Tag: Affordable Care Act

Cross posted from The Stars Hollow Gazette

In an a cover story  for Time magazine, journalist Steven Brill spent seven months examining how medical bills are what is really killing us: the extraordinary costs of health care is a “bitter pill”  that nickels and dimes even the insured patient for every pill, band-aid and blanket:

Simple lab work done during a few days in the hospital can cost more than a car. A trip to the emergency room for chest pains that turn out to be indigestion brings a bill that can exceed the price of a semester at college. When we debate health care policy in America, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high? [..]

· Hospitals arbitrarily set prices based on a mysterious internal list known as the “chargemaster.” These prices vary from hospital to hospital and are often ten times the actual cost of an item. Insurance companies and Medicare pay discounted prices, but don’t have enough leverage to bring fees down anywhere close to actual costs. While other countries restrain drug prices, in the United States federal law actually restricts the single biggest buyer-Medicare-from even trying to negotiate the price of drugs.

· Tax-exempt “nonprofit” hospitals are the most profitable businesses and largest employers in their regions, often presided over by the most richly compensated executives.

· Cancer treatment-at some of the most renowned centers such as Sloan-Kettering and M.D. Anderson-has some of the industry’s highest profit margins. Cancer drugs in particular are hugely profitable. For example, Sloan-Kettering charges $4615 for a immune-deficiency drug named Flebogamma. Medicare cuts Sloan-Kettering’s charge to $2123, still way above what the hospital paid for it, an estimated $1400.

· Patients can hire medical billing advocates who help people read their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who now works as an advocate in Stamford, CT.

Mr. Brill was a guest on MSNBC’s “The Last Word“, he discussed with guest host Ezra Klein the costs of health care, who’s to blame and how we can fix the US broken health care system:

Cross posted from The Stars Hollow Gazette

In a recent on air essay on his PBS program, Moyers & Company and an opinion piece at Huffington Post, Bill Moyers took a look at the revolving door of special interest groups and their lobbyists, how they win and the rest of us lose.

We’ve seen how Washington insiders write the rules of politics and the economy to protect powerful special interests but now, as we enter the holiday season, and a month or so after the election, we’re getting a refresher course in just how that inside game is played, gifts and all. In this round, Santa doesn’t come down the chimney — he simply squeezes his jolly old self through the revolving door. [..]

The last time we looked, 34 former staff members of Senator Baucus, whose finance committee has life and death power over the industry’s wish list, were registered lobbyists, more than a third of them working on health care issues in the private sector. And the revolving door spins ever faster after a big election like the one we had last month, as score of officials, elected representatives and their staffs vacate their offices after the ballots are counted. Many of them head for K Street and the highest bidder. [..]

Reforms were passed that are supposed to slow down the revolving door, increase transparency and limit the contact ex-officials and officeholders can have with their former colleagues. But those rules and regulations have loopholes big enough for Santa and his sleigh to drive through, reindeer included. The market keeps growing for insiders poised to make a killing when they leave government to help their new bosses get what they want from government. That’s the great thing about the revolving door: one good turn deserves another.

The door continues to spin with the latest exodus from Commodity Futures Trading Commission (CFTC). DSWright at FDL‘s News Desk has the latest:

Step right up and Spin the Revolving Door – and what is your prize? Why, a nice job on Wall Street working for the people you used to regulate – you wrote in the loopholes, now you get the cash for exploiting them! [..]

Many Americans understood that the Dodd-Frank “reforms” were mostly worthless. They will not prevent another crisis or another massive TARP type bailout as the law did absolutely nothing about Too Big To Fail banks (which have actually gotten bigger).

This should not have been a surprise given one of the law’s namesakes, Senator Chris Dodd, was caught red handed getting special loans from perhaps the worst offender in irresponsible mortgage origination – Countrywide. Senator Dodd barely survived an ethics investigation from his similarly compromised colleagues.

But what critics may not have understood was that Dodd-Frank was apparently a jobs program for politically connected staffers.

The last count of lobbyists, as of October, directly involved in advising the president, a member of his cabinet or campaign staff is 55.

Cross posted st The Stars Hollow Gazette

First, this morning House Majority Leader Eric Cantor (R-VA) made the rounds of talk shows spouting how the Affordable Health Care bill can be repealed with a simple majority in the House and Senate since the bill was passed under reconciliation. Without a filibuster proof majority in the Senate, Ryan Lizza at The New Yorker points out the obstacles for that to happen:

Many Republicans, especially in the blog and talk-radio swamps, would cry, “Use reconciliation!” Readers familiar with the congressional debates of 2009-2010 will remember that this procedure allows certain budgetary measures to pass through the Senate with a simple majority. [..]

