The Politics of Health Care

[Crafty_Dog]

Expert: Premiums for Individual Health Plans in Exchange Will Be High
Next year, premiums for individual health plans offered through the state health insurance exchange will grow significantly from current rates, according to a health insurance expert, the Sacramento Business Journal reports.
Last week, Garry Maisel -- CEO of Sacramento-based Western Health Advantage -- discussed the issue at a Drexel University-sponsored event on health care costs (Robertson, Sacramento Business Journal, 5/10).
Details of Exchange
The exchange -- named Covered California-- primarily will serve individuals and small businesses.
Supporters hope that the exchange will function similar to websites like Amazon and Expedia so that users will be able to choose between various health plans through an easily navigable online store.
The exchange is expected to open for registration in October (California Healthline, 5/10).

On May 23, the exchange is scheduled to name the health insurers that it has selected to offer plans through the online marketplace.
The insurers then will file proposed rates with state regulators.

Details of High Premiums

Maisel said that he thinks premiums for individual health plans "will go up 40% to 70% … and this will cause a national furor."
He said a variety of factors could boost premiums for individual health plans in the exchange, including that:

•   Policies will offer more choice and more closely resemble employer-sponsored health insurance;
•   Health plans will be paying a greater percentage of health care costs;
•   Insurers will not be able to deny coverage for individuals based on pre-existing conditions or charge more for poor health status;
•   Health plans will be required to charge younger beneficiaries a higher percentage of what older people pay for insurance;
•   Higher enrollment of older individuals will mean higher health care costs; and
•   Many individuals will be eligible for health plan subsidies (Sacramento Business Journal, 5/10).

==========
As far as our group plan premium goes, we are going up "only" 21.8% 

[DougMacG]

Some are starting to figure out the connection between our failed trust in the IRS and the trainwreck known as Obamacare.  The first big investment the federal government made in heathcare reform was for the IRS to spend (invest?) nearly a billion and hire thousands of new IRS agents to scrutinize further those of us that they believe need more scrutinizing.  http://www.breitbart.com/Big-Government/2012/07/07/ObamaCare-Irs-Agents

Byron York today:

http://washingtonexaminer.com/byron-york-irs-scandal-raises-fears-about-enforcing-obamacare/article/2529589

What's happened heightens fears about how the IRS will handle taxpayer information and wield its power when it enforces Obamacare starting next year."

The IRS is critical to Obamacare. The structure created by the Affordable Care Act requires the government to know about both the health care coverage (or lack of it) and the financial resources of every American. The IRS, which already knows the latter, was the only agency with the reach to do the job.
Sign Up for the Byron York newsletter!

A look at the text of the health care law reveals that much of it consists of amending the Internal Revenue Code to give the IRS more power. When Obamacare goes fully into effect in January, every American will have to prove to the IRS that he or she has "qualifying" health coverage, meaning coverage with a list of features approved by Health and Human Services Secretary Kathleen Sebelius. That will be done by submitting a document to the IRS, something like a W-2, to confirm coverage.

The IRS will also decide who is, and who is not, eligible for Obamacare's subsidies. The law authorizes the IRS to share confidential taxpayer information with the Department of Health and Human Services for the purpose of determining those subsidies. And since subsidies don't just apply to a relatively small number of the nation's poorest citizens -- under the law, they can go to a family of four with a household income of nearly $90,000 -- they will affect a huge segment of the population.

In addition, the IRS will keep track of even the smallest changes in Americans' financial condition. Did you get a raise recently? You'll need to notify the IRS; it might affect your subsidy status. Have your hours been reduced at work? Notify the IRS. Change jobs? Same.

Last August, IRS official Nina Olson testified before Congress on the changes Obamacare will bring to Americans' dealings with the nation's tax collector. "Do you believe that most Americans are going to update the IRS or state exchanges when they change jobs, get married, move states, whatever?" Michigan Republican Rep. Tim Walberg asked Olson.

"I think it's going to be a very great learning curve," Olson answered. If Americans don't keep the IRS up to date on their financial status, they might incur penalties, which the IRS will collect by withholding income tax refunds. "I think it will be a surprise to taxpayers if they don't update their information,"
-------
WSJ today:

A larger government always creates more openings for abuse, as Americans will learn when the IRS starts auditing their health care in addition to their 1040 next year.

"ObamaCare is "the most extensive social benefit program the IRS has been asked to implement in recent history."  This March the IRS Inspector General reiterated that ObamaCare's 47 major changes to the revenue code "represent the largest set of tax law changes the IRS has had to implement in more than 20 years." Thus the IRS is playing Thelma to the Health and Human Service Department's Louise. The tax agency has requested funding for 1,954 full-time equivalent employees for its Affordable Care Act office in 2014."

"Instead of going after tax cheats, these bureaucrats will write and enforce tax regulations for parts of the economy in which they have no core competence. For example, do ski instructors or public school teachers count as seasonal workers? How long is a "full time" work week? Is it 40 hours, or 30?"

"...the IRS and HHS are now building the largest personal information database the government has ever attempted. Known as the Federal Data Services Hub, the project is taking the IRS's own records (for income and employment status) and centralizing them with information from Social Security (identity), Homeland Security (citizenship), Justice (criminal history), HHS (enrollment in entitlement programs and certain medical claims data) and state governments (residency)."
http://online.wsj.com/article/SB10001424127887324715704578481461934680982.html?mod=WSJ_Opinion_LEADTop

What could possibly go wrong?

Newt Gingrich:  "Why would you trust the bureaucracy with your health if you can't trust the bureaucracy with your politics?"

[ccp]

The Obama crony in charge of your medical records
   
By Michelle Malkin  •  May 22, 2013 06:43 AM

The Obama crony in charge of your medical records
 by Michelle Malkin
Creators Syndicate
 Copyright 2013

Who is Judy Faulkner? Chances are, you don’t know her — but her politically connected, taxpayer-subsidized electronic medical records company may very well know you. Top Obama donor and billionaire Faulkner is founder and CEO of Epic Systems, which will soon store almost half of all Americans’ health information.

If the crony odor and the potential for abuse that this “epic” arrangement poses don’t chill your bones, you ain’t paying attention.

As I first noted last year before the IRS witch hunts and DOJ journalist snooping scandals broke out, Obama’s federal electronic medical records (EMR) mandate is government malpractice at work. The stimulus law provided a whopping $19 billion in “incentives” (read: subsidies) to force hospitals and medical professionals into converting from paper to electronic record-keeping systems. Penalties kick in next year for any provider who fails to comply with the one-size-fits-all edict.

Obamacare bureaucrats claimed the government’s EMR mandate would save money and modernize health care. As of December 2012, $4 billion had already gone out to 82,535 professionals and 1,474 hospitals; a total of $6 billion will be doled out by 2016. What have taxpayers and health care consumers received in return from this boondoggle? After hyping the alleged benefits for nearly a decade, the RAND Corporation finally admitted in January that its cost-savings predictions of $81 billion a year — used repeatedly to support the Obama EMR mandate — were, um, grossly overstated.

Among many factors, the researchers blamed “lack of interoperability” of records systems for the failure to bring down costs. And that is a funny thing, because it brings us right back to Faulkner and her well-connected company. You see, Epic Systems — the dominant EMR giant in America — is notorious for its lack of interoperability. Faulkner’s closed-end system represents antiquated, hard drive-dependent software firms that refuse to share data with doctors and hospitals using alternative platforms. Health IT analyst John Moore of Chilmark Research, echoing many industry observers, wrote in April that Epic “will ultimately hinder health care organizations’ ability to rapidly innovate.”

Question: If these subsidized data-sharing systems aren’t built to share data to improve health outcomes, why exactly are we subsidizing them? And what exactly are companies like Faulkner’s doing with this enhanced power to consolidate and control Americans’ private health information? It’s a recipe for exactly the kind of abuse that’s at the heart of the IRS and DOJ scandals.

As I reported previously, a little-noticed HHS Inspector General’s report issued last fall exposed how no one is actually verifying whether the transition from paper to electronic is improving patient outcomes and health services. No one is actually guarding against GIGO (garbage in, garbage out). No one is checking whether recipients of the EMR incentives are receiving money redundantly (e.g., raking in payments when they’ve already converted to electronic records). And no one is actually protecting private data from fraud, theft or exploitation.

But while health IT experts and concerned citizens balk, money talks. Epic employees donated nearly $1 million to political parties and candidates between 1995 and 2012 — 82 percent of it to Democrats. The company’s top 10 PAC recipients are all Democratic or left-wing outfits, from the Democratic Congressional Campaign Committee (nearly $230,000) to the DNC Services Corporation (nearly $175,000) and the America’s Families First Action Fund Democratic super-PAC ($150,000). The New York Times reported in February that Epic and other large firms spent hundreds of thousands of dollars lobbying for the Obama EMR “giveaway.”

Brandon Glenn of Medical Economics observes “it’s not a coincidence” that Epic’s sales “have been skyrocketing in recent years, up to $1.2 billion in 2011, double what they were four years prior.”

It’s also no coincidence, as a famous Democratic presidential candidate once railed, that the deepest-pocketed donors “are often granted the greatest access, and access is power in Washington.” That same candidate, Barack Obama, named billionaire Democratic donor Faulkner as the only industry representative on the federal panel overseeing the $19 billion EMR “incentives” program from which her company benefits grandly.

The foxes are guarding the Obamacare henhouse. The IRS vultures are circling overhead. The shadow of tyranny and the stench of corruption are unmistakable. If you see something, say something. BOLO is our watchword.

[Crafty_Dog]

An Open Letter to Massachusetts Physicians,

Last summer, the Commonwealth of Massachusetts enacted legislation that will fundamentally alter the physician-patient relationship by giving politicians the right to specify the processes that must occur during an office visit. The relevant law is Section 108 of Chapter 224 of the Acts of 2012, which reads as follows:

The first paragraph of section 2 of chapter 112 of the General Laws ... is hereby amended by inserting (the following)... The board (of Registration in Medicine) shall require, as a standard of eligibility for (medical) licensure, that applicants demonstrate proficiency in the use of computerized physician order entry, e- prescribing, electronic health records and other forms of health information technology, as determined by the board. As used in this section, proficiency, at a minimum shall mean that applicants demonstrate the skills to comply with the “meaningful use” requirements. http://malegislature.gov/Laws/SessionLaws/Acts/2012/Chapter224

Thus, any Massachusetts physician who does not use a Federally certified EMR AND meet the contemporary Meaningful Use requirements will be denied a license to practice medicine effective 2015. Most unfortunately, the Meaningful Use mandates will continue to become every more onerous in Stages 2, 3, 4, 5, 6 and 7.

As we all know, the practice of medicine has become increasingly difficult as a result of external mandates. These mandates specify which medicines we may prescribe, which radiology tests we can order, how many days our patients are allowed to remain in the hospital, which CME classes we must take, etc. And now, the politicians intend to tell physicians which software they must use in their office and which EMR options must be utilized during the office visit.

The Government's decision to foist “certified” EMRs on the medical profession is predicated on the hypothesis that the widespread adoption of EMRs will eventually reduce the cost of healthcare. Unfortunately, data published to-date does not support this hypothesis. (see http:// www.antheliohealth.com/downloads/Council-EHR-commentary.pdf) Thus, the continued imposition of the EMR mandates will only delay the implementation of a truly effective solution that could reduce the cost of healthcare.

As the developer of an EMR, I sincerely believe that a well designed EMR is a useful tool for many practices. However, the Federal and State Government's misguided obsession to stipulate which features must be in the EMRs, and how the physician should use the EMRs in the exam room places the politicians in the middle of the exam room between the patient and the physician, and seriously disrupts the physician-patient relationship.

It is past time that physicians reclaim control of their offices, if not the practice of medicine.

I strongly encourage all Massachusetts physicians you to contact Governor Deval Patrick, Secretary of Health and Human Services John Polanowicz, your Massachusetts state Senator and Representative and ask them to rescind Section 108 of Chapter 224 of the Acts of 2012. Also tell the politicians to desist from interfering in the physician-patient relationship, which is a prerequisite for high quality healthcare.

Please feel free to forward this letter to your colleagues. I also encouraged you to plagiarize this letter, as needed, for your communication to your state representative.

Hayward Zwerling, M.D. FACP, FACE

HZMD@me.com
mobile: 978-407-0101
President, ComChart Medical Software,  www.ComChart.com
The Lowell Diabetes & Endocrine Center, www.DiabetesEndocrine.com

[ccp]

Of course all edited by the liberal politburo members of taxachussets.

  Compare the hearty tugging headline with buried deep in the article is the fact that hospitals will have to eat the cost (thus try to recoup somewhere else) by billing everyone else more, or hit the states up for money.

****In 2011 alone, patients and families were spared nearly $150 million in hospital costs.


Hospital emergency room entranceBlend Images | ERproductions Ltd | Blend Images | Getty Images

(HealthDay News) -- An Affordable Care Act provision has shielded thousands of young U.S. adults and their families from millions of dollars in treatment costs for serious medical emergencies, a new study shows.

Starting in September 2010, federal health care reform has required private health plans to cover young adults up to age 25 under their parents' insurance.

More than 22,000 cases of emergency hospital treatment in 2011 involving young adults aged 19 to 25 received coverage under private plans due to the expansion, the study found. The coverage protected patients and parents from an estimated $147 million in hospital charges.

The study was published in the May 30 issue of the New England Journal of Medicine.

"Without this provision, they'd be facing hospital bills," said study author Andrew Mulcahy, a health policy researcher at RAND Health, a nonprofit research organization. "Their family might be on the hook for it. If they can't pay, as a last resort, the hospital might have to eat the cost and write it off. Ultimately, in some states, the taxpayers are on the hook because the state chips in and tries to compensate hospitals for care that is uncompensated."

The study also noted that the provision increased health insurance rates about 3 percent among the young adults who sought emergency treatment.

Recent reports have estimated that this particular provision of the Affordable Care Act has led to the coverage of an additional 3.1 million young adults nationally.

In the study, researchers examined details about emergency medical care provided to adults aged 19 to 31 at 392 hospitals from 2008 through 2011.

