory Board, or IPAB.

In the days that followed, while the left mainly cheered at Obama’s philosophical defense of the welfare state, the right zeroed in on the president’s call for a stronger IPAB. The National Review flamed the forgettable-sounding board as “the real death panel, the true seat of rationing, and the royal road to health-care socialism.” (For good measure, the magazine ran a cover image depicting the commission as a ghoulish crowd of Grim Reapers.) As it happened, the Republicans had been gunning for IPAB for quite some time. Legislation to kill the independent panel was put forward as early as July 2010 in the Senate, and this January, Tennessee Tea Partier Phil Roe introduced a bill to repeal it in the newly TeaParty/Republican House. Now, by emphasizing its importance, Obama had put IPAB back at the front of the conservative firing line.

The fallout had all the markings of a straightforward partisan battle... a reflexive attack on faceless bureaucrats tailor-made for the Tea Party era. But then, just two days after Obama’s speech at George Washington, a little-known Democratic congresswoman named Allyson Schwartz signed on as a cosponsor of Roe’s bill. Her defection was enough of a partisan hiccup to earn some prominent ink in the Beltway press. An article that landed on the cover of the New York Times in mid-April suggested that conscientious opposition to IPAB was becoming an issue that crossed the political aisle.

What Schwartz’s defection really represented, however, was not the MacGuffin of earnest bipartisanship but a serious moment of escalation in a war that the medical industry is waging against the lynchpin of President Obama’s health care reforms. To understand why, it helps to know a little bit about Schwartz and who she represents. A former health care executive from a suburban district outside Philadelphia, she is the health policy brains of the New Democrat Coalition, a group of forty-two House members whose close relationship with several hundred Washington lobbyists has made them one of the most successful political money machines since the Republican K Street Project collapsed in 2007. In the past several years, they have played an instrumental role in helping the financial and health care industries limit and weaken proposed reforms; IPAB would appear to be their next target. And if the history of the group is any indication, where Schwartz goes, the votes of a substantial number of her New Democrat colleagues are liable to follow.

Likewise, to understand why so many forces are amassing against IPAB, it helps to know what it represents: namely, our best hope not only of reining in Medicare costs and hence future budget deficits, but also of reforming the exorbitant, entrenched, ineffective practice of American medicine itself.

Since Medicare was signed into law in 1965, oversight and administration of the program has fallen to the Centers for Medicare & Medicaid Services. However, the CM2 has consistently been hampered by Congress, which, through both subtle and direct means, has placed itself at the center of Medicare’s affairs, dictating terms and blocking reforms.

If the CM2 has been answerable in great detail to Congress, it is important to remember that Congress has been, and still is, heavily answerable to the health care industry. For members sitting on committees that deal with Medicare, health care companies and trade groups have provided a steady stream of industry-sponsored studies and campaign contributions in the hope—usually fulfilled—that lawmakers will take their side. To help counter this influence, congressional budget hawks in 1997 created the Medicare Payment Advisory Board to give lawmakers independent expert advice. Med-PAC has since produced scores of recommendations for lowering costs ... suggesting, for instance, that the CM2 agree to pay the lowest price among different products designed for treating knee osteoarthritis, all of which work more or less the same way, rather than the average price of those products (likely savings: $500 million over ten years). But such recommendations are only advisory. Lawmakers are free to ignore them, and under pressure from, say, medical device makers, they usually do.

So when the Patient Protection and Affordable Care Act was being drafted, key senators like West Virginia’s Jay Rockefeller and White House officials decided that what was needed was a health care equivalent of the Base Realignment and Closure (BRAC) Commission, the highly successful independent body Congress created in 1988 to make decisions about which military bases to close ... decisions that Congress had repeatedly shown itself unable to make on its own. IPAB fits that bill. Composed of fifteen experts plucked from the health care world, IPAB will have the authority to impose binding, fast-tracked changes to Medicare once per capita costs rise beyond specific levels outlined in the health reform bill. Congress could reject IPAB’s recommendations, but it would have to offer its own alternative cost-saving measures, reducing the chances of meddling. IPAB is prohibited by law from rationing care or raising premiums, and its authority over some sectors of health care won’t kick in for years. Moreover, the Patient Protection and Affordable Care Act left many of the board’s powers undefined. But over time, with a proactive chair and a supportive White House, the board has a great deal of potential to fundamentally change the way Medicare does business.

