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theJeanneScottletter

THIS WEEK IN HEALTH CARE REFORM

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

February 17, 2011

This week’s issue of theJeanneScottletter refers you to latest new postings at my site:

This is high season for budget blueprints on Capitol Hill.

http://www.health-politics.com/issue.html#jost

Kaiser Family Foundation "Pop Quiz" -- Testing American Understanding of PPACA... er, "Obamacare"

http://www.health-politics.com/issue.html#popquiz

Katie Bar the Door, All Heck Breaking Loose Over Obama's Proposed "Doc-Fix"

http://www.health-politics.com/issue.html#docfix

The "Doc-Fix" ... Blaming the SGR Crisis on PPACA; and Holding PPACA Hostage

http://www.health-politics.com/issue.html#SGR

Happy Valentine's Day, Here's My 2012 Budget, says President Obama

http://www.health-politics.com/issue.html#budget2011

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

http://www.health-politics.com/issue.html#ranking

PPACA Does Raise Some Taxes; And Gives Some Tax Breaks, Too. Here's the List:

http://www.health-politics.com/issue.html#ducktax

Some Medicare Part D Drug Plan "Doughnut Hole" FAQs

http://www.health-politics.com/issue.html#donutFAQs

Budget Cuts, Budget Cuts ... Oh What to Cut ... What to Cut: TeaParty vs. GOP vs. America

http://www.health-politics.com/issue.html#teagop

Politico ran a story about the 16 freshman TeaParty/GOPers who have turned down their government health care insurance. It is interesting for the incongruous responses given (and as usual I have added a comment or two... or seven... or eight):

http://www.health-politics.com/issue.html#freshman

And other very good things to see and know:

Killing the IPAB, one last chance at real cost controls for Medicare…

www.health-politics.com/breaking.html#killIPAB

Law Jokes are on the Humor page:

www.health-politics.com/humor.html

GENERAL COMMENTS

Reminder: The HUMOR page on my web site has been updated and a whole new section of “DOCTOR-LAWYER” jokes has been added (some may be offensive, so please be advised). http://www.health-politics.com/humor.html#medicinevslaw. Several other new jokes have been added and a couple f old ones deleted. Check back often for new ones

Jeanne is always looking for new good “clean” (O.K., even not so clean) lawyer jokes. jeanne.matthews@health-politics.com

Jeanne’s Speaking:

INDIANA HFMA, WINTER INSTITUTE
Date: Thursday, February 24, 2011
Where: Renaissance North, Indianapolis
Contact: Shawn Williams, SWilliams@blueandco.com

WASHINGTON-ALASKA HFMA, EVERGREEN AAHAM
Date: Friday, February 25, 2011
Where: Seattle Hilton Airport Conference Center
Contact: David Heilsberg, HeilsbJ@whmc.org

UTAH HFMA
Date: Friday, March 11, 2011
Where: Salt Lake City
Contact: Chris Bruerton, Christopher.Bruerton@imail.org

KENTUCKY HFMA
Date: Thursday, March 17, 2011
Where: Lexington
Contact: Theresa Scholl, theresa.scholl@clarkmemorial.org

NEBRASKA AAHAM
Date: Friday, April 22, 2011
Where: Holiday Inn Midtown, Grand Island NB
Contact: Velda Walker, Velda.Walker@boystown.org

OKLAHOMA HFMA
Date: Friday, April 29, 2011
Where: Renaissance Hotel, NW Hwy.
Contact: Velda Walker, velda.walker@boystown.org

IOWA "HAWKEYE" AAHAM
Date: Thursday-Friday, September 15-16, 2011
Where: Hilton Garden Inn, Johnson IA
Contact: Kristina Gursky, KGursky@icsystem.com

PHILADELPHIA & KEYSTONE AAHAM CHAPTERS
Date: Tuesday-Thursday, September 20-22, 2011
Where:
Contact: Carolyn Brown, cbrown@philhaven.org

AAHAM ANI NATIONAL
Date: Thursday, October 6, 2011 (keynote)
Where: The Wynn, Las Vegas NV
Contact: Sharon Galler, sharon@aaham.org

Back on the speaker’s circuit, Jeanne’s schedule is filling up fast as she is in the midst f discussions with several other groups for dates in 2011 and even 2012. If interested give her a buzz: 703-371-4894, jeanne.matthews@health-politics.com

And finally….

As always, let me know your questions. I am still an amateur at web site maintenance (and can’t afford a professional “webmaster” <sigh>), so bear with me if there are glitches and “challenges.” Do let me know any technical issues… and make sure your personal or corporate e-mail system doesn’t simply route this to “SPAM.”