The study focused on injuries so severe that the young adults would have to receive emergency treatment regardless of insurance coverage, including broken bones and head injuries.

"We were very careful in looking at the most serious conditions -- conditions so serious you have to go to the ER for treatment," Mulcahy said. "This study is about real-world impact and a very direct test of whether the provision is improving financial protection."

Those sorts of injuries accounted for about 6 percent of emergency department visits by young adults, the researchers concluded.

The research team then compared the coverage of those aged 19 to 25 to patients aged 26 to 31, who were unaffected by the new health care law. That way, they could rule out other trends that might have affected the subjects' insurance coverage.

"We found that the provision resulted in increased financial protection for young adults and the hospitals who provided care for these patients," Mulcahy concluded. "We're careful to say it didn't result in additional visits. It's a shift. The provision didn't lead to more people going to the ER. They would have gone without this provision, but they would have been uninsured."

However, the RAND study's focus on nondiscretionary hospital treatment raises more questions than answers, said health economist Devon Herrick, a senior fellow at the National Center for Policy Analysis, a free-market think tank headquartered in Dallas.

"RAND is touting the financial protection provided by the Affordable Care Act, but then they say only 6 percent of these visits fall under the category of nondiscretionary," Herrick said. "The other 94 percent, to me, is the more interesting story. Are we wasting money on discretionary emergency room treatment? Are they going to the ER for trivial things that would better be left with them covering the cost rather than using their insurance?"

Herrick added that while the study notes in passing a 3 percent increase in insurance rates, it does not go into a more detailed cost-benefit analysis regarding the expanded coverage.

"What is it costing the employers' and parents' health plans, and the young adults?" he asked. "Could the same population have gotten very economical coverage on their own?"

More information

The U.S. Department of Health and Human Services has more about the Affordable Care Act.

SOURCES: Andrew Mulcahy, health policy researcher, RAND Health; Devon Herrick, health economist and senior fellow, National Center for Policy Analysis; May 30, 2013, New England Journal of Medicine

Copyright @2013 HealthDay. All Rights Reserved.****

     

[ccp]

I might add that the NEJM has become a political tool for the politburo health care policy makers at the IVys.  I believe that opposing views are more or less not printed. 

Jama has also succumbed to the political pressure.   In one article that was critical of the state of electronic health records and that so far they have not produced any productivity cost savings gains the author who is a IT doctor noted near the end of the article something to the effect that doctors should stop "whining" about EHR and just be glad they are a part of the "first phase" of the IT revolution in medicine.   This is akin to changing the phrase global warming to climate change.   All of a sudden this is the *first phase*.  Now that this guy's scheme is more or less failure.  Indeed this scumbag should stop whining about us, the people who are forced to put up with this and admit he has not done HIS job.

I was once asked to respond to a pre-published article about how doctors need to do more.  My response was that the author was misguided.  Doctors can be good caring doctors but I don't see why you are calling us to be masochistic saints.  I never got a response and his article to  my knowledge was never published.  In any case the medical community is more a less in a reign of quiet terror trying to comply.   

You think the IRS is tough?

[DougMacG]

http://thehill.com/blogs/healthwatch/health-reform-implementation/302895-court-challenges-could-tear-down-major-pieces-of-obamacare

Court challenges could tear down major pieces of ObamaCare

President Obama’s healthcare law is under attack in the courts even as the administration sprints toward full implementation.
 
Despite surviving a stiff challenge at the Supreme Court last year, some of the law’s biggest provisions remain at risk from legal challenges.  One set of lawsuits accuses the Internal Revenue Service of illegally implementing new subsidies to help people buy insurance. Separately, more than 60 lawsuits have been filed challenging the law’s mandate for health plans to cover birth control.
 
A loss for the administration on the contraception mandate would undermine a key selling point for the law that Democrats used to court women in the 2012 elections.
 
The challenge to the law’s insurance subsidies, while more obscure, poses a far bigger and more dangerous threat to the Affordable Care Act.  Simon Lazarus, senior counsel at the Constitutional Accountability Center, has argued that there’s a very real chance the Supreme Court’s conservative majority would strike down the IRS’s approach to insurance subsidies if it gets the chance.  Lazarus supports the healthcare law and believes the IRS has taken the right approach to implementing its subsidies. But it’s easy to see how the case could play out under the strict “textualist” approach championed by Justice Antonin Scalia, he said.
 
“One has to be concerned about that,” Lazarus said.  If the Supreme Court or judges in the lower courts adopt a narrow reading of the healthcare law, the consequences could be “devastating,” Lazarus said.  That’s exactly why the people behind the lawsuit think they have a real chance to win.
 
The healthcare law sets up new marketplaces where people can buy health insurance. Most people who use the marketplaces will be eligible for a subsidy to help pay for their premiums.  The law’s challengers say subsidies should only be available to people who get insurance through a state-run marketplace. If the federal government runs a state’s marketplace — which it will in the majority of states — no subsidies should be available, the lawsuit argues.  Why not? Because the text of the Affordable Care Act refers to subsidies flowing through exchanges “established by the state.”  The IRS has said subsidies will be available in all 50 states, no matter who runs the exchanges. The law’s critics say that clearly contradicts the text of the statute.
 
“The IRS rule we are challenging is at war with the Act’s plain language and completely rewrites the deal that Congress made with the states on running these insurance exchanges,” attorney Michael Carvin said in a statement when his clients filed their challenge to the subsidies.
 
The law’s supporters say the context of the entire statute makes clear that Congress intended for all 50 exchanges to function the same way.  “There are layers of reasons why this claim would and should be rejected,” Lazarus said.
 
But a judge or Supreme Court justice like Scalia could easily hone in on the “established by the state” language, making the case for “textualism” — adhering strictly to the specific words used in a statute, rather than trying to determine its intent.  “It’s a way of taking one isolated provision of a statute and just reading that one provision,” Lazarus said.  Lazarus has been urging the left to focus aggressively on the subsidies challenge, even though the lawsuits are still in their early stages.
 
Two suits have been filed challenging the subsidies; neither has gotten a hearing yet in court. There’s a chance the cases would have to wait until at least next year, for procedural reasons.  Although they don’t believe the suits stand much chance of success, some supporters of the healthcare law believe their side lost the public relations battle over the Supreme Court’s ObamaCare case, in part because liberal academics didn’t take the challenge seriously.
 
“However such maneuvers play out in court, the administration and its allies need to play their game out of court as well. Specifically, they need to not repeat their near-death experience with the individual mandate challenge, when they left their adversaries free to frame the legal issues, unanswered, for the media, politicians, and the public,” Lazarus wrote in a recent op-ed.
 
The more immediate legal threat to the Affordable Care Act comes from challenges to its birth control mandate.   
The contraception mandate is a relatively small part of the overall healthcare law, but it is a major talking point for the White House.  Obama focused extensively on the birth-control mandate during the 2012 campaign, and Democrats made the policy a cornerstone of their aggressive pitch to female voters.  An eventual Supreme Court decision on the contraception policy might not have huge implications for the rest of the healthcare law, but it would be politically explosive.
 
Two federal appeals courts have heard oral arguments over the contraception policy, and challengers have filed 60 lawsuits in courts across the country.  The plaintiffs, most of whom are business owners, say the policy violates their First Amendment right to religious liberty by forcing them to provide a service they find immoral.  The Obama administration has given an exemption to churches and houses of worship, and has carved out a middle ground for religious-affiliated employers like Catholic hospitals and universities.
 
For-profit companies are also challenging the policy. Those cases have moved faster, and though courts have been split on the issue, several have questioned whether business owners can invoke religious liberty over healthcare plans they don’t provide personally, but rather through their companies.
 
The 3rd Circuit Court of Appeals heard a case this week filed by a cabinet-making company whose owners object to providing contraception. The lower court in that case sided against the company, saying religious liberty belongs to people — not corporations.  "Religious belief takes shape within the minds and hearts of individuals, and its protection is one of the more uniquely 'human' rights provided by the Constitution,” the lower court said.

[Crafty_Dog]

http://www.forbes.com/sites/theapothecary/2013/06/03/democrats-new-argument-its-a-good-thing-that-obamacare-doubles-individual-health-insurance-premiums/?partner=yahootix

http://www.washingtontimes.com/news/2013/may/2/south-carolina-house-passes-bill-making-obamacare-/

[ccp]

Couple of thoughts.  I don't really know if this is true or not.  I've posted before there absolutely is no shortage of doctors in urban areas though the same is not true in many rural areas.  Also the source of these numbers stands to gain big from reporting this.   There bread and butter is more medical school slots.  They along with many other medical organizations have a profound self interest.   Frankly I don't trust them.   OF course they are going to say we need more.  It is like a Democrat politician saying we need more taxes.   It is never enough.   Don't forget that many physicians come here from other countries.  By the thousands every year.  Ultimately nurse practitioners will continue to take over primary care and will eventually supplant physician roles in this.  It is inevitable.

There are even some who say that certain procedures need no longer be done by doctors.  Like colonoscopies.  Why not just have techs trained to do these for a lot less money?

http://wallstcheatsheet.com/stocks/does-obamacare-mean-fewer-doctors-and-less-accessible-healthcare.html/?a=viewall

[Crafty_Dog]

Can England's NHS Survive?
Nicholas Black, M.D.
June 19, 2013DOI: 10.1056/NEJMp1305771

The past few months have witnessed the most intense and prolonged criticism of England's National Health Service (NHS) in its 65-year history. Some critics have suggested that the NHS faces a crisis that can be resolved only by altering the fundamental principle on which it was founded — provision of funding from general taxation, with care being free at the point of use. Although the criticism was sparked by a February report on an inquiry into shortcomings at one hospital,1 the problems originated in 2010, when two profound forces were unleashed on the NHS: public-sector financial austerity and administrative reorganization. Together, these three factors have created the current turmoil.

Never before has the NHS had to cope with no increase in funding for a sustained period. With rising demand, the NHS is required to improve its productivity at an unprecedented rate of 4% per year.2 The government is convinced that to achieve this improvement, two fundamental changes are needed.

The first concerns the local commissioning organizations that are responsible for purchasing hospital and community services for their geographically defined populations of 200,000 to 1 million people. The 151 existing administrative bodies called Primary Care Trusts, which were led by nonclinical managers, have been replaced by 212 Clinical Commissioning Groups that are led by primary care doctors (general practitioners [GPs]) who, the government believes, will be more effective in controlling the use of the £60 billion (approximately $90 billion) spent on secondary and community care services. (Spending on tertiary care — £20 billion [$30 billion] — will be managed at a national level by a new entity called NHS England.) The second means of achieving better productivity is by increasing the competition among providers of hospital and community services through the greater use of non-NHS providers (including private for-profit, not-for-profit, and charity or volunteer organizations).

Prolonged financial stringency and a reorganization were challenging enough without a high-profile report suggesting that NHS hospitals may not be safe.1 The Francis Report on the inquiry into the Mid Staffordshire NHS Foundation Trust told a sad and troubling story of a hospital in which the humanity of care in some wards was appalling and in which the proportion of deaths deemed avoidable may have been higher than the 5% observed elsewhere in England and in other high-income countries. Despite uncertainty about the appropriateness of allowing public inquiries to influence policy,3 the government has responded by announcing several initiatives:

commitment to a simple single rating of the quality of a hospital (despite the fact that an independent expert review panel established by the government offered no encouragement for taking this approach4); a review of 14 other hospitals considered “suspect” on the basis of their standardized mortality ratios (despite the lack of validity of this measure5); a review of patient safety in the NHS, chaired by Donald Berwick; and the creation of a position for a chief inspector of hospitals to strengthen the existing quality regulator, the Care Quality Commission (despite a lack of evidence that regulation and inspection are effective mechanisms for improvement).

For the NHS to survive in its present form, it will need to overcome four formidable challenges. The first is financial constraint. Although the government claims to be maintaining funding in real terms, high rates of inflation in health care plus some financial maneuvers, such as withholding from the NHS any funds in its budget that it hasn't spent, mean there has been an actual funding reduction of almost 1% per year since 2011. Of greater concern is that social services have undergone a substantial cut of about 7% per year since 2011, which is resulting in more emergency admissions to hospitals and delays in discharges. These problems will be exacerbated if the new GP-led commissioners succeed in shifting some care from hospitals to more appropriate settings, since such a shift will further reduce the funds that hospitals receive. And overshadowing all these funding issues, the government's policy of protecting the level of health care spending is increasingly being questioned in Parliament by backbench members of the ruling party (i.e., those who do not occupy positions in government) who are unhappy about the repercussions that this protection has for other spending areas, such as defense and law enforcement. The final note of gloom is the growing realization that financial austerity seems to be set to continue beyond 2015.
The second challenge is that the NHS may face opposition to its attempts to improve productivity. During the first 2 years of austerity, improvement was achieved mostly by freezing (or even reducing) staff pay, a policy that will not be sustainable. Similarly, driving down prices paid to suppliers for consumables cannot be extended indefinitely. In addition, professionals may oppose changes in working arrangements, such as requirements that hospital doctors work in the evenings and on weekends to boost the intensity of use of hospital facilities. But it's the more major initiatives to improve productivity, such as merging, downgrading, or closing hospitals, that will meet with the greatest opposition — not only from staff and the public, but also from politicians concerned about being reelected. And in the brave new world of markets, opposition to structural changes will even come from the economic regulator seeking to ensure that competition is maintained, regardless of its effect on the quality of care.

The third challenge is a lack of managerial capacity, stemming largely from the government's imposition of a reorganization that had little support from key staff members. This problem has been exacerbated by widespread criticism of managers, in the wake of the Francis Report, by members of the public, the media, and politicians. Although criticisms of some clinical and managerial staff were justified, wholesale condemnation was inappropriate and has contributed to the departure of some excellent managers (particularly when generous retirement options were available). The loss of managers is particularly apparent in the commissioning arena, where the effects will be intensified by the shifting of responsibility to GPs, most of whom will initially lack appropriate experience and training. Although they will receive technical help, it is unclear whether the initial enthusiasm of those GPs who have opted to take on this role will last. The honeymoon might end when GPs realize how uncomfortable it can be to ration care to patients and reduce funds for their local hospital.

