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

 Source: OECD

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Gosh Darn All  Those Pesky Uninsured People…

 

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:

ALL AMERICANS HAVE ACCESS TO HEALTH CARE. AFTER ALL, YOU JUST GO TO AN EMERGENCY ROOM!”

- 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.

 

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

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 déjà 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.

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

Just Between You and Me: The Independent Payment Advisory Board represents the only significant cost-reduction mechanism in PPACA... and even then it is a watered down, strictly-limited plan to try to ultimately change the way that health care in the United States is financed, but also the way it is delivered.  The griping and complaining coming mainly from the medical community has been the hallmark of the AMA's political strategy for years as that organization opposes every single effort to make the kinds of changes needed to rein in the ever-escalating costs of health care in the USA.  This is the same AMA that vociferously opposed Medicare back in the 1960's complaining that it would lead to socialized medicine, only to find that when enacted, physicians incomes soared into the stratosphere. Back before Medicare, physicians were well-compensated and enjoyed the privileges and benefits of a "higher-than-most" incomes and the social status and prestige that accompanied them. After Medicare, physician incomes broke their old barriers and reached ever increasing heights, to the top one-half 1% in American society.  Today, physicians expect -- indeed demand -- that they retain incomes that keep them at this pinnacle of economic society. Yes, they work long hours; yes,  they have invested much into their education and training; and yes, they deserve to be well-compensated. But at the levels that they earn today?

When they say they are "under-reimbursed" (as Dr. Mark Warner, president of the anesthesiologist group says), what do they mean? Will they have to go on welfare, or does it mean that maybe they will make $20-30K less next year? Maybe instead of that $100K Mercedes 500S, they will have to settle for an $80K Lexus (note, not American-made). Have you ever looked at the magazines in a physician's waiting room? Luxury goods galore are being advertised in journals directed at the very rich.  O.K., O.K., I admit that many physicians are struggling to pay back the costs of their education and their office overhead has increased, but to say that they will abandon patients and refuse Medicare if they don't get to keep their high rates of reimbursement when austerity is not needed but demanded, borders on uncontrolled greed.

The fact is that over 50% of all health care is already being paid or subsidized by the government. To threaten to "kill the golden goose" is outrageously short-sighted and self-defeating. Yes, 30,000-50,000 physicians could survive very well without Medicare and other government programs, but there are over 700,000 of them practicing out there, what about the rest? How long could they go without Medicare should they boycott over these changes?  If the Balanced Budget Act of 1997 (a GOP-sponsored and passed bill, BTW) had been fully applied, physicians reimbursement under Medicare would already be 23% less. But, of course, physicians have blocked the application of that law, every year by threatening to stop taking Medicare patients. The nation's health care is being held hostage by the need to maintain physician incomes at ultra-high levels.

The IPAB isn't a solution to the problem, we still need a wholesale restructuring of the processes by which health care is delivered, i.e., fewer ultra-high compensated physicians at the primary care level and more what I like to call "medical extenders." (I don't like the term "physician assistant" and while "nurse practitioner" is better, but it still inadequately describes what we need.) We need a large cadre of well-educated, well-trained primary care providers, who would be in charge of most first-level care.  Medical doctors, with years more of training, would almost all be highly-trained (and very well compensated) specialists taking referrals from these primary providers.  These well-educated, well trained primary practitioners would be well-paid (low to mid $100K, in today's dollars), sufficient to attract the numbers of qualified individuals to the profession, but not at the levels paid to fully licensed and frequently over-educated, over-trained, and over-paid physicians now providing this care. I know, I know, this turns the oft-used mantra "we need more primary care physicians" on its head. We don't and it is a fool's rush to say we do.

Of course, the physician lobby opposes this. It's a threat to them. But in practice, we might get by with fewer than 500,000 specialist physicians and have more than 1 million primary care providers for virtually the same dollars with, in my opinion, better care for all.  But then that's me.  Ain't gonna happen under present political movements... but the risk is high, ultimately, the US health care system will collapse of its own weight... and that will be the worst result of all.

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

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).

Let Sleeping Gorillas Lie: Setting the Benefit Rules Under PPACA

Deep down in the bowels of the 2309 pages of the Patient Protection and Affordable Care Act of 2010 (“PPACA”) – lies an 800 pound gorilla of an issue, the one that has given rise to claims of a “government takeover of health care.”   PPACA (PL 111-148, PL 111-152) requires the Department of Health and Human Services (DHHS) to decide which medical services and equipment are "essential health benefits" that must be covered by every health insurer will. Drug and device manufacturers, physicians and other providers, patients, and others are watching closely to see how DHHS officials settle questions such as whether the government will spell out every treatment that insurers must cover or write the rules more broadly.

