So what do you think about that?

Lie of the Year. Not?

noreply@blogger.com (sparker) — Wed, 21 Dec 2011 16:21:00 +0000

Paul Krugman's post today highlights an important aspect of the debate about the Affordable Care Act. The issues: when are facts lies, when are lies facts, and is it even possible to capture complex issues in sound-bites that don't distort?

Here is Krugman's post its entirety:

Politifact, R.I.P.

This is really awful. Politifact, which is supposed to police false claims in politics, has announced its Lie of the Year — and it’s a statement that happens to be true, the claim that Republicans have voted to end Medicare.

Steve Benen in the link above explains it, but let me just repeat the basics.

Republicans voted to replace Medicare with a voucher system to buy private insurance — and not just that, a voucher system in which the value of the vouchers would systematically lag the cost of health care, so that there was no guarantee that seniors would even be able to afford private insurance.

The new scheme would still be called “Medicare”, but it would bear little resemblance to the current system, which guarantees essential care to all seniors.

How is this not an end to Medicare? And given all the actual, indisputable lies out there, how on earth could saying that it is be the “Lie of the year”?

The answer is, of course, obvious: the people at Politifact are terrified of being considered partisan if they acknowledge the clear fact that there’s a lot more lying on one side of the political divide than on the other. So they’ve bent over backwards to appear “balanced” — and in the process made themselves useless and irrelevant.

Way to go, guys.

First, here's the link to the actual Politifact article. I'm disappointed that Krugman didn't include it but rather linked to the Benen piece.

I had read (well OK, skimmed the first several paragraphs of) the Politifact story the other day. What I read seemed consistent with what I understood to be true, and quite honestly, I left it being disappointed in the Democrats' spin.

Then I read Krugman today, and thought, "Whoa! Maybe I missed something!"

Take a minute and read the Benen piece referenced by Krugman and let me know what you think.

Has Politifact damaged its credibility in your eyes? It has for me.

I'd have chosen Politifact's top vote-getting lie ("The economic stimulus created "zero jobs.") as lie of the year, myself.

A local success story

noreply@blogger.com (sparker) — Fri, 07 Oct 2011 19:38:00 +0000

This success story by Allen Weiss, M.D., President and CEO of Naples Community Hospital (NCH) is just wonderful ... and worth sharing.

October 6, 2011

Dear Friends and Colleagues,

We did it! Working together, 3,750 colleagues— along with our spouses and insured children—have bent the healthcare cost curve downward. We have better health, better health benefits, and, as a result, no increase in the cost of our health insurance!

In fact, all of us are now spending less for healthcare than we did in 2008. Compare that to the national average annual healthcare premium for family coverage, which is rising 9% a year—with many places around the nation experiencing double-digit increases. Meanwhile, here in Naples, our costs are down, and our colleagues enjoy access to the best care locally available, and we are objectively healthier.

How did we do it?

I am pleased to share our story as viewed by our partner Willis, a risk manager and insurance company (www.Willis.com), who collaborated with former Chief Human Resources Officer Brian Settle, Chief Financial Officer Vicki Orr, Chief Nursing Officer Michele Thoman, Chief of Staff Kevin Cooper, Chief Operating Officer Phil Dutcher, and the whole benefits team, which orchestrated our coverage.

Two-and-a half years ago, our team recognized that people working in hospitals and medical offices have physically and emotionally demanding jobs. They confronted a challenging environment for reimbursement. And they were motivated by the ideal that we in healthcare should be a model for the community we serve.

We also understood from the Department of Health and Human Services study in 2007 that 87.5% of health care claims costs are due to an individual’s unhealthy lifestyle. So we focused on “keeping the well people well”; helping the chronically ill improve; ensuring the sick had good and quick access to care; and screening all who volunteered with age and gender-specific tests to detect occult disease early. As I think you’ll agree, all common sense solutions.

Results have been heartening. More than 88% of our colleagues, spouses and insured children see a health coach, don’t use tobacco, and have undergone basic screening tests such as height and weight ratios, waist to hip ratios, simple blood tests, and, when appropriate by nationally accepted guidelines, mammograms and colonoscopies. As expected, the first year saw a large increase in spending, driven by the cost of testing and treating abnormalities which if left untreated would have evolved into cancer or worse. Indeed, 43% of colleagues had polyps removed when they had colonoscopies. Mammography services increased by 21%, and there was a 19% increase in individuals establishing a relationship with a physician. Initially, reports of diabetes increased significantly; but with treatment the number of emergency room visits for diabetes dropped, and we’ve improved overall outcomes for diabetics by avoiding diabetic complications.

Year-over-year results reflect more than a 17% reduction in cost and a savings—more than $6.5 million over the past year and that saves us from having to increase employee’s insurance costs. Starting this month we are no longer hiring those who use tobacco. NCH is becoming the prime example of a community already recognized for having the nation’s longest life span for women and second longest for men, according to University of Washington studies. And we want to keep it that way—and bend that healthcare cost curve even further.

Respectfully,

Allen S. Weiss, M.D., President and CEO

P.S. Feel free to share Straight Talk by emailing me at allen.weiss@nchmd.org to be added; and join us on Facebook at www.facebook.com/nchflorida.

While there's no new news here, it's great to hear that my local hospital - the largest private sector employer in the county - is being proactive in managing both the health of its employees, and its health care costs.

Is yours??

Readers’ questions and where they led me

noreply@blogger.com (sparker) — Thu, 21 Jul 2011 00:36:00 +0000

Two readers questioned the statistics about Medicare spending I presented in my blog post the other day. The statement in question:

About 25 percent of Medicare spending is for people in their last year of life; and slightly more than half of Medicare dollars are spent on patients who die within two months.

They were right to question. How could both these statistics be true?

The original source for my statement was WNET New York Public Media’s 1997 series “Before I Die,” “How Much Do We Spend on End-of-Life Care?”:

Medicare, the health insurance program for the elderly, spends nearly 30 percent of its budget on beneficiaries in their final year of life. Slightly more than half of Medicare dollars are spent on patients who die within two months.

I changed the “nearly 30 percent” to “about 25 percent” based a 2001 Health Affairs article, thinking it was a more recent statistic, but left the rest of the statement as WNET wrote it. Unfortunately, the WNET statement is not attributed, but something is clearly wrong since the two statements ARE inconsistent.

I’ve done some further research trying to find another source. I found a report by the Centers for Medicare & Medicaid Services, Office of the Actuary, on its “Last Year of Life Study.” It found:

The percentage of Medicare expenditures attributable to those beneficiaries in their last year of life increased from 26.5 percent in 1994 to 27.9 percent in 1999.

I also found a post titled “28% of Medicare spent during last two months of life” on a discussion forum for the Mississippi Estate Planning Community. The post included a slide containing this statement:

It’s notable that ~28% of average Medicare recipient spending occurs in the final year of life and 12% occurs in final two months of life.

The slide (including the erroneous blog post title) was taken from a February 2011 publication titled USA, Inc., which examines the US economy as if it were a public company. (A very interesting report, by the way. More about it below.) The data on the slide were sourced to “CMS, Medpac, Report to the Congress: Medicare Payment Policy, 3/10," but when I searched that document, I couldn’t find the information.

My conclusion: It’s probably safe to say that about 25% of Medicare spending is for the last year of life, and that about half of that is spent in the final two months. Wish I could find a better source and more recent information.

Thanks to Bob and Rob for being such thoughtful readers.

More on the USA, Inc., report:

The report was created and compiled by Mary Meeker, a partner at Silicon Valley venture capital firm Kleiner Perkins Caufield & Byers. In the 1990s, she was a highly-regarded Morgan Stanley analyst covering the early internet industry.

From “About USA, Inc.” --

This report looks at the federal government as if it were a business, with the goal of informing the debate about our nation’s financial situation and outlook. In it, we examine USA Inc.’s income statement and balance sheet. We aim to interpret the underlying data and facts and illustrate patterns and trends in easy-to-understand ways. We analyze the drivers of federal revenue and the history of expense growth, and we examine basic scenarios for how America might move toward positive cash flow. It includes a 2-page foreword; a 12-page text summary; and 460 PowerPoint slides containing data-rich observations. There’s a lot of material – think of it as a book that happens to be a slide presentation.

Thinking about mortality lately

noreply@blogger.com (sparker) — Sat, 16 Jul 2011 23:23:00 +0000

A man I worked with early in my career died last week. Receiving the email notification from my former firm’s alumni group brought back memories of him and that time in my life. Rather than just send a card, I wrote a letter to his wife, telling her of the role he’d played in my career and sharing my memories of him. It got me thinking.

I realized that I’ve written a lot of condolence cards lately. Several friends or their family members are seriously ill, and CaringBridge has become a “favorite” in my web browser. When did this start to happen?

As I am faced with the mortality of my family and friends, I’m forced to also face my own. I notice that I struggle with two issues: wanting to be able to control and direct my own end-of-life care when the time comes, and being aware of the cost to society (Medicare) of that care. (I’ve written about the end-of-life costs of medical care before, but as a reminder, here are two statistics: About 30 percent of Medicare spending is for people in their last year of life; and slightly more than half of [those] Medicare dollars are spent on patients who die within two months.)

I’ve been reading quite a bit about these subjects recently – not by plan, just by coincidence – but then, nothing’s really a coincidence, is it?

Most of you (my readers) are in the same stage of life as me. You too have probably lost friends and family members, or have others who are seriously ill. I recommend several articles and podcasts if you - like me - are thinking about these issues:

“The Good Short Life” -- A very moving and thought-provoking Opinion piece in last Sunday’s NYTimes by a man in the final stages of ALS. The last sentence is “It’s time to be gone.”

“Death and Budgets”-- David Brooks’ Thursday column. It brings together the issue of end-of-life-care choices and health care costs.

“Being mortal, and other tragedies: Why modern medicine so often fails people facing the end of their lives; how America can have better; and other discussions with a medical writer”— A compelling and informative discussion taped in April in LIVE from the New York Public Library with surgeon/writer Atul Gawande.

“Letting Go: What should medicine do when it can’t save your life?” – A wonderful article by Gawande in the April 2010 New Yorker Annals of Medicine.

In both the interview and the “Letting Go” article, Gawande movingly describes his experiences as a physician struggling to have “the conversation” about end-of-life choices with several of his patients. He talks about four questions shared with him by palliative care specialist Dr. Susan Block that he found to be helpful:

1) What do you understand to be your prognosis?
2) What fears do you have about what’s to come?
3) What are your goals as time grows shorter?
4) How much suffering are you willing to go through for the possible trade-off of added time?

I encourage you to read these articles, and especially to listen to (or watch – both are available at the website) the Gawande interview.

Let me know what you think.

The Business of Health Care: Defining the Future - FREE AND ONLINE!

noreply@blogger.com (sparker) — Mon, 20 Jun 2011 23:51:00 +0000

In January, I attended the University of Miami's Global Business Forum “The Business of Health Care: Defining the Future” and shared my experience on this blog. (See three posts starting here.)