Finally, there is concern that the way the NHS has been reorganized will impede attempts to achieve greater integration of services across health care and with social services — integration that is essential to achieving efficient, high-quality care.

So, will the NHS survive these challenges? There are three reasons for optimism. First, there are already examples of enterprising clinicians, managers, and politicians working together to reengineer their local services in imaginative ways. Second, despite legitimate concerns about the quality of some services, public support for the NHS is undiminished, as witnessed by the inclusion of a celebration of the NHS in the Olympics opening ceremony last July and as reflected in national surveys. Public enthusiasm is mirrored not only by that of most clinicians and managers but also by the majority of politicians (including the current government, even if not by all its backbenchers). Though partly ideological, such support reflects the steady annual improvements in the NHS's effectiveness and safety seen in recent years. And third, turmoil provides an opportunity for innovation. It can produce collective efforts in which factional interests are set aside and long-standing controversial issues, such as bringing health care and social services closer together (even by combining their budgets into one), are finally addressed.

Although some of the challenges in England are unique, the underlying problem of meeting rising demand for care with steady or diminishing resources is faced by many countries. Just as we can learn from other health care systems, our experiences over the next few years in redesigning the organization and delivery of services will undoubtedly provide lessons for others.

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article was published on June 19, 2013, at NEJM.org.
Source Information
From the Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London.
References
References
1.   1
Report of the Mid Staffordshire NHS Foundation Trust public inquiry (Robert Francis, chair). Staffordshire, United Kingdom: Mid Staffordshire NHS Foundation Trust, February 2013.
2.   2
Roberts A, Marshall L, Charlesworth A. A decade of austerity? The funding pressures facing the NHS from 2010/11 to 2021/22. London: Nuffield Trust, December 2012.
3.   3
Black N, Mays N. Public inquiries into health care in the UK: a sound basis for policy-making? J Health Serv Res Policy 2013;18:129-130
4.   4
Rating providers for quality: a policy worth pursuing? London: Nuffield Trust, March 2013.
5.   5
Shahian DM, Wolf RE, Iezzoni LI, Kirle L, Normand S-LT. Variability in the measurement of hospital-wide mortality rates. N Engl J Med 2010;363:2530-2539[Erratum, N Engl J Med 2011;364:1382.]
Free Full Text | Web of Science | Medline

[Crafty_Dog]

second post


By DAVID B. RIVKIN JR. And ELIZABETH P. FOLEY

Signs of ObamaCare's failings mount daily, including soaring insurance costs, looming provider shortages and inadequate insurance exchanges. Yet the law's most disturbing feature may be the Independent Payment Advisory Board. The IPAB, sometimes called a "death panel," threatens both the Medicare program and the Constitution's separation of powers. At a time when many Americans have been unsettled by abuses at the Internal Revenue Service and Justice Department, the introduction of a powerful and largely unaccountable board into health care merits special scrutiny.

For a vivid illustration of the extent to which life-and-death medical decisions have already been usurped by government bureaucrats, consider the recent refusal by Health and Human Services Secretary Kathleen Sebelius to waive the rules barring access by 10-year old Sarah Murnaghan to the adult lung-transplant list. A judge ultimately intervened and Sarah received a lifesaving transplant June 12. But the grip of the bureaucracy will clamp much harder once the Independent Payment Advisory Board gets going in the next two years.

The board, which will control more than a half-trillion dollars of federal spending annually, is directed to "develop detailed and specific proposals related to the Medicare program," including proposals cutting Medicare spending below a statutorily prescribed level. In addition, the board is encouraged to make rules "related to" Medicare.

The ObamaCare law also stipulates that there "shall be no administrative or judicial review" of the board's decisions. Its members will be nearly untouchable, too. They will be presidentially nominated and Senate-confirmed, but after that they can only be fired for "neglect of duty or malfeasance in office."


Once the board acts, its decisions can be overruled only by Congress, and only through unprecedented and constitutionally dubious legislative procedures—featuring restricted debate, short deadlines for actions by congressional committees and other steps of the process, and supermajoritarian voting requirements. The law allows Congress to kill the otherwise inextirpable board only by a three-fifths supermajority, and only by a vote that takes place in 2017 between Jan. 1 and Aug. 15. If the board fails to implement cuts, all of its powers are to be exercised by HHS Secretary Sebelius or her successor.

The IPAB's godlike powers are not accidental. Its goal, conspicuously proclaimed by the Obama administration, is to control Medicare spending in ways that are insulated from the political process.

This wholesale transfer of power is at odds with the Constitution's separation-of-powers architecture that protects individual liberty by preventing an undue aggregation of government power in a single entity. Instead, power is diffused both vertically—with the federal government exercising limited and enumerated powers and the states exercising all remaining authority—and horizontally, with the powers of the federal government divided among the executive, legislative and judicial branches.

This diffusion of power advances another key liberty-enhancing constitutional requirement: accountability. Accountability enables the people to know what government entity is affecting them, so that they can hold officials responsible at the polls. Congress can also hold the executive responsible through oversight and measures like impeachment.

As Chief Justice John Marshall observed in Wayman v. Southard (1825), Congress may delegate tasks to other bodies, but there is a fundamental constitutional difference between letting them "fill up the details" of a statute versus deciding "important subjects," which "must be entirely regulated by the legislature itself." Distinguishing between the two, the court said, requires an inquiry into the extent of the power given to the administrative body.

The power given by Congress to the Independent Payment Advisory Board is breathtaking. Congress has willingly abandoned its power to make tough spending decisions (how and where to cut) to an unaccountable board that neither the legislative branch nor the president can control. The law has also entrenched the board's decisions to an unprecedented degree.

In Mistretta v. United States (1989), the Supreme Court emphasized that, in seeking assistance to fill in details not spelled out in the law, Congress must lay down an "intelligible principle" that "confine the discretion of the authorities to whom Congress has delegated power." The "intelligible principle" test ensures accountability by demanding that Congress take responsibility for fundamental policy decisions.

The IPAB is guided by no such intelligible principle. ObamaCare mandates that the board impose deep Medicare cuts, while simultaneously forbidding it to ration care. Reducing payments to doctors, hospitals and other health-care providers may cause them to limit or stop accepting Medicare patients, or even to close shop.

These actions will limit seniors' access to care, causing them to wait longer or forego care—the essence of rationing. ObamaCare's commands to the board are thus inherently contradictory and, consequently, unintelligible.

Moreover, authorizing the advisory board to make rules "relating to" Medicare gives the board virtually limitless power of the kind hitherto exercised by Congress. For instance, the board could decide to make cuts beyond the statutory target. It could mandate that providers expand benefits without additional payment. It could require that insurers or gynecologists make abortion services available to all their patients as a condition of doing business with Medicare, or that drug companies set aside a certain percentage of Medicare-related revenues to fund "prescription drug affordability." There is no limit.

If the Independent Payment Advisory Board exercises these vast powers, political accountability will vanish. When constituents angrily protest, Congress, having ceded its core legislative power to another body, will likely just throw up its hands and blame the board.

Since ObamaCare eliminates both judicial review for any of the board's decisions and public-participation requirements for rule making, this unprecedented insulation of the board guts due process. Even the president's limited ability to check the board's power—since he can remove members only for neglect or malfeasance—represents a more circumscribed standard than usual for presidential appointees.

The bottom line is that the Independent Payment Advisory Board isn't a typical executive agency. It's a new beast that exercises both executive and legislative power but can't be controlled by either branch. Seniors and providers hit hardest by the board's decisions will have nowhere to turn for relief—not Congress, not the president, not the courts.

Attempts to rein in government spending are laudable, but basic decisions about how and where to cut spending properly belong to Congress. In the 225 years of constitutional history, there has been no government entity that violated the separation-of-powers principle like the Independent Payment Advisory Board does.

While the board is profoundly unconstitutional, it is designed to operate in a way that makes it difficult to find private parties with standing to challenge it for at least its first several years in operation. An immediate legal challenge by Congress might be possible, but also faces standing difficulties. Unless and until courts rule on IPAB's constitutionality, Congress should act quickly to repeal this particular portion of ObamaCare or defund its operations.

Mr. Rivkin, a partner at Baker Hostetler LLP, served in the Justice Department under Presidents Reagan and George H.W. Bush and represented 26 states in challenging ObamaCare. Ms. Foley is a professor of constitutional law at Florida International University and the author of "The Law of Life & Death" (Harvard, 2011).

[DougMacG]

Gallup found that more than four in 10 companies have frozen hiring because of Obama-Care, and almost one in five have cut workers to minimize the cost of the law.

Another 38% said they'd "pulled back on their plans to grow their business."

http://news.investors.com/ibd-editorials/062113-661003-obamacare-hurting-hiring-jobs-work-hours.htm

The biggest job growth categories are now temp and part time.

"local governments across the country have been cutting part-time hours to 29 or fewer a week so they can avoid ObamaCare as much as possible"
------

Did ANYONE see this coming?  
http://dogbrothers.com/phpBB2/index.php?topic=1791.msg68932#msg68932
"Why France Has So Many 49-Employee Companies
http://www.businessweek.com/articles/2012-05-03/why-france-has-so-many-49-employee-companies
------
"The ACA requires businesses with 50 or more employees to offer “affordable” insurance to anyone working 30 or more hours per week—which must cost no more than 9.5 percent of the worker’s household income. In addition, businesses must also provide insurance for dependents, though potentially at an additional cost to the employee." 
http://inthesetimes.com/article/15092/obamacare_how_it_could_flatline/

[ccp]

From where I sit the only reason health care spending is down is because so many people are hurt by the economy they can't afford even the copays.  Around here every doctor I know states their census is down "15%".   Obama care has NOTHING to do with this.  It is the poor economy.

Yet we are being lied to. 

As an older primary care doctor I wish the following as true but I know it is not.   Primary care will be taken over by nurse practitioners.   It is a done deal.  The only thing remaining is the political battle between pharmacists, nursing organizations and doctor organizations.   For now NPs will jockey themselves upwards for positions once filled by MDs.  For now they will sell they are cheaper to the politicians.  As they gain power they will start demanding more money the same as us.  Done deal.  Christiansen certainly was right.   Classic disruption.   No chance at stopping it.  The medical organizations still are in denial.   Eventually NPs will slither into specialties too.  I predict that.  I am ahead of the ball on that to my knowledge.   

For everyone else you will get a somewhat lower level of care.  For most simple stuff in primary care it doesn't make a lot of difference but for the increasing complicated stuff it does.

 ..

****Reverse the Doctor Shortage by Restoring Primary-Care Prestige (Op-Ed)
LiveScience.comBy Dr. Bruce Koeppen, Quinnipiac University  | LiveScience.com – 18 hrs ago..

Dr. Bruce Koeppen is founding dean of the Frank H. Netter MD School of Medicine at Quinnipiac University. He contributed this article to LiveScience's Expert Voices: Op-Ed & Insights.

The United States currently faces a growing physician shortage. While this shortage is across many of the specialties and subspecialties of medicine, it is most acute in the primary-care disciplines, traditionally defined as family medicine, general internal medicine and general pediatrics. As medical educators, we must tackle the challenge of restoring the prestige of a career in primary care.

It is quite an undertaking. Fewer students enter medical school with an eye toward a career in primary-care medicine, and many of those who do often change their mind as they go through training.

The reasons for students' decisions vary, and include perceptions that primary-care medicine is less prestigious than subspecialty medicine, that the knowledge base to be mastered is too broad, that the lifestyle (being on call) is too demanding and that the work-patient interactions are not interesting. Earnings potential may be a factor for some, but for the majority of students, I believe the other factors are more important.

If we are to reverse the trend of fewer medical students choosing careers in primary care, we must address the aforementioned perceptions and change the environment in which primary-care physicians are trained.

The goal of effective primary care is to keep patients out of hospitals . Yet residency training in the primary-care disciplines occurs predominantly in acute-care facilities. It is no wonder that resident physicians surrounded by specialists in this working and learning environment change their minds and pursue careers in subspecialties.

Primary care is delivered outside hospitals, and residency training for primary-care disciplines must also take place, predominately, outside hospitals. The Affordable Care Act provides grants to establish "Teaching Health Centers," environments in which exactly that kind of training takes place. We need to learn from these Teaching Health Centers, expand them and provide new training sites with stable funding beyond the term of these initial grants.

The latest trend in primary-care delivery is the patient-centered medical home, in which teams of health professionals — consisting of physicians, nurse practitioners, physician assistants, physical and occupational therapists, social workers, mental-health counselors, and nutritionists — take care of patients. As delivery of care moves from the traditional solo-practice model to patient-centered medical homes, the perceptions of what it means to be a primary-care physician will change.

In the medical-home model, each professional brings specific expertise to the care of the patient, freeing physicians to focus on aspects of patient care that require their expertise. With each member of the team practicing at the "top of their training," the result is an exciting and fulfilling work environment for all. Most importantly, patients receive better-coordinated, higher-quality care. Done right, this model will lower total health care costs by keeping patients well longer.

Through changes in both training and work environments, I believe we will see more medical students choosing careers in a primary-care discipline that they will find professionally fulfilling. Changes in the reimbursement system for primary-care services will also help.

I believe this is an exciting time to be a primary-care physician. If the U.S. can make the necessary changes, its health care system will be a better place for everyone — the workforce will be happier and more productive, and patients will stay healthier longer.****

[Crafty_Dog]

http://www.forbes.com/sites/theapothecary/2013/06/23/even-in-over-regulated-washington-state-obamacare-will-increase-individual-market-premiums-by-34-80-percent/

[bigdog]

http://thehill.com/blogs/healthwatch/health-reform-implementation/309003-obamacares-employer-mandate-delayed

From the article:

The ObamaCare employer mandate requiring businesses to provide their workers with health insurance will be delayed by a year, the administration said Tuesday in a stunning announcement.

Delaying the requirement until 2015 is an enormous victory for businesses that had lobbied against the healthcare law.