Hang in there…

theJeanneScottletter

THIS WEEK IN HEALTH CARE REFORM

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

February 10, 2011

This week’s issue of theJeanneScottletter refers you to latest new postings at my site:

Congress Passes Socialized Medicine and Mandates Health Insurance ... in 1798

http://www.health-politics.com/issue.html#1798

The Medical Industrial Complex is Pumping Tens of Thousands to Support TeaParty/GOP

http://www.health-politics.com/issue.html#campaign$

ACCOUNTABLE CARE ORGANIZATIONS: New Rules Soon … Very Soon

http://www.health-politics.com/issue.html#ACOs

Alternatives to the Individual Mandate? Be Careful What You Ask For!

http://www.health-politics.com/issue.html#alternative

Happy Birthday Ronald Reagan

http://www.health-politics.com/issue.html#Reagan

Will PPACA Cost More Than Predicted? Maybe, But Whatever it Costs, It Will Be Less than Doing Nothing

http://www.health-politics.com/issue.html#donothing

PPACA Calls For New, Simplified Health Insurance Forms

http://www.health-politics.com/resource.htm#forms

Pay Gap: Women Physicians Falling Further Behind Their Male Counterparts

http://www.health-politics.com/issue.html#paygap

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

http://www.health-politics.com/breaking.html#means

Health Care Now 17.6% of GNP, Oh My! Oh My!

http://www.health-politics.com/breaking.html#GNP

And other very good things to see and know:

Mark Fiore, an animated political cartoon (making fun, of among others, Mike Huckabee’s TV-ad opposing PPACA).

http://www.markfiore.com/forward/emailref/1977l

GENERAL COMMENTS

Jeanne is always looking for new good “clean” (O.K., even not so clean) lawyer jokes. jeanne.matthews@health-politics.com

Jeanne’s Speaking:

INDIANA HFMA, WINTER INSTITUTE
Date: Thursday, February 24, 2011
Where: Renaissance North, Indianapolis
Contact: Shawn Williams, SWilliams@blueandco.com

WASHINGTON-ALASKA HFMA, EVERGREEN AAHAM
Date: Friday, February 25, 2011
Where: Seattle Hilton Airport Conference Center
Contact: David Heilsberg, HeilsbJ@whmc.org

UTAH HFMA
Date: Friday, March 11, 2011
Where: Salt Lake City
Contact: Chris Bruerton, Christopher.Bruerton@imail.org

KENTUCKY HFMA
Date: Thursday, March 17, 2011
Where: Lexington
Contact: Theresa Scholl, theresa.scholl@clarkmemorial.org

NEBRASKA AAHAM
Date: Friday, April 22, 2011
Where: Holiday Inn Midtown, Grand Island NB
Contact: Velda Walker, Velda.Walker@boystown.org

OKLAHOMA HFMA
Date: Friday, April 29, 2011
Where: Renaissance Hotel, NW Hwy.
Contact: Velda Walker, velda.walker@boystown.org

IOWA HFMA
Date: Thursday-Friday, September 15-16, 2011
Where: Hilton Garden Inn, Johnson IA
Contact: Kristina Gursky, KGursky@icsystem.com

PHILADELPHIA & KEYSTONE AAHAM CHAPTERS
Date: Tuesday-Thursday, September 20-22, 2011
Where:
Contact: Carolyn Brown, cbrown@philhaven.org

AAHAM ANI NATIONAL
Date: Thursday, October 6, 2011 (keynote)
Where: The Wynn, Las Vegas NV
Contact: Sharon Galler, sharon@aaham.org

And finally….

Hang in there…

theJeanneScottletter

THIS WEEK IN HEALTH CARE REFORM

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

February 3, 2011

This week’s issue of theJeanneScottletter refers you to latest new postings at my site:

Federal Court Decisions Holding PPACA Unconstitutional are Poorly Reasoned

http://www.health-politics.com/issue.htm#judges

Is PPACA to Blame for Health Insurance Premium Increases?

http://www.health-politics.com/issue.html#insurance

More Lies about PPACA ???

http://www.health-politics.com/issue.html#lies2

TeaParty/GOP Senatecritters Introduce Bill to Gut PPACA

http://www.health-politics.com/issue.html#gutPPACA

U.S. Total Taxes (federal, state and local) are the lowest since 1950

http://www.health-politics.com/issue.html#taxes

Congresscritter Paul Ryan’s “Government Hammock”

http://www.health-politics.com/issue.html#hammock

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

http://www.health-politics.com/breaking.html

And other very good things to see and know:

A president uses his pulpit to call for health reform, but initial agreement over the need for change eventually descends into partisan bickering. Angry constituents shout down lawmakers during congressional town halls. Congress ultimately faces pressure to repeal the health law. If this all sounds familiar, it's because it already happened — in the fight over the Medicare Catastrophic Care Act, more than two decades ago:

http://www.californiahealthline.org/road-to-reform/2011/when-health-repeal-was-catastrophic.aspx

GENERAL COMMENTS

The HUMOR page on my web site has been updated and a whole new section of “DOCTOR-LAWYER” jokes has been added (some may be offensive, so please be advised). http://www.health-politics.com/humor.html#medicinevslaw

Hang in there…

theJeanneScottletter

HEALTH CARE REFORM UPDATE

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

January 27, 2011

theJeanneScottletter as many of you may have come to know and, (hopefully) love, is no more. Something better (maybe) this way comes.