Beginning in 2014, IPAB will be able to green-light many of MedPAC’s most promising ideas. But potentially even more important, it could take the best results of a number of innovative delivery reform experiments mandated by the new law ... for instance, the “bundling” of services into a single payment to encourage doctors to forego unnecessary tests, or rewarding health care networks for providing higher-quality integrated care for patients with expensive chronic diseases ...and fast-track their implementation system-wide. The hope is that, over time, these changes could substantially lower the rate at which Medicare costs are expected to grow. And since private insurers often follow Medicare’s lead, the reforms could lower cost growth in the broader health care system, which is the real source of the problem.

Given the threat IPAB represents to a status quo that is very lucrative for the health care sector, the industry has gone into a lobbying frenzy. Groups like PhRMA, the incredibly powerful drug industry trade group, were out of the gate almost as soon as Congress had passed the act. Though PhRMA supported the bill ... which did, after all, expand their potential market of patients by about thirty million ... their press release on the occasion of its passage was quick to mention “concerns” about IPAB and its “overly broad powers.” It was a message that Republicans found intrinsically appealing. But for any repeal effort to actually work, bipartisanship would be required.

Luckily for IPAB’s opponents, a group called the New Democrat Coalition was waiting in the wings.

The New Democrat Coalition quietly emerged on the scene in 1997, toward the end of the Clinton era. Like the Democratic Leadership Council and the Blue Dog Democrats, two other groups that broke through in the age of “Third Way” politics, they sought to tap into the vast campaign finance coffers of corporate America. While the Blue Dogs are known as a largely southern and rural club with interests in social issues, fiscal conservatism, and energy, the New Democrats have tended to come from suburban districts across the country and focus on matters of trade, finance, and health care. Throughout the group’s history, its members ... names like Gary Peters, Adam Smith, and Martin Heinrich—have mainly been congressmen who are little known outside their districts, unlikely to chair a committee or hold a prominent leadership post. Instead, they have been positioned along the fault lines of major policy battles, using their status as fence-sitters to extract concessions for the business community.

If the New Democrats have a favorite buzzword, it is “innovation.” Their PR literature is full of phrases like “championing innovation,” “growing the innovation economy,” and “funding the innovation agenda.” In practice, the term has largely served as cover for the priorities of their corporate backers. For example, when the financial industry came to Congress in the late 1990s asking for the removal of the Depression-era Glass-Steagall Act’s restrictions on investment banks merging with depository institutions, many New Democrats voted for the Gramm-Leach-Bliley Act, which paved the way for “too big to fail” banks. New Democrats also threw their weight behind the Commodities Futures Modernization Act, which limited regulation of financial derivatives, including the—yes—“innovative” products that played a major role in the financial crisis.

When Republicans took back Congress and the White House in 2000, the GOP was able to monopolize campaign cash from lobbyists through the K Street Project, and the power of the New Democrats waned. For a time, membership in the group was akin to being “just a name on the list,” the current vice chair Representative Ron Kind has said.

All that began to change after the 2006 election. With their party again at the levers of power, setting the policy agenda for Congress, the New Democrats’ stock began to rise once more. The business community needed new Democratic allies in Congress; the New Democrats needed seed money for their campaign finance war chest. Then, when Barack Obama swept into office in 2008 promising broad reforms, some of Washington’s most powerful lobbying constituencies had more need for the New Democrats than ever.

During the health care reform debate, biotech companies wanted to prevent generic versions of a lucrative new class of drugs called biologics from entering the marketplace, claiming that a proposed seven-year monopoly, endorsed by the Federal Trade Commission and the Obama administration, would block “meaningful incentives for innovation.” In stepped the New Democrats, lending their collective support to an industry-endorsed twelve-year monopoly that included language consumer groups said would allow near-automatic renewals of monopoly periods if manufacturers changed dosages or delivery methods. With public attention focused squarely on the debate over the “public option,” ensuring that drug companies got the monopoly they wanted was a breeze.

Likewise, as Congress sought to reform the regulation of Wall Street in the aftermath of the financial crash, the New Democrats mobilized to block meaningful reform of derivatives. Though they were unable to squeeze out all the concessions they desired, their pressure shifted the boundaries of the debate toward weaker reforms.