But reconciliation wouldn’t work here-the process can only be used for policies that have budgetary effects and a C.B.O. score. Much of the A.C.A., such as the insurance exchanges and subsidies, would fall under these categories. But a lot of it, including the hated individual mandate, does not. Repealing the exchanges and subsides without repealing the mandate and the other regulations and cost controls in the law would create a health-care Frankenstein that a President Romney would be rather nuts to support.

That said, the SCOTUS ruling has some rather complex ramifications and Chief Justice Robert’s ruling was rather sly. First was there are the three bit from SCOTUSblog that Lambert Strether pointed out at Corrente:

First, here’s the reasoning:

   Essentially, a majority of the Court has accepted the Administration’s backup argument that, as Roberts put it, “the mandate can be regarded as establishing a condition — not owning health insurance — that triggers a tax — the required payment to IRS.” Actually, this was the Administration’s second backup argument: first argument was Commerce Clause, second was Necessary and Proper Clause, and third was as a tax. The third argument won.

Second, here are the implications for the role of the State as we have understood it from the New Deal onward; what Phillip Bobbitt would call a change a Constitutional Order:

   The rejection of the Commerce Clause and Nec. and Proper Clause should be understood as a major blow to Congress’s authority to pass social welfare laws.

Third, here is the new Constitutional Order:

   Using the tax code — especially in the current political environment — to promote social welfare is going to be a very chancy proposition.

Chancy or not — and it will be the precariat that suffers mischance, and not the elite, in any case — that’s what they’re going to do.

Next from Scarecrow at FDL News Desk who argues that Chief Justice Robert’s “incoherent decision” will “shackle congress” and “screw millions of uninsured:

In the process, he did violence to constitutional law and logic.  Consider, for example, Robert’s logic on the “mandate.”  In saving the “mandate,” Roberts essentially defined it as not a mandate.  You are not really required to purchase insurance, he noted; instead, you may choose not to purchase insurance and instead pay a minor tax.  As we know, taxing is just a way to collect revenues, a contribution to the common, aggregate costs of public programs.  In this case, the program is paying for many people’s health care through a system of risk/cost sharing.

But if the so-called mandate is not really a mandate but rather an option that can be avoided by paying a tax, and if a legitimate purpose of this tax, as government and amicus briefs argued, is to help cover aggregate costs across a pool of many insured and uninsured people, then what does that do to Robert’s argument about the Commerce Clause?  When arguing about the Commerce Clause, Roberts insists it’s a requirement to purchase a “product,” which forces you to take an action, and thus to engage in commerce when you would not otherwise have done that.  Regulating “inaction” is not permissible, Roberts argues.

But if, as Roberts concludes, the “mandate” is not a mandate, and the tax’s purpose is to help cover pooled costs, and not to buy a “product,” then there is no “mandate” to purchase a “product.”  So no one is forced to engage in commerce as Roberts framed it.  Indeed the “commerce” is already there in the risk sharing system across millions of people, all engaged in commerce by paying premiums into a pooled risk scheme.  Robert’s entire premise for striking down the Commerce Clause rationale is thus contradicted by his argument about how it’s permissible for Congress to enact a tax to support funding of collective health care costs.  That’s what the tax does; but it’s also what paying insurance premiums does.

Roberts’ reasoning on Medicaid is equally illogical. His premise is that Congress cannot expand an existing program administered by states that depends on shared state/federal funding by conditioning funding for the whole program on the states actually implementing the expansion.  As Brad DeLong observes, if Congress were just now creating a fully expanded Medicaid, to be implemented by states but mostly paid for by the feds, there would be no question that Congress could condition federal funding on the states actually carrying out the programs.  But if the program already exists for half the needy population, Congress cannot complete the program for the other half and use the same leverage to achieve the same degree of state cooperation.

As per the CBO, if the states actually implement the expansion and make an effort to get those eligible to sign up, 16 to 17 million more people will have health care coverage. But without that leverage to get the states to accept Medicaid expansion it leaves the poor between around 50% and 133% of the poverty line in a real no man’s land, because they would both be ineligible for Medicaid AND the coverage subsidies in the exchanges.

As for the states voluntarily opting in for the Medicaid expansion, David Dayen doesn’t think that will happen either, even though the cost for the states would only be responsible for less than 10% of the costs.