From now on, I will be regularly sending links to my web site – www.health-politics.com -- (where you can “enjoy” my insightful, perhaps sometimes jaundiced, and yes, now-and-then over-the-top comments) along with links to news items and other sites where you can keep up with the fast-moving developments in health care reform.

If you miss the lawyer jokes and other Jeanne-type “humor,” I will be posting many items on the humor page of my web site: www.health-politics.com/humor.html

This week’s issue of theJeanneScottletter refers you to latest new postings at my site:

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

http://www.health-politics.com/issue.html#toofew

The State of the Union

http://www.health-politics.com/issue.html#sotu2011

Let Sleeping Gorillas Lie: Setting the Benefit Rules Under PPACA

http://www.health-politics.com/issue.html#gorillas

TeaParty/GOP Plan Would Decimate Key Services

http://www.health-politics.com/issue.html#decimate

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

http://www.health-politics.com/issue.html#uninsuredCDC

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

http://www.health-politics.com/issue.html#killIPAB

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

http://www.health-politics.com/breaking.html

And other very good things to see and know:

FACTCHECK.ORG

http://factcheck.org/2011/01/factchecking-obamas-address/

Hang in there…

theJeanneScottletter

HEALTH CARE REFORM UPDATE

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

January 10, 2011

(See important updates on Jeanne below, especially the new and improved web site: www.health-politics.com)

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.

O.K., O.K., I know the new theJeanneScottletter isn’t as much fun as the old one, but we can still have fun. A couple of things are happening: more and more communications are going out via the new “social media” – Facebook and twitter, for example. I haven’t yet gotten the hang of twitter (granddaughters are you listening, I need help), but I am on Facebook, and you can see my almost daily postings, paronomasia (look that one up), “NEW” lawyer jokes (rare) and political mutterings, just “friend me” and you can see what’s happening 2-3 times a day.

More critically is that I have updated – and will continue to update – my web page, adding new features and… A BLOG! Now I admit now that I gave reached an advanced age and following my recently re-built and rehabilitated heart (it does prove that lawyers have a heart, even if they have to borrow one from someone else), my social inhibitions have changed. I spent 40 years in and around Washington working on health care, I’m not about to give up now. www.health-politics.com Don’t forget the hyphen, it’s very important.

SPEAKING

I am still on the road speaking, with the latest topic title (building on my “PPACA for Dummies” theme): “PPACA: It Really is a Big [Bleeping] Deal. Save it, Build on it, Reform it, or Kill it. You Choose”

Vice President Joe Biden was quoted as saying on the passage of the health care reform law (the “Patient Protection and Affordable Care Act of 2010”, “PPACA”), that this was a big [bleeping] deal. And it was… a dramatic new direction for U.S. health care. But since then, the law’s opponents have been on the attack. Republicans swept the fall 2010 elections vowing to repeal the new law. Will they? Most polls show that with the exception of the insurance mandate provision, Americans favor the new law, especially the protections afforded against predatory private insurance companies. What will happen in 2011 and beyond? Jeanne Scott Matthews brings over 40 years of inside the beltway Washington DC experience in health care to try to shed some light on what might happen. You don’t want to miss her presentation… as whatever happens, U.S. health care will be changed forever.

It’s so much fun, you wouldn’t want to miss it.

Watch for me at some of these really cool future events:

Tri-State HFMA, Tunica, Mississippi, January 19, 2011

American Society for Automation in Pharmacy, Amelia Island, Florida, January 21, 2011

Indiana HFMA Winter Institute, Indianapolis, February 24, 2011

Washington Alaska HFMA, Seattle, February 25, 2011

Kentucky HFMA, Lexington, March 17, 2011

Oklahoma HFMA, Oklahoma City, April 28, 2011

LAWYER JOKE

And we do need a lawyer joke: (remember, I have long ago run out of the clean family lawyer jokes and have started to open my R-rated files … the X-rated may have to wait … so don’t blame me … well O.K. … you can blame me)

A really, really DUMB lawyer joke:

Joe was a successful lawyer in his 30's. He had a booming corporate practice, a good home, a loving wife and children. In fact, only one thing darkened his skies; he had back pains. These pains had been going on for a number of years and, despite all the doctors' advice and treatment, had grown increasingly worse. Finally Joe is referred to a specialist who runs some tests on him. The specialist tells him, "You have a rare condition where your testicles have receded up into your body and are pressing against your spine, giving you one hell of a backache."

"What can be done?" asks Joe.

"The only treatment for this is to remove your testicles."

Well, Joe is quite taken aback with this advice, but - after talking it over with his wife - agrees that it is an acceptable price to pay for relief of the backaches.

So, the day arrives and the operation is performed. Afterward, when he is back on his feet, Joe is feeling depressed, in spite of the fact that his backaches are now gone. He doesn't feel much like a man any more.