Today UM issued the following release:

The University of Miami School of Business Administration has unveiled a multimedia website featuring insight on The Business of Health Care from some of the world's most prominent industry executives and government leaders - the nation's Secretary of Health and Human Services, the FDA Commissioner, the CEOs and presidents of General Electric, the American Medical Association, and the American Hospital Association, among others.

These thought leaders were among 800 top executives and other health industry professionals who gathered for the University's 2011 Global Business Forum to explore health care reform, aging, medical innovation, global health challenges, wellness and prevention, hospital design and delivery, and more.

View videos and photos, download session papers, and access the presentations to learn more about The Business of Health Care and the 2011 University of Miami Global Business Forum.

Thanks to UM's generosity and the wonders of the internet, I can re-visit some of the excellent sessions I attended, catch up on some I missed, and share it all with you. Enjoy!

Advance Directives, Hospice Benefits and Palliative Care

noreply@blogger.com (sparker) — Mon, 14 Feb 2011 02:18:00 +0000

Grim? Macabre? Maybe, but important to know.

That’s how I’d sum up what I learned last week at a meeting 20 League of Women Voters members and I had with Dr. Paul Mitchell, Medical Director and VP of Physician Relations at Avow Hospice in Naples, FL. He is also on staff at NCH Healthcare System with a specialty in palliative care. Dr. Mitchell had been invited to speak to the League’s Social Policy Committee about the greatly maligned and misunderstood advance care Medicare consultation I wrote about previously (“An unhelpful distraction from an important national discussion”).

It was clear from the outset that Mitchell was frustrated with the politicization of this Medicare provision, like all doctors I’ve heard speak on the topic. He began his remarks with what an advance directive is and why it’s important. An advance directive is a general term that describes two kinds of legal documents: living wills and medical powers of attorney. These documents protect our right to refuse medical treatment we do not want, or to request treatment we do want, in the event we lose the ability to make decisions for ourselves.

Mitchell told us that it’s important to have an advance directive so that our wishes will be known and can govern our end-of-life care. Without an advance directive, when we become unable to participate our health care decisions will be made by someone else who may not know how we’d want to be treated. Especially at a time when doctors admit they practice defensive medicine, an advance directive could prevent treatment that may (or may not) prolong our life and make us miserable in the process.

It’s especially important to choose a health care proxy you think will actually be willing and able to carry out your wishes when the time comes. For example, while it might seem logical for spouses to name each other, it might be wiser to choose someone who is less emotionally-involved. It depends, of course, on the people, but it’s really important to have “the conversation” with your family members while you’re healthy, and decide.

It’s also important to avoid having multiple surrogates (deciders) who would have to reach agreement on a course of action. (Can’t you imagine?) But it’s possible to name one person to act, and to specify that in that person’s absence or inability, another person is authorized to act.

Talk of advance care planning led to talk about palliative and hospice care. Palliative care is a medical specialty focused on improving the quality of life of people facing serious illness. Emphasis is placed on pain and symptom management. Many people with chronic conditions that cannot be cured but are not immediately life-threatening receive palliative care. Importantly, palliative care is not necessarily end-of-life care. It is not the same as hospice care, although hospice care is a subset of palliative care.

Hospice care is focused on providing quality care to people in the last months of life who have decided to stop treatments meant to cure them, and is ideally provided in one’s own home. Most people don’t know that hospice care is covered by Medicare Part A (hospital insurance), and that it requires little or no out-of-pocket payment – including for prescription drugs. For more on the Medicare hospice benefit, click here.

Once again, the League of Women Voters of Collier County, FL’s Social Policy Committee provided a great service for its members by inviting Dr. Mitchell to speak to us. Our group had lots of questions, and Dr. Mitchell was exceptionally knowledgeable and willing to answer them.

If you haven’t done so already, I hope you will look into preparing your own advance directive and medical power of attorney (or health care proxy). Click here and get started.

Local experts on health care reform share their insights

noreply@blogger.com (sparker) — Mon, 31 Jan 2011 03:20:00 +0000

The League of Women Voters of Collier County, FL, recently held two meetings at which local experts addressed the topic of health care reform:

Allen Weiss, M.D., President and CEO of the NCH Healthcare System, Naples, FL, spoke on January 10th on “Health Care Reform: What’s Next … and What About Me?”, and
Ronald Riner, M.D., President and CEO of the Riner Group, a health care management consulting firm in Naples, FL, spoke on January 12th on “The Impact of Health Care Reform on Small Business.”

The Naples Daily News summed up Dr. Weiss’s remarks as: “U.S. health-care overhaul is needed to survive.” From the article:

Ninety-two percent of government spending could be spent on health care by 2050 if cost controls and change isn’t made, Dr. Allen Weiss, president and chief executive officer of the NCH Healthcare System, said Monday.

“We won’t be able to pay back China,” he said.

Speaking to members of the League of Women Voters during a luncheon at the Naples Hilton, Weiss provided a big picture perspective about today’s anxiety over health-care reform passed last year under the Patient Care and Affordability Act [sic]. He said the country went through similar unease when the Social Security program was started in the late 1930s and later when Medicare began in the mid-1960s.

“People hate change,” he said, adding that people will get over the current anxiety as they did after both Social Security and Medicare were up and running.

...[But] “One way or another, the health-care bubble is going to burst,” he said.

In other words, reform of the health care delivery system is both necessary and inevitable, and the current agitation (such as calls to overturn the law) is nothing more than a to-be-expected fear of change which too shall pass.

Weiss has been actively moving NCH toward more efficient high-tech medical care for years, and began implementing Cerner Corp. solutions including Electronic Medical Records as early as 2005. In an August 30, 2010, piece in the Naples Daily News titled “The power of information in health care,” Weiss wrote:

Information, they say, is power. And nowhere is that truer than in health care, where the information we acquire and record about our patients gives us the power to heal and even save lives.

It’s no coincidence that information technology has become a top-level priority at NCH. In particular, our integrated medical record infrastructure enables us to link all healthcare providers — from the time a patient expresses medical concern through visiting a primary care physician, referral to a specialist, potential admission to the hospital, post-hospital care in a rehabilitation center or skilled care facility, to home care.

This robust, computerized information infrastructure allows us to determine best practices and establish treatment benchmarks. This is a quantum change from the standard paper analog record, where medical research about processes — such as the time needed to stop a heart attack — had to be calculated manually. With an Electronic Medical Record (EMR), all digital records can be analyzed in moments for any period of time. The data collected digitally becomes new knowledge about how best to care for patients and obtain the best outcomes.

Referring to another characteristic of “Health Care 21” (my new term for health care in the 21st century), Weiss told the LWVCC that local medical providers are moving toward forming accountable care organizations (ACOs). An ACO is a health care delivery model that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs.

My take-away from Weiss’s talk was that he is on-board and well ahead of the curve in terms of understanding what hospital systems have to do to succeed in the 21st century. While he made it clear that he is a-political on the subject, my impression was that he accepts the Affordable Care Act’s requirements as the law of the land, not necessarily anything he disagrees with. While he expressed some sympathy for the disruption and cost local practitioners have to deal with in adapting to Health Care 21, he left me with no doubt that he knows where things are headed.

In a January 17th Naples Daily News Guest Commentary, Weiss wrote:

Both short and long term, health-care reform will make our local delivery system better.

Dr. Riner spoke to the League of Women Voters’ Social Policy Committee on January 12th. His presentation is available here.

In Riner’s view, “the overall impact of health care reform is likely to be neutral to positive for small business.” In the short term, the health care law’s requirements will have a “small effect,” he said, with the major impact occurring in 2014 as a result of these provisions:

Creation of insurance exchanges, allowing small businesses to purchase from a multitude of plans in their state;
Tax credit for small businesses providing health insurance;
Exemption from the pay-or-play provisions imposed by the ACA on medium-to large-sized firms;
Employees of small businesses not offered insurance through work are allowed access to insurance exchange, with subsidies available for low-income individuals and families, and acceptance of pre-existing conditions.

Long term, Riner said, the impact on small businesses is likely to be “neutral in terms of cost.” Businesses with 50 or more employees will be required to offer health insurance coverage or pay a penalty. But offsetting this cost, businesses are likely to see these savings and quality improvements:

Lower insurance cost to employers purchasing via an exchange;
Tax credit for small business offering insurance;
Shift of insurance cost to individual from employer as individuals have additional purchase options via exchanges;
Improved worker productivity with improved access to health care;
Larger pool of candidates if health care insurance benefit is not tied to size of employer.

The second part of Dr. Riner’s presentation was review of the effect of the health care law on future health care spending. He made the frequently-stated point that the law did not do enough to bend the health care cost curve.

I asked Dr. Riner what he would have liked the government to have included in the law to address the cost issue, and I got the same thing I get whenever I ask that question: not much. Riner said practitioners need to “involve the patient” in the health care purchasing decision (“If it’s an entitlement, it’s a freebie”) and “talk more about the fraud issue” so people will begin to question the need for tests and procedures being ordered. He also said “the medical community needs to police itself.”

Well, we’ve seen where that’s gotten us!

He also talked about the lack for tort reform, an oft-cited complaint despite the fact that studies show the cost of malpractice claims to be no more than a drop in the bucket when it comes to health care costs. “These costs, all told, have been estimated to be only about 2 percent of healthcare expenses,” says Leemore Dafny, Kellogg School Assistant Professor of Management and Strategy, an economist and expert in healthcare competition, just one of many sources of this statistic.

After hearing Dr. Weiss on Monday and Dr. Riner on Wednesday, I went off to Miami for the Global Business Forum on the Future of Health Care I wrote about earlier this month.

Looking back on the entire week, I’d say that despite the probably-valid concern that not enough has been done to curb health care costs, the kinds of changes encouraged and/or required by the Affordable Care Act are inevitable and for the best.

The smart practitioners like Dr. Weiss know it, and are on-board.

Take-aways and Learnings from The Business of Health Care Forum – Part 2

noreply@blogger.com (sparker) — Sun, 23 Jan 2011 19:30:00 +0000

Last week I shared some of my observations from The University of Miami’s Global Business Forum on “The Business of Health Care: Defining the Future.” I also mentioned three of the most-frequently mentioned trends that are expected to transform health care delivery – electronic health care records (EHRs), accountable care organizations (ACOs), and Comparative Effectiveness Research, each of which has received federal funding through the stimulus act and/or the new health care law. I’ll write more about these at a later date.

This week, I want to tell you about some of the amazing new technologies I learned about at the conference in a session called “Telehealth, Robotics and Ubiquitous Computing: The De-Institutionalization of Health Care.”

Think about how much time and money could be saved if medical expertise could be provided when and where it was needed – whether a specialist was onsite or not.

Imagine if a surgeon could monitor and advise on a time-critical procedure -- from anywhere in the world.

What if a trauma team could examine the victim of life-threatening injuries from a fire or car accident before the victim arrived at the ER, through high-definition cameras transmitting directly from the ambulance en route to the hospital? Or if the same could be done for a wounded soldier on the battlefield in Afghanistan?

Believe it or not, these technologies are already in limited use in health care delivery today.