In each case, one or two New Democrats would take the lead, either by introducing legislation, circulating a “Dear Colleague” letter, or writing up an op-ed endorsing a particular bill. As a floor vote neared or a debate intensified, additional members of the coalition would join in. Eventually, as was the case with derivatives language in Wall Street reform and biologics in health care reform, the coalition would take an official vote on whether to endorse a given measure and then fire off a letter on official coalition stationary to party leadership with dozens of signatures, making clear that the New Democrats meant business and could deliver the votes to prove it.

True to form, when Allyson Schwartz announced she would support the Republican effort to repeal IPAB, her first action was to send around a “Dear Colleague” letter. A few weeks later, an op-ed in USA Today followed; in it, Schwartz wrote that IPAB “has the potential for stifling innovation.” Not surprisingly, the only others discussing IPAB in terms of its “innovation stifling” effects have been the drug industry and its allies.

As of early June, only a handful of Democrats have signed on as cosponsors to Phil Roe’s bill, including one other New Democrat, Nevada’s Shelley Berkeley. But we already know how many in the New Democrat coalition feel about an independent board to help reduce Medicare costs: during health care reform, several signed letters opposing its formation. And if past is prologue, the question is not whether other New Democrats will join Schwartz, but how many will do so, and when.

If an IPAB repeal bill passes the House with a couple dozen or more Democratic votes, it will set in motion a cascade of events that could end very badly for Barack Obama and his administration’s efforts to rein in long-term federal spending. What would once have seemed a partisan ... and hence dismissible ... TeaParty/Republican attack on a core pillar of the president’s health care reform will instead have a bipartisan glow. The Beltway media, long fixated on bipartisanship as an automatic indicator of worthiness, will quickly deem the bill to be the moderate position and IPAB as bureaucratic overreach. Indeed, industry groups are already touting Democratic opposition and labeling the repeal effort, in the words of a recent PhRMA press release, “a bipartisan issue,” knowing the value that label confers.

From there, it’s not hard to imagine what comes next. For Democratic senators wishing to come to the aid of their friends in the health care industry, the bipartisan sheen generated by the New Democrats’ support would provide cover for them to desert the White House and join Republicans in support of a Senate version of a bill killing IPAB. If enough of them do so, Senate Majority Leader Harry Reid will be under tremendous pressure to allow a floor vote, and if the bill passes, the president will find himself in a terrible bind.

On the one hand, he could sign the bill, but that would mean killing off the single most important cost-cutting and reform-enforcing element of his signature legislative accomplishment. That seems unlikely, especially given that in his April speech at George Washington University he made strengthening IPAB central to his plan for further deficit reduction.

More likely, since the bill probably won’t garner a veto-proof majority, Obama will simply veto it, and thus preserve IPAB. But this will be politically costly in an election year, especially for a president who has spent much of his first term portraying himself as a champion of bipartisanship and who is staking his reelection bid on winning over independents. It’s hard to imagine, then, that the New Democrats will be able to repeal IPAB before the 2012 election. But, by joining with Republicans in the attempt, they may well succeed in turning Medicare from a winning issue for Democrats into a losing one.

Lobbyists for doctors, hospitals and drug companies are urging lawmakers to derail a planned government panel that health industry officials fear will sharply curb Medicare spending -- a critical revenue source for them.

The American Medical Association, American Hospital Association and Pharmaceutical Research and Manufacturers of America are among many groups that want to weaken or kill the Independent Payment Advisory Board, which was created by the health law to cap the growth of Medicare spending beginning in 2015.

A House GOP leadership aide said the board is among several provisions the House will be aiming to repeal this year. Some Democrats will help, seeing the board as an encroachment on Congress’ authority. It’s “dangerous,” Rep. Pete Stark, D-Calif., declared last year.

AMADoctor groups have been the most vocal critics on Capitol Hill, but the board also worries consumer organizations such as the seniors lobby AARP, which fears that Medicare savings targets could have an “unintended impact on beneficiaries’ access to or quality of care,” according to spokesman David Allen. Dozens of organizations representing interests as varied as Medicare beneficiaries, social workers and hospices signed a letter last January to Senate Majority Leader Harry Reid, D-Nev., expressing “strong opposition” to the board. 

TeaParty/GOP Housecritter Phil Roe, T-Tenn., plans to introduce legislation Wednesday to eliminate the board; TeaParty/GOP Senatecritter John Cornyn, T-Texas, is expected to follow. If legislation fails, opponents have another strategy: blocking Senate confirmation of presidential appointees to the board.