It also means that one of healthcare reform’s central requirements will be implemented after the 2014 midterm elections, when the GOP is likely to use the Affordable Care Act as a vehicle to attack vulnerable Democrats.

[G M]

Why?

http://thehill.com/blogs/healthwatch/health-reform-implementation/309003-obamacares-employer-mandate-delayed

From the article:

The ObamaCare employer mandate requiring businesses to provide their workers with health insurance will be delayed by a year, the administration said Tuesday in a stunning announcement.

Delaying the requirement until 2015 is an enormous victory for businesses that had lobbied against the healthcare law.

It also means that one of healthcare reform’s central requirements will be implemented after the 2014 midterm elections, when the GOP is likely to use the Affordable Care Act as a vehicle to attack vulnerable Democrats.

[G M]

Great quotes:

IOWAHAWK: You know who really feels stupid right now? All those people who bribed the White House for Obamacare waivers. Suckers!


Kristina Ribali‏@KristinaRibali
 Obamacare was so popular it had to be passed in the dead of night and delayed until after two elections.

[DougMacG]

George Will today: 
Although the Constitution has no Article VIII, the administration acts as though there is one that reads: “Notwithstanding all that stuff in other articles about how laws are made, if a president finds a law politically inconvenient, he can simply post on the White House Web site a notice saying: Never mind.”

Never mind that the law stipulates 2014 as the year when employers with 50 full-time workers are mandated to offer them health-care coverage or pay fines. Instead, 2015 will be the year. Unless Democrats see a presidential election coming.
--------------------------------

Hey Obama – why couldn’t a Republican President delay all of Obamacare for 10,000 years?

As the Obamacare law is written, the employer mandate is to begin in January 2014. This is what the law said when it was passed by the House and Senate, and signed by President Obama in 2010.

However, it has been reported that President Obama has just delayed the employer mandate part of Obamacare until January 2015. Obama did this without approval from Congress.

It was Obama himself who delayed part of Obamacare for one year. If Obama can do this, I would love to hear him explain why a Republican President could not delay all of Obamacare for 10,000 years.
http://danfromsquirrelhill.wordpress.com/

[ccp]

I find this very hard to believe this is NOT political.   A "glitch".  Give me a break.  Everyone knows there are far more smokers on the lower non-taxpaying socioeconomic side of the voting spectrum.
This appears to be just another Democrat party thing.

******A break for smokers? Glitch may limit penalties

FILE - In this June 11, 2007 file photo, Helen Heinlo smokes outside of a coffee shop in Belmont, Calif. Some smokers trying to get coverage in 2014 under President Barack Obama’s health care law may get a break from tobacco-use penalties that could have made their premiums unaffordable. The Obama administration _ in yet another health care overhaul delay _ has quietly notified insurers that a computer system glitch will limit penalties that the law says the companies may charge smokers. A fix will take at least a year to put in place. (AP Photo/Paul Sakuma, File)


Associated Press
Ricardo Alonso-Zaldivar, Associated Press 31 minutes ago  Barack Obama

WASHINGTON (AP) -- Some smokers trying to get coverage next year under President Barack Obama's health care law may get a break from tobacco-use penalties that could have made their premiums unaffordable.

The Obama administration — in yet another health care overhaul delay — has quietly notified insurers that a computer system glitch will limit penalties that the law says the companies may charge smokers. A fix will take at least a year to put in place.

Older smokers are more likely to benefit from the glitch, experts say. But depending on how insurers respond to it, it's also possible that younger smokers could wind up facing higher penalties than they otherwise would have.

Some see an emerging pattern of last-minute switches and delays as the administration scrambles to prepare the Oct. 1 launch of new health insurance markets. People who don't have coverage on the job will be able to shop for private insurance, with tax credits to help pay premiums. Small businesses will have their own insurance markets.

Last week, the White House unexpectedly announced a one-year postponement of a major provision in the law that requires larger employers to offer coverage or face fines. Officials cited the complexity of the requirement as well as a desire to address complaints from employers.

"This was an administration that was telling us everything was under control," health care industry consultant Robert Laszewski said. "Everything was going to be fine. Suddenly this kind of stuff is cropping up every few days."

A June 28 Health and Human Services Department document couched the smokers' glitch in technical language:

"Because of a system limitation ... the system currently cannot process a premium for a 65-year-old smoker that is ... more than three times the premium of a 21-year-old smoker," the industry guidance said.

If an insurer tries to charge more, "the submission of the (insurer) will be rejected by the system," it added.

Starting in 2014, the law requires insurance companies to accept all applicants regardless of pre-existing medical problems. But it also allows them to charge smokers up to 50 percent higher premiums — a way for insurers to ward off bad risks.

For an older smoker, the cost of the full penalty could be prohibitive.

Premiums for a standard "silver" insurance plan would be about $9,000 a year for a 64-year-old non-smoker, according to the online Kaiser Health Reform Subsidy Calculator. That's before any tax credits, available on a sliding scale based on income.

For a smoker of the same age, the full 50 percent penalty would add more than $4,500 to the cost of the policy, bringing it to nearly $13,600. And tax credits can't be used to offset the penalty.

The underlying reason for the glitch is another provision in the health care law that says insurers can't charge older customers more than three times what they charge the youngest adults in the pool. The government's computer system has been unable to accommodate the two. So younger smokers and older smokers must be charged the same penalty, or the system will kick it out.

That's not what insurers had expected. Before the glitch popped up, experts said the companies would probably charge lower penalties for younger smokers, and higher penalties for older ones.

"Generally a 20-year-old who smokes probably doesn't have much higher health costs than someone who doesn't smoke in any given year," said Larry Levitt, an insurance market expert with the nonpartisan Kaiser Family Foundation. "A 60-year-old is another story."

The administration is suggesting that insurers limit the penalties across all age groups. The HHS guidance document used the example of a 20 percent penalty.

In that case the premium for a 64-year-old would be about $10,900, a significant cut from the $13,600 if insurers charged the full penalty.

It's unclear what insurance companies will do. A spokesman for America's Health Insurance Plans, the main industry trade group, said insurers were aware of the issue and expected the administration would fix it eventually.

Another workaround for the companies would be to charge the full penalty to both younger and older smokers. In that case, there wouldn't be any savings for older smokers, and younger ones would see a big price shock.

Levitt said he suspects insurers would keep the penalties low to sign up more young people. Laszweski said he thought they would do the opposite.

"It's going to throw cold water on efforts to get younger people to sign up," he said.

Workers covered through job-based health plans would be able to avoid tobacco penalties by joining smoking cessation programs because employer plans operate under different rules. But experts say that option is not guaranteed to smokers trying to purchase coverage individually. *****

[DougMacG]

Obvious question:  If Obamacare implementation is taking longer than expected, isn't it also costing more than expected?  Isn't that against the law?  lol

http://townhall.com/tipsheet/guybenson/2013/07/09/report-white-house-has-known-obamacare-implementation-would-collapse-for-months-n1637123

[DougMacG]

12 percent support implementing ObamaCare’s individual mandate

http://www.healthpocket.com/healthcare-research/surveys/people-wanting-obamacare-penalty-waived-outnumber-supporters-three-to-one#.Ud8J_6xHddj

[Crafty_Dog]

Why the President's ObamaCare Maneuver May Backfire
By postponing the employer mandate, Obama has given millions of Americans the legal standing to sue.
By DAVID B. RIVKIN JR.and LEE A. CASEY

President Obama's announcement on July 2 that he is suspending the Affordable Care Act's employer health-insurance mandate may well have exposed his actions to judicial review—even though that is clearly what he sought to avoid.

The health-care reform law's employer mandate requires businesses with more than 50 employees to provide a congressionally prescribed set of health-insurance benefits or pay a penalty calculated at about $2,000 per employee. The law was to take effect on Jan. 1, 2014, but Mr. Obama has "postponed" its application until 2015. His aim, the administration said, was to give employers more time to comply with the new rules. But it was also seen as a way to avoid paying at least part of ObamaCare's mounting political price in the 2014 congressional elections.

Whatever the reason, the president does not have the power to stop the implementation of a law. If there is one bedrock constitutional legal principle, it is that the president must "faithfully execute" federal statutes. He cannot suspend laws he dislikes on policy grounds or because he fears their political consequences.

U.S. President Barack Obama speaks about Affordable Care Act at The Fairmont Hotel on June 6, 2013 in San Jose, California.

Mr. Obama, however, has made a habit of exercising an unlawful suspending power, refusing to enforce selected federal laws, including various provisions of the immigration laws against young, undocumented aliens; work requirements enacted as part of the 1996 federal welfare reform law; and the testing accountability provisions of the No Child Left Behind education law.

One key problem with suspension power—aside from the fact that it destroys the balance of power between the two political branches—is that, when skillfully exercised, it sidelines the judiciary. The Constitution requires that a party commencing litigation must have what is commonly called "standing," i.e., the party must have suffered or will suffer a legal injury that a court can redress. A determined president can head off litigation by effectively rewriting federal statutes in ways that do not create individual injuries so no party has standing.

By suspending the Affordable Care Act's employer insurance mandate, however, the president has potentially given millions of Americans the necessary standing to challenge his conduct. This is because the Affordable Care Act is a highly integrated law, with many of its key provisions dependent on each other. In addition to the employer mandate, the law also contains an "individual mandate," requiring most Americans to sign up for a required level of health-insurance coverage or pay a penalty.

The individual mandate was one of the core parts of the Affordable Care Act considered by the Supreme Court in the 2012 case of NFIB v. Sebelius, where the court upheld the statute against constitutional attack. Throughout that litigation, the Obama administration portrayed the individual mandate as an "integral part of a comprehensive scheme of economic regulation" that included the employer insurance mandate, which was intended to give millions of Americans a way of meeting their new obligation to have health insurance. In other words, suspending the employer insurance mandate prevents the individual insurance mandate from working the way Congress intended.

Like the employer mandate, the individual mandate by law will take effect in January 2014 (unless the president postpones that as well). Individuals who will then have to buy their own health insurance will arguably have suffered an injury sufficient to give them standing to sue.

Once in court, these litigants can argue that the very integrated nature of the Affordable Care Act would make it unlawful to apply one part against them, while suspending another section. They can also argue that only Congress can determine whether, once a statute is fundamentally changed post-enactment, it should survive or fall.

This inquiry usually arises when courts, having invalidated on constitutional grounds part of a statute, must determine whether or not Congress would have wanted the valid remaining parts of the law to remain in effect. The relevant constitutional doctrine is called "severability."

As the Supreme Court noted in the leading severability case, Ayotte v. Planned Parenthood of Northern New England (2006), the ultimate fate of the revised statute is decided based on the "legislative intent." In the case of the Affordable Care Act, if the courts were, for example, to determine that the employer insurance mandate is unconstitutional, the well-established severability analysis would lead them to conclude that the individual mandate (and likely the entire law) must also fall because Congress did not intend those provisions to operate in the absence of the employer insurance mandate. The president's suspension of that part of the law, therefore, should also produce the same result, rendering the remainder of the statute unenforceable.

This argument should find favor with judges who are weary of the use of suspension power that improperly aggrandizes presidential authority, diminishes congressional power, and denies the judiciary an opportunity to have its say. Courts would have to conclude that the whole statute must fall while the president's suspension is in effect. While reaching this conclusion, they might also declare the suspension itself unconstitutional. Both results would mark a significant win for the American people.
—Messrs. Rivkin and Casey are lawyers in the Washington, D.C., office of Baker & Hostetler LLP. They pioneered the constitutional arguments against the individual mandate and represented 26 states in challenging ObamaCare before the trial and appellate courts.

[Crafty_Dog]

Health Plan Cost for New Yorkers Set to Fall 50%
By RONI CARYN RABIN and REED ABELSON
Published: July 16, 2013 782 Comments

Individuals buying health insurance on their own will see their premiums tumble next year in New York State as changes under the federal health care law take effect, Gov. Andrew M. Cuomo announced on Wednesday.


State insurance regulators say they have approved rates for 2014 that are at least 50 percent lower on average than those currently available in New York. Beginning in October, individuals in New York City who now pay $1,000 a month or more for coverage will be able to shop for health insurance for as little as $308 monthly. With federal subsidies, the cost will be even lower.

Supporters of the new health care law, the Affordable Care Act, credited the drop in rates to the online purchasing exchanges the law created, which they say are spurring competition among insurers that are anticipating an influx of new customers. The law requires that an exchange be started in every state.

“Health insurance has suddenly become affordable in New York,” said Elisabeth Benjamin, vice president for health initiatives with the Community Service Society of New York. “It’s not bargain-basement prices, but we’re going from Bergdorf’s to Filene’s here.”

“The extraordinary decline in New York’s insurance rates for individual consumers demonstrates the profound promise of the Affordable Care Act,” she added.

Administration officials, long confronted by Republicans and other critics of President Obama’s signature law, were quick to add New York to the list of states that appear to be successfully carrying out the law and setting up exchanges.

“We’re seeing in New York what we’ve seen in other states like California and Oregon — that competition and transparency in the marketplaces are leading to affordable and new choices for families,” said Joanne Peters, a spokeswoman for the Department of Health and Human Services.

The new premium rates do not affect a majority of New Yorkers, who receive insurance through their employers, only those who must purchase it on their own. Because the cost of individual coverage has soared, only 17,000 New Yorkers currently buy insurance on their own. About 2.6 million are uninsured in New York State.

State officials estimate as many as 615,000 individuals will buy health insurance on their own in the first few years the health law is in effect. In addition to lower premiums, about three-quarters of those people will be eligible for the subsidies available to lower-income individuals.

“New York’s health benefits exchange will offer the type of real competition that helps drive down health insurance costs for consumers and businesses,” said Mr. Cuomo.

The plans to be offered on the exchanges all meet certain basic requirements, as laid out in the law, but are in four categories from most generous to least: platinum, gold, silver and bronze. An individual with annual income of $17,000 will pay about $55 a month for a silver plan, state regulators said. A person with a $20,000 income will pay about $85 a month for a silver plan, while someone earning $25,000 will pay about $145 a month for a silver plan.