To ease his distress, he decides to go to the clothing store and treat himself to something nice to wear. He goes in and is greeted by the salesman who asks what he desires.

"I'd like to look at a new coat."

"Certainly, sir. You'd be a 44 long."

"That's right! How did you know?"

"It's my job. Now, how about a nice pair of pants to go with it?"

"Sure."

"That would be a 33 medium."

"Right again! How did you know?"

"It's my job. And now, can I interest you in a shirt to compliment the coat and pants?"

"OK. What size am I?"

"A medium, with a 16" neck."

"That's amazing! You're right again."

"Just my job, sir. How about some shoes? You'd be a size 11D"

"Wow! Right again! Sure." By now Joe is feeling better.

Then the salesman suggests some new underwear to go with the new suit. "Your pants are a size 36."

"Nope," says Joe, "I'm a size 34."

"Oh no, sir. You're a 36."

"No, no. I've been a size 34 since I was 18."

The salesman looks distressed, but insists, "You are a size 36. If you wore a size 34, your testicles would be pressed up into your body and would give you one hell of a backache.

Pray for the all those involved in the shootings in Tucson this weekend: for the survivors and wounded that they may recover quickly and fully; for the slain, that they may rest in peace; for the families of those who were killed, that they may find some solace and understanding in the warm memories they will have of their loved ones now gone; and particularly for our nation, that this grievous wound will serve more to bring us altogether than to continue to tear us apart.

theJeanneScottletter

HEALTH CARE REFORM UPDATE

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

November 3, 2010

Jeanne is recovering from her post-election day hangover, so her thoughts today may be slightly discombobulated (where’s the alka seltzer <sigh>). But the issue of health care “reform” – the singular issue that she has been working on and for over the 40+ years she has been in Washington – is foremost in her haze of the new day. What now? Joe Biden called it a BFD when it passed last March 23, but the lies distortions and misrepresentations about the Patient Protection and Accountable Care Act that have circulated ever since have apparently won the day. The Koch brothers funded “Tea-Party” movement (and its defeat of moderates in the old Republican party), has won the first round and is ahead on points. Never underestimate the power of dumb people in large groups.

And while the Tea-Partiers do not have the votes to repeal PPACA, they do have the will and the intention to throw some pretty substantial roadblocks in its way and to continue their campaign of lying about the law and fabricating distortions and misrepresentations to confuse the electorate and panic seniors into voting against their own best interests.

Let’s look first at the Tea-Party roadblocks, first at the state level and in a later report, as the new Congress gets going, we’ll look at what we can expect from Washington… mostly gridlock and lots of shouting, screaming and bullying, but no real action). For now at least, the action is at the state level:

Many provisions in PPACA require state action for full implementation, But the 2010 election has seen Democratic governors in at least 10 states have been replaced by Tea-Party activists. The Tea-Party also picked up seats in legislatures in many states (http://www.ncsl.org/tabid/21253/default.aspx). In the four races for state insurance commissioner, two went to Tea-Party candidates opposed to the law, while voters in California picked a Democrat in favor of it. One incumbent ran unchallenged.

Tea-Party gubernatorial winners included Sam Brownback of Kansas, who called the reform law "an abomination." Tennessee's governor-elect, Bill Haslam, said the law is an "intolerable expansion" of federal power and a "reminder of the incredible arrogance of Washington." In Ohio, former House Budget Committee Chairman John Kasich defeated Democratic incumbent Ted Strickland after criticizing the law as doing nothing to control costs and echoing one of the biggest lies about PPACA, saying that the new law would "give bureaucrats more control over our personal health care decisions."

While unable to overturn the federal law, the newly elected officials will be under pressure to act. They could lean on their congressional delegations to repeal or change the legislation (more about this later), seek waivers from some of its provisions, veto state legislation related to it and appoint like-minded people to important positions, such as insurance commissioner slots. At the very least, states may opt to slow implementation, while Republican lawmakers look ahead to the 2012 presidential election.

"If the Republican governors were to get together and say 'we're going to derail this train,' they could do much more to reverse the national health [law] than an effort to repeal it in Congress," said Ross Baker, a political science professor at Rutgers University. "The governors could, without defying federal law, simply implement it inefficiently, throw sand in the gears."

But they also have to face reality, and the real world of politics: even governors who vehemently opposed the bill may be forced to come to the realization that if they don't act in key areas – such as establishing health insurance marketplaces (i.e., the exchanges) – the federal government will do it for them. In addition, the new law includes substantial new federal funding to expand the Medicaid program and grants to set up or bolster other programs, including public health. Governors may be reluctant to turn down the money. Or they may do as so many of them have already, publicly denounce the law while accepting the funding and they laying claim to the benefits the law gives to the state’s citizens. (See Minnesota governor and putative Tea-Party candidate for President in 2012, Tim Pawlenty.)

While Congress may end up in gridlock, the law requires state officials to make decisions in several during the next few years, with lasting impacts on consumers, insurers, state finances, employers and the uninsured.