Supporters of the board -- led by President Barack Obama -- aren’t ready to give ground. They say it’s one of the few cost-containment measures in the law and are counting on savings generated by the board to help finance the law’s expansion of insurance coverage. Health and Human Services spokeswoman Jessica Santillo said the board “is one of the key parts of health reform that will set our system on a path to sustainability in the long run.”

But some of the administration officials who made this argument so forcefully when Congress was debating the health bill are now gone: White House budget director Peter Orszag, National Economic Council director Larry Summers, Office of Management and Budget health adviser Ezekiel Emanuel and Robert Kocher, special assistant to the president on health care.

The broad, powerful opposition to the board underscores the difficulty of trying to rein in Medicare spending even as federal deficits soar. Supporters say the board will make the tough decisions Congress has ducked, but lawmakers and interest groups are loath to see their influence diluted by handing authority to an independent group.

The board is to be run by 15 health care experts named by the president and confirmed by the Senate; they will be paid $165,300 a year and serve six-year terms. The panel will make recommendations for slowing Medicare spending, such as changes to payment systems, with spending targets pegged to the economy’s growth rate. Congress must adopt the recommendations or substitute its own – so long as it meets the targets.

The law states the board may not “include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums, increase Medicare beneficiary cost sharing or otherwise restrict benefits or modify eligibility criteria.”  The Congressional Budget Office says the board may save up to $15.5 billion by 2019 with much more savings expected later because Medicare payments to hospitals will be exempted until fiscal 2020. Medicare spending was projected to total $509 billion in 2010.

The 5-year exemption negotiated by hospitals means doctors and drug makers will bear the brunt of Medicare reductions during that period, say officials of those groups. Doctors could take “a big hit,” said Dr. Mark Warner, president of the American Society of Anesthesiologists. “And we are already under-reimbursed.”

Drug companies fear the board may consider reducing subsidies to Medicare prescription drug plans. They also want stronger congressional oversight of the board. The CEO of drug maker Sanofi-aventis, Chris Viehbacher, says he wants the provision repealed or amended. “There needs to be transparency and oversight. (The board) has to be accountable. I think their evaluation is going to be flawed because a major chunk of costs aren't included, like the hospitals, and there needs to be a process of oversight," said Viehbacher, who is chairman of PhRMA.

Katie Orrico, director of the Washington office of the American Association of Neurological Surgeons, decried the board as “a group of 15 unelected, unaccountable individuals who will be making significant changes to Medicare.” The AMA’s president, Cecil Wilson, complained the board “would put in place another arbitrary system, in the mold of the Medicare physician payment formula, and could leave physicians subject to two sets of cuts.”  The formula imposes doctor pay cuts to help control spending, but Congress usually rescinds them 

The American Hospital Association said on its website that the board “threatens the long-time, open and important dialogue between hospitals and their elected officials.” AHA officials declined to elaborate.

The providers’ message resonates with many congressional Republicans who have attacked the board for its expansion of government power over the health care system. “While the GOP is absolutely concerned about the insolvency of current entitlement problems, it’s the structure of the IPAB that is very problematic,” said a House TeaParty/GOP leadership aide. “Republicans support competitive models to lower cost-- programs that are designed to empower people and put them in control of decisions, not a board of bureaucrats.””

Rep. Phil Gingrey, R-Ga., a physician and co-chairman of the 18-member House Republican Doctors Caucus said in searching for cuts the board will have no choice but to target “payments to providers. We just absolutely must repeal that provision.”

Many House Democrats share their view. Last January, 72 joined Republican colleagues in sending a letter to then-House Speaker Nancy Pelosi, opposing inclusion of the board in the law. In September, 14 Democrats, three of whom were re-elected, voted to repeal the board.

Those who want to kill or weaken the board face significant hurdles. Several key Senate Democrats, including Kent Conrad of North Dakota, Mark Warner of Virginia and John “Jay” Rockefeller of West Virginia, will fight any attempt to remove the board. “With IPAB, we finally have a way to take special interests out of the process and create an independent entity with the sole mission of protecting Medicare’s long-term quality and solvency," said Rockefeller, who is planning to introduce a bill eliminating the hospitals’ exemption.

Given those obstacles, lobbyists are still considering their strategy on repealing the provision. Orrico said her group, which is a member of two coalitions fighting the provision, the Alliance of Specialty Medicine and the Surgical Coalition, is working hard to find Democrats to join Roe and Cornyn and is “cautiously optimistic” they will succeed.