Dr. Yulan Wang, Chairman and CEO of InTouch Health, spoke to us from California through a robotic device (avatar!) called RP-7 that enables medical practitioners to provide “remote presence” health care services. It was amazing! I urge you to click here to see how an RP-7 robot was used to treat a stroke victim in a remote rural part of Michigan.

Dr. Jeffrey S. Augenstein, M.D., Professor of Surgery and Director of the internally-recognized Ryder Trauma Center at the University of Miami/Jackson Memorial Medical Center described how a combination of built-in cameras and GPS technology in a car can be used to transmit both the location of an accident as well as the nature and severity of the victim’s injuries.

Dr. Augenstein also showed us how telehealth technologies were used to treat victims of last year’s earthquake in Haiti. (Click here.)

These are just two examples of ways telemedicine capabilities can be used to improve the efficiency and effectiveness of health care in a trauma setting. Here are some other uses being studied at the Ryder Trauma Center’s Injury Research Center:

Use of the RP-7 to “virtually bring world class trauma physicians to the battlefield to support and mentor deployed military physicians who are treating injured soldiers.”
Use of audio and video feeds transmitted via the internet from a disaster situation (e.g., an airplane crash involving multiple casualties) to determine the severity of injuries, make clinical assessments and determine whether those injured must be evacuated for necessary care.
Use of live streaming video and an electronic “rounds cart” to reduce the spread of infections in Trauma Intensive Care Unit (TICU) hospital rounds by enabling the trauma team (attending, residents, fellows, nurses, nurse practitioners, and pharmacists) to watch a live video stream from the patient’s bedside, see the vital signs on the monitor, view the settings on the respiratory ventilator, and see any wounds the patient has. Using a “rounds cart” requires only the cart’s operator to be at the bedside rather than a team of 10.
Use of a high-definition camera attached to a retractable arm which will extend over the operating table in the operating room to transmit real-time audio and video feeds of a surgical procedure, enabling trauma surgeons to observe and consult on cases remotely.

I was quite impressed by the many ways technology is being adapted to deliver health care more efficiently, effectively and cost-effectively. The doctors at the University of Miami’s Miller School of Medicine and entrepreneurs like Dr. Wang from InTouch Health are doing amazing things.

I came away from this session certain that telehealth care will play a large part in solving the health care cost problems we struggle with today.

"The number doesn't mean what they say it means."

noreply@blogger.com (sparker) — Thu, 20 Jan 2011 02:02:00 +0000

I wanted you to be aware of an Associated Press story that ran in many newspapers today (including - in part - in the Naples Daily News) under the title "Fact check: Job loss estimate shaky." It refers to the Republicans' claim that the health care law is "job-killing" and fact-checks the claim that it kilss 650,000 jobs. Here it is in full, as reported on yahoo news:

FACT CHECK: Shaky health care job loss estimate

By RICARDO ALONSO-ZALDIVAR, Associated Press - Tue Jan 18, 11:25 am ET

WASHINGTON – Republicans pushing to repeal President Barack Obama's health care overhaul warn that 650,000 jobs will be lost if the law is allowed to stand.

But the widely cited estimate by House GOP leaders is shaky. It's the latest creative use of statistics in the health care debate, which has seen plenty of examples from both sides.

Republicans are calling their thumbs-down legislation the "Repealing the Job-Killing Health Care Law Act." Postponed after the mass shootings in Tucson, a House vote on the divisive issue is now expected Wednesday, although Democrats promise they'll block repeal in the Senate.

A recent report by House GOP leaders says "independent analyses have determined that the health care law will cause significant job losses for the U.S. economy."

It cites the 650,000 lost jobs as Exhibit A, and the nonpartisan Congressional Budget Office as the source of the original analysis behind that estimate. But the budget office, which referees the costs and consequences of legislation, never produced the number.

What follows is a story of how statistics get used and abused in Washington.

What CBO actually said is that the impact of the health care law on supply and demand for labor would be small. Most of it would come from people who no longer have to work, or can downshift to less demanding employment, because insurance will be available outside the job.

"The legislation, on net, will reduce the amount of labor used in the economy by a small amount _roughly half a percent_ primarily by reducing the amount of labor that workers choose to supply," budget office number crunchers said in a report from last year.

That's not how it got translated in the new report from Speaker John Boehner, R-Ohio, and other top Republicans.

CBO "has determined that the law will reduce the 'amount of labor used in the economy by.roughly half a percent.,' an estimate that adds up to roughly 650,000 jobs lost," the GOP version said.

Gone was the caveat that the impact would be small, mainly due to people working less. Added was the estimate of 650,000 jobs lost.

The Republican translation doesn't track, said economist Paul Fronstin of the nonpartisan Employee Benefit Research Institute.

"CBO isn't saying that there is job loss as much as they are saying that fewer people will be working," explained Fronstin. "There is a difference. People voluntarily working less isn't the same as employers cutting jobs."

For example, the budget office said some people might decide to retire earlier because it would be easier to get health care, instead of waiting until they become eligible for Medicare at age 65.

The law "reduces the amount of labor supplied, but it's not reducing the ability of people to find jobs, which is what the job-killing slogan is intended to convey," said economist Paul Van de Water of the Center on Budget and Policy Priorities. The center advocates for low-income people, and supports the health care law.

In theory, any legislation that increases costs for employers can lead to job loss. But with the health care law, companies can also decide to pass on added costs to their workers, as some have already done this year.

To put things in perspective, there are currently about 131 million jobs in the economy. CBO projects that unemployment will be significantly lower in 2014, when the law's major coverage expansion starts.

A spokeswoman for House Ways and Means Committee Republicans pointed out that CBO's report did flag that some employers would cut hiring. "The CBO analysis does not claim that the entire response is people exiting the labor market," said Michelle Dimarob.

The law's penalties on employers who don't provide health insurance might cause some companies to hire fewer low-wage workers, or to hire more part-timers instead of full-time employees, the budget office said. But the main consequence would still be from more people choosing not to work.

That still doesn't answer the question of how Republicans came up with the estimate of 650,000 lost jobs.

Dimarob said staffers took the 131 million jobs in the economy and multiplied that by half a percent, the number from the CBO analysis. The result: 650,000 jobs feared to be in jeopardy.

"For ordinary Americans who could fall into that half a percent, that is a vitally important stat, and it is reasonable to suggest they would not characterize the effect as small," she said.

But Fronstin said that approach is also questionable, since the budget office and the GOP staffers used different yardsticks to measure overall jobs and hours worked. The differences would have to be adjusted first in order to produce an accurate estimate.

Said Van de Water, "The number doesn't mean what they say it means."

Many of us have friends and acquaintances who support repeal of the health care law. Many of those are no doubt repeating the "jobs-killing" language. Now we all have the facts to set them straight.

I encourage us to use them.

Take-aways and Learnings from The Business of Health Care Forum – Part 1

noreply@blogger.com (sparker) — Mon, 17 Jan 2011 02:49:00 +0000

Last week I attended a Global Business Forum at the University of Miami called “The Business of Health Care: Defining the Future,” and I really learned a lot.

The three-day conference, attended by more than 700 people, featured more than 30 panel discussions organized along six “tracks” whose titles alone provide a good overview of the issues and challenges of health care delivery in the United States:

The Aging Population: Economic and Ethical Issues Surrounding the Shift in Demographics;
Wellness and Prevention: The Obesity Epidemic, Nutrition, Innovative Therapies, and Education;
Global Health Issues: Emerging Markets, Access, and the Environment;
Age of Innovation: Disruptive Medical Technologies, Biotechnology, and Telemedicine;
Economics and Health Care: Cost, Accessibility, Reform, and Implementation; and
Health Care Delivery 2030: Hospital Design, Technology, and Delivery Systems of the Future.

These are the sessions I attended:

“The Silver Mirror”: A Global Documentary Film Shedding New Light on Aging: Preview and Panel Discussion – which, among other things, raises the question “If we are given more time to live, what is that time for?”;
Opening Keynote #1 – Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services (HHS), introduced by Donna Shalala, President, University of Miami and former U.S. Secretary of HHS in the Clinton Administration (click here for a report on her remarks);
Opening Keynote #2 – Margaret Hamburg, M.D., Commissioner, U.S. Food and Drug Administration, in an interesting conversation about the FDA’s current challenges and focus, with Donna Shalala;
Health Care Entrepreneurs in a Changing Environment;
Patient-Centered Care and Accountable Care Organizations in an Era of Health Care Reform;
Insuring the Future: The Financing of Health Care (click here for a report);
Security and Innovation in Health Information Technology;
How Advanced Data Storage and Mining is Transforming Health Care and Changing People’s Lives; and
Telehealth, Robotics and Ubiquitous Computing: The De-Institutionalization of Health Care.

Needless to say, days later, I’m still dealing with information overload!

My key take-aways from the conference were:

Due to a confluence of factors, health care reform will succeed.
The health care sector represents an excellent, currently-undervalued investment opportunity.
Exciting, innovative new technologies are being developed and embraced that will transform health care delivery in ways that were once unimaginable.

Due to a confluence of factors, health care reform will succeed.

Several factors were frequently cited in support of panelists’ belief that this attempt at health care reform will succeed:

Baby boomers are becoming Medicare-eligible. The phrase “pig in a python” was used several times, a reference to a 1996 book with a similar name subtitled “How to Prosper From the Aging Baby Boom.” The comparison is to the inexorable movement of the baby boom generation as it ages, through the rest of the population which struggles to cope with this huge demographic bubble.
There is finally an awareness and a consensus that the health care system is broken and that the current cost trajectory is unsustainable.
Government knows it can’t do it alone, that stakeholders must be part of the solution, and views its job as facilitating the change.
Technology is now available that can help with the transformation.

The health care sector represents an excellent, currently-undervalued investment opportunity.

The effect of the aging of the Baby Boom Generation is significant. Thursday’s luncheon keynote speaker James D. Forbes, Global Principal Investments Executive, Bank of America Merrill Lynch, said that private equity investors are well aware of studies showing that people 65 and older start consuming two-and-a-half to three times more health care than younger people, because of chronic conditions like diabetes, hypertension and heart disease. He said nearly half of all health care expenditures come from just 5 percent of the population. As a result, he said, promising new investment targets lie ahead — especially in managed care, acute care, home health care and medical devices such as stents and artificial joints that will keep Baby Boomers active. “I think the opportunity over the next five to 10 years exists in finding the companies that can address that 5 percent,” he predicted.

Forbes said another reason he is bullish about the health care sector is the health care reform legislation, which he said has created “tremendous opportunities” for private equity firms. “Health care reform is not going to be repealed,” Forbes told us. “It’s not going to happen, folks. That’s the political reality.” (Most, if not all, pundits agree. Even if it passes in the House, there aren’t enough votes in the Senate, and even if it passed in the Senate, the President would veto it.)

Exciting, innovative new approaches and technologies are being developed and embraced that will transform health care delivery in ways that were once unimaginable.

One of the most frequently-mentioned trends is the digitization of health care records. In that regard, two panelists in the Health Care Entrepreneurs session emphasized the importance of the Obama Administration’s support for Electronic Health Records (EHRs) in driving the adoption of this much-needed technology.