The least expensive plans, some offered by newcomers to the market, may not offer wide access to hospitals and doctors, experts said.

While the rates will fall over all, apples-to-apples comparisons are impossible from this year to next because all of the plans are essentially new insurance products.

The rates for small businesses, which are considerably lower than for individuals, will not fall as precipitously. But small businesses will be eligible for tax credits, and the exchanges will make it easier for them to select a plan. Roughly 15,000 plans are available today to small businesses, and choosing among them is particularly challenging.

“Where New York previously had a dizzying array of thousands upon thousands of plans, small businesses will now be able to truly comparison-shop for the best prices,” said Benjamin M. Lawsky, the state’s top financial regulator.

Officials at the state Department of Financial Services say they have approved 17 insurers to sell individual coverage through the New York exchange, including eight that are just entering the state’s commercial market. Many of these are insurers specializing in Medicaid plans that cater to low-income individuals.

=====================================

 North Shore-LIJ Health System, the large hospital system on Long Island, intends to offer a health plan for individuals as well as businesses for the first time. Some of the state’s best-known insurers, UnitedHealth Group and WellPoint, are also expected to participate. Insurers may decline to participate after they receive approval for their rates, but this is unlikely.


For years, New York has represented much that can go wrong with insurance markets. The state required insurers to cover everyone regardless of pre-existing conditions, but did not require everyone to purchase insurance — a feature of the new health care law — and did not offer generous subsidies so people could afford coverage.

With no ability to persuade the young and the healthy to buy policies, the state’s premiums have long been among the highest in the nation. “If there was any state that the A.C.A. could bring rates down, it was New York,” said Timothy Jost, a law professor at Washington and Lee University who closely follows the federal law.

Mr. Jost and other policy experts say the new health exchanges appear to be creating sufficient competition, particularly in states that have embraced the exchanges and are trying to create a marketplace that allows consumers to shop easily.

“That’s a very different dynamic for these companies, and it’s prodding them to be more aggressive and competitive in their pricing,” said Sabrina Corlette, a professor at Georgetown University’s Center on Health Insurance Reform.

But some consumers may still find the prices and plans disappointing. Jerry Ball, 46, who owns a recycling business in Queens, said the cost of covering his family increased so rapidly in the last few years that he had to scale back their coverage. Still, he pays nearly $18,000 a year for a high-deductible policy for a family of three.

He said he would be reluctant to part ways with his insurer, Oxford, and was disappointed that even the least expensive Oxford plan being offered next year would cost about as much as he pays now.

With another plan, he said: “Will I be able to maintain my doctors? I’m concerned that some of the better doctors aren’t going to take health insurance.”

He acknowledged that the new law would allow him for the first time to easily switch plans, but it is still hard for him to believe it guarantees coverage for pre-existing conditions. “I have to be careful. I can’t be denied coverage, right?” he asked.

[G M]

Heh, let's just see...

[DougMacG]

Moderate Democrats are quitting on Obamacare

By Scott Clement, Published: July 23 2013  Washington Post:

The landmark health-reform law passed in 2010 has never been very popular and always highly partisan, but a new Washington Post-ABC News poll finds that a group of once loyal Democrats has been steadily turning against Obamacare: Democrats who are ideologically moderate  or conservative.

74 percent of moderate and conservative Democrats supported the federal law making changes to the health-care system. But just 46 percent express support in the new poll. 

Just 58 percent of Democrats now support the law

http://www.washingtonpost.com/blogs/the-fix/wp/2013/07/23/moderate-democrats-are-quitting-on-obamacare/
---------

Stated the other way, 42% of Democrats don't support the agenda.

[G M]

Just wait until the pain really sets in.

Moderate Democrats are quitting on Obamacare

By Scott Clement, Published: July 23 2013  Washington Post:

The landmark health-reform law passed in 2010 has never been very popular and always highly partisan, but a new Washington Post-ABC News poll finds that a group of once loyal Democrats has been steadily turning against Obamacare: Democrats who are ideologically moderate  or conservative.

74 percent of moderate and conservative Democrats supported the federal law making changes to the health-care system. But just 46 percent express support in the new poll. 

Just 58 percent of Democrats now support the law

http://www.washingtonpost.com/blogs/the-fix/wp/2013/07/23/moderate-democrats-are-quitting-on-obamacare/
---------

Stated the other way, 42% of Democrats don't support the agenda.

[Crafty_Dog]

Meantime, here in CA, the Denny family is covered through DB Inc.  Our rates went up 27% this year.

=======================================================================

Obama's New York Model
How the state destroyed its insurance market using ObamaCare rules.


President Obama has found a new example for the pending wonders of his health-care reform—New York. In his latest sales pitch last week, he declared that insurance rates in New York's ObamaCare exchange "will be at least 50% lower next year than they are today. Think about that: 50% lower."

Thinking is good, which is why you may have guessed that there's more to this story than a 50% discount. The real news is that New York ruined its individual insurance market two decades ago by imposing the same regulations that ObamaCare is about to impose on every other state. If the Empire State's premiums do now fall, it will be because the Affordable Care Act partially deregulates New York insurance.

The culprit behind New York's long-standing insurance woes is a regulation known as "community rating" that hides in higher premiums the income transfers from one group to another. Insurance works best when people pay rates that are tied to their expected health risks over time. But a few states limit how much premiums can vary from person to person.


ObamaCare takes this community rating national. The law says that no individual can pay more than three times what the least expensive person pays, regardless of risk. Today 42 states have rating bands that are five to one or more.

New York's ratio is one to one. This means that insurers must vastly overprice coverage for, say, a 28-year-old who exercises regularly and doesn't smoke but vastly underprice coverage for a 55-year-old with high-cost chronic illnesses. Democratic Governor Mario Cuomo adopted this rule in 1992.

Premiums shot up 30% to 40% on average in the first year, often much more, and continued to spike. Insurers shed books of business, while customers cancelled their policies. Enrollment fell 38% in three years. About a dozen major insurers at the time sold the dominant style of indemnity coverage, similar to traditional fee-for-service Medicare. By 1996, every one had fled the state.

Bad incentives caused the exodus. The majority of people under 65 with low risks can avoid community rating's economic distortions by not buying coverage, especially because another rule called "guaranteed issue" lets them wait until they are sick before they buy coverage.

And that is what they do. Mutual of Omaha, by far the largest New York indemnity carrier at the time, watched the average age of its membership increase by 11 and a half years before it became the last one to turn out the lights. The average age of people who dropped coverage was 37.5.

In 1996 Albany tried to fix Mr. Cuomo's mess by requiring any managed-care insurer doing business in New York to also sell on the individual market, but the market never recovered. In 1992, some 1.2 million New Yorkers bought individual plans, which fell to 128,000 by 2001, and a mere 31,000 today. Think about that: Out of 19.5 million residents, and with three out of every 15 nonelderly adults uninsured, 0.0016% of the population uses this market.

Liberals claim community rating is a fair trade for subsidizing the needy and to counter the lotteries of disease and accident. But this forces young, generally low-income people starting their careers to pay hundreds of dollars more every month for insurance, rather than simply subsidizing the needy directly.

Individual per person premiums now average about $500 a month, far more in New York City and slightly less upstate. In less regulated Connecticut the comparable figure is $306, and in still less regulated Pennsylvania it is $225. In the Empire State insurance is available to anyone, only the price is unaffordable for millions.

ObamaCare's central planners are hoping to avoid a national reprise of New York by requiring and subsidizing individuals to buy insurance. The White House is planning a national campaign to persuade the young adults and minorities most likely to lack insurance to sign up, just as they turned out at the ballot box in 2012. But being forced to buy an overpriced product is different from casting a vote. Even with subsidies, ObamaCare's plans will sometimes be cheap to consumers, sometimes not, but never free.

Low- to moderate-income people with little net worth are highly sensitive to month-to-month finances. Some 17% of all workers already decline insurance that is sponsored by their employers, preferring more take-home pay. The figure for young workers is 40%. More than one in four of the uninsured are also "unbanked," meaning they lack a checking account or credit card, according to Jackson Hewitt Tax Service.

The ObamaCare gamble is that these Americans will act against their financial self-interest and buy insurance that is more expensive than what they need. But the great liberal fear is that they won't, and that premiums will then have to increase and some exchanges might fail. New York is less a model than a warning.

[Crafty_Dog]

Republican Health Care Panic
By PAUL KRUGMAN
Published: July 25, 2013 737 Comments


Leading Republicans appear to be nerving themselves up for another round of attempted fiscal blackmail. With the end of the fiscal year looming, they aren’t offering the kinds of compromises that might produce a deal and avoid a government shutdown; instead, they’re drafting extremist legislation — bills that would, for example, cut clean-water grants by 83 percent — that has no chance of becoming law. Furthermore, they’re threatening, once again, to block any rise in the debt ceiling, a move that would damage the U.S. economy and possibly provoke a world financial crisis.


Yet even as Republican politicians seem ready to go on the offensive, there’s a palpable sense of anxiety, even despair, among conservative pundits and analysts. Better-informed people on the right seem, finally, to be facing up to a horrible truth: Health care reform, President Obama’s signature policy achievement, is probably going to work.

And the good news about Obamacare is, I’d argue, what’s driving the Republican Party’s intensified extremism. Successful health reform wouldn’t just be a victory for a president conservatives loathe, it would be an object demonstration of the falseness of right-wing ideology. So Republicans are being driven into a last, desperate effort to head this thing off at the pass.

Some background: Although you’d never know it from all the fulminations, with prominent Republicans routinely comparing Obamacare to slavery, the Affordable Care Act is based on three simple ideas. First, all Americans should have access to affordable insurance, even if they have pre-existing medical problems. Second, people should be induced or required to buy insurance even if they’re currently healthy, so that the risk pool remains reasonably favorable. Third, to prevent the insurance “mandate” from being too onerous, there should be subsidies to hold premiums down as a share of income.  (This paragraph seems important to me-- this is the essence of the Obama argument and one which needs to be answered in as pithy terms as it is made here.-- Marc)

Is such a system workable? For a while, Republicans convinced themselves that it was doomed to failure, and that they could profit politically from the inevitable “train wreck.” But a system along exactly these lines has been operating in Massachusetts since 2006, where it was introduced by a Republican governor. What was his name? Mitt Somethingorother? And no trains have been wrecked so far.

The question is whether the Massachusetts success story can be replicated in other states, especially big states like California and New York with large numbers of uninsured residents. The answer to this question depends, in the first place, on whether insurance companies are willing to offer coverage at reasonable rates. And the answer, so far, is a clear “yes.” In California, insurers came in with bids running significantly below expectations; in New York, it appears that premiums will be cut roughly in half.

So is this a case of something for nothing, in which nobody loses? No. In states like California, which have allowed discrimination based on health status, a small number of young, healthy, affluent residents will see their premiums go up. In New York, people who don’t think they need insurance and are too rich to receive subsidies — probably an even smaller group — will feel put upon by being obliged to buy policies. Mainly, though, those insurance subsidies will cost money, and that money will, to an important extent, be raised through higher taxes on the 1 percent: tax increases that have, by the way, already taken effect.

Over all, then, health reform will help millions of Americans who were previously either too sick or too poor to get the coverage they needed, and also offer a great deal of reassurance to millions more who currently have insurance but fear losing it; it will provide these benefits at the expense of a much smaller number of other Americans, mostly the very well off. It is, if you like, a plan to comfort the afflicted while (slightly) afflicting the comfortable.

And the prospect that such a plan might succeed is anathema to a party whose whole philosophy is built around doing just the opposite, of taking from the “takers” and giving to the “job creators,” known to the rest of us as the “rich.” Hence the brinkmanship.

So will Republicans actually take us to the brink? If they do, it will be crucial to understand why they would do such a thing, when their own leaders have admitted that confrontations over the budget inflict substantial harm on the economy. It won’t be because they fear the budget deficit, which is coming down fast. Nor will it be because they sincerely believe that spending cuts produce prosperity.

No, Republicans may be willing to risk economic and financial crisis solely in order to deny essential health care and financial security to millions of their fellow Americans. Let’s hear it for their noble cause!

=========================

http://washingtonexaminer.com/irs-employee-union-we-dont-want-obamacare/article/2533520?custom_click=rss

[ccp]

Are Republicans fooling themselves about Obamacare?

By BYRON YORK | JULY 22, 2013 AT 7:40 PM


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Topics: Analysis Columnists

Photo - 
When Washington conservatives gather to talk among themselves, and the discussion turns to Obamacare -- it happens pretty frequently -- it's not unusual to hear predictions that the president's health care law will "collapse of its own weight." It's a "train wreck," many say, quoting Democratic Sen. Max Baucus. It's unworkable. It's going to be a big, smoking ruin.

Some predict chaos beginning Oct. 1, when the law requires Obamacare exchanges, the online marketplaces in which people will be able to shop for insurance, to be up and running. And maybe that will happen; the day is a little more than two months off, and the administration seems far behind schedule in the work that needs to be done.

On the other hand, a lot of thoughtful conservatives are looking beyond Oct. 1 to Jan. 1, the day the law (except for the parts the president has unilaterally postponed) is scheduled to go fully into effect. On that day the government will begin subsidizing health insurance for millions of Americans. (A family of four with income as high as $88,000 will be eligible for subsidies.) When people begin receiving that entitlement, the dynamics of the Obamacare debate will change.
 

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At that point, the Republican mantra of total repeal will become obsolete. The administration will mount a huge public relations campaign to highlight individuals who have received government assistance to help them afford, say, chemotherapy, or dialysis, or some other life-saving treatment. Will Republicans advocate cutting off the funds that help pay for such care?

The answer is no. Facing that reality, the GOP is likely to change its approach, arguing that those people should be helped while the rest of Obamacare is somehow dismantled.

The administration is fully aware of its advantage. Last week officials invited several prominent liberal bloggers to a special White House Obamacare briefing. From the reporting that resulted -- one headline included the declaration "Implementing the Affordable Care Act is going to be a huge success" -- administration officials are quite confident that, whatever problems arise, Obamacare will be solidly in place after the money starts flowing on Jan. 1.