There are other options. TeaParty Housecritter Tom Price, T-Ga., said he will look for ways to eliminate funding needed to launch the board, but faces formidable technical and political obstacles. Another option, said a Democratic aide, is to try to amend the law so the board could recommend revenue increases rather than cuts to meet spending targets.

If all else fails, opponents may have success blocking Senate confirmation of board members Obama is expected to nominate by October. Lobbyists said they plan to trumpet opposition research on every nominee. “Anyone who is a real expert in the health business has stuff that is going to be dredged up and wouldn’t make it through the confirmation process,” said Joe Antos, a scholar at the American Enterprise Institute. 

Over one quarter of Americans between the ages of 18-64 do not have any health insurance. The CDC released a new study showing 59.1 million Americans do not have health insurance and even worse, the people who cannot afford it are increasingly members of the middle class.

The 26% excludes the population which qualifies for Medicare (age 65 or older).

  • In the first quarter of 2010, approximately 50 million (26%) persons aged 18--64 years had no health insurance for at least part of the 12 months preceding their interview, and 30 million (16%) had no insurance for more than a year. From 2006 to 2009, the number of adults aged 18--64 years without health insurance at some point during the prior year increased by an average of about 1.1 million per year. About half of the total increase occurred among those with family incomes two to three times the federal poverty level. Although lack of insurance can be linked to poverty, in 2009, 32% of persons aged 18--64 years with family incomes two to three times the poverty level and 21% with family incomes three to four times the poverty level went without health insurance for part of the preceding 12 months.

  • In 2009, adults aged 18--64 years with no health insurance for the previous 12 months were seven times as likely to forgo needed health care because of cost as those with continuous insurance coverage. In 2009, more than 40% of adults aged 18--64 years who had high blood pressure, asthma, or diabetes and no health insurance went without some medical care because of cost during the preceding 12 months.

Even worse, more people with chronic conditions don't have health insurance.

Among persons aged 18--64 years with diabetes mellitus, those who had no health insurance during the preceding year were six times as likely (47.5% versus 7.7%) to forgo needed medical care as those who were continuously insured.

It would be more interesting of those who do, those who are forced into individual plans, how many are afraid to use it for fear of being canceled and also of interest, how many of those individual plans cover very little in actual costs.

Below is a state map of those who did not have health insurance from 2009 (via the CDC).




In 1979, Sister Theresa Kane was given a very special task. As president of the Leadership Conference of Women Religious, an umbrella group for most orders of U.S. Catholic nuns, Kane was asked to deliver four minutes of welcoming remarks, on behalf of American sisters, to the newly elected Pope John Paul II during his first papal visit to the United States. At a gathering inside the grand church in Washington, D.C., known as the Shrine of the Immaculate Conception, Kane offered the pope a warm greeting, and then launched into this:

As I share this privileged moment with you, Your Holiness, I urge you to be mindful of the intense suffering and pain which is part of the life of many women in these United States. I call upon you to listen with compassion and to hear the call of women...As women, we have heard the powerful messages of our church addressing the dignity [of] and reverence for all persons. As women, we have pondered these words. Our contemplation leads us to state that the church, in its struggle to be true to its call to reverence and dignity for all persons, must respond by providing the possibility of women as persons being included in all ministries of the church."

All ministries -- including, of course, the priesthood. Her meaning was not lost on the pope or, it seems, his henchmen in cassocks.

Chief among the new pope's enforcers was Joseph Ratzinger, the bishop from Bavaria, whom, three years later, JPII would appoint to the position of prefect for the Congregation of the Doctrine the Faith, an entity once known as the Roman Inquisition. As prefect, Ratzinger soon had his Congregation all but living up to its historical inquisitive reputation as he conducted a jihad against liberal bishops, clerics and nuns in the U.S., and around the world. Today, the former prefect is known as Pope Benedict the XVI, still an enforcer, and one with a long memory.

On April 28, nearly 33 years after Theresa Kane's unprecedented challenge to the pope, the Vatican delivered a verdict against LCWR, the nuns' group led by Kane in 1979: Its members were defying Catholic doctrine, Vatican investigators said, by promoting "radical feminist themes," as well as contradicting church teaching on homosexuality and the no-girls-allowed priesthood. Further, as Laurie Goodstein of the New York Times reported it, "The sisters were also reprimanded for making public statements that 'disagree with or challenge the bishops, who are the church's authentic teachers of faith and morals.'"