EHRs have been around for some time, but “There’s more focus on standards [now] than there was under Bush,” said panelist Kevin Hutchinson, entrepreneurial executive, former CEO, Prematics and Surescripts, and former COO, MedicalLogic/Medscape.

This focus is the result of the Health Information Technology for Economic and Clinical Health (HITECH) Act of February 2009, which is part of the American Recovery and Reinvestment Act (ARRA or the stimulus bill). HITECH provides federal stimulus money to doctors and hospitals to help pay for their adoption of EHRs – but only if they serve Medicare patients and meet certain standards, especially those of “meaningful use” and interoperability. Interoperability is the ability to exchange records between different EMR systems, which should facilitate co-ordination of care in non-affiliated health care facilities.

Hutchinson, a self-described “staunch Republican” who has worked in health IT since the mid-1990s, said the HITECH requirements were necessary. “Vendors were never going to agree” on standards on their own, he said. “The parent had to step in and say ‘thou shalt’” in order to move it along. Since May 2009, Hutchinson has served on the Federal advisory committee charged with making recommendations to the National Coordinator for Health IT on standards, implementation specifications, and certification criteria for the electronic exchange and use of health information. While he admitted to concern that too many standards are being developed, he said the good news is that “the EHR vendors themselves are as much at the table as the users.”

In the same session, Michael Mindlin, a hedge fund manager and securities analyst at Stelliam Investment Management who follows the health care industry, also emphasized the importance of interoperability of EHRs.

He said as an investor, he also likes the incentives in the ARRA and the ACA for Comparative Effectiveness Research, whose aim is to improve health outcomes by developing and disseminating evidence-based information to patients, providers, and health care decision-makers about the effectiveness of treatments relative to other options. It is believed that Comparative Effectiveness Research has the potential to reduce unnecessary treatments, which in turn, may help lower costs.

Mindlin also likes the health care laws’ Accountable Care Organizations (ACO), which the Kaiser Family Foundation calls “the hottest three-letter word in health care.” An ACO is a model for delivering health care services that offers doctors and hospitals financial incentives to provide good quality care to Medicare beneficiaries while keeping down costs. Here in Collier County, NCH Hospital System CEO Allen Weiss told the League of Women Voters last week that practioners here are headed in that direction, and the Naples Daily News reported in November that “Lee Memorial is working on getting the different components of an ACO in place, starting with an integrated information system across the hospital system.”

Electronic Health Records, Comparative Effectiveness Research and Accountable Care Organizations are just three of the Affordable Care Act's approaches to health care delivery that were enthusiastically discussed at the conference. In my next post, I’ll describe some of the new health care delivery and management technologies.

It started out as a good day...

noreply@blogger.com (sparker) — Thu, 06 Jan 2011 03:29:00 +0000

There it was, at the top of page 5B of today’s Naples Daily News, my Guest Commentary titled “An unhelpful distraction from vital national discussion.” As my readers know, I had submitted this piece just before New Year’s in response to a column by syndicated conservative columnist and FOX News regular Cal Thomas (“Death panels? Palin’s warnings coming true”).

The good feeling about being published lasted only until I reached my first meeting of the day where, instead of being greeted with kudos on my article, I was confronted with “Did you see that Obama caved? It’s in today’s New York Times!!”

And there it was: “U.S. Alters Rule on Paying for End-of-Life Planning:”

The Obama administration, reversing course, will revise a Medicare regulation to delete references to end-of-life planning as part of the annual physical examinations covered under the new health care law, administration officials said Tuesday.

The move is an abrupt shift, coming just days after the new policy took effect on Jan. 1. ...

While administration officials cited procedural reasons for changing the rule, it was clear that political concerns were also a factor. The renewed debate over advance care planning threatened to become a distraction to administration officials who were gearing up to defend the health law against attack by the new Republican majority in the House.

Anger. Disbelief. Disappointment. I’ve been going through the range of emotions all day today.

I’ve tried to put myself in the Administration’s position and consider the alternatives: allow the story to grow day by day during this first week of the new Congress, providing fodder for the Sunday talk shows and churning up support for the Republican Party’s plan to overturn the health care act ... or pull it back, stop it in its tracks and regain control of the message. A friend explained it by saying, “the White House is picking its battles.”

It may well be that it was the right thing to do politically. But I must admit that, for the first time, I find myself among those who are criticizing the Administration for its inept communication around this issue.

For a calmer response, I recommend health care blogger Maggie Mahar’s take on the story in her post “A Reversal of Fortune for End-of-Life Planning” which says, in part:

Where supporters of advance care planning see a valuable opportunity to empower patients and improve the quality of their last days or months, opponents like Marc Siegel, internist and regular medical commentator for Fox News and other media organizations, sees the Medicare regulation as “the government incentivizing” these discussions “as a way of advancing their own agenda, which clearly is decreasing end-of-life care.” ...

Why are we finding ourselves back in the “death panel” morass? The issue seemed to have moved offstage in recent months, and perhaps Obama thought including reimbursement for end-of-life planning in the hundreds of new Medicare rules would be uncontroversial. But that would be underestimating the media forces that are all too ready to bring accusations of rationing and “pulling the plug on Granny” back to life. Clearly, the administration now feels that including reimbursement for voluntary end-of-life planning discussions in Medicare benefits will only make advancing health reform more contentious in the face of the new Conservative majority in the House whose stated goal is to repeal the legislation.

This is short-sighted and infuriating to those of us interested in real health reform for a host of reasons....

Before the administration’s reversal, Merrill Goozner, writing on his blog GoozNews puts the blame for the (then predicted) debacle squarely on the administration. “It would have been better if the new leadership at the Centers for Medicare and Medicaid Services used adoption of this new rule to educate the public about the importance of developing end-of-life directives, while simultaneously stressing that such actions are totally voluntary. Instead, CMS chief Donald Berwick snuck it into a rule that no one reads. If this winds up becoming the next political football for opponents of health care reform, reformers like Berwick will have no one but themselves to blame.”

My point exactly – inept communication. But Mahar continues:

For better or worse, the football has now been punted out-of-bounds. Perhaps it would have been better for the administration to openly campaign and promote the idea of advance directives before including the rule in the new Medicare regulations. But they tried that last year when the battle over passing the Patient Protection and Affordable Care Act brewed in Congress. The attacks by Palin and her cohorts that include the Right-to-Life faction, religious conservatives and some doctors who clearly profit monetarily from the testing, interventions and futile treatments employed during that last scramble in the month or two before death, were deafening and confused many Americans. Advance planning became synonymous with rationing.

The truth is, rationing of a far more insidious type is already taking place. Some 50 million Americans remain uninsured and are unable to access needed care. Another 25 million are under-insured; covered by bare-bones insurance policies that require patients to pay high deductibles out-of-pocket, and limit coverage to a few thousand dollars. Norman Ornstein, a resident scholar at the American Enterprise Institute writes in the Washington Post that “death panels,” do in fact exist: not as part of the Affordable Health Care Act but “from Republican administrations in states such as Arizona and Indiana,” that have stopped covering organ transplants and some “experimental” but life-saving surgeries in Medicaid patients. Faced with souring budget deficits and an increase in Medicaid rolls, “[s]tates have to react, and one solution to their constraints is rationing care,” writes Ornstein.

Mahar concludes:

End-of-life counseling is a compassionate service that not only saves money, but also improves the quality of life for dying patients. Removing reimbursement for counseling from Medicare regulations is a purely political move—perhaps designed to increase bipartisan support for health reform legislation. Most likely, it will have little effect on the loud calls for repeal and the continued misinformation campaign about “death panels.” If the administration can promote a forceful, yet meaningful and intelligent discussion of advanced planning in the months ahead, perhaps the Medicare provision can be added back—prominently, this time—to the new regulations.

We can only hope.

Why we can't have our cake and eat it, too

noreply@blogger.com (sparker) — Sun, 02 Jan 2011 19:49:00 +0000

This piece by Rick Ungar on Forbes.com is an easy-to-understand explanation. Consider sharing it with your friends.

The Truth About The Opposition To Health Care Reform
Dec. 28 2010
By RICK UNGAR

A new CNN Poll out today speaks volumes about what is bugging the country about health care reform.

The survey reveals that 59% of those polled oppose the health care reform law with only 39% in support.

But that’s just a small piece of the story.

When the numbers are broken down, it turns out that 61% favor the part of the legislation that prohibits insurers from dropping people when they get sick while 64% like the parts that stop private health insurance companies from denying coverage to those who have pre-existing conditions. We already know that the public supports the provisions that have already gone into effect such as allowing children to stay on their parents’ policies until they are 26, no denial of coverage to people under 19 because of pre-existing conditions, free preventative care and immunization, etc.

So what, exactly, is it that they don’t like?

You guessed it. 60% of those polled object to the legislation requiring that everyone who does not have health insurance be forced to buy it. Clearly, that is the consideration that is carrying the day as that number pretty much mirrors the overall number of those who oppose the law while favoring the remaining key elements of the law.

While you may be among those who object to mandated coverage – and I certainly understand the arguments against it- there is a side to the story that is being completely ignored.

Without mandated coverage, it would be impossible for insurance companies to provide coverage to those with pre-existing conditions and continue to stay in business as a profit making enterprise, unless the price of insurance premiums paid by those who are healthy become so expensive that it is virtually unaffordable by 99% of the nation.

Health insurance operates on a system of pooling risks. As a rule of thumb, 80% of the pool must be comprised of healthy participants in order to pay for the 20% who are sick. This ratio ends up leaving the insurance company a profit margin of somewhere between 2%-4%.

If the insurers are to be required to accept the huge influx of participants with a history of costly illness, they must either have a similar influx of healthy people to balance the ratio at 80-20 or charge vastly increased premiums to all participants. The only way to accomplish the number of additional healthy people to pay for the increased number of sick folks is to mandate coverage for pretty much everyone.

There is simply no way around this if we want to have those with pre-existing illnesses covered – unless, of course, you want to put the government in the business of providing health care to those with pre-existing conditions, thereby removing them from the private market pools.

This is one where you cannot have it both ways. If Americans are hell bent on opposing mandated health coverage (or if SCOTUS eventually finds that the provision is unconstitutional), then we must give up on the idea of private insurers covering those with pre-existing medical conditions or, alternatively, accept that government will be getting deeper into the business of health care.

So, you have to ask yourself -

Do you want to give up on providing coverage to those with pre-exiting illness, leaving these people to fend for themselves?

If your answer is ‘yes’, you need go no further. I would, however, caution you to keep in mind that there is a very reasonable chance that you may join the ranks of those with a pre-existing condition at some point before you reach the age of Medicare qualification. If you do – and you might be shocked to learn how small illnesses can keep you from obtaining a health insurance policy- then you too will find out what it is like to be on your own in the face of extraordinary medical costs. It isn’t pretty.

If this is not what you would wish for yourself, and you do want coverage for those with a pre-existing medical problem, then you must ask yourself if you are prepared to accept mandated coverage so that the private markets can provide the coverage, government issued insurance for those who cannot qualify for private coverage or dramatically higher premium costs for everyone who buys a policy.