"Neither Democrats nor Republicans liked to emphasize how much the Affordable Care Act debate was about redistribution rather than health care as such, but there's a lot of money here," wrote Slate's Matthew Yglesias, who attended the briefing. "The law is structured to be financially beneficial to a large majority of people, and the infrastructure is in place to make that clear to a critical mass of them."

Truth be told, many Republicans did note that redistribution is at the heart of Obamacare. But the fact is, the redistributing will begin Jan. 1. And whatever else goes wrong with Obamacare, look for the White House to apply whatever fixes it must to make sure the money keeps flowing.

"The last few months have shown us that the administration will do whatever it needs to do -- whether it is in the law or not, within its formal powers or beyond them -- to prop up collapsing elements and avoid political disasters in the near term," said Yuval Levin, a former Bush administration staffer and one of Obamacare's most perceptive critics, in an email exchange. "That often means pure ad hoc governing where they just do whatever they have to in order to avoid allowing the system's worst problems and failings to become apparent in the near term."

None of this is to say Obamacare won't face huge problems. The most obvious is that it will make things worse for more people than it helps. If that disparity is huge -- that is, if on one side there are many millions of people paying more for coverage than they did previously, losing coverage they were satisfied with, and suffering through great uncertainty, while on the other side there are far fewer people receiving direct government subsidies -- if that happens, then the political fight over Obamacare will intensify rather than fade. But even then, the subsidies are unlikely to go away.

Obamacare could face even bigger problems. The most serious is the so-called "death spiral," which could occur if too few young, healthy people sign up for coverage, dramatically raising the cost of covering everyone else.

But collapse of its own weight? The administration's insurance against that is the billions of dollars that will start flowing out of Washington Jan. 1. Once that happens, Republicans will likely stop talking about Obamacare's collapse and will instead start searching for ways to limit the harm done to millions of Americans.

Byron York, the Washington Examiner's chief political correspondent, can be contacted at byork@washingtonexaminer.com. His column appears on Tuesday and Friday on washingtonexaminer.com.

[Crafty_Dog]

Hmmm , , ,

[G M]

Nothing defines efficiency like massive federal programs, and we are flush with cash so everything should go great!

[Crafty_Dog]

As best as I can tell the point that it would be Obama shutting down the government is the key to the politics of it all and saving the nation from Obamacare

    By
    JIM DEMINT
    And
    MIKE NEEDHAM


Few Americans are clamoring to shut down the federal government, but polls indicate that a majority of Americans agree that ObamaCare will be a disaster for their family's health care and for the nation's economy. So why is President Obama threatening to shut down the government if Congress sends him a year-end spending bill to fully support government operations but without funding for his (unfair, unworkable and unaffordable) health-care law?

This question is not being addressed fairly by the media, so the American people are not being told the truth about the coming political showdown over ObamaCare. Here's what's really happening.

The full implementation of the federal takeover of America's health-care system is approaching the point of no return, when tens of millions of Americans will be forced to sign up for government-controlled health care beginning this fall. Virtually all Republicans in Congress have run their election campaigns promising to stop ObamaCare, and every one of them has voted to repeal it.

Democrats should have supported repeal as well, because the president's new system will be unaffordable and unfair for many of the nation's low-income and younger Americans. ObamaCare will likely cause insurance premiums to double or triple for the young and healthy, and lead to a decline in wages for low-income Americans due to compliance regulations and penalties on their employers.

House Speaker John Boehner stands next to a printed version of the Patient Protection and Affordable Care Act during a news conference on Capitol Hill in May.

Yet despite all the grand speeches, votes and chest-pounding by Republicans promising to try to stop this destructive new law, none of this has required much courage so far—nor has it been effective. ObamaCare can be stopped only if Congress denies funding for it in the next spending bill, which must be passed in September. That would immediately halt the implementation of ObamaCare and fulfill a defining GOP promise to the American people. Voting for a spending bill that excludes ObamaCare will take courage and integrity.

The president has not been forthright with America about health care. He promised that people would not lose their health-care plan if they wanted to keep it, but now we know that millions will lose their current coverage. He promised that premiums would decrease, but premiums for employer-sponsored coverage have increased, on average, by $2,370 per family since 2009. The president promised that the law would be fair, but he is forcing every American to buy government-approved health-care plans while delaying that mandate for businesses and granting exemptions to members of Congress and unions.

There are some who argue that ObamaCare can't be defunded because most of its spending is deemed "mandatory." Their assertions are wrong. According to the Congressional Research Service, ObamaCare "administrative costs will have to be funded through the annual discretionary appropriations." Furthermore, annual appropriations bills routinely carry funding limitations to mandatory spending and often block a wide range of potential government activities. The Hyde Amendment to a 1976 appropriation bill, for example, blocked all taxpayer funding of abortion, and has every year since 1976. Congress can disallow funding for ObamaCare and effectively stop the implementation of the law.

Yet doing that will require resolve. President Obama, along with all the Democrats, will accuse Republicans of trying to shut down the government by giving the president a spending bill that he must veto. But there is no "must" about it. If the president opts to shut down all of government instead of just ObamaCare, that will be his choice, not the wish of conservatives.

The truth is rarely a factor in today's political battles, though. Much of the media will echo the White House talking points about Republicans shutting down the government. Seniors will be told that Social Security and Medicare are in jeopardy if ObamaCare is not funded, the poor will be threatened with loss of benefits—well, you know the rest.

This is why some Republican leaders and consultants are pleading with conservatives in the House and Senate not to pick a fight with the president over ObamaCare. The Republican old guard warns that any fight could jeopardize the GOP's chances of taking the majority in the Senate in 2014 and keeping the House majority. Their do-nothing strategy? Allow ObamaCare to be fully implemented so the American people will see what a mess it is.

The problem with this logic is that once ObamaCare is fully implemented, it will destroy what's left of our personalized, free-market health system and make it very challenging to bring affordable, high-quality health care to Americans. The bureaucracy and the costs of national health care will grow dramatically, becoming increasingly difficult to dismantle as they grow.

ObamaCare will destroy the private-insurance market, incentivize businesses to cancel current health coverage for their employees, create physician shortages, and force Americans and states into total dependency on the federal government. After all that, it will be difficult, if not impossible, for the free market to resurrect a private health-care system built on doctor/patient decision-making.

So the fight to stop ObamaCare now is an urgent matter. Elected leaders in both parties should summon the courage to put their political futures on the line, because the future of America is truly on the line. Politicians who oppose ObamaCare should not vote to fund it. Those who want a socialized health-care system should vote to fund it. There is no middle ground and no place to hide.

Republicans could lose the national debate. But a failure of Republicans to show the courage of their convictions on such a fundamental issue will inspire no one and will further alienate the American people from their government. This carries far greater risks to the nation's future than the threat of a government shutdown or the risk of losing the next election.

Mr. DeMint, a former Republican senator from South Carolina, is president of the Heritage Foundation. Mr. Needham is president of Heritage Action for America, a grass-roots advocacy organization.

[Crafty_Dog]

Many Health Insurers to Limit Choices of Doctors, Hospitals
Main Reason Behind These Limited Plans: Cost

     By ANNA WILDE MATHEWS
 
This fall, Indiana's new online health-insurance marketplace will present some tough choices for consumers like John Nowak, who will be able to pick a plan from his current insurer—or go for one that includes his primary-care doctor.

That is because Mr. Nowak's current insurer won't include Indiana's biggest health-care provider, 19-hospital Indiana University Health, in the plans it sells on the consumer exchange. If Mr. Nowak buys a new exchange plan from WellPoint Inc.'s WLP -1.02% Anthem Blue Cross and Blue Shield, he will generally have to pay the cost out of his own pocket if he sees the system's doctors, because they aren't in the network.


Mr. Nowak, a 48-year-old Indianapolis medical-spa owner, likes WellPoint. But he has been seeing an Indiana University-affiliated physician for five years, and "when you get a trust with a doctor, you want to stick with them," he said.

Similar situations are likely to occur around the country, as details emerge about the coverage available through the new consumer marketplaces created by the federal health law. Many of the plans will include relatively few choices of doctors and hospitals. In some cases, plans will layer on other limits, such as requirements that patients get referrals to see specialists, or obtain insurer authorization before pricey procedures.

A McKinsey & Co. analysis of 955 consumer exchange-plan filings, from 13 states that were among the earliest to make them public, found that 47% were health-maintenance organizations or similarly designed plans. Such plans generally don't pay for care provided outside their networks. A number of other plans, though classed as preferred-provider organizations, or PPOs, will also have limited choices of doctors and hospitals in their networks.

The big reason behind these limited plans: Cost.


Insurers are betting that consumers who buy plans on the exchanges will be willing to trade some choice and flexibility in order to get cheaper premiums. Smaller networks of providers generally translate to lower premiums, because insurers can negotiate discounts with health-care providers who will then have less competition for patients within the network.

WellPoint said it is using more-limited networks for most of the new marketplaces, and it aims to take at least 10% out of the premium costs.

"Individuals are making a lot of choices based on cost, particularly because it's coming out of their pockets," said Steve Hamman, a vice president at Blue Cross and Blue Shield of Illinois, a unit of Health Care Service Corp. He said his insurer's exchange products with smaller provider networks will cost 20% to 30% less than some other plans with a bigger selection of hospitals and doctors that the insurer will also sell in the marketplace.

One upshot of these efforts is that some consumer exchange plans will sideline well-known institutions—some of which may be most likely to balk at discounted rates. In the Chicago area, Blue Cross and Blue Shield of Illinois said it would sell some plans that don't have Rush University Medical Center or Northwestern Memorial Hospital in their networks.

In Los Angeles, most insurers won't include UCLA Medical Center, which struck a deal only with WellPoint. BlueCross BlueShield of Tennessee will have some plans that don't include Vanderbilt University Medical Center.

Traditionally, Americans have been reluctant to accept curbs on their health-care choices, strategies that many rejected in the 1990s. In 2012, just 16% of employees with workplace-provided coverage were enrolled in HMOs, according to a Kaiser Family Foundation survey. HMOs represented less than 5% of the consumer plans sold through eHealth Inc.'s eHealthInsurance.com in a 2012 tally.

But insurer-sponsored research involving tens of thousands of consumers has shown that people buying in the new exchanges, many now uninsured, will be most closely focused on premiums. In tests, many were willing to sacrifice choice of providers for a lower price.

Mary Ann Galloway, 63, an Indianapolis health-care consultant who is uninsured, said that when she looks for coverage on the new exchange, "probably cost is the most overriding issue for me." She would be willing to settle for a smaller choice of providers, and even switch from her current Indiana University-affiliated doctor, "if the costs and benefits were better somewhere else."

Some plans will be built largely around just one hospital system. In New York, North Shore-Long Island Jewish Health System is launching a plan that will generally cover care only at its own 15 hospitals and likely one other it doesn't own, and from doctors who work for the system or an affiliated association.

"We want to be very competitive and provide a good network at low cost," said Michael J. Dowling, North Shore-Long Island Jewish's chief executive.

For some people, smaller-network plans may be the only option. In New Hampshire, WellPoint will be the sole carrier in the new consumer marketplace, where its plans will include 14 of the 26 hospitals, and 65% of the primary-care doctors, that are in its biggest PPO network. WellPoint said limited networks "have the potential to produce cost savings and continue to offer quality care and convenience."

The federal law requires exchange plans to include enough providers so that services are available "without unreasonable delay," and many states also have more specific standards.

A spokeswoman for the federal Department of Health and Human Services said that in the new marketplaces, "plans will compete side by side, and consumers can compare based on the factors that are important to them to find the plan that best fits their needs and budget."

As for Mr. Nowak, he said he'll likely seek a plan that included his doctor.

"The premium is important to me, but my doctor is more important," he said.

Indiana University Health said it would be included in the exchange plans of at least one Indiana carrier, MDwise Inc., a largely Medicaid-focused nonprofit in which it has an ownership stake.

Write to Anna Wilde Mathews at anna.mathews@wsj.com

[Crafty_Dog]

Republicans are busy debating what gives them the most "leverage" in their fight to get rid of ObamaCare. One powerful tool, it happens, is an issue that few of them so far have wanted to talk about.

The issue is the White House's recent ObamaCare bailout for members of Congress and their staffs. The GOP has been largely mute on this blatant self-dealing. The party might use what's left of its summer recess to consider just how politically potent this handout is, and what—were they to show a bit of principle—might be earned from opposing it.

The Affordable Care Act states clearly that all members of Congress and their staff must buy their health insurance through an ObamaCare exchange. The law just as clearly does not reconstitute the generous government premium subsidies that members and staff currently receive. Since most members and staffers earn too much to qualify for subsidies in the dreaded ObamaCare exchanges, they were looking at an enormous financial hit come January.

Democrats in particular freaked out, and so the White House in early August conjured out of thin air a bailout for the political elite. The Office of Personnel Management announced—with no legal authority—that Congress could keep receiving its giant subsidies. Oh, and the OPM also declared that each member of Congress also gets to define which of his staff is covered by the law. Chances are many staffers will never have to deal with the exchanges at all.

This deal ought to have led to a wild GOP protest, both on philosophical and legal grounds. Instead, there has been nary a peep of complaint.
[image] Getty Images

The charitable explanation is that the announcement came after Congress had left for recess, giving Republicans little opportunity to unify around a response. The less charitable explanation is that Republicans themselves are under huge pressure from their own staffers to shut up and keep the subsidies flowing.

Some members, like Arkansas's Tim Griffin, went so far as to post on his Facebook page a "myth vs. fact" explanation (read: defense) of OPM's ruling. The responses on his Facebook page were scathing.

Few things infuriate Americans more than special privileges for Washington. The public could care less that insurance hikes might lead to a Washington "brain drain." (Most would view that as progress.) Americans scrabbling for work, struggling to pay bills and facing soaring insurance premiums are not sympathetic to congressional complaints that the loss of their subsidies is unfair. As word has spread about the White House fix, a bipartisan fury has started to build at town-hall meetings, at rallies, and in letters and phone calls to Congress.