And being on the hook for even a small amount of funds isn’t going to make any of these governors happy. Heck, here’s a Democrat, former West Virginia Governor and current Senator Joe Manchin, making the argument for them:

   We should all recognize that the health care challenges that many West Virginians and Americans face are not going to go away unless Congress takes additional action to repair this bill. Now that the Court has ruled, we can move forward with fixing what is wrong with this bill and saving what is right. I have always been determined to reduce the burden on states from the Medicaid expansion, and this ruling affirms my position – and makes clear that states must have the flexibility to live within their means by determining Medicaid eligibility as each state sees fit. I have always said one size doesn’t fit all.

That’s going to be a compelling set of logic for a non-trivial number of governors. They’ll also distort how much the expansion would put their states “on the hook.” 26 states sued to eliminate the Affordable Care Act entirely, and they almost got there. Why wouldn’t they jump at the chance to eliminate the portion that creates half of the coverage benefits?

This isn’t going to be universal. New Mexico’s Republican Governor Susanna Martinez, for example, certainly sounds like she’ll take the money. But Southern states in particular, who paradoxically house the citizens most in need of the Medicaid expansion coverage, will be likely resisters at the outset. And it’s not like a lot of success in modern America comes from rallying at the grassroots level for poor and disenfranchised people.

As was noted by Ezra Klein of the Washington Post, opponents of the ACA see this as a win:

“We won,” said Georgetown law professor Randy Barnett, who was perhaps the most influential legal opponent of the Affordable Care Act. “All the arguments that the law professors said were frivolous were affirmed by a majority of the court today. A majority of the court endorsed our constitutional argument about the Commerce Clause and the Necessary and Proper Clause. Yet we end up with the opposite outcome. It’s just weird.”

Yes, it’s weird but so was the whole ACA bill from the very start.

Cross posted from The Stars Hollow Gazette

It would seem that there really are rational Republicans in elective office. Thank you to Louisiana Attorney General Buddy Caldwell who recognized that the Patient Protection and Affordable Care Act neither protects the patient or makes health care affordable. The only thing that will do that is single payer and that isn’t in the bill. Single payer health care spreads the cost of health care across the spectrum, covering everyone, and insures access to care from birth to death. So, AG Caldwell is suing the Obama Administration because he trusts the government more than the greedy, profit driven insurance companies.

ThinkProgress spoke with Louisiana Attorney General Buddy Caldwell outside the Supreme Court on Wednesday. Caldwell opposes Obamacare and the individual mandate, but for a different reason than most of his fellow litigants: it props up the private health insurance industry. “Insurance companies are the absolute worst people to handle this kind of business,” he declared. “I trust the government more than insurance companies.” Caldwell went on to endorse the idea of a single-payer health care system, saying it’d “be a whole lot better” than Obamacare:

   KEYES: You don’t think the subsidies for low-income people are going to be helpful?

   CALDWELL: No, no. The worst thing you can do is give it to an insurance company. I want to make my point. All insurance companies are controlled in their particular state. If you have a hurricane come up the east coast, the first one that’s going to leave you when they gotta pay too many claims is an insurance company. Insurance companies are the absolute worst people to handle this kind of business. I trust the government more than insurance companies. If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.

I don’t know about the rest of Mr. Caldwell’s politics but I wish there was a Democrat in the White House that agreed with him on this.

Cross posted from The Stars Hollow Gazette

Today the Supreme Court heard arguments about the severability of the individual mandate in the Affordable Health Care bill  and the expansion of Medicaid.

The day after the Supreme Court suggested that President Obama’s health care law might be in danger of being held unconstitutional, the justices on Wednesday turned their attention to the practical consequences and political realities of such a ruling.

The justices seemed divided on both questions before them: What should happen to the rest of the law if the court strikes down its core provision? And was the law’s expansion of the Medicaid program constitutional?

The two arguments, over almost three hours, were by turns grave and giddy. They were also relentlessly pragmatic. The justices considered what sort of tasks it makes sense to assign to Congress, what kinds of interaction between federal and state officials are permissible and even the political character of the lawsuits challenging the law. One justice dipped into Senate vote counting.

The court had in other words, on the third and final day of a historic set of arguments, moved from the high theory of constitutional interpretation to the real-world consequences of what various rulings would entail.

The arguments on severability, which hinged totally on whether the mandated stays or goes, boiled down to three points:

1. sever only the mandate, allow the rest of the law to stand and let Congress sort it out;

2. sever the mandate along with insurance regulations like guaranteed issue and community rating, to prevent what the government argues would be an insurance death spiral;

3. or throw out the whole law, which did not include a standard severability clause.