Those are your choices. You can choose any one of them – but you cannot have it all.

So the next time you complain about ‘Obamacare’, be prepared to throw into the discussion your opposition to providing health care to those who have already been ill , including yourself should you be struck with an illness in the near future. Or, if you continue to support coverage for those with pre-existing illnesses, be prepared to state your acceptance of government provided insurance for the previously ill or, alternatively , your support for huge increases in premium charges.

Anything less makes a conversation about health care reform only half of a conversation – and that just is not good enough.This is a serious problem and it requires serious conversation in order to reach a desired, if not perfect, solution.

An unhelpful distraction from an important national discussion

noreply@blogger.com (sparker) — Thu, 30 Dec 2010 21:19:00 +0000

Today the Naples Daily News ran a commentary on its Editorial Opinion page titled “Death panels? Palin’s warnings coming true,” and yesterday it ran one titled “Politically-motivated end runs ignore our Constitution.” As I predicted in my post on Sunday, the death panel discussions are back.

A reader suggested I forward Sunday’s post to the Naples Daily News for publication, and after reading these two pieces, I decided to do just that. I did some more research, tweaked and edited. Below is what I submitted earlier today. Hopefully it will be printed.

On Sunday, the New York Times reported that starting January 1, “the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment.”

Since then, much has been written about this, and today the Naples Daily News printed an opinion piece by Cal Thomas, a conservative columnist and FOX News regular, titled “Death panels? Palin’s warnings coming true.”

Needless to say, there’s another interpretation. But first, the facts.

One of the new Medicare benefits under the Affordable Care Act is coverage for an annual wellness visit beginning in 2011.

According to the regulation, “the annual wellness visit will include the establishment of, or update to, the individual’s medical/family history, measurement of his/her height, weight, body-mass index or waist circumference, and blood pressure, with the goal of health promotion and disease detection and encouraging patients to obtain the screening and preventive services that may already be covered and paid for under Medicare Part B.”

The annual wellness visit can – “upon agreement with the individual” - also include “voluntary advance care planning,” which is defined in the regulation as “verbal or written information regarding an individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions, and whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.”

An advance directive is a general term that describes two kinds of legal documents, living wills and medical powers of attorney. These documents allow a person to give instructions about future medical care should he or she be unable to participate in medical decisions due to serious illness or incapacity. Each state regulates the use of advance directives differently; in Florida they are regulated by the Florida Agency for Health Care Administration.

This is the context within which the “death panel” fear-mongering is being revisited.

Unless we as a nation begin to tackle health care spending in the final weeks and months of life, we won’t really be able to control health care costs. Statistics abound, but here are just a few from a recent PBS Frontline special “Facing Death:”

Nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility, yet 7 out of 10 Americans say they would prefer to die at home.

More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying.

Almost a third of Americans see 10 or more physicians in the last six months of their life.

Patients with chronic illness in their last two years of life account for about 32 percent of total Medicare spending.

Medicare pays for one-third of the cost of treating cancer in the final year, and 78 percent of that spending occurs in the last month.

One large-scale study of cancer patients found that costs were about a third less for patients who had end-of-life discussions than for those who didn't.

Personally, if I’m miserable and in pain, with no realistic chance of a cure, I can think of nothing worse than having my life prolonged by a lot of costly and ultimately useless procedures in a hospital or nursing home. It’s good to know that I can make plans before that happens so I’m cared for according to my wishes. That’s why I’m going to have a discussion about end-of-life care with my internist and prepare an advance directive, even though I’m not yet covered by Medicare.

And given the many competing needs for government funding, I think we as a nation need to begin the discussion of just how much end-of-life care should be paid for with our limited tax dollars. Allowing Medicare to pay doctors to advise patients – with their consent - about their options for end-of-life care is a reasonable, necessary, and important first step toward addressing this difficult issue.

Bandying about the phrase “death panels” is an unhelpful distraction from an important national discussion.

We have to get out ahead of this issue. Please consider sending a letter to the editor of your own local newspaper. Help offset the cries about death panels!

A reasonable, necessary and important first step

noreply@blogger.com (sparker) — Mon, 27 Dec 2010 00:50:00 +0000

I was caught off-guard this morning by a front-page headline in the New York Times:

Obama Returns to End-of-Life Plan That Caused Stir, by Robert Pear

Oh boy, I thought. Here we go again.

But as I read the article, I couldn’t help but admire the boldness of the move. From the article:

When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.

Under the new policy, outlined in a Medicare regulation, the government will pay doctors who advise patients on options for end-of-life care, which may include advance directives to forgo aggressive life-sustaining treatment. ...

The final version of the health care legislation, signed into law by President Obama in March, authorized Medicare coverage of yearly physical examinations, or wellness visits. The new rule says Medicare will cover “voluntary advance care planning,” to discuss end-of-life treatment, as part of the annual visit.

Under the rule, doctors can provide information to patients on how to prepare an “advance directive,” stating how aggressively they wish to be treated if they are so sick that they cannot make health care decisions for themselves. ...

The new policy is included in a huge Medicare regulation setting payment rates for thousands of services including arthroscopy, mastectomy and X-rays.

The rule was issued by Dr. Donald M. Berwick, administrator of the Centers for Medicare and Medicaid Services and a longtime advocate for better end-of-life care.

“Using unwanted procedures in terminal illness is a form of assault,” Dr. Berwick has said. “In economic terms, it is waste. Several techniques, including advance directives and involvement of patients and families in decision-making, have been shown to reduce inappropriate care at the end of life, leading to both lower cost and more humane care.”

Needless to say, this regulation will get the “death panel” discussions going all over again.

But as many of us know, unless we begin to tackle health care spending in the final weeks and months of life, we won’t really begin to control health care costs.

Statistics abound, but here are just a few from a recent PBS Frontline special “Facing Death:”

Nearly 70 percent of Americans die in a hospital, nursing home or long-term-care facility, yet 7 out of 10 Americans say they would prefer to die at home.
More than 80 percent of patients with chronic diseases say they want to avoid hospitalization and intensive care when they are dying.
Almost a third of Americans see 10 or more physicians in the last six months of their life.
Patients with chronic illness in their last two years of life account for about 32 percent of total Medicare spending.
Medicare pays for one-third of the cost of treating cancer in the final year, and 78 percent of that spending occurs in the last month.
One large-scale study of cancer patients found that costs were about a third less for patients who had end-of-life discussions than for those who didn't.

Personally, if I’m miserable and in pain, with no realistic chance of a cure, I can think of nothing worse than having my life prolonged by a lot of costly, and ultimately useless, procedures in a hospital or nursing home.

And as heartless as it may seem, given the many competing needs for government funding, I think we as a nation should be discussing just how much “end-of-life” care should be paid for with our limited tax dollars.

So in my opinion, allowing Medicare to pay doctors to advise patients on their options for end-of-life care and to encourage patients and their families to think and talk about what they want (and don’t want) done, is a reasonable, necessary, and important first step toward addressing this difficult issue.

Already the media is all over this, so I wanted to personally read the proposed regulation and know the facts. It took quite a while, but I found it on the CMS website. It’s dated 12/03/10 and is included in a revision to the regulation that covers Annual Wellness Visits, including Personalized Prevention Plan Services.

It simply says that a covered Annual Wellness Visit can include “voluntary advance care planning upon agreement with the individual,” and defines “voluntary advance care planning” as:

verbal or written information regarding the following areas:

a. An individual’s ability to prepare an advance directive in the case where an injury or illness causes the individual to be unable to make health care decisions.

b. Whether or not the physician is willing to follow the individual’s wishes as expressed in an advance directive.

The effective date of the revision is January 1, 2011, and the implementation date is April 4, 2011. Congressional approval is not required.

It will be interesting to watch how it plays out.

The latest ruling on the Affordable Care Act

noreply@blogger.com (sparker) — Thu, 16 Dec 2010 04:59:00 +0000

By now you’ve heard about Judge Henry Hudson’s ruling for the U.S. District Court for the Eastern District of Virginia that the Affordable Care Act’s “individual mandate” to purchase health insurance is unconstitutional.

Here’s what the Obama Administration had to say about the ruling in The White House Blog on Monday:

Today’s narrow ruling in Virginia on the constitutionality of a provision of the Affordable Care Act is just one of many recent rulings on similar cases that have come down in recent months. Since the law passed, opponents of reform have filed more than 20 different legal challenges. Judges have already granted the Administration’s motion to dismiss 12 of these cases. And in two cases, federal judges looked at the merits of the opponents’ arguments, determined that the Affordable Care Act is constitutional and upheld the law.

We disagree with the ruling issued today in Virginia and the Department of Justice is considering its appeal options.

We are pleased that Judge Hudson agrees that implementation of the law will continue uninterrupted. In the nine months since the health reform law was passed, we’ve made tremendous progress to strengthen our health care system, including lowering costs and implementing a new patient’s bill of rights to end some of the worst insurance company abuses. That work continues. And we’re confident that when it’s all said and done, the courts will find the Affordable Care Act constitutional. (Read more...)

It’s been interesting to note how the various news media have been covering the decision. Here are some excerpts from recent coverage summarized by Kaiser Health News “Daily Health Policy Report” today:

The Wall Street Journal: Health-Law Ruling Viewed As Limited
A Virginia judge's ruling on the health overhaul may be narrower than either side of the case let on after Monday's decision (Adamy, 12/14).

NPR: Court Decision In Virginia Not The Final Word On New Health Law
Just about everyone agrees that U.S. District Court Judge Henry Hudson's decision to strike down the central tenet of the new health law won't be the end of the saga. But Hudson did something no one expected. When he declared unconstitutional the requirement that most people get health insurance, he allowed the rest of the law to remain intact. And if the Supreme Court agrees with that structure, says Neera Tanden of the Center for American Progress and a former Obama Administration health aide, it "could have the effect of wreaking havoc in the insurance system" (Rovner, 12/14).

The New York Times: Ruling Has Some Mulling The Necessity Of Mandating Insurance
Though they have battled for more than a year, President Obama and the health insurance industry agree that the requirement for most Americans to obtain insurance, struck down by a federal judge, is absolutely essential to the success of the new health care law (Pear, 12/14).

The Washington Post: Mandatory Health Insurance Now Law's Central Villain
With a court ruling in Virginia this week that the government cannot require Americans to buy health insurance, President Obama has landed in the position of defender-in-chief of an idea he once opposed (Goldstein, 12/15). The Post also has a chart detailing the status of health law legal challenges.

Bloomberg: Health Care's Future Is 'Up For Grabs' As U.S. Supreme Court Clash Looms
The focus of the debate over President Barack Obama's health-care overhaul is already turning toward the U.S. Supreme Court, even though it may be years before the justices resolve the law's constitutionality (Stohr, 12/15).

In a piece today titled “Health Suits Raise Questions About Court Partisanship,” Kevin Sack of The New York Times wrote about something that’s been bothering me for some time -- the effect of partisanship in the courts:

With a loose web of conservative plaintiffs leading the charge, and judicial rulings breaking thus far along ideological lines, the drive to scuttle the Obama health care law is once again highlighting the role of partisanship in America’s courts.