With a little fortitude, the GOP still has the opportunity to be on the right side of public opinion. The White House's unilateral bailout is a tailor-made opportunity for the GOP to highlight, yet again, the administration's unequal application of its flawed health law: waivers for Democratic union buddies, exemptions for big business, and now a special handout to Mr. Obama's political class.

The special deal is also an opportunity to oppose, yet again, the White House's extralegal actions.

Mostly, it is an opportunity to insist that Democrats either fully experience their experiment in social engineering—by living without subsidies within the ObamaCare exchanges they created—or give every other American relief. The reality is that Democrats, far more than Republicans, wanted this fix. They are terrified of their own creation. As leverage goes, there's little to compare with Democratic self-interest.

Imagine forcing Democrats, daily, to justify this self-dealing—a gravy handout reviled equally by independent, Democratic and Republican voters. Imagine the House attaching to a must-pass piece of legislation, say, a provision that requires Congress and staffers and administration officials to live uniformly and subsidy-free in the ObamaCare exchanges, or give a pass to ordinary Americans. Let's see Senate Majority Leader Harry Reid handle that one.

A handful of Republicans—Sens. David Vitter and Mike Enzi, and Reps. Ron DeSantis and Shelley Moore Capito—are already calling for action. Any of their legislative approaches might serve as a starting point for a broader effort.

Of course, for Republicans to take this route, they'd have to risk their own self-interest. The GOP is currently sniping over who has more "principles" in the fight against ObamaCare. Those advocating a defund provision for the law this fall seem willing to hold hostage the economy and American households as part of a shutdown fight.

Yet nothing would make a greater statement about principles than a GOP willingness to first hold its own financial self-interest hostage in a fight. If Republicans want to show that they "stand for something," this is it. If they really are willing to do "whatever it takes" to oppose this law, there would be no more meaningful way to prove it.

[DougMacG]

The key now for Obamacare's success is to get young people to sign up.

Karl Rove's Crossroads group put out this helpful ad.

[youtube]http://www.youtube.com/watch?v=hfP6LmJiSec[/youtube]

[Crafty_Dog]

That , , , is , , , absolutely , , , fg , , , awesome! 

[ccp]

August 12, 2013


A Limit on Consumer Costs Is Delayed in Health Care Law

By ROBERT PEAR

WASHINGTON — In another setback for President Obama’s health care initiative, the administration has delayed until 2015 a significant consumer protection in the law that limits how much people may have to spend on their own health care.

The limit on out-of-pocket costs, including deductibles and co-payments, was not supposed to exceed $6,350 for an individual and $12,700 for a family. But under a little-noticed ruling, federal officials have granted a one-year grace period to some insurers, allowing them to set higher limits, or no limit at all on some costs, in 2014.

The grace period has been outlined on the Labor Department’s Web site since February, but was obscured in a maze of legal and bureaucratic language that went largely unnoticed. When asked in recent days about the language — which appeared as an answer to one of 137 “frequently asked questions about Affordable Care Act implementation” — department officials confirmed the policy.

Please click here for the remainder of the article: http://www.nytimes.com/2013/08/13/us/a-limit-on-consumer-costs-is-delayed-in-health-care-law.html?_r=2&utm_source=News+Now+08152013&utm_campaign=News+Now+8%2F15%2F2013&utm_medium=email&&pagewanted=print

[Crafty_Dog]

Jeffrey Singer: The Man Who Was Treated for $17,000 Less
Bypassing his third-party payer, my patient avoided a high hospital 'list price.'
WSJ

    By
    JEFFREY A. SINGER

Every so often I have an extraordinary and surprising experience with a patient—the kind that makes us both say, "Wow, we've learned something from this." One such moment occurred recently.

A gentleman in his early 60s came in with a rather routine hernia in his lower abdomen, one that is easily repaired with a simple outpatient surgical procedure. We scheduled the surgery at a nearby hospital.

My patient is self-employed and owns a low-cost "indemnity" type of health insurance policy. It has no provider-network requirements or preferred-hospital requirements. The patient can go anywhere. The policy pays up to a fixed amount for doctor and hospital bills based upon the diagnosis. This affordable health-insurance policy made a lot of sense to this man, based on his health and financial situation.

When the man arrived at the hospital for surgery, the admitting clerk reviewed the terms of his policy and estimated the amount of his bill that would be paid by insurance. She asked him to pay his estimated portion in advance. (More hospitals are doing that now because too often patients don't pay their portions of the bills after insurance has paid.)

The insurance policy, the clerk said, would pay up to $2,500 for the surgeon—more than enough—and up to $2,500 for the hospital's charges for the operating room, nursing, recovery room, etc. The estimated hospital charge was $23,000. She asked him to pay roughly $20,000 upfront to cover the estimated balance.

My patient was stunned. I received a call from the admitting clerk informing me that he wanted to cancel the surgery, and explaining why. After speaking to the man alone and learning the nature of his insurance policy, I realized I was not bound by any "preferred provider" contractual arrangements and knew we had a solution.

I explained that just because he had health insurance didn't mean he had to use it in every situation. After all, when people have a minor fender-bender, they often settle it privately rather than file an insurance claim. Because of the nature of this man's policy, he could do the same thing for his medical procedure. However, had I been bound by a preferred-provider contract or by Medicare, I wouldn't have been able to enlighten him.

Hospitals and other providers make their "list" prices as high as possible when negotiating contracts with health plans and Medicare regulators. No one is ever expected to pay the list price. Anybody who has seen an "Explanation of Benefits" statement from a health plan will note a very high charge from the provider, and an "adjusted charge" based upon the contracted fee schedule, which usually leaves the patient with little or nothing in out-of-pocket expenses. The only people routinely faced with list prices are those few people who have insurance like my patient's—that doesn't include a pre-negotiated fee schedule with contracted providers—or those who have no insurance.

Most people are unaware that if they don't use insurance, they can negotiate upfront cash prices with hospitals and providers substantially below the "list" price. Doctors are happy to do this. We get paid promptly, without paying office staff to wade through the insurance-payment morass.

So we canceled the surgery and started the scheduling process all over again, this time classifying my patient as a "self-pay" (or uninsured) patient. I quoted him a reasonable upfront cash price, as did the anesthesiologist. We contacted a different hospital and they quoted him a reasonable upfront cash price for the outpatient surgical/nursing services. He underwent his operation the very next day, with a total bill of just a little over $3,000, including doctor and hospital fees. He ended up saving $17,000 by not using insurance

This process taught us a few things. First, most people these days don't have health "insurance." They have prepaid health plans. They pay premiums to take advantage of a pre-negotiated fee schedule arranged for and administered by a third party. My patient, on the other hand, had insurance.

Second, even with the markdown for upfront "cash-pay" patients, none of the providers was losing money on my patient. Otherwise they wouldn't have agreed to the prices. With the third-party payer taken out of the picture, we got a better idea of the market prices for the services. It is the third-party payment system that interferes with true price competition, so "market clearing prices" can't develop.

Take the examples of Lasik eye surgery or cosmetic surgery. These services are not covered by insurance. Providers compete on the basis of quality, outcomes and price. And prices have continually dropped as quality and services have improved—unlike the rest of health care.

When my patient returned for his post-op visit we discussed the experience. It was clear to both of us that the only way to make health care more affordable is to diminish the role of third-party payers. Let consumers and providers interact through market forces to drive down prices and drive up quality, like we do when we buy groceries, clothing, cars, computers, etc. Drop the focus on prepaid health plans and return to the days of real health insurance—that covers major, unforeseen events, leaving the everyday expenses to the consumer—just like auto and homeowners' insurance.

Sadly, we are heading in the exact opposite direction. ObamaCare expands the role of the third party and practically eliminates the role—and the say—of the patient in the delivery of health care. Will they ever learn?

Dr. Singer practices general surgery in Phoenix, Ariz., and is an adjunct scholar at the Cato Institute.

[DougMacG]

41% of 603 small business owners said they have delayed hiring because of the federal healthcare law. One in five already cut hours, while 20% have reduced payroll. Mercer, a human resources consulting company, said its own survey found that 12% of all U.S. employers reported plans to reduce workers’ hours as a direct result of the Affordable Care Act. The impact was more pronounced in the retail and hospitality industries, with 20% of employers saying they will cut part-time hours.

http://www.foxbusiness.com/industries/2013/09/11/with-eye-on-obamacare-companies-move-to-cut-workers-hours/

With Eye on ObamaCare, Companies Move to Cut Workers’ Hours

[DougMacG]

The administration admits Obamacare will provide coverage next year to only half as many of America's uninsured as anticipated just last year.

http://www.reuters.com/article/2013/09/18/us-usa-healthcare-spending-idUSBRE98H11T20130918
------------------

During his first run for president, Barack Obama made one very specific promise to voters: He would cut health insurance premiums for families by $2,500, and do so in his first term.

But it turns out that family premiums have increased by more than $3,000 since Obama's vow, according to the latest annual Kaiser Family Foundation employee health benefits survey.

http://finance.yahoo.com/news/health-premiums-3-065-obama-224300715.html
------------------

Pew Survey: 53% of Americans Disapprove of Obamacare, (42% approve), Highest Negative Since Law’s Passage

http://www.people-press.org/2013/09/16/as-health-care-law-proceeds-opposition-and-uncertainty-persist/

[DougMacG]

The parts of Obamacare that were popular were also available in Republican alternative bills.  Now one is being put forward for your consideration:

http://www.nationalreview.com/node/358874/print

American Health Care Reform Act

200 pages versus 2700 for Obamacare

"... letting people purchase plans across state lines and allowing small businesses to pool together to negotiate lower rates. It would also amend existing law to increase transparency in payments and pricing so patients would have a better understanding of the cost of care and ultimately become more discerning consumers.

The plan seeks to “level the playing field” between consumers who receive insurance from an employer and those who purchase insurance on the individual market. The latter group would receive significant tax breaks to offset the cost of buying insurance: Individuals would be able to claim a $7,500 deduction against their income and payroll taxes for qualifying health plans, while families would be able to deduct $20,000. The legislation would also expand access to portable health savings accounts, and increase the maximum allowable contribution to such accounts.

The bill would increase federal funding for state high-risk pools, which insure people with especially expensive and preexisting conditions, by $25 billion over ten years, and would cap premiums in those pools at 200 percent of the average premium in a given state. It would also guarantee that individuals with preexisting conditions could move between insurance plans while maintaining coverage in the interim.

Medical liability law would be reformed to cap awards on punitive damages, as well as attorneys’ fees, in an effort to limit the common (and increasingly expensive) practice of “defensive medicine.” Federal funding for abortion coverage would be explicitly prohibited except in cases of rape, incest, and risks to the life of the mother."

[DougMacG]

Lawmakers can prove their backbone by defunding Obamacare

I have been interested in the political atmosphere of our country since my preteen years. It has been particularly interesting to observe the political shenanigans adopted by many of those wishing to obtain or maintain power. Fortunately, there have also been many who were truly interested in serving the people who put them in office. Looking at one’s life, voting record and words can provide significant insight into which of the aforementioned categories a political figure fits.

In the 1960s, John F. Kennedy wrote a book titled “Profiles In Courage,” which was very inspiring, as he examined the lives of individuals who had enough daring to go against the flow and make a real difference in society. As a young, very intelligent president of our country, he was faced with many daunting problems, not the least of which was an attempt by the Russians to supply Cuba with nuclear weapons, which would have been situated just 90 miles off of our shores.

Although there have been many attempts to rewrite the history of the Cuban missile crisis, the bottom line is that Kennedy had the necessary backbone to stand up to Nikita Khrushchev and avert an enormous detrimental shift in the power structure of the world while enhancing America’s international image.

Some readers are probably already irritated that I have said something positive about someone who is not a member of their political party. It is my belief that if JFK were alive today, advocating personal responsibility and patriotism, he might find his views at odds with many in the Democratic Party.

Perhaps it is time to de-emphasize political affiliations and labels, and instead concentrate on the philosophies that define one’s beliefs and actions. The direction of our country is not good, and “we the people” — not we the Democrats or we the Republicans — are in desperate need of courageous leadership, guided by an understanding of our Constitution.

Our divided government was formed by diligent men who had studied the history of governmental structures throughout the world and wanted to design a system that would not succumb to the temptation to continuously expand its size and scope at the expense of the people.

An important concept was the separation of powers with checks and balances among the three branches of government. It was a rather ingenious idea to invest each of the three branches of government with enough power to check unwarranted power grabs by the others.

There is, however, a breakdown in this system when officeholders are more concerned about their legacy or their re-election than they are about the proper functioning of government. Our Founders were most concerned about the possibility of the executive branch seizing power and disregarding constitutional constraints.

I suspect they would have been horrified to witness the manipulative and secretive strong-armed techniques utilized by the current administration to push through Obamacare. I’m sure they would also be shocked to see an administration that picks and chooses the laws it wishes to enforce, thereby diminishing the power of the legislative branch of government.

This practice in some ways resembles that of the centralized government system that swept the Soviet Union, whose notorious founders wrote that it was sometimes necessary to force ideas on a populace that will eventually come to accept and endorse the ideas. Similarly, our current leadership is certain that Americans will eventually see the wisdom of governmental oversight in almost every aspect of their lives.

If we are to pass a free and prosperous nation on to our progeny, it is imperative that the legislative branch of government exhibit the courage to exercise the check function it possesses. Lawmakers cannot be afraid that they will be blamed for a government shutdown if they defund Obamacare.

They have the ability to separate the health care law from the rest of the federal budget and fund one without funding the other. In doing so, they need to make it abundantly clear that they are willing to fund the government and its essential functions, but they feel that Obamacare is detrimental to the future economic health of America.

If the Democrat-controlled Senate reattaches the law, or if the executive branch makes the decision to fund Obamacare at the expense of other vital national functions, the electorate must take notice and act decisively in 2014. Many say that those who want to restore constitutional restraints are fighting a useless battle, but we must remember that freedom is reserved only for those willing to fight for it.

I am confident that the people will awaken from their apathy and vigorously support whoever has the backbone to stand up for them.