The Justices seemed divided over point #2 and #3 rather than #1. For the most part, the discussions and comments were reflective of the consequences of overturning the entire law or any part of it:

[..] A common reaction, across the bench, was that the Justices themselves did not want the onerous task of going through the remainder of the entire 2,700 pages of the law and deciding what to keep and what to throw out, and most seemed to think that should be left to Congress.  They could not come together, however, on just what task they would send across the street for the lawmakers to perform.  The net effect may well have shored up support for the individual insurance mandate itself.

The dilemma could be captured perfectly in two separate comments by Justice Antonin Scalia – first, that it “can’t be right” that all of the myriad provisions of the law unrelated to the mandate had to fall with it, but, later, that if the Court were to strike out the mandate, “then the statute’s gone.”  [..]

Justice Anthony Kennedy, who is considered the swing vote on the individual mandate, expressed concern “possible unintended consequences in the form of huge costs to insurance companies if the mandate – which would bring millions of healthy young people into the healthcare system and spread out costs – was invalidated alone”:

“We would be exercising the judicial power if one … provision was stricken and the others remained to impose a risk on insurance companies that Congress had never intended,” Kennedy said. “By reason of this court, we would have a new regime that Congress did not provide for, did not consider.”

The four liberal justices expressed deep reservations about tossing out the sweeping law that has hundreds of other provisions, some of them already in effect.

Justice Sonia Sotomayor, one of the four and an Obama appointee to the court, asked whether the court should allow Congress to decide what to do next. “What’s wrong with leaving it in the hands of people who should be fixing this, not us?”

Justice Ruth Bader Ginsburg went further. She said many parts of the law had not been challenged in court. “Why make Congress redo those?”

On the matter of Medicaid expansion a majority of the justices were inclined to support the government’s role in prodding states to expand the state-federal Medicaid healthcare program for the poor, providing coverage for an estimated 17 million Americans:

The court’s more liberal justices all expressed puzzlement about why there should be a problem with the expansion in light of the fact that it is almost entirely to be paid for by the federal government. The states say they are being coerced into participating because a decision not to may cause them to lose not only the new money but also existing funds.

Justice Elena Kagan described a hypothetical program only slightly different from the real one. “It’s just a boatload of federal money for you to take and spend on poor people’s health care,” she said to a lawyer for the states, Paul D. Clement. “It doesn’t sound coercive to me, I have to tell you.” [..]

He (Chief Justice John G. Roberts Jr) said the court’s decision on the Medicaid expansion should be informed by the reality that the states have “since the New Deal” cheerfully accepted federal money.

“It seems to me that they have compromised their status as independent sovereigns because they are so dependent on what the federal government has done,” the chief justice said.

Justice (Antonin) Scalia addressed the political realities of the litigation itself, asking Mr. Clement whether there was “any chance that all 26 states opposing it have Republican governors, and all of the states supporting it have Democratic governors?”

Mr. Clement responded, “There’s a correlation, Justice Scalia.”

In her last article on Wednesday’s sessions, Slate‘s Dahlia Litwick gives her assessment of the last three days:

Amid all the three-day psychodrama, it’s easy to get confused about what’s happened and what hasn’t. Court watchers seem to generally agree that the individual mandate is in real peril and will rise or fall with Chief Justice Roberts and Justice Kennedy. Court watchers also agree that 19th-century tax law-while generally adorable-will not prevent the justices from deciding the case by July. And they also agree that they may have counted five justices who appear willing to take the whole law down, along with the mandate, and the Medicaid expansion as well.

But the longer they talked, the harder it was to say. A lot of today’s discussion started to sound like justices just free-associating about things in the law they didn’t like. That doesn’t reveal all that much about the interplay between the four separate challenges-what happens when they all have to be looked at together-or anything at all about what will happen at conference or in the drafting of opinions. Could the five conservative justices strike down the entire health care law, and take us into what Kagan described this morning as a “revolution”? They could. Will they? I honestly have no idea anymore. As silent retreats go, this one was a lot less enlightening than I’d hoped.

Constitutional law professor Jonathan Turley discussed the hearings with Keith Olbermann on Countdown, calling this case a “game of chicken” that “can be deadly.”

Cross posted from The Stars Hollow Gazette

Can the government force you to eat broccoli or buy a cell phone? Those were some of  the questions asked during the first two of three days of hearings before the US Supreme Court over whether it is constitutional for the government to mandate an individual to buy health care insurance from a private company or face a “penalty” to be collected by the Internal Revenue Serve. Candidate Barack Obama opposed a mandate but changed his mind, including it his “signature” [Affordable Care Act , taking single payer and then the option for a public sponsored insurance off the table. At this point, the majority of the public is opposed to the mandate and about a third want the entire bill scrapped, even though it has a few good provisions such removing pre-existing conditions as a reason to deny coverage and the implementation of lifetime caps on what the insurance company will pay.