As punishment, Cardinal William Levada, who now occupies Ratzinger's old job at the Congregation for the Doctrine of the Faith, appointed Archbishop J. Peter Sartain of Seattle to oversee LCWR for up to five years, giving him final say on every speaker at the group's conference and every public utterance made in its name. He'll also revise LCWR's governing statues and oversee the revision of a handbook that, according to the Times, was "used to facilitate dialogue on matters that the Vatican said should be settled doctrine." Links between LCWR and two liberal Catholic groups will also be investigated.

Speaking on CBS This Morning [video] last week, Sister Maureen Fiedler, host of the public radio program, Interfaith Voices, said, "If this were the corporate world, I think we'd call it a hostile takeover."

On Friday, in an unprecedented act of defiance, the LCWR board, after a week of meetings in Maryland on how to respond to both the Vatican crackdown, issued a statement of its members' intention to contest the hierarchy's takeover of their organization. It reads, in part:

Board members concluded that the assessment was based on unsubstantiated accusations and the result of a flawed process that lacked transparency. Moreover, the sanctions imposed were disproportionate to the concerns raised and could compromise their ability to fulfill their mission. The report has furthermore caused scandal and pain throughout the church community, and created greater polarization.

The sisters said that LCWR President Sister Pat Farrell and Executive Director Sister Janet Mock would travel to Rome to take up these concerns with the prefect and the bishop he appointed to rule over the sisters, and would then consult with the organization's general membership in August. One option the organization could choose is to disassociate with Rome altogether and reconfigure itself as a 501(c)(3) non-profit corporation. The Leadership Conference of Women Religious, according to its Web site, "has approximately 1500 members who are elected leaders of their religious orders, representing approximately 80% of the 57,000 Catholic sisters in the United States."

Theologian Mary E. Hunt, co-director of the Catholic feminist resource center, WATER, told me in a telephone interview from her office in Silver Spring, Md., that the Vatican set its sights on LCWR because, as an organization that is part of the church structure, its members are "canonically vulnerable" -- meaning that they are subject to the law of the hierarchy, known as canon law, as interpreted by its appointed enforcers. Should the group dissolve itself and incorporate as a non-profit, it need only operate within the bounds of U.S. law, under which the religious freedom of its members is guaranteed under the First Amendment.

A Cult of Power

When examined in combination with the recent tantrum taken by the U.S. Conference of Catholic Bishops over the birth control mandate in the health-care reform law signed by President Barack Obama in 2010, Pope Benedict's crusade against the nuns would seem to render the Roman curia and the bishops, above all other things, a cult of misogyny. But that would be too simple a reading. At its heart, the church hierarchy is a cult of power; misogyny is but one tool for the already powerful to ensure that power remains in their possession.

One need only look at the current scandal engulfing the Vatican over dealings at the Vatican bank, and an internecine battle waged by partisans and enemies of Vatican Secretary of State Cardinal Tarcisio Bertone. Last week, the pope's own butler was arrested for allegedly having leaked confidential papal correspondence and documents to journalist Gianluigi Nuzzi, author of a just-released book about Pope Benedict.

Then there's the recently revealed pay-offs doled out by Cardinal Timothy Dolan, while he served as Archbishop of Milwaukee, to priests accused of abusing children who agreed not to contest their own defrocking.

The campaign to discredit Bertone is believed to be orchestrated by partisans of his predecessor, who want Bertone out of the way before Benedict dies, in order to prevent him from presiding over the conclave that will elect the next pope. In Dolan's case, he used payouts as a means of preserving his own power while serving as Archbishop of Milwaukee, by getting troublesome priests out of the way. (It seems to have worked; Dolan is now the cardinal archbishop of New York.) Dolan's payola scheme, of course, is but one tiny aspect of the enormous and shameful disaster the hierarchy brought upon itself by covering up the crimes against children committed by more than a few priests over the course of decades -- all in an effort to preserve its own power by maintaining a false appearance of propriety that put countless children at risk.

Writing at Religion Dispatches, Mary Hunt contends that the Vatican's attack on the nuns isn't simply about nuns -- or women. It's about the laity -- keeping the people of the church from actually claiming them the power granted them during the reforms of the Second Vatican Council, and maintaining the power of the clerics. "The effort to rein in LCWR is meant as much to scare the rest of us into line as to corral the nuns," Hunt writes.