States must decide whether to set up their own insurance marketplaces, called exchanges, and whether to grant state regulators more authority, such as the power to review and reject premium increases before consumers start paying the new rates. One of the most difficult steps will be planning how to enroll millions of newly eligible low-income residents into Medicaid programs starting in 2014. Obama administration officials say most states are already working to carry out the law – and they expect that will continue no matter how power may have shifted in Tuesday's election.

Creating Exchanges

State Tea-Party leaders could refuse to set up and run health insurance exchanges, marketplaces where consumers shop for health insurance coverage. But if the states don't do it, the federal government will do it for them. And many governors and insurance commissioners may balk at that.

States also determine how exchanges operate. They could, for example, allow all insurers in the market to offer their wares, just as Utah now does. Or they could be more selective, allowing only those that pass muster with the state or with an appointed group, as is currently done in Massachusetts.

Even Tea-Party governors most critical of the law will likely want to set up their own insurance exchanges, said Michael Leavitt, the former Governor of Utah who was secretary of Health and Human Services under President George W. Bush, and is now advising states on the matter. "My guess is that folks in Wyoming might not be enthusiastic about the federal government running an exchange in their state."

Overseeing Insurers

The new law calls for states to work with the federal government to establish ways to review what are deemed "unreasonable" premium increases, but it is up to the states to decide what to do about such increases. Many states currently do not give regulators veto power over premiums, although they can exert pressure on insurers. A handful of states allow insurers to file their new rates without waiting for any review.

State lawmakers must decide whether to boost their state insurance commissioner’s authority to reject premium increases or leave current law in place. As the public sees how PPACA strengthens the consumer in addressing the myriad of abuses that have become commonplace in the private health insurance sector, there will be pressure from the public – and from the federal government – to increase such authority.

Under the new law, most insurers must spend at least 85% of their revenue on direct medical care or issue rebates to consumers. Regulations outlining what is considered medical care – and how to issue refunds – are awaiting final approval by the Department of Health and Human Services… and are already being hotly contested by the private insurance industry.

States can seek an exemption from the rules if they fear that meeting them could cause severe disruptions in the market for individual coverage. Maine, which is served by very few insurers, has already said it would seek an exemption and more states are expected to follow.

Turn Down Federal Funding?

Another complication: Most states have already sought and accepted millions in federal grants to help increase scrutiny of premium increases, bolster consumer assistance offices and design health insurance exchanges. States that discontinue those programs would forfeit grant money in future years.

Still, not all states sought funding. Minnesota and Alaska, for example, did not seek money to begin planning for state-based exchanges. Wyoming, Iowa, Georgia and Minnesota also did not seek funding to boost insurance premium review efforts.

More grants will be available in 2011, including funding for community health centers. But elected officials may run into trouble with voters if their actions are seen as letting insurers off the hook for some of the law’s popular provisions, such as a bar on rejecting applicants with pre-existing conditions.

"If they are seen as a subsidiary of the insurance industry, that’s not good for them politically," says Jonathan Oberlander, professor of social medicine and health policy at the University of North Carolina-Chapel Hill.

Lies and Distortions About PPACA:

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: http://www.politifact.com/truth-o-meter/statements/2010/apr/27/bill-oreilly/oreilly-says-no-one-fox-raised-issue-jail-time-not/

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

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theJeanneScottletter

THIS WEEK IN HEALTH CARE REFORM

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

July 5, 2010

WILL IT OR WON’T IT? … REDUCE FUTURE FEDERAL DEFICITS

(A JEANNE SCOTT RANT)

Budget Debt Cartoon.gif

This week the argument about whether health care reform will make the government’s balance sheet better or worse has exploded once again. A new report by the Congressional Budget Office offers fodder for both sides: those who predict that, because of reform, tomorrow’s budget deficits will be even worse than they are today; and those who argue that “reform,” at least as envisioned in Patient Protection and Affordable Care Act, will actually reduce future federal spending deficits.

The new CBO report actually contains two different projections. The first and more optimistic is the “current law” scenario. In it, the CBO assumes that laws now on the books will remain on the books and that, over time, these laws will take effect as planned. As far as health care is concerned, that means the government implements PPACA as projected. It spends a lot of new money on Medicaid, drug assistance for seniors and subsidies for less affluent people buying private insurance. But it also saves a lot of money (by, for example, paying less money to for-profit Medicare Advantage plans and Medicare payment reforms to hospitals and other providers) and raises some new taxes (most notably, through a tax on expensive private health insurance plans, Medicare premium increases on the wealthy, and less so on neighborhood tanning salons <smile>).

