Last week, the Obama administration has released an ambitious national plan to prevent Alzheimer’s disease by 2025, while improving the treatment of today’s Alzheimer’s patients. As a first step towards better Alzheimer’s care, the Department of Health and Human Services launched the website alzheimers.gov, a “one-stop shop” for patients and their families, with information on diagnosing Alzheimer’s, treatment options, and support for caregivers.

It’s the result of a bill passed unanimously by both the House and Senate calling for a national plan to combat Alzheimer’s. Unfortunately, while everyone in Congress says they want to make fighting the disease a priority, one party’s proposed budget could make life much harder for Alzheimer’s patients and their families.  

The National Alzheimer’s Project Act

About 5.3 million Americans currently suffer from Alzheimer’s, a number that’s expected to more than double by 2050. Most Alzheimer’s care is paid for by Medicare and Medicaid, at a cost of $170 billion annually. By 2050, the cost of Alzheimer’s care will grow to over $800 billion each year– more than our entire military budget.

To deal with this rapidly growing problem, the National Alzheimer’s Project Act was introduced before Congress in February 2010 and passed in December of that year. The Act created an office within the Department of Health and Human services that would, for the first time, develop a plan to combat Alzheimer’s disease with the same intensity as the fights against AIDS and cancer.

The New York Times talked to some of the bill’s cosponsors shortly before it passed:

“If you go to war, you have planning, planning, planning,” said Representative Christopher H. Smith, Republican of New Jersey, who co-sponsored the bill. “Well, this is a war on a dreaded disease. We need to bring all the disparate elements together for the greatest possible result.”

While the act itself does not authorize more money, one of the recommendations of the national plan “is likely to be for an increase in research money for Alzheimer’s,” said another co-sponsor of the bill, Senator Susan Collins, Republican of Maine.

“We spend one penny on research for every dollar the federal government spends on care for patients with Alzheimer’s,” she said. “That just doesn’t make sense. We really need to step up the investment.”

The National Alzheimer’s plan released by the Obama administration does just that– devoting $130 million over the next two years towards Alzheimer’s-related research by the National Institutes of Health (NIH). It’s a drop in the bucket compared to what we spend to combat diseases like cancer, but it’s still a 25% increase in federal money for Alzheimer’s research.

The Plan

Reuters reports on two studies that will receive immediate funding under the new plan:

Among the immediate actions will be funding for a study involving an antibody drug that attacks amyloid — a protein thought to be a cause of Alzheimer’s — in an international study of people who are genetically predisposed to develop the disease early.

The second will test the use of an insulin nasal spray to restore memory in patients with Alzheimer’s.

An earlier, small study of the latter approach by Suzanne Craft of the University of Washington published last year showed memory improvements in people with mild to moderate Alzheimer’s or a pre-Alzheimer’s condition called amnestic mild cognitive impairment.

The plan also calls for an additional $26 million to go towards caregiver support and public awareness of the disease. Kaiser Health News describes some of these initiatives:

Chief among those is a government website, alzheimers.gov, also launched Tuesday[...] It features information on Alzheimer’s diagnosis, caregiver support, insurance coverage and clinical trials for new treatments. A radio, TV and print campaign will promote the site beginning this summer and encourage families to plan ahead for the care of their loved ones.

The site will also serve as a resource for health care providers, featuring up-to-date information on how to diagnose and treat Alzheimer’s. Sebelius noted that the health law requires Medicare providers to check patients for cognitive impairment during annual wellness visits, but it will be increasingly important for all providers to have guidelines for Alzheimer’s diagnosis and to look for signs of illness prior to age 65.

The online resources will complement several on-the-ground initiatives. Grants are being awarded this summer to educational centers that work with geriatricians, nurses and others to develop new curricula and training programs. Sebelius said that the administration’s goal is to “improve the care, immediately, that people with the disease receive.”

The Catch

Funding for the plan remains an issue though. Effective immediately, $50 million will be transfered from this year’s NIH budget to Alzheimer’s-related research, like the two studies mentioned in the Reuters article. But the remaining $80 million for research, and much of the $26 million for care and awareness, were requested in President Obama’s 2013 budget, which has yet to be passed.