The discussion was kicked off in early January at the Institute of Medicine, an arm of the National Academy of Sciences, which will held one closed-door meeting followed by a two-day public briefing. The institute is charged with producing recommendations for HHS, which it is expected to issue in September. IOM officials will hold several additional meetings, with the next round expected in March. The institute's report will not spell out which specific services should be covered but will advise DHHS officials on policy principles and criteria to consider.

As a practical matter, many policy makers believe DHHS officials will issue a proposed rule on essential health benefits by the end of the year so that insurance plans will have time to change benefits as needed before the provisions take effect in 2014.

The Federal Role: The discussion goes to the core of disagreements over how much influence the federal government should have over coverage in the United States. The implications are huge for companies whose products could be excluded or patients whose care will depend on what insurers will reimburse.

The discussion goes to the core of disagreements over how much influence the federal government should have over coverage in the United States. The implications are huge for companies whose products could be excluded or patients whose care will depend on what insurers will reimburse.

The definition of essential health benefits will have a huge impact on providers of medical products and services. In many cases, it will determine whether their products or services are paid for or not. This is the sleeper issue of health reform.

One key question is whether DHHS officials will be prescriptive in detailing which treatments should be covered, or will give insurers more flexibility. The law specifies general categories that insurers must cover—such as outpatient and inpatient care, emergency services, pediatric dental and vision care, wellness services, rehab therapy and mental health care.

Beyond those broad categories, the DHHS Secretary is required to ensure that the scope of essential health benefits "is equal to the scope of benefits provided under a typical employer plan, as determined by the Secretary." DHHS officials will rely in part on a survey that the Labor Department will conduct of employer plans.

Under some federal programs, such as the Medicare part D prescription drug programs, insurers are free to design benefit plans differently as long as they provide a certain value of overall coverage. But when it comes to the minimum benefit package, the law does not give insurers as much leeway.

But it is unclear whether DHHS officials will seek to provide a specific list of treatments or take a broader approach, such as asking insurers to mirror benefits in particular plans, such as the most popular insurance policies in a state or in the Federal Employee Health Benefits Program (the “FEHBP”). If DHHS leaders take the more general route of tying the new standards to existing insurance plans, then they will have to fine-tune that because the law does not allow some current practices, such as charging patients higher rates if they are older, are terminally ill or have disabilities.

The language that protects against the higher rates contains a clause that some attorneys find curious. The provision says that DHHS officials shall "not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability or expected length of life." That wording raises questions about whether DHHS officials will be engaged in decisions that have traditionally been made by insurers—including making coverage decisions, setting rates, creating incentive programs or designing benefits.

How Much Is Enough? Another question centers on what level of coverage DHHS officials will require insurers to provide.

"My concern is that they will set the minimum so generously that it will be difficult to make it affordable—and subsidies will have to be high and rich to enable people to get that coverage," said Nancy L. Johnson, a former GOP House member from Connecticut. In other words, if DHHS officials decide that the typical employer-sponsored insurance plan covers a wide range of expensive services, then the cost of insurance could be high. The law provides subsidies for coverage for people earning up to four times the federal poverty level, so the federal government would be picking up some of the costs of that insurance for many Americans.

A third issue arising from that language is the definition of "discriminate" and how far federal officials will go in making sure policies are not discriminatory.  Will the new law allow provisions of the Americans with Disabilities Act to be applied to health insurance, for example? Up until now they have not been. However, the discrimination language does not mean that insurance companies must stop placing limits on the amount of care patients get. For instance, insurers will probably be able to continue putting limits on services—say, restricting care to a certain number of days of treatment—as long as the limits apply to everyone.

It is not yet known whether federal officials will pore through treatment guidelines and coverage exclusions that are buried in insurance documents that most patients don't read in order to make sure there are no policies that treat people with certain conditions differently.

All of these issues have the potential to significantly change insurance practices and the practice of medicine.

The question is, what do a lot of these terms mean? There's no legislative history on it. How much does the secretary exert her power over coverage? It's going to be a huge fight. This is one of the foundational aspects of the law.

Official Definition of "essential health benefits" as defined at PPACA's official site: http://www.healthcare.gov/glossary/e/essential.html

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

The above chart from the OECD is disconcerting.  The U.S. ranks 22nd in the number of physicians per 1,000 population among the 30 industrialized nations who are members of the OECD.  But our physicians are (except for Japan) the highest compensated of all the nations listed.  Supply and demand? Has the number of trained physicians been deliberately held down by vested interests.  Are U.S. standards for physician-training and licensing so high that we keep competition out?

I have discussed my views about the issue of the number of primary care practitioners and how we might move toward doubling the number of providers earlier. A  Does this "shortage" play a part in the cost disparency in the provision of U.S. health care versus other industrialized nations?  In my opinion, it does.  What are we going to do about it?  Probably nothing because too many vested interests stand in the way and we lack the political will and muscle to do anything about it. <sigh>

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 http://www.nytimes.com/2012/04/19/us/vatican-reprimands-us-nuns-group.html 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].

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