Add it all up, as the CBO did, and the budget deficit actually gets a little smaller. The emphasis is on “little,” since the net reduction is actually pretty small (in relative terms, compared to total spending). Instead of running really, really, really big deficits, the government ends up running only really, really big deficits. Still, it’s an improvement -- and maybe even a bigger improvement than the CBO predicts. When calculating the current law scenario, CBO decided that reform would generate no new savings after 2030. In fact, many experts expect that reform’s greatest potential to generate savings lie in the medium- to long-term, as systems for reducing wasteful care become more adept. More important, health care reform includes myriad changes to the medical delivery system -- everything from creating an electronic medical record system to scrutinizing new drugs and devices for effectiveness. CBO does not anticipate these changes saving much money. But if they do -- as respected experts (including yours truly, claim they will -- then the savings could actually be substantially larger than CBO has allowed.

Of course, none of these means anything to the critics, who could care less what it looks like on paper. They insist the real problem with health care reform is that it will never be fully implemented. As this argument goes, policy-makers will chicken out when it comes time to impose cuts that affect powerful industries or enact taxes that might affect some constituents. (So what else is new <sigh>).

The CBO sketches out a possibility along those lines with its “alternative” scenario -- a world in which the government refuses to impose various policies that might be politically unpalatable. In this scenario, health care reform doesn’t reduce the deficit. It causes the deficit to rise, although, again, not by that much. Could this, more dour prediction prove correct? Absolutely. All of these projections -- the good ones and the bad ones -- are possible. But it’s wrong to assume the more pessimistic scenario is more likely.

During the 1990s, policy-makers passed -- and then implemented -- a set of tax and spending changes (the now infamous Balanced Budget Act of 1997, “”BBA”) that eventually balanced the budget and actually led to budget surpluses (you remember those?). But among these were cuts to Medicare actually more severe (as a percentage of total Medicare spending) than the ones health care reform anticipates.

The next decade’s policy-makers might not be as responsible as the last decade’s (hard to imagine, but they actually could do worse). But if not -- if they want to abandon the commitments of the new health reform law -- it won’t be easy. If, for example, a new president and Congress decide in 2017 they don’t really want to impose the new tax on health benefits, they can rescind it. But then they'll have to come up with something to replace the anticipated revenue -- or willingly run up even higher deficits. And, given the political consequences of either move, they might very well decide to stick with the tax after all.

If that all sounds fanciful, consider what is happening right now on the related BBA issue: planned sustainable growth rate reductions to physician payments in Medicare. The cuts are the product of a poorly designed BBA payment formula from the 1990s. But calls to rescind the formula have gone nowhere this year, because doing so would mean running higher long-term deficits and there’s no political appetite for that. Faced with this dilemma, Congress has instead resorted to passing a temporary stay, good for just a few months and paid for by money already set aside for other purposes. In this political environment, getting a “permanent fix” of the formula seems highly unlikely until somebody figures out how to pay for it.

True, political environments change. Two, five, or 10 years from now, politicians might decide to be careless with taxpayer dollars -- and taxpayers might let them get away with it. But that’s always true. Today’s lawmakers can’t force tomorrow’s to be fiscally responsible. All they can do is pass fiscally responsible laws and hope future generations carry them out. With health care reform, they’ve done just that.

IN OTHER NEWS

SOME STATE INSURANCE COMMISSIONERS PUSH BACK OVER FEDERAL CONTROLS OF HEALTH INSURANCE: Some state insurance commissioners are not happy with a proposal that would give the federal government the authority to centralize premium rate reviews of health insurance. The commissioners are organizing a renewed effort against the authority proposed by new legislation. The Health Insurance Rate Authority Act, introduced by Senatecritter Dianne Feinstein (D-Calif.) on March 4, would grant the DHHS secretary the power to approve, deny or modify premium rate increases in states -- 23 at the moment -- where insurance commissioners do not already have that regulatory authority. Her bill wouldn't supersede the authority of insurance commissioners who already have authority to review rates. But in some states — such as Illinois — Insurance Commissioners do not have much authority to review rates and can do little to stop increases before they are instituted. In others, like New York and Maine, insurance regulators are given broad authority. States where the Insurance Commission already has wide authority would not be impacted by the Feinstein proposal. The health insurance industry itself is backing those state insurance commissioners who oppose federal expansion, a significant number of which are located in “red” states.

BUT CONSUMER GROUPS ARE PUSHING FOR EVEN MORE CONTROLS OVER PRIVATE HEALTH INSURERS: Just as a few Insurance Commissioners and their supporters in the insurance industry have started a push back, consumer advocates are asking for even tougher rules on how much information insurers must provide to justify premium increases, a step required by the new health overhaul law.

Under PPACA, many insurers later this year will have to publicly report how much they plan to raise premiums and, most critically, why. Consumer advocates say that draft DHHS rules on what the information insurers must provide, fall short and should require details on increases in CEO salaries, broker commissions and prices charged by doctors, hospitals and drug companies. Insurers counter by saying that requiring too much information would add to their administrative costs. (???)