Legal scholars say there is nothing new and nothing particularly insidious about the use of the federal courts to revisit divisive policy debates once they have moved beyond Congress.

What is different about the health care cases, they say, is that multiple filings in diverse districts have resulted in a constitutional conflict over a landmark law even before it has taken full effect. Ideologically driven disagreements are rare among judges at the lower court level, they say, but do arise in cases where the issues are novel and highly charged.

How common is it that partisanship influences judicial decisions? From Mr. Sack’s article:

Although the science is imprecise and often disputed, some scholars have found patterns of partisan divisions at all levels of the federal judiciary, based on the appointing president. At the district court level, there is generally a high degree of consensus among judges in similar cases, except when they confront polarizing constitutional questions like abortion, campaign finance and now health care.

“When the law is fairly clear, politics don’t matter much,” said Mark A. Hall, a professor of law and public health at Wake Forest University. “But when the law is unsettled, inchoate, undeveloped, let’s say, it’s natural that judges’ political, social and economic views will shape how they see things.”

Andrew D. Martin, a professor of law and political science at Washington University in St. Louis, has studied the influence of ideology on judicial decisions. “Where district judges are presented with questions of first impression and have to make the type of constitutional judgments the Supreme Court does all the time, it’s not at all surprising to see those choices line up along party lines,” Professor Martin said.

Liberal critics of Judge Hudson’s ruling have been quick to highlight his background, and to tweak conservatives.

“It’s ironic, when Sarah Palin and others decry activist judges every other day, that a Bush appointee would make new law that strikes a critical element of a law properly enacted by Congress,” said Neera Tanden, a health policy expert at the Center for American Progress, a liberal research group.

Representative Pete Stark, a California Democrat who leads the Ways and Means subcommittee on health, added, “Apparently Republicans are now for judicial activism after they were against it.”

But David B. Rivkin Jr., a Republican lawyer from Washington who represents the plaintiffs in the Pensacola case, said those who label judges by presidential appointment “are delegitimizing the judiciary.” Mr. Rivkin said that it was “a matter of accident and irrelevance” that the health care rulings had broken down along such lines and that he had “not heard a single partisan remark” from his clients.

“The people who brought this lawsuit,” he said, “are all about the law.”

Yeah, right.

Tomorrow, the hearing begins on the case led by Florida’s Attorney General Bill McCollum for attorneys general and governors of 20 states, before Judge Roger Vinson of Federal District Court. According to Sack, Judge Vinson has been hostile to the law in preliminary opinions and could become the second judge to find that a central provision is unconstitutional. Stay tuned. For the background on the constitutional challenges to the Affordable Care Act, see my post of November 25th.

Do you think that partisanship has been at work in the courtroom? Whatever happened to "blind justice?" What's your take, and how do you think it will play out once the question reaches the Supreme Court?

Why reinvent the wheel?

noreply@blogger.com (sparker) — Thu, 25 Nov 2010 16:52:00 +0000

I admit it. I was overly ambitious when I wrote in September that I planned six posts about the constitutional challenges to the Affordable Care Act. I’m not a lawyer, and frankly I found the material I was trying to summarize to be more technical than I was interested in.

Still, it’s important to understand the issues, and a recent paper by Katherine Hayes and Sara Rosenbaum from the George Washington University School of Public Health and Health Services posted on the HealthReformGPS website really does what I intended to do. So why reinvent the wheel?

Here, then, are excerpts from that paper that summarize what I think we need to know:

The lawsuits tend to focus on four key provisions of the law:
The requirement that beginning January 1, 2014, non-exempt individuals either maintain health insurance coverage (termed “minimum essential coverage”) or pay a tax penalty.

The requirement that states participating in Medicaid expand their programs, beginning January 1, 2014, to cover all non-elderly persons with incomes below 133 percent of the federal poverty level (FPL), including individuals who previously were ineligible for federal Medicaid benefits, coupled with additional federal funding for newly eligible beneficiaries.

Federal standards regulating the individual and group health insurance markets, including, among others, the prohibition against the denial of coverage based on health status and the bar against the use of annual or lifetime limits.

The requirement that employers either offer a health plan that provides minimum essential coverage as well an adequate subsidy toward its cost or else contribute to the cost of employee coverage secured through a state health insurance exchange.

The authors then outline the constitutional questions raised about these provisions that are “central to the issue of whether Congress has the power to enact the law and whether in doing so Congress has impinged on states’ powers under the Constitution:”

Does the individual responsibility requirement exceed Congress’ commerce clause powers?

Does the requirement to expand Medicaid amount to commandeering of state resources in violation of the Tenth Amendment?

Do the insurance market reform and state insurance exchange provisions violate the states’ right to regulate insurance as part of their police powers?

Does the employer requirement violate state sovereign immunity under the Tenth Amendment?

Then, noting that Florida’s Judge Vinson dismissed the third and fourth of these questions in his decision in October allowing the case brought by the attorney general of Florida and 13 other states to go forward, the authors seem to conclude that only the first two questions remain.

With respect to the first question, they write:

Does the challenge to the individual mandate have legal merit? One court already has concluded that it does not, and that the law, even if unique, falls well within Congress’ constitutional powers to regulate commerce. Will the other courts agree?

And with respect to the second:

Do the law’s Medicaid expansions, when placed within the overall context of health reform, so fundamentally alter the relationship between the states and the federal government where Medicaid is concerned that a voluntary program in fact has been made compulsory? From a legal perspective, does the fact that a state can opt out of Medicaid at any time essentially overpower the states’ arguments that they can no longer run their health systems without Medicaid?

Here is the expected timing for the cases to be heard and ultimately reach the Supreme Court:

The Virginia case should be decided by the end of the year.
The attorney generals’ case will hold oral arguments on December 16, and should be decided by early 2011.
Each of these decisions will likely be appealed to the respective court of appeal. How fast they move forward depends on how quickly the appeals are filed, heard by the courts, and decided.
Then it will be up to the Supreme Court whether to take the case on an expedited basis given its importance.

“[E]xperts anticipate that there will be no final resolution of the claims until 2012 at the earliest,” conclude the authors. “Until that time, implementation [of the ACA’s provisions] can be expected to continue, although were several federal Circuits to collectively find the law unconstitutional, the disruptive effect could be considerable.”

So we’ll stay tuned.

And now that these issues have been summarized, I’ll be able to return in this blog to my broader study of the U.S. health care delivery system and the ACA implementation issues that are playing out every day.

Can the Republicans really kill health care reform?

noreply@blogger.com (sparker) — Sun, 07 Nov 2010 17:40:00 +0000

The following was first posted on Sparker's Soapbox, my political blog, on November 6, 2010:

Since Tuesday’s elections, the leaders of the new House and Senate majorities have trumpeted their intention to repeal the Affordable Care Act, or at least cut off its funding (although they haven’t said how they’d make up the cost savings that would be lost). I must admit, the saber-rattling was getting to me.

The country does appear to be split about the ACA. An exit poll conducted by Edison Research for the AP reported that “about half – 48 percent – of voters want the health care law repealed. Another 31 percent said it should be expanded and 16 percent want it left in place as is.”

Among Florida voters, “a majority want it either expanded (30 percent) or left as it is (19 percent). About 44 percent of voters said [the health care law] should be repealed,” according to an exit poll by Edison Research for the National Election Pool.

But health care blogger Maggie Mahar looked at the issue and concluded:

[I]t is essential to realize that this [election result] was not a vote against health care reform. As [the Edison/AP exit poll] revealed, nearly two-thirds of voters identified the economy as the most important issue weighing on their minds; less than one-fifth named health care as their top concern

Given the economy, Democrats would undoubtedly have lost their majorities regardless of what they did or didn’t do with health care reform, simply because they were the party in power. Writes Mahar:

Conservatives will continue to claim that the election was a referendum on reform. This is yet another Big Lie. If the administration had failed to pass reform legislation, the president’s party still would have been trounced at the polls, and the administration branded “impotent.” If the Obama administration had managed to push a stronger health care bill through Congress -- let’s imagine that a handful of progressives defied all odds, and passed a single-payer bill -- the majority of Americans who now are wary of reform would be totally terrified. (The fear-mongers would have made sure of that.) Progressives might have lost even more seats.

How much could the Republicans actually do? Given Obama's veto pen, any effort to repeal the entire law could not succeed. And Mahar points out that for all their threats, the Republicans may not really be able to do much about the funding:

It is unclear just how much of the reform legislation’s financing turns on Congressional approval. Reportedly, only about $100 million of the funding needed for the $1 trillion bill is subject to the Congressional appropriations process.... Moreover, as John Gever points out on MedPage Today: “The items in the ACA that require significant appropriations are either popular -- like bringing insurance to the uninsured -- or don't matter much to the electorate, like electronic health records. Killing these won't score points with the voters Republicans will need in 2012 to defeat Obama, and could actually hurt them.”

I suspect that Gevar is right when he says:

Everything you have read and heard about what the new Congress will do is posturing for 2012. It's all about the rhetoric, not the legislation. That's why you will see little actual change -- on anything -- until then.

So while I’ll be keeping an eye on what happens, I’m going to try not to let the Republicans’ threats get to me.

Health care and the campaign

noreply@blogger.com (sparker) — Wed, 27 Oct 2010 04:11:00 +0000

Readers of my Sparker's Soapbox blog know I've been busy trying to decide who to vote for in our local school board elections. That's why I haven't posted to this blog very often in the past couple of weeks. I'll be back to health care reform next week, but I did want to let you know about an outstanding editorial than ran in Sunday's New York Times under the title "Health care and the campaign."

It's so good, I'm posting it here in full:

Republican candidates and deep-pocketed special interests are spreading so many distortions and outright lies about health care reform that it is little wonder if voters are anxious and confused.

Here are a few basic facts that Americans need to keep in mind before they go to the polls, and afterward. First, most aspects of the reform do not go into effect until 2014. Second, things are indeed bad out there: The costs of medical care and insurance premiums are (still) rising, and some employers are (still) dropping coverage. But for that, you should blame the long-standing health care crisis and the current bad economy. Health reform is supposed to help with these problems.

Here is a look at the claims being made on the campaign trail — and the distortions they contain:

PURE NONSENSE: John Raese, the Republican candidate for the Senate in West Virginia, is claiming that the law will require patients to go through a bureaucrat or panel to reach a doctor. That is flat out untrue. You will still choose your own doctor or insurance plan without interference. Nor, despite other claims, will the law provide subsidized insurance to illegal immigrants. They are precluded from using even their own money to buy policies on new exchanges.

The Obama administration will not be compiling a federal health record on all citizens, including each individual’s body mass index, as Ann Marie Buerkle, a Republican running for a House seat in upstate New York, has claimed on her Web site. The administration is offering incentives to doctors to record various vital statistics in electronic medical records and report the data in the aggregate, to help understand national health trends.

WE CALL THAT CAPITALISM: Republican politicians never tire of denouncing health care reform as a “government takeover” — or socialism. What is true is that the law relies heavily on private insurers and employers to provide coverage. It also strengthens regulation of those insurers and provides government subsidies to help low- and middle-income people buy private insurance on the exchanges.