Jeff Sessions (R-Alab.) discussing Senate Republicans' budget proposals

Last Wednesday, the Senate held five meaningless budget votes, in what Politico calls “the latest chapter in Washington’s dysfunctional spending wars.” In an attempt to embarrass the President, Republicans introduced a proposal supposedly based on Obama’s budget blueprint, but with no actual policy details included, that was defeated 99-0. Four actual Republican budget proposals also failed in lopsided votes.

So it’s looking like Congress won’t pass any budget this year, which is actually fine– last year’s bipartisan debt deal already set spending levels for the rest of this year. The bigger problem– at least for Alzheimer’s funding– is what happens if Congress doesn’t reach an agreement on deficit reduction.

You might remember that the debt deal included a “trigger”: if Congress fails to enact its own deficit reduction bill by December 23, 2011, it will trigger an automatic 7.8% spending cut on all domestic programs. A report by the advocacy group United for Medical Research says 33,000 NIH jobs would be lost as a result. It seems unlikely that the NIH would be able to increase funding for Alzheimer’s research if these cuts take effect.

Although if Republicans get their way, Alzheimer’s research and treatment could still be in trouble. For one thing, the House budget, authored by Paul Ryan, includes what the White House’s Office of Management and Budget acting director Jeff Zients calls a “magic asterisk– or in more technical parlance an ‘allowance’” for $897 billion in unspecified cuts. House Republicans refuse to say what would be cut, so Zients applies the cut evenly across the budget, and finds that:

Investments in science, medical research, space, and technology would be cut by more than $100 billion over the next decade. The number of new grants  from NIH for promising research projects would shrink by more than 1,600 in 2014 and by over 16,000 over a decade, potentially curtailing or slowing research to fight Alzheimer’s disease, cancer, and AIDS.

Even if Republicans chose to spare health research grants, there’s still the matter of their massive cuts to Medicaid. Medicare doesn’t cover long-term care, so many people with Alzheimer’s rely on Medicaid to pay for nursing homes or home care workers. Paul Ryan’s budget proposal would cut Medicaid spending by $810 billion over the next ten years (to get a sense of how big that cut is, total Medicaid spending in 2011 was $400 billion).

It’s hard to say how states will make up this shortfall, but it’s likely that they’ll be forced to scale back coverage for long term care. While low income seniors and people with disabilities make up only 25% of Medicaid beneficiaries, they account for over two-thirds of all Medicaid spending.

It’s great that the two parties could come together to say they wanted to fight Alzheimer’s disease. But when Republican politicians talk about cutting discretionary spending and Medicaid to pay for tax cuts for the wealthy, they’re making that fight much more difficult.

President Obama congratulates Marcelas Owens for getting all ten questions right on our new health reform quiz

Our quiz has always been one of the most popular features with new visitors to What If Post, but recently we realized the facts in it are a little out of date. We wrote the questions back in 2008, and– as you may have noticed– some things have changed in American healthcare since then…

Of course, we’re talking about the Affordable Care Act, which Congress passed and President Obama signed into law just over two years ago. But there’s been so much misinformation floating around that many people still don’t know what’s in it. Are you one of them? Take our new quiz and find out how much you know about the health reform law!

While we wait for the Supreme Court to announce its decision on health reform in June, we thought it might be useful to have all of our posts about the hearings in one place. There were four separate hearings, each examining a different question– we did one post on each (except for the individual mandate, which got two):

• Part 1: When Is a tax not a tax? Does the Anti-Injunction Act prevent the Court from ruling on the individual mandate until 2015?
• Part 2:  Key questions about the mandate and Part 2 Continued: The Broccoli Question Is the individual mandate constitutional?
• Part 3: What should happen if the mandate falls? If the mandate is unconstitutional, should the Court throw out just that part or should it throw out the entire law?
• Part 4: The Medicaid Expansion Does the new law’s Medicaid expansion unfairly force states to participate?

And if that’s not enough, we also looked at Why Obama’s Supreme Court comments made sense and Why one word could determine the fate of health reform. Enjoy!