Under the new health overhaul law, insurers seeking “unreasonable” premium increases must publicly provide justification for their rates to consumers, state regulators and the federal Department of Health and Human Services (DHHS). The federal government will not have the power to reject premium increases, although some states have that ability. Federal officials still haven’t defined what will qualify as an unreasonable increase. The National Association of Insurance Commissioners is developing recommendations for federal regulators and has solicited opinions from insurers. The NAIC draft form includes queries about the maximum increase faced by policyholders, any increase or decrease in underlying medical costs and three years of average annual premium changes.

Consumer groups want additional information in that form about what medical providers are charging insurers. In a separate letter, the American Medical Association called on regulators to require more information about insurer administrative costs, including CEO salaries and lobbying expenses.

Insurers also weighed in. Aetna, for example, urged regulators to drop a requirement that the form include disclosure of minimum and maximum rate increases for individual policy holders, which it said would “add multiple levels of cost and complexity” to the reporting process. Averages would be sufficient, the insurer said.

After discussing points made by the consumer groups and insurers, the NAIC members agreed Thursday to make revisions to the form and reconsider it later this month. While the draft form probably provided enough information for a casual consumer wondering how much rates were going up, it lacked detail needed for groups, Congress, the media or others wanting to do a more sophisticated analysis, say those asking for more details. This year, such an analysis performed by auditors hired by California regulators uncovered errors in calculations used by insurers WellPoint and Aetna to justify premium hikes. Both companies withdrew the proposed increases following the audit.

REGULATIONS, REGULATIONS, REGULATIONS … WE HAVE LOTS AND LOTS OF NEW RULES

HERE IS JEANNE’S UPDATED LIST OF WHAT’S OFFICIALLY OUT THERE

GO AND READ THEM YOURSELVES, I’M GETTING TOO OLD FOR THIS (SMILE)

http://www.hhs.gov/ociio/regulations/index.html#patients

Patient’s Bill of Rights (Issued by the Office of Consumer Information and Insurance Oversight)

Regulation on “Grandfathered” Health Plans under the Affordable Care Act (Issued by the Office of Consumer Information and Insurance Oversight)

Dependent Coverage of Children Who Have Not Attained Age 26 (Issued by the Office of Consumer Information and Insurance Oversight)

Early Retiree Reinsurance Program (Issued by the Office of Consumer Information and Insurance Oversight)

Health Care Reform Insurance Web Portal Requirements (Issued by the Office of Consumer Information and Insurance Oversight)

COBRA Continuation of Coverage (Issued by the Centers for Medicare & Medicaid Services)

Health Insurance Reform for Consumers (Issued by the Centers for Medicare & Medicaid Services)

Health Insurance Reform for Employers (Issued by the Centers for Medicare & Medicaid Services)

Self-Funded Nonfederal Governmental Plans (Issued by the Centers for Medicare & Medicaid Services)

Requests for Comments

Medical Loss Ratios

Premium Review Process

DID YOU HEAR . . .

. . . about the tenacious lawyer whose client was hung. . .

. . . He sued for whiplash.

***

Did you hear about the famous Hollywood lawyer who specialized in motor vehicle cases . . .

. . . she was so good, she got Stevie Wonder a driver's license.

***

Did you hear about the time it got so cold . . .

. . . that lawyer's were putting their hands in their own pockets!

***

Did you hear about the lawyer who stepped in some cow dung . . .

. . . she thought she was melting...

Jeanne is back on the speaker’s circuit… and her fall schedule is rapidly filling up.

Give her a call now (703) 371-4894, or drop her an e-mail, jeanne.scott@health-politics.com

Hopefully she will soon have her web site back up. www.health-politics.com

“Personally, I don’t think you can make a lawyer honest by an act of legislature.

You’ve got to work on his conscience.

And his lack of a conscience is what makes him a lawyer.”

… Will Rogers

DID YOU HEAR . . .

Did you hear about the attorney who was a sports mechanic on the side . . .

. . . he fixed basketball games.

***

Did you hear about the lawyer who was so fond of arguing . . .

. . . he wouldn't eat anything that agreed with him.

Did you hear about the lawyer who lost his client's

marijuana appeal before the Supreme Court . . .

. . . He resolved to get the laws changed before a joint session of Congress.

***

Did you hear about the lawyer who fancied himself a wit in court?

. . . Actually he was only half right.

***

Did you hear about the lawyer who was lost in thought?

. . . Seems it was unfamiliar territory.

********************************************

theJeanneScottletter

THIS WEEK IN HEALTH CARE REFORM

IMPLEMENTING HEALTH INSURANCE REFORM

… Making U.S. Health Care Work …

June 28, 2010

HIGH RISK INSURANCE POOLS: The key early program of the nation's new health law aims to provide affordable coverage to about 200,000 people with pre-existing medical conditions, such as cancer or diabetes, through federal high-risk insurance pools. The law called for the program to be in place 90 days after its enactment, but “in place” and “operational” are two very different things. In practice, the pools will be ready for residents in about 20 states that asked the U.S. Department of Health and Human Services to run the pools for them, but of the 30 others that are running the pools themselves, 20 will be ready in early or mid-July and 10 are working through legislative and other issues that may take weeks or months to resolve. In Michigan, for instance, residents won't be able to join the pools until October. In Florida, government funding for the new coverage plan for these uninsured may only be enough to pay for fewer than 5 percent of those eligible, State officials estimate up to 750,000 Florida residents could potentially qualify for coverage in the government's high-risk insurance pool. But Jerry Ashford, who runs the Florida Comprehensive Health Association — the state's small, decades-old, high-risk insurance program — says the $351 million federal allocation to Florida may only cover 20,000 to 30,000 residents.