Those exchanges will promote greater competition among insurers and a better deal for consumers, which last time we checked was a fundamental of capitalism.

WHAT ABOUT MCDONALD’S? Conservative commentators pounced after the fast food chain and several other large employers that provide skimpy, low-cost policies to their workers warned that they might drop their health plans entirely if forced to comply with the new law. They particularly objected to a requirement that they begin raising the low annual limits on what their plans are willing to pay for health care.

In response, the administration has granted some 30 waivers for one year (Rush Limbaugh promptly accused the administration of allowing these employers to “break the law”) and has signaled willingness to smooth out other bumps on the road toward full reform. In 2014, all plans will have to meet minimal standards and large employers will have to provide coverage or pay a stiff fine.

WHAT ABOUT MY PREMIUMS? Some Republicans are also claiming that health reform is driving up premiums. There have been sharp increases in some states, primarily in response to soaring medical costs. Some insurers may also be trying to increase their profits before the reform law holds them in check. A few very welcome provisions that take effect early, like requiring insurers to cover preventive care without cost-sharing, will play a minor role in premium increases for next year.

Reform has also energized federal officials and many state regulators to challenge and force down big increases sought by insurers. The Justice Department just filed suit against Blue Cross and Blue Shield of Michigan for allegedly using its market power to drive up costs for its competitors and its own subscribers.

MEDICARE SCARE TACTICS: Republican candidates routinely and cynically charge that the reform law will “cut” $500 billion from Medicare — leaving the clear implication that benefits will be reduced. In reality, the law will slow the rate of increase in payments to health care providers over the next decade, and benefits for most beneficiaries will be as good or better than they are now.

The only beneficiaries apt to see a change are those enrolled in private Medicare Advantage plans that will lose their unjustified subsides. Many of these beneficiaries, roughly a quarter of the Medicare population, may have to pay more for their plans or may lose the extra benefits, like gym memberships or dental care, that the subsidies pay for. Some inefficient plans will die out, but the efficient private plans will compete successfully with traditional Medicare — on an even playing field.

MEDICAID SCARE TACTICS: Republican governors are complaining bitterly that reform will force them to expand their Medicaid programs. What they are not saying is that the federal government will pick up the vast bulk of the added expense to cover millions of vulnerable Americans. States that do not want this largess will be shortchanging the health of their poorest citizens, who will continue to use costly — to the state and the taxpayers — emergency rooms for routine health care.

WHAT THEY’RE NOT SAYING: Health care reform has already brought substantial benefits, mostly starting in late September. Insurers are now barred from dropping coverage after a beneficiary becomes sick. Dependents can stay on their parents’ policies until age 26. Insurers must cover preventive services and annual checkups without cost-sharing. Lifetime limits on how much insurance plans will pay for treatment are gone.

The major benefits start in 2014, when tens of millions of the uninsured will gain coverage through Medicaid or by buying private coverage — with government help for low- and middle-income Americans — on the new competitive exchanges. If you lose your job, you will no longer lose access to insurance. And with government help the coverage should be affordable.

Far too few Democrats are explaining this on the campaign trail. The barrage of attack ads are hard to push back against. But the voters need to know that health care reform will give all Americans real security.

Please share this with people you know right away, before Election Day. Help get the word out.

Well, maybe not

noreply@blogger.com (sparker) — Fri, 15 Oct 2010 02:04:00 +0000

Last Friday, in a post titled “So far, it’s still legal,” I reported on the first ruling in a federal court case challenging the constitutionality of the Affordable Care Act.

Today, less than a week later, I have to say “Well, maybe not.”

As expected, the judge who last month heard the oral arguments in the motion to dismiss STATE OF FLORIDA et al v. UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES et al decided today to allow the case to proceed to trial. A full hearing on the constitutional issues will take place on December 16.

From “Challenging Health Law, Suit Advances” on NYTimes.com this evening:

In a foreboding ruling for the Obama administration, a federal judge in Florida decreed Thursday that a legal challenge to the new health care law by officials from 20 states could move forward and warned that he would have to be persuaded that its keystone provision — a requirement that most Americans obtain insurance — is constitutional.

“At this stage in the litigation, this is not even a close call,” wrote Judge Roger Vinson of Federal District Court in Pensacola, Fla., before asserting that the insurance mandate was an unprecedented exercise of Congressional authority.

“Of course, to say that something is ‘novel’ and ‘unprecedented’ does not necessarily mean that it is ‘unconstitutional’ and ‘improper,’ ” Judge Vinson continued. “There may be a first time for anything. But, at this stage of the case, the plaintiffs have most definitely stated a plausible claim.”

In addition, the judge ridiculed the government’s assertion that the penalty imposed on the uninsured is a tax, but seemed unpersuaded by the argument that the Medicaid expansion is commandeering. (We discussed these three issues, among others, in an earlier post.) According to NYTimes.com:

Calling it an “Alice-in-Wonderland tack,” Judge Vinson wrote that Congress had tried to reap a political advantage during the debate by denying it was imposing a tax, and then sought a legal advantage in court by insisting it had done so.

The judge also said he would hear further argument on the plaintiffs’ assertion that the law’s vast expansion of Medicaid, a shared state and federal program, amounts to an unconstitutional commandeering of state tax dollars. But because states can at least theoretically withdraw from the program, Judge Vinson wrote that the law currently “provides very little support” for the argument.

At least 15 cases challenging the constitutionality of the Affordable Care Act are proceeding in several states.

The first trial will take place on Monday in Virginia. According to NYTimes.com, the judge in that case “already has offered his opinion that the law ‘extends Commerce Clause powers beyond its current high watermark.’” Not a good sign.

It’s high drama, and the ultimate decision will no doubt be made by the Supreme Court. But first these cases must make their way through the various stages of appeal. We’ll just have to sit on the edge of our chair, watch them proceed – and keep our fingers crossed.

So far, it’s still legal!

noreply@blogger.com (sparker) — Fri, 08 Oct 2010 21:15:00 +0000

Can the Federal government require people to buy health insurance?

Yesterday, a federal judge in Michigan said it can. An Associated Press article titled “Foes of health-care reform law lose key court ruling,” by Ed White sums it up well.

Significantly, this is the first ruling on the merits in a case challenging the constitutionality of the Affordable Care Act. The plaintiffs in the case (of course) plan to appeal.

A ruling on the motion to dismiss a similar lawsuit filed by 20 states is expected next Thursday. See Is the Affordable Care Act unconstitutional? and Constitutional challenges to the Affordable Care Act for some background.

This is just the first of many steps along the road to the Supreme Court, where this issue will no doubt be decided. But it’s a great first step!

Introducing Sparker's Soapbox

noreply@blogger.com (sparker) — Sat, 02 Oct 2010 20:40:00 +0000

I believe we are at a significant turning point in our country. And I believe that the outcome of the upcoming elections – and the 2012 elections after that - will set the direction of our future in irreversible ways that we can’t even begin to imagine.

I’ve vowed to do everything I can to help get out the vote for Democratic candidates in the upcoming election.

My first step was resigning from the board of the League of Women Voters of Collier County, whose nonpartisan policy meant that I couldn’t take partisan positions or campaign for candidates. I did that last week.

My second step was setting up a new blog. It's called "Sparker's Soapbox" and you can find it at http://www.sparkers-soapbox.blogspot.com/. I hope people who want what I want for our country will read it, tell others about it, and take action.

Please take a minute to visit “Sparker’s Soapbox.” If you like what you see, I hope you’ll subscribe – either by entering your email address where requested, or by clicking here.

I will continue my study of health care reform and posting on “So what do you think about that?” but the number of posts I write will likely be limited until after the November 2 election. Thanks in advance for understanding.

What we're up against...

noreply@blogger.com (sparker) — Tue, 28 Sep 2010 17:20:00 +0000

My friend and fellow blogger Greg Hudson posted today on a recent AP poll that showed that the more people knew about the new health care law, the more they liked it. I urge you to read Greg's post.

But the confusion out there is great, and many are working mightily to scare people and twist the facts. For example -- one of my readers forwarded me an email yesterday from something called Newsmax.com with the headline "Obamacare Investigative Report. Learn the Real Story Now." She rightly asked, "Laugh or cry?"

It begins:

Dear Newsmax Reader,

Thursday was an historic day.

Not only did the White House celebrate the six-month anniversary of Obamacare being signed into law, but the President also traveled the country attempting to sell the benefits of this sweeping legislation to an already skeptical public.

But Americans shouldn’t be skeptical. They should be fearful.

The years ahead will be wrought with financial hardship and the public safety dangers that will be left in the wake of this unconstitutional act.

An act that has been sold to us as “reform.”

But this is not “reform.” It’s an attack on your safety, your freedoms, and the vision our Founding Fathers had for this great country.

Newsmax has spent months investigating The Patient Protection and Affordable Care Act.

We gathered a panel of the premiere medical minds in the country, as well as one of the nation’s top constitutional scholars who also happens to be New York’s former Lieutenant Governor.

And together we prepared the most comprehensive investigative report of Obamacare to date.

A report that uncovers:

The dangerous loopholes and clauses

The truth behind rationing and the “Complete Lives System”

Which special interests and powerful individuals are pulling the strings and benefiting from Obamacare

The dirty secret that this “reform” will shortchange the middle class and poor

The true impact of socialized medicine in America

The new clauses that allow many government agencies to spy on you

And much more . . .

It is absolutely critical that every American not only reads this FREE report, but shares it with their friends, family, and neighbors.

And that’s why I’ve reserved a copy for you here.

There's more. And then it closes with:

P.S. – We need you to help us get the word out. The more people who learn the dangerous truths buried in Obamacare’s pages, the safer Americans will be. And the sound medical guidance and health solutions presented in this report will help protect the citizens of this country in the years ahead.

So after you are finished reading this shocking briefing, please share it with your friends, family, and neighbors.

Newsmax.com is not just a crazy guy with a computer. It is run by an organization called Newsmax Media which, according to Wikipedia, was started in 1998, "supported by a group of politically conservative investors, including the family of the late Central Intelligence Agency Director William J. Casey." A later investor was Richard Mellon Scaife, known for his involvement in conservative political causes and profiled in washingtonpost.com in 1999 as "Funding Father of the Right."

This is what those of us who care about health care reform are up against, folks. The new Republican "Pledge to America" promises to kill the ACA ... and folks like Newsmax.com are stoking the fire.

The AP poll shows that the more Democrats and Independents know about the ACA, the more they like it. But it also shows that "Accurate knowledge of the law made no difference in overwhelming opposition from Republicans."

So what do you think about that?

Today was a big day

noreply@blogger.com (sparker) — Fri, 24 Sep 2010 03:39:00 +0000

Today was the day the first set of benefits under the Affordable Care Act became available.

Starting today (in the words of AmericasFairHealthCare.org):

Full access to coverage - Children under 19 can no longer be rejected from health care plans due to pre-existing conditions. New plans cannot exclude anyone from coverage for a pre-existing condition.
No more "lifetime limits" - Insurers can no longer limit the amount of coverage someone can receive over their lifetime.
Free preventive care - New health insurance plans must provide preventive services such as mammograms and immunizations.
Expanded coverage to young adults - Young adults can stay on their parents' health plan until age 26.