This isn't this first time that the Vatican has sought to silence U.S. nuns. In one famous case, 24 sisters were threatened with expulsion from their orders for having signed a statement that asserted "a diversity of views" on the subject of abortion existed within the church, including the belief that abortion could sometimes be a moral choice. The ad was sponsored by Catholics for Choice, then under the leadership of Frances Kissling. Cardinal Ratzinger presided over the inquisition.

But this time is different, Hunt contends, because of the role played by nuns in the passage of Affordable Care Act, the health-care reform law initiated by the Obama administration and signed by the president. When the bishops, via the USCCB, sought to to block the legislation, largely because of measures that dealt with coverage of women's reproductive health issues, the administration turned to Sister Carol Keehan, president and CEO of the Catholic Health Association, which represents some 600 Catholic hospitals and 1400 health-care facilities. When Keehan backed the bill, she lent a Catholic imprimatur to the administration's much-contested hallmark piece of law. After Obama signed the bill, he sent Keehan one of the ceremonial signing pens he used to make the bill a law. Keehan's defiance was compounded when a coalition of U.S. nuns penned a letter supporting the law that was signed by leaders of 55 religious orders and umbrella groups, including the Leadership Conference of Women Religious. .

Earlier this year, Sister Keehan stepped up again, when, after the administration announced that Catholic institutions would not be exempt from the law's mandate to employers that their health insurance plans fully cover patients' contraceptive costs, and do so without demanding a co-payment from the patient. After the predictable outcry from the bishops, the administration offered an "accommodation" requiring health insurance companies to pick up the tab for the conception coverage, and Keehan gave her approval.

Nuns Defy Bishops on Health Care; Bishops Cry Foul on 'Religious Freedom'

In choosing the nuns to provide a stamp of Catholic approval for both the health-care law itself and the contraception "accommodation," the Obama administration acted on a calculation that the bishops' hard-core position against contraception and abortion under any circumstances was not supported by the majority of American Catholics, whose views are more in line with those represented by the nuns. The administration's concern was winning buy-in from Catholic lay people -- the voters -- and its legislative strategists knew that the moral imprimatur of the nuns would go a long way to that end. But in executing its strategy, the administration dared to do what no other before it had: expose the powerlessness -- the impotence, if you will -- of the hierarchy when faced with the will of what the church reform documents of Vatican II called "the people of God." The bishops, and presumably the pope, were not amused.

While it's true that the Vatican investigation of the Leadership Conference of Women Religious began nearly four years ago, the timing of the Vatican's announcement of its "hostile takeover" of LCWR coincides with the launching of a barrage of lawsuits against the administration by the bishops and Catholic entities challenging the requirement that all health insurance companies contracted for employer-provided health plans offer contraceptive coverage to the insured, and with no co-payment by the patient. This requirement applies to virtually all employer-provided health plans, including those that cover the employees of Catholic hospitals, universities and other institutions. The timing of the Vatican attack on the nuns also aligns with the timing of a public relations offensive by the bishops that frames the contraceptive mandate as an infringement of religious liberty -- an offensive that includes a heretofore unprecedented attempt at overt political organizing by the clerics for what they're calling a "Fortnight for Freedom," spanning from June 21, which commences the feasts of St. John Fisher and St. Thomas More, through to July 4th.

Sarah Posner, writing at Religion Dispatches, reports:

Fusing the martyrdom of Catholic saints with Independence Day, the Bishops write, "Our liturgical calendar celebrates a series of great martyrs who remained faithful in the face of persecution by political power . . . . Culminating on Independence Day, this special period of prayer, study, catechesis, and public action would emphasize both our Christian and American heritage of liberty."

All of this will of course come to a head as the general election campaign is heating up over the summer months. The Bishops urge commemoration of "resistance to totalitarian incursions against religious liberty" and call on "an immense number of writers, producers, artists, publishers, filmmakers, and bloggers employing all the means of communications—both old and new media—to expound and teach the faith. They too have a critical role in this great struggle for religious liberty. We call upon them to use their skills and talents in defense of our first freedom."

The irony here is that a good part of the problem the Vatican and the bishops are having with their American nuns and parishioners is, in fact, their very Americanness. For the hierarchy of the Catholic Church in Rome, its American flock, as it assimilated into the greater American culture, became increasingly troublesome. American Catholics, often enthusiastic in their patriotism, are, in reality, subject to two different and contradictory faiths: the American civic religion of liberty, individualism and participatory democracy, and the Roman tradition of collective submission to ecclesiastical authority. As time has passed, the American religion in many ways came to surpass the faith tradition of their ancestors in terms of forming a primary set of values. Roman Catholicism, for many, is more a subcultural identity than a daily practice of the rules and rituals mandated by the magisterium.