MAJOR CHALLENGE – DRAFTING AND PUTTING INTO EFFECT THE MYRIAD OF REGULATIONS NEEDED TO IMPLEMENT PPACA: Republicans have accused the Department of Health and Human Services of missing key deadlines, such as one requiring the establishment of an advisory committee for an advertising campaign to educate young women about breast cancer among others. HHS has, however, beaten some deadlines, as it did by sending out rebate checks to seniors who fall into the Medicare prescription "doughnut hole." But concerns remain high as to whether HHS — which bears most of the burden of implementing the reforms in the health care law — can effectively meet all of its objectives without making errors. The process for making rules is long and rigorous, and new rules often have to go through multiple agencies and departments.

THE INDEPENDENT PAYMENT ADVISORY BOARD: One of the key components of PPACA (and a serious but ephemeral contributor to its “cost savings” projections) is an independent advisory board, scheduled to start making recommendations on how to improve and coordinate care. To be appointed by President Barack Obama with the advice and consent of the Senate, Independent Payment Advisory Board members will determine new payment formulas under Medicare, subject to scrutiny from Congress and the Medicare Payment Advisory Commission. The Congressional Budget Office estimates the board will reduce Medicare spending by $28 billion through 2019.

The IPAB carries the weight of expectations and change on a variety of fronts. During the ugly process of enactment, lots of concessions had to be made in order to garner the votes needed for passage. The IPAB was specifically limited on any decisions that might be considered “killing Granny,” or rationing of health care. Whole groups of costs were to be initially considered “off-limits” to IPAB review. Although initially exempted from IPAB's decisions under a deal crafted with the White House and Senate leaders, hospitals are concerned about cuts coming from a variety of directions to healthcare, including this new board, Learn more about the IPAB in my handy-dandy “Everything You Ever Wanted to Know About the PPACA Independent Payment Advisory Board But Were Afraid to Ask,” segment below.

FOUR OUT OF FIVE DOCTORS SAY THAT IF THEY WERE STRANDED UPON A DESERT ISLAND WITH NO LAWYERS, THEY WOULDN'T NEED ANY ASPIRIN

THE TANNING TAX kicks in this week: Those who frequent tanners will be among the first to face tax increases as a result of the health-care reform bill signed by President Obama in March. Included in the more than 2,000-page bill was a provision set to begin Thursday that applies a new 10 percent tax on indoor tanning. The objections aren't necessarily to the tax itself — it'll mean about 50 cents added onto a typical $5 visit — but are more about the principle behind the tax. Called an “excise tax,” the fee is estimated — some say overestimated — to raise about $2.7 billion over the next 10 years. $2.7 BILLION ??? Will Americans spend $27 billion on tans? That seems a mite high.

REPEALING PPACA ??? There seems to be little public appetite anymore to repeal the health law. House members of both parties are ready to go home and explain what the law does, for better or worse, and in some cases, discuss possible reforms to answer those calling for repeal. When it comes to constituent and party leadership cries for repeal of the law, rank-and-file Democrats and Republicans agreed full repeal was unlikely in the near future, and it was better to focus on provisions that could be reformed.

***

Jeanne’s Lawyer Joke of the Week

Six surgeons were sitting around discussing their favorite patients when the first stated that he especially enjoyed operating on poets and artists because . . .

“When I cut them open, they are filled with beautiful colors and the operating room is bathed in wonderful light."

“No way!” said the second surgeon, “I prefer operating on accountants. Inside everything is neat and orderly and all the parts are numbered.”

“Nah,” said the third surgeon, “librarians are the best. Everything inside them is in alphabetical order."

The fourth responds: “Try electricians, man! Everything inside them is color coded!”

The fifth intercedes: “Personally, I prefer engineers. They always understand when you have a few parts left over at the end."

“You're all wrong,” said the sixth surgeon,

“The best are lawyers. No guts, no heart, no spine.

They only have two parts -- their mouths and their rears, and both of these are interchangeable!”

Used with permission

We've all heard that a million monkeys banging on a million typewriters will eventually reproduce the entire works of Shakespeare. Now, thanks to the Internet, we know this is not true.

Jeanne is back on the speaker’s circuit… and her fall schedule is rapidly filling up.

Give her a call now (703) 371-4894, or drop her an e-mail, jeanne.scott@health-politics.com

Hopefully she will soon have her web site back up. www.health-politics.com

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