Consumer Reports also offers an excellent concise Guide to New Benefits—including the fine print. You’ll find it here. (H/T to HealthBeat blogger Maggie Mahar.)

The New York Times has run no fewer than seven articles in the last three days related to health care reform. Together, they give a sense of the benefits, concerns and controversies swirling around, six months from the day the ACA was signed into law.

Here they are, as summarized on the Times’ excellent Health Care Reform News webpage (with editorial comments from me) for your perusal.

For Many Families, Health Care Relief Begins Today
By KEVIN SACK, 9/22/10
As a number of the law’s central provisions take effect, The Times talked to three families about the changes.

Cap Lifts, and So Do Spirits

By KEVIN SACK, 9/22/10
Bill and Victoria Strong’s 3-year-old daughter, who has a degenerative condition, can now be covered by health insurance that does not have a lifetime cap on benefits.

States Ask Obama for Phase-In on Health Insurance
By ROBERT PEAR, 9/22/10
Regulators are seeking a waiver for a provision of the new health care law that requires health insurers to spend at least 80 cents of every premium dollar on medical care. [The provision in question is the “medical loss ratio,” which I wrote about on August 26 under the title “ObamaCare’s Tax on Taxes?? ]

Insurers Scramble to Satisfy New Health Care Rules

By REED ABELSON, 9/22/10
Insurers are cutting administrative staff to lower overhead costs, investing in big technology upgrades and training employees to field the expected influx of customer inquiries. Despite the talk among some Republicans of repealing all or part of the law, insurers say they cannot afford to put off the changes. Many said they were fundamentally altering their business models to cope... [This is a good thing! To those who say the ACA doesn’t do enough to cut costs, please note: this IS cutting costs!]

G.O.P. Cites Tax Cuts and Health Care as Main Focus With 'A Pledge for America'
By DAVID M. HERSZENHORN, 9/22/10
House Republicans on Thursday are issuing a legislative blueprint called “A Pledge to America” that they hope will catapult them to a majority in the November elections. [For the text of the “legislative blueprint," click here. Talking heads are asking how the plan can be paid for, especially the part that repeals the ACA and its individual mandate yet insists “Health care should be accessible for all, regardless of pre-existing conditions or past illnesses.”]

Medicare Advantage Premiums to Fall Slightly in 2011
By ROBERT PEAR, 9/21/10

A surprise decrease after experts had predicted that Medicare Advantage costs to beneficiaries would rise. [More good news! How is this possible? Thanks to CMS-chief Donald Berwick's tough negotiations with insurance companies. In his words, “The Affordable Care Act gave us new authority to negotiate with health plans in a competitive marketplace. As a result, our beneficiaries will save money and maintain their benefits." On average, CMS expects Medicare Advantage premiums will be one percent lower in 2011 than today.]

Short of Repeal, G.O.P. Will Chip at Health Law
By ROBERT PEAR, 9/20/10
Republicans say they will try to withhold money needed to administer the health care overhaul.

Regarding Republicans' plan to repeal health care reform, the Times notes several hurdles:

Not even the most optimistic Republicans expect to gain the two-thirds majorities that would be needed to overcome a veto.
The law responds to a genuine need. The Census Bureau reported last week that 50.7 million people were uninsured in 2009, an increase of 4.3 million or nearly 10 percent over the previous year.
The health care law saves money, by the reckoning of the Congressional Budget Office, so Republicans would need to find ways to achieve equivalent savings if they repealed the law. (The budget office affirmed last month that the law would “produce $143 billion in net budgetary savings” over 10 years.)
While trying to repeal the health care law, Republicans do not agree on what to replace it with.
Popular and unpopular provisions of the law are intertwined and difficult to separate. People like the idea of being able to buy insurance regardless of any pre-existing condition. They dislike the idea of being compelled to do so. But without such a requirement, people could wait until they got sick and then buy coverage — a situation that has proved unworkable in states that have tried it.

If you are a regular reader of this blog, you already know at least something about each of these issues. Please let me know if they raise any questions you’d like me to discuss. As always, I’d love to hear what you think!

Constitutional challenges to the Affordable Care Act

noreply@blogger.com (sparker) — Thu, 16 Sep 2010 05:33:00 +0000

Part 2 of my series “Is the Affordable Care Act unconstitutional?”

On Tuesday, a Federal judge heard oral arguments on the motion to dismiss STATE OF FLORIDA et al v. UNITED STATES DEPARTMENT OF HEALTH AND HUMAN SERVICES et al (“the case”), and as I expected, it looks like the judge will allow at least some of the claims to proceed to trial. According to the New York Times article “Suit on Health Care Bill Appears Likely to Advance:”

“Although he did not issue a formal ruling, Judge Roger Vinson of Federal District Court said at the close of a two-hour hearing that he leaned toward denying the federal government’s motion to dismiss the lawsuit, on at least one count. That would end the jockeying over whether states have legal standing to challenge the law, and move the case to a full debate over its fundamental constitutional question: Is the federal government’s power so broad that Congress can require citizens to purchase a commercial product like health insurance? ...

“Judge Vinson did not detail which claims he might sustain and which he might dismiss as improper. But he said he would issue an opinion no later than Oct. 14, and scheduled arguments on the merits of the case for Dec. 16....

“Experts on both sides expect the challenges to eventually present the Supreme Court with a landmark opportunity.... Given that all but one of the state plaintiffs are Republicans, the lawsuit is seen as one prong of a partisan strategy to eviscerate the law in the courts, at the ballot box and on Capitol Hill.”

This post will discuss two of the constitutional questions that are raised, and the underlying provisions of the ACA that are the subject of the legal challenge, borrowing liberally from the Times article as well as Professor Blumstein’s presentation and other sources (For more on the relevance of Blumstein’s lecture to this post, click here.)

Can Congress require citizens to purchase health insurance?

The ACA requires almost every citizen to have health insurance for him/herself and his/her dependents starting in 2014. This requirement is referred to as the “individual mandate.”

One of the Constitutional provisions in question is the Commerce Clause in Article I of the Constitution which states that Congress shall have power "To regulate Commerce with foreign Nations, and among the several States, and with the Indian Tribes." According to the Supreme Court, it allows Congress to “regulate activities that substantially affect interstate commerce.” But is this regulation of commerce?

From the Times article reporting on yesterday’s oral arguments:

“David B. Rivkin Jr., a Washington lawyer hired to represent the plaintiffs, argued that if the government could regulate individual decisions to not purchase health insurance there could be no meaningful limits on federal power. ‘Congress can regulate commerce,’ he said. ‘But Congress cannot create it.’”

Ian H. Gershengorn, a deputy assistant U.S. attorney general representing the defendants,] countered that decisions to not buy insurance, taken in the aggregate, have a direct effect on commerce because uninsured people still consume health care, and often cannot pay. That uncompensated care, he said, is subsidized by others and drives up costs for hospitals, governments and privately insured individuals.

“‘The appearance of inactivity here is just an illusion,’ Mr. Gershengorn said. What Congress is regulating, he said, is how and when people will pay for the medical services they will inevitably consume. ‘This is not telling people you have to buy a product,’ he said. ‘It’s saying this is how you have to pay for your health care.’”

Another provision of the Constitution in question here is the Due Process Clause of the Fifth Amendment to the Constitution. Does requiring people to purchase and maintain health insurance “deprive them of their right to be free of unwarranted and unlawful federal government compulsion” – i.e. of their due process - as claimed by the plaintiffs? This question was not addressed in Professor Blumstein’s lecture or in the coverage of Tuesday’s hearing, which leads me to believe it’s not one of the stronger of the plaintiffs’ arguments. But this remains to be seen.

Can Congress require the states to absorb large numbers of new people into their Medicaid programs?

This issue relates to what’s referred to as the “expanded Medicaid mandate.” In order to service and help pay for the 30+ million people who will receive health insurance for the first time under the ACA, Congress expanded Medicaid to cover all individuals under age 65 with incomes up to 133% of the federal poverty level. The FPL for a family of three in 2009 was $18,310, so Medicaid eligibility would begin at $24,352.

Since Medicaid is operated by the individual states and funded with a combination of federal and state money, this expansion of Medicaid placed a new requirement on the states. For example, Florida will be required to add 1.3 million uninsured people to its Medicaid rolls.

The ACA provides that the states will receive 100% federal funding for the eligibility expansion from 2014 (when it begins) through 2016, declining annually to 90% federal financing for 2020 and subsequent years. The states claim this additional burden is onerous, and that they have no choice but to pay it. They claim, according to the Times, that “by vastly expanding the shared state and federal Medicaid program, [the new law] amounts to a coercive commandeering of state resources.” And that, they claim exceeds Congress’s authority.

Professor Blumstein thinks this is where the ACA is most vulnerable. As he explained in his lecture:

“States have inherent authority to act under the police power, [while] the Federal Government is one of enumerated powers and must find a source of authority to enact legislation. The Federal Government must respect aspects of state sovereignty and therefore may not ‘commandeer’ states to enact legislation or administratively to enforce federal policies.

“The Federal Government may provide financial incentives for states to participate in federal programs (cooperative federalism) and may impose conditions on how states implement federal programs in which they participate. [But] states’ decisions to participate (or de-participate) in cooperative federalism programs must be made voluntarily and knowingly by each individual state on its own behalf. (New York v. United States; Printz v. United States)

“When financial inducements in federal spending programs cross the line from ‘pressure’ to coercion,’ they violate the autonomy of states guaranteed in the structure of the Constitution. (South Dakota v. Dole) ...

Is the Medicaid expansion coercion and commandeering? The government says “no” but the judge didn’t seem convinced. The Times:

“The Justice Department responds that the Medicaid program ... is voluntary, and that states may withdraw if they wish. But [Plaintiffs said] that presented states with a Hobson’s choice that ignored the safety-net role played by Medicaid for more than four decades. ‘I think it’s disingenuous,’ he told Judge Vinson. ‘The idea that we could walk away from Medicaid is just essentially nonsensical.’

“The judge seemed to empathize. ‘This really puts all 50 states on the short end of the stick,’ he said. ‘States are in a Catch-22 situation.”

The individual mandate and the expanded Medicaid mandate are probably the two most focused-on aspects of the case, at least as of now. In addition, several other constitutional issues were raised in the case. I’ll be looking at them in my next post.

For seven days only...

noreply@blogger.com (sparker) — Mon, 13 Sep 2010 15:21:00 +0000

As readers of my most recent post ("Is the Affordable Care Act unconstitutional?") know, a hearing on the government's motion to dismiss a major lawsuit claiming the Affodable Care Act is unconsitutional will take place tomorrow - Tuesday, September 14, 2010.

An article in today's Wall Street Journal titled "Conservative Duo Test Heatlh Law" tells us a bit about David Rivkin and Lee Casey, the lawyers who will be arguing the case for the states.

Wall Street Journal articles are only available to nonsubscribers for seven days. I thought you might like to read it.

Click here.