American Catholics have long flouted the popes' prohibition on the use of birth control, and are not inclined, as a bloc, to be moved by the bishops' complaint of liberty infringed -- especially when the liberty the bishops claim for themselves is the right to deprive a class of people, who represent half of world's population, of a fundmental aspect of health care particular to that class -- a class that is deemed unworthy by the bishops for admission into their ranks, by dint of the shape their bodies take at birth. Although sexism still thrives in the United States, the average American, even the average American sexist, does not generally classify it as one of the precious religious freedoms for which Americans should lay down their lives.

In the years leading up to the sex-abuse scandal that has gripped the church for more than a decade, many American Catholics viewed the bishops and the popes as simply out of touch with the modern world in matters of sexuality, especially on the reproductive front. But since the scandal, the bishops find themselves widely discredited as it became known that so many were aware of the sexually predatory behavior of some priests toward minors, and acted to cover up the crimes of those clerics. One such bishop was William Levada, who served as archbishop of San Francisco and Portland, Ore., and is now the Vatican prefect in charge of the nuns' persecution.

The nuns, on the other hand, have only grown in moral stature since Vatican II in the eyes of many Catholics, as they seriously implemented the council's mandate to go out into the world and do good works. Today, the most visible Catholic advocates for social and economic justice are often nuns, who work with the poor and minister to the sick. They are, by and large, better educated than the bishops who would rule them, and are consequently often more articulate in expressing their work in the context of their religious values, which they commonly frame in terms of the Gospel's calls to work for justice and healing, rather than as demands for obedience to a power structure whose princes preach adherence to a set of rules that is, at once, cruel and absurd.

Is it any wonder then, that when the Vatican condemned LCWR for, as the New York Times' Laurie Goodstein reported, "for focusing its work too much on poverty and economic injustice, while keeping 'silent' on abortion and same-sex marriage," Catholic across the country expressed outrage in demonstrations that took place in some 50 cities?

Vatican Inc.

When Sister Maureen Fiedler described the Vatican's action in the language of big business, she wasn't just being clever. According to Mary Hunt, the Vatican's power structure is very similar to that of a corporation, while the structure of the U.S. coalition of women's religious orders function more on the model of your local food co-op -- very process-oriented and deliberative. Speaking of the Vatican, she told AlterNet: "This is a business, where people do what people do in business."

But with the scandal currently gripping Rome over the pope's leaked correspondence and problems with transparency at the Vatican Bank, and the worldwide disaster of the sexual abuse claims against priests and the bishops who harbored them, Vatican Inc. seems to be treading the path of Lehman Brothers and Enron. The sexual abuse debacle has led to the bankrupting of two archdioceses in the U.S., under the burden of settlements made to victims: Milwaukee, less than two years after Cardinal Dolan became Archbishop of New York, and Portland, Oregon, under the leadership of Cardinal Levada. Such was Levada's brutality, in fact, that he punished a priest who reported a child-abusing fellow priest to the police -- a move that came back to haunt him when the whistle-blower, Father Jon Conley, brought a defamation case against the archdiocese after paving the way for the family of an abused child to win a $750,000 settlement from the archdiocese. (Politics Daily contributor Jason Berry told the sordid tale here in 2010.)

Now head of the church in the city once described by Pope John Paul II as "the capital of the world," Cardinal Dolan is among those charged with making the case for the bishops bogus claim of religious persecution by the U.S. government. But as the U.S. bishops mount their "Fortnight for Freedom" campaign (perhaps better named "Fortnight of Fury"), the Vatican stock would appear to be tanking.

"Roman Catholicism, in its institutional form, is imploding," Hunt told AlterNet.

Some might see in that implosion a divine act of creative destruction. For without the institution, what remains of the church could be simply the "people of God." And in the Gospel of Matthew, that's pretty much how Jesus defined the church.

In its statement, the LCWR board asserted:

[The board] believes that the matters of faith and justice that capture the hearts of Catholic sisters are clearly shared by many people around the world. As the church and society face tumultuous times, the board believes it is imperative that these matters be addressed by the entire church community in an atmosphere of openness, honesty, and integrity.

Read the Vatican document condemning the Leadership Conference of Women Religious here [PDF].


editorial content: © 2012; all rights reserved