Paul Clement (left), the lawyer who argued against the individual mandate, and Solicitor General Donald Verrilli (right), who defended it

When the government defended the individual mandate before the Supreme Court, it cited two distinct powers Congress has under the Constitution:

• the power to regulate commerce; and
• the power to tax.

Our earlier coverage of the mandate hearing (here and here) looked at the arguments dealing with the first power– the question of whether Congress can make people purchase insurance in order to regulate the healthcare market. But even if the Court rules that Congress can’t regulate commerce by making people buy insurance, they could still uphold the mandate if they decide it counts as a tax.

First, remember that the mandate says two things: (1) You have to have health coverage, and (2) if you don’t, you have to pay a tax penalty of $695 or 2.5% of your income (whichever is higher). Now, even the lawyers challenging the law admit that it’s totally constitutional for Congress to tax people without health coverage. Their argument is that the mandate doesn’t count as a tax, because Congress didn’t call it a “tax”– they called it a “penalty.”

In other words, health coverage for 30 million people might be struck down because Congress didn’t use the right word to describe it.  

Is the mandate a tax?

Jack Balkin, a professor of constitutional law at Yale, lays out the rules for what makes a tax constitutional:

The rules for the taxing power are well settled since the New Deal. The tax (1) must promote the general welfare, (2) must raise revenue; and (3) and it must not be a criminal penalty in disguise. The individual mandate passes this test with flying colors.

However, some people, like Justice Ginsburg for example, have argued that the mandate doesn’t pass the revenue test, because “if it’s successful nobody will pay the penalty and there will be no revenue to raise.”

Balkin points out that Ginsburg  is wrong for two reasons:

[1] That argument proves too much– it would also apply to taxes on contraband, drugs and guns, which the Court has previously upheld [...] The mandate was estimated to raise some 4 billion dollars in revenue. In earlier cases, involving taxes on guns and drugs, the Court found that 500 dollars was sufficient.

[2] But there’s an even more important response to Ginsburg’s concern. That’s not the way the individual mandate was actually designed. The penalty was not set to ensure total compliance. It was not set to be equivalent to the most expensive health care premium available, but only to the average amount of health care premiums calculated nationally. That means that Congress expected that some people would rather pay the penalty. Congress knew it wouldn’t get 100 percent compliance, and the bill was not intended to ensure 100 percent compliance. This is like a tax on pollution, which allows some people to continue to pollute if it is worth it to them to pay the tax.

If it’s really a tax, why did Congress call it a penalty in the law?

Several of the Justices asked why, if the mandate is in fact a tax, Congress didn’t just call it that and avoid any question of whether it’s constitutional.

The answer, of course, is politics. President Obama and the Democrats were worried about Republicans attacking the mandate as a tax increase, so they went out of their way to call it a penalty instead. You can see how well that worked:

Since politicians will always avoid the t-word whenever possible, it really shouldn’t matter what Congress called it in the bill. What matters is whether the mandate fits the definition of a tax (which, as you can see from the ad, even Republicans admit) and whether Congress intended to use its taxing power under the constitution.

Solicitor General Donald Verrilli, in one of his better answers, argued that Congress did exercise its taxing power:

“On the — December 23rd, a point of constitutional order was called to, in fact, with respect to this law. The floor sponsor, Senator Baucus, defended it as an exercise of the taxing power. In his response to the point of order, the Senate voted 60 to 39 on that proposition.

The legislative history is replete with members of Congress explaining that this law is constitutional as an exercise of the taxing power. It was attacked as a tax by its opponents. So I don’t think this is a situation where you can say that Congress was avoiding any mention of the tax power.

It would be one thing if Congress explicitly disavowed an exercise of the tax power. But given that it hasn’t done so, it seems to me that it’s — not only is it fair to read this as an exercise of the tax power, but this Court has got an obligation to construe it as an exercise of the tax power, if it can be upheld on that basis.”

What will the Court decide?