Ben S. Carson is professor emeritus of neurosurgery at Johns Hopkins University.

http://www.washingtontimes.com/news/2013/sep/18/carson-a-moment-that-defines-courage/#ixzz2fMM9w77n

[Crafty_Dog]

http://www.youtube.com/watch?v=R7cRsfW0Jv8&noredirect=1

http://www.youtube.com/watch?v=BsN75nt1aUU&noredirect=1

[ccp]

Not too long ago I posted how I cannot understand the reluctance of anyone in public life to call a liar a liar.  I guess it is the fear of a slander law suit.  That said it is about time liars are being called out for what they are.  The next hope is there actually will be political consequences for public servants who lie.  So far not much in that department:

*****Republican accuses fellow lawmakers of ‘lying’ about Obamacare exemption

1:15 PM 09/19/2013
Alex Pappas
Political ReporterSee All Articles
   
Republican Sen. David Vitter is slamming his fellow lawmakers for “lying” and telling their constituents that there is no such thing as an Obamacare exemption for members of Congress and their staff members.

“Some are lying, trying to mislead the public about the Obamacare exemption for Congress,” Republican Sen. David Vitter said in a statement Thursday. “President Obama recently issued a special rule for Congress and congressional staff to get a special subsidy to purchase health insurance on the Obamacare Exchange unavailable to every other American at similar income levels. That’s an exemption, plain and simple.”

Vitter has been leading the Republican fight in the Senate with an amendment that kills federal Obamacare subsidies for lawmakers and their staff. It would require that all members of Congress, the president, vice president, and Obama administration appointees to purchase health insurance on the Obamacare exchange without taxpayer-funded subsidies.

To show that lawmakers are “denying” the existence of the exemption, Vitter’s office on Thursday released to the media a letter that fellow Louisiana Sen. Mary Landrieu, a Democrat, sent to a constituent. She said the notion they are getting special treatment “could not be further from the truth.”

“Once again, let me assure you that there is no exemption for Members of Congress and their staff in the [Affordable Care Act], nor will I ever support an ‘exemption’ for myself of my staff,” Landrieu wrote.

Vitter’s office provided a copy of the letter he sent to the same constituent: “Senator Landrieu is trying to mislead you, to put it kindly. Others might say she is lying.”

“As you have no doubt read, President Obama recently issued a special rule for Congress only. Under it, Congress and congressional staff get a special subsidy to purchase health insurance on the Obamacare Exchange unavailable to every other American at similar income levels,” he said. “That special subsidy is worth approximately $11,000 per family.”

Vitter’s office also released a graphic that he says proves his point:

The Obamacare fix for lawmakers and staff was made because the Affordable Care Act includes an amendment from a Republican senator that changes how the government currently covers most of the cost of health-care premiums for members and their staffers. The new law mandates that members and staff must enter into exchanges or be covered by insurance “created” by law.

The Office of Personnel Management announced in August that it plans to provide a subsidy of about 75 percent of the cost for the healthcare of members and staff.****

[Crafty_Dog]

http://www.upworthy.com/his-first-4-sentences-are-interesting-the-5th-blew-my-mind-and-made-me-a-little-sick-2?g=2

[DougMacG]

My guess is that his stats are essentially correct, but that doesn't lead to any easy or obvious solution.  One might imply from the presentation that we could have costs like whomever if we ran our system like theirs.  Not true.  Their prices are lower because the largest healthcare market in the world has already paid the bulk of the sunken costs that developed those products and services.  For example, the cost of a drug or medical device is largely the research and development which is spent before the first unit hits the shelf.  In many cases the US is paying for that.  Then when they compete for additional sales on the margin for the contract in Canada, UK, etc. they only have to cover and profit over their variable cost, not the fixed cost that went into it.  But if the development cost is not covered by someone else, us, that drug or device would not exist. 

If the US bid out the cost of providing replacement hips to one only provider as he suggests, would there be multiple suppliers left to bid next year, operating just fine on zero revenues, ready to compete?  If not, we are right back to the price and quality that you get without competition.

The underlying problem in my view is the prevalence of third party pay and the lack of any process of driving the price down on the demand and payer side. 

At the heart of it is freer and more open competition.  There really isn't any and the solution to it isn't easy.  We limit the supply of doctors, nurses, hospital beds, approved drugs, devices and nearly everything else in the industry and by doing so remove the forces that work to lower the costs of all products in all the industries that don't do these sorts of things, such as computers and electronics where the prices are always going down while quality, performance, reliability keep getting better.

[DougMacG]

Iraq war a mistake: 53%, not a mistake: 42%  - March 2013

Obamacare/Obama's handling of healthcare, disapprove: 58%,  approve: 38%  - Sept 2103

Obamacare's approval is only 59% with Democrats!

http://www.powerlineblog.com/archives/2013/09/obamacare-more-unpopular-than-the-iraq-war.php

http://www.foxnews.com/politics/2013/09/17/fox-news-poll-68-percent-concerned-about-their-health-care-under-new-law/

http://www.gallup.com/poll/1633/iraq.aspx

[ccp]

CD,  

Perhaps Gilder's entropy theory of new knowledge entropy leading to growth also leads to higher costs.   Medicine is certainly one area where knowledge is expanding rapidly and leading to innovation new knowledge and more advanced treatments.  It has certainly helped mankind.  Most of the entropy is here in the US.  Maybe one consequence is higher cost.  But why are costs higher than say compared to electronic devices?  Let me just say this.  Yes the cost of communicating devices may be down but our costs for such things are MUCH higher than 30 yrs ago.  Automobiles are far higher than adjusted for inflation with all the engineering that goes into them.   One could get a very nice luxury car for 3K in the 60s.  Now the same deemed "level" of luxury is 40 to 50 K.  That is far higher than inflation.  That is far higher than wages.

Back in the day we just had a TV set that cost a few hundred dollars and no cable/satellite or monthly fees.   We had land lines (though long distance calls were relatively more expensive) without all these subscriptions for internet.      

Doug writes:

"Their prices are lower because the largest healthcare market in the world has already paid the bulk of the sunken costs that developed those products and services."

Nearly all the innovation comes from the West.  

Off the top of my head I cannot think of one innovative medicine, device, etc. that was not from America, or Europe.

He is making the case for oligopolies or single payer actually.

There are payers who reimburse less then Medicare so he is wrong about this.  Plus Medicare patients can buy supplements if they want.

It seems to me the trend is towards oligopolies anyway.   We are seeing huge trends towards hospital consolidation, physicians organizing or aligning with hospitals, hospitals, skilled nursing facilities taking control of the provider market and control costs, providers, increase their bargaining clout.  Nurse organizations are gaining more control because (for now) nurses get paid less.

He is also DEAD wrong about doctors ordering tests to "cover their butts" is negated by capping pain and suffering awards aka Texas and some other states.  This would have little impact on test ordering.  Plainly put, I as well as any other doctor does not want to be sued any less because I may know the damages are capped.  

As for how much this accounts for excessive health care I might agree it may not be that much.   It is very difficult to determine what is excessive and what is not.  Anyone who tells you this is not telling all the details.

Doug writes,

"but that doesn't lead to any easy or obvious solution"

The reason is because there isn't one.    It is all an experiment in progress.   Yet he seems to be advocating single payer system.

Doug writes,

"We limit the supply of doctors, nurses"

Well in rural fly over areas there is not an overabundance of doctors who like everyone else don't prefer to live in the middle of "no where".  But in the North East I can certainly say there is no shortage of most types of physicians though in some specialties that may be the case.  The market is flooded with foreign born, foreign trained doctors.  Even some of them tell me now they wish the newbies would "stop coming".

As for nurses, with the resurgence of nursing (RNs some years ago were not in demand unless they got their MBA and go into hospital administration etc), NPs, PAs, etc the schools cannot churn them out fast enough.  Their ranks were not limited just that it didn't pay to be a nurse.  That has swung back the other way.

Just today it is posted the median salary for a surgeon is around 177 K on yahoo and surgery is not all that it is cracked up to be.  Many general surgeons are struggling in my area at least.  An ortho surgeon ran off from NJ to Montana.   A cardiologist left NJ for New Mexico.   The 177 seems low to me.  OTOH I was recently told of one ortho surgeon who is boarded in spine surgery (apparently rare) and charges 80K for a procedure.  The insurance in one case negotiated him "down" to something like 25K.  IT was done out of network.   The out of network thing seems to be one loophole  that works as a way to game the system by some hospitals and doctors.
So while we have some doctors on the one end making huge sums most are not.

[ccp]

http://finance.yahoo.com/news/the-most-overrated-jobs-of-2013-192901302.html

[G M]

http://www.usatoday.com/story/news/politics/2013/09/23/aca-family-glitch-issues/2804017/

'Family glitch' in health law could be painful

 Kelly Kennedy, USA TODAY 11:55 p.m. EDT September 23, 2013



 It could leave up to 500,000 children without coverage and cost some families thousands of dollars.



WASHINGTON — A "family glitch" in the 2010 health care law threatens to cost some families thousands of dollars in health insurance costs and leave up to 500,000 children without coverage, insurance and health care analysts say.

That's unless Congress fixes the problem, which seems unlikely given the House's latest move Friday to strip funding from the Affordable Care Act.

Congress defined "affordable" as 9.5% or less of an employee's household income, mostly to make sure people did not leave their workplace plans for subsidized coverage through the exchanges. But the "error" was that it only applies to the employee — and not his or her family. So, if an employer offers a woman affordable insurance, but doesn't provide it for her family, they cannot get subsidized help through the state health exchanges.

That can make a huge difference; the Kaiser Family Foundation said an average plan for an individual is about $5,600, but it goes up to $15,700 for families. Most employers help out with those costs, but not all.

"We saw this two-and-a-half years ago and thought, 'Has anyone else noticed this?'" said Kosali Simon, a professor of public affairs at Indiana University who specializes in health economics. "Everyone said, 'No, no. You must be wrong.' But we weren't, and that's going to leave a lot of people out."

The issue has recently received attention, especially after former president Bill Clinton highlighted it in a recent speech.

"The family glitch is definitely a drafting error that Congress made that needs to be fixed," said Joan Alker, executive director of the Georgetown University Center for Children and Families. "But that seems unlikely."

New rules state that those families will not be penalized for not purchasing coverage, but the point of the law was to make coverage affordable for families.

Other challenges for families remain as the Obama administration and the health care industry gear up for the Oct. 1 opening of the exchanges, websites for each state on which customers can shop for and buy health insurance. The law requires uninsured Americans to buy health insurance; many are eligible for government subsidies to help them for the policies. For example:

• Kids may not receive Medicaid or exchange coverage if their parents aren't eligible and, therefore, don't know to check.

• Undocumented immigrants may not learn their children are eligible for insurance.

The law has already helped children, Alker said, because it "stabilizes Medicaid and CHIP," the insurance program for children.

However, 70% of uninsured kids are eligible for Medicaid and CHIP, but they're not all enrolled, she said.

"There has to be a lot of outreach and education about the importance of getting health care," she said. "These kids could enroll today."

If congressional Republicans were to succeed in cutting funding for the law, the CHIP program would expire in October, said Bruce Lesley, president of First Focus, a bipartisan advocacy group for families.

The Children's Health Insurance Program provides insurance for kids whose family incomes are too high for Medicaid, but whose families still can't afford coverage. The Affordable Care Act extended it for two years, which means as many as 6 million children have health care.

Eliminating money for the law would force states to rethink their children's programs quickly, Alker said.

But even with the funding, not all kids are getting coverage. In fact, two-thirds of kids are eligible for Medicaid or CHIP but not enrolled. Advocates hope that adults signing up for insurance through the health exchanges will find out their kids are eligible, and have said as many as 4 million kids could sign up.


Former president Bill Clinton speaks about health care at the Clinton Presidential Center in Little Rock on Sept. 4, 2013.(Photo: Danny Johnston, AP)


"In Massachusetts, the uninsured rate for kids is lower than 2%," Lesley said, explaining that when Massachusetts implemented "RomneyCare," children were enrolled for insurance in droves. The Massachusetts program became law in 2006 under then-Gov. Mitt Romney, last year's unsuccessful Republican nominee for president.

The Obama administration is working with the YMCA and other organizations to get the word out about children's eligibility, he said.

This can be a particularly big deal for immigrant families, where one parent might be a documented immigrant, a second could be undocumented, and the children could be U.S. citizens.

"Most of the kids are United States citizens," said Jenny Rejeske, a health policy analyst for the National Immigration Law Center. "We know already that many kids in mixed-status families don't have insurance."

Though she said the majority of immigrants are in the country legally, undocumented immigrants may be afraid to seek benefits for their children. Those children, she said, need immunizations and preventive care, in part to keep everybody else's kids healthy, too.

"I feel very confident saying it is safe for mixed-status families to sign up," she said. "The information they give will not be used for immigration enforcement."

The information will go only to the agencies that need to see it, and there are "protections" built in to the Affordable Care Act so families will go sign up their children, she said.

Others who might miss coverage options for kids include veterans receiving care through the VA but who don't have benefits for their families, as well as grandparents receiving Medicare. There is a child-only coverage option that would allow the child to receive subsidized insurance.

Alker said kids also benefit when their parents have coverage because the family is more likely to be financially secure. Medical bills are the leading cause of bankruptcy. She also cited examples, such as maternal depression or healthy pregnancy benefits that affect children as well as adults.

According to a Georgetown policy brief, 11.5 million parents and 6.3 million children were uninsured in 2010. Three-quarters of the parents' incomes fell below the poverty line, and 38% lived in deep poverty. About half of them are white, 29% are Hispanic, and 17% are African American.

Despite their concerns, the analysts said several promising things for families have happened through the law, including:

• Foster kids who have "aged out" of the system can continue to receive insurance through Medicaid until they are 26

• American children of immigrant parents -- even undocumented -- can get insurance subsidies through the new health insurance exchanges, and may be eligible for Medicaid.

• The children and spouses of disabled veterans, who receive their health care through Veterans Affairs, could be eligible for subsidized insurance through the exchange, even if the veteran is not. The same could apply to children who live with retired grandparents who receive care through Medicare.