As always, it’s hard to say for sure based on the justices’ questions. Still, it’s incredibly disturbing that the entire 2,700 page health reform bill could fall based on a single word choice. Jonathan Cohn of The New Republic probably put it best:

Think about that for a second: If the justices strike down the Affordable Care Act, they would be stopping the federal government from pursuing a perfectly constitutional goal via a perfectly constitutional scheme just because Congress and the President didn’t use perfectly constitutional language to describe it. Maybe labels matter, although case law suggests otherwise. But do they matter enough for the Court to throw out a law that will provide insurance to 30 million people, shore up insurance for many more, and help to manage one-sixth of the American economy? It wouldn’t seem so.

Conservative policy analyst Charles Blahous

If you were following the news this week, you might have seen this story:

President Obama’s landmark health-care initiative, long touted as a means to control costs, will actually add more than $340 billion to the nation’s budget woes over the next decade, according to a new study by a Republican member of the board that oversees Medicare financing.

Sounds bad, right? Well it turns out that every part of that sentence is misleading.

For starters, while the author, Charles Blahous, is a trustee of Medicare (the President traditionally appoints one member of each party), the study wasn’t published by Medicare, or any other government agency. It was published by the Mercatus Center, a conservative think tank funded by the Koch family. But more importantly, it’s just as wrong as past claims that “Obamacare” will increase the deficit. Here’s why.  

In order to tell whether a given bill will increase or decrease the deficit, the nonpartisan Congressional Budget Office (CBO) first figures out a baseline deficit– in other words, what the deficit would be over the next ten years if we follow all the policies Congress has already enacted. Then it looks at how much the bill would add to, or subtract from, that baseline.

Now, Balhous’ study doesn’t argue that the CBO’s estimate of the cost of health reform is wrong– which is what you’d think when you read headlines like: “Study: Health care law to add billions to budget.” Instead, Balhous is saying that the way the CBO calculates its baseline is wrong.

The Current CBO Baseline: Technically Medicare is separate from the rest of the federal budget– the Medicare tax that’s taken out of our paychecks goes into a special Medicare trust fund. Now, the law says that Medicare can’t spend more than what’s in that trust fund. But the law also says that Congress can move money into the trust fund pretty much whenever. So when the CBO figures out its baseline, it basically ignores the fact that there’s a separate fund, assuming that if it starts to run out of money, Congress will simply add however much it needs to keep paying out the same benefits. The money that Congress puts in is usually borrowed, which is why we have a deficit.

Balhous’s new baseline: Balhous says that the CBO should assume that Congress won’t add more money to the trust fund. Instead, when the trust fund starts to run out of money– which is expected to happen in 2016– the CBO should assume that it will automatically cut Medicare spending until Medicare is only spending as much as it’s taking in. In other words, the CBO’s baseline should assume there will be automatic cuts to benefits or cuts in payments to doctors starting in 2016.

This new baseline is kind of a trick to make health reform look bad. The Affordable Care Act pays for itself, in part, by cutting $500 billion in Medicare spending (mostly by reducing payments to private insurers in Medicare Advantage and to certain types of health care providers). Using Balhous’s baseline, these cuts don’t count, because it assumes Medicare was already going to cut that spending automatically. Take away that $500 billion in savings, and suddenly “Obamacare” adds $340 billion to the deficit.

But if you’re going to apply Blahous’s baseline to health reform, you have to apply it to everything else Congress does. No one wants to do that, because it’s a really weird way of looking at the federal budget. The Washington Post’s Ezra Klein explains:

When you hear people talk about our future deficits, what they’re saying is that the trust funds that support disability insurance, Medicare, Social Security, and highway spending will run out, but the programs will keep spending. That’s where the deficits come from. Blahous argues that these programs will never spend a dollar more than is in their trust funds. And when you assume that, all our deficit problems go away:

This graph compares our debt (as a percentage of GDP) using the two baselines. As you can see from the red line, Blahous's method assumes that the deficit somehow magically disappears on its own.

In other words, sure, you can use Balhous’ new baseline if you want to make Obamacare look bad. But in order to do that you also have to say, “There is no deficit problem,” which of course no one believes.

Really, all the talk about the trust fund is just smoke and mirrors. The study didn’t uncover any new information– it simply changed the yardstick we measure bills against in a way that specifically disadvantages the Affordable Care Act. The real question we should be asking: If we add up all the new spending, taxes, and cuts to old spending in the new law, does it save money? And the answer is clearly yes.