Dahlia Lithwick, a senior editor and legal correspondent for Slate, gives her analysis of the first two days:

One thing was clear after the two hour session (pdf) at the Supreme Court on the constitutionality of the Affordable Care Act: The outcome of President Obama’s signature legislative achievement probably rests on the shoulders of two men-Chief Justice John Roberts and Justice Anthony Kennedy. Or, to put it differently, everyone else seems to have staked a clear position. [..]

In the beginning, all eyes were on Kennedy who opened his questioning by asking Solicitor General Donald Verrilli to “assume this law is unprecedented.” (Gulp. That isn’t the way Verrilli wanted this to begin.) Both Kennedy and Roberts pressed Verrilli to enunciate a limiting principle on the congressional power asserted here. Or as Kennedy put it, early in the argument: “Can you identify any limits on the commerce clause?” [..]

Kennedy had serious doubts and Verrilli appeared unable to allay them. The odds on a 5-4 vote to strike down the law looked good. Kennedy asked far fewer questions of the challengers, although near the end of the morning he said, in his inimitably oblique style that young people are “uniquely, proximately very close to affecting the rates of insurance and the cost of providing medical care in a way that is not true in other industries.” That may suggest he believes that the health insurance market really is unique in some ways. [..]

My sense is that we saw only a part of what the justices were really thinking today. We heard Roberts and Kennedy expressing doubts about each side of the argument. But we didn’t get to hear them think aloud about what it actually means to strike down a monumental act of congress. We can assume that is weighing on some of the justices, nonetheless. The other thing we didn’t hear much about today was case law. Justice Stephen Breyer pointed out more than once that the justices weren’t there to debate whether or not they liked the bill. But it may be worth counting up the references to forced gym memberships, cellphone purchases, and broccoli mandates, and tallying them up against references to actual court cases. That’s either because the mandate is so unprecedented that precedent doesn’t matter. Or, because precedent just doesn’t matter.

What we do know is that an individual can survive very well without broccoli or a cell phone but at some point that individual will need health care. In another article by Ms. Lithwick she points out that the conservative argument that this is about freedom has a very dark side:

It’s always a bit strange to hear people with government-funded single-payer health plans describe the need for other Americans to be free from health insurance. But after the aggressive battery of questions from the court’s conservatives this morning, it’s clear that we can only be truly free when the young are released from the obligation to subsidize the old and the ailing. [..]

Freedom also seems to mean freedom from the obligation to treat those who show up at hospitals without health insurance, even if it means letting them bleed out on the curb. When Solicitor General Donald Verrilli tries to explain to Justice Scalia that the health care market is unique because “getting health care service … [is] a result of the social norms to which we’ve obligated ourselves so that people get health care.” Scalia’s response is a curt: “Well, don’t obligate yourself to that.” [..]

Freedom is the freedom not to rescue. Justice Kennedy explains “the reason [the individual mandate] is concerning is because it requires the individual to do an affirmative act. In the law of torts, our tradition, our law has been that you don’t have the duty to rescue someone if that person is in danger. [..]

Freedom is to be free from the telephone. [..]

Freedom is the freedom not to join a gym, not to be forced to eat broccoli. It’s the freedom not to be compelled to buy wheat or milk. And it’s the freedom to purchase your health insurance only at the “point of consumption”-i.e., when you’re being medivaced to the ICU (assuming you have the cash). [..]

Some of the members of the court find this notion of freedom troubling. Justice Ruth Bader Ginsburg notes that: “Congress, in the ’30s, saw a real problem of people needing to have old age and survivor’s insurance. And, yes, they did it through a tax, but they said everybody has got to be in it because if we don’t have the healthy in it, there’s not going to be the money to pay for the ones who become old or disabled or widowed. [..]

Sotomayor, again pondering whether hospitals could simply turn away the uninsured, finally asks: “What percentage of the American people who took their son or daughter to an emergency room and that child was turned away because the parent didn’t have insurance-do you think there’s a large percentage of the American population who would stand for the death of that child if they had an allergic reaction and a simple shot would have saved the child?” {..]

This case isn’t so much about freedom from government-mandated broccoli or gyms. It’s about freedom from our obligations to one another, freedom from the modern world in which we live. It’s about the freedom to ignore the injured, walk away from those in peril, to never pick up the phone or eat food that’s been inspected. It’s about the freedom to be left alone. And now we know the court is worried about freedom: the freedom to live like it’s 1804.

My biggest problem is that forcing people to buy insurance from a private company that does not insure access to care and cost controls or without an inexpensive public option, like buying into Medicare, is just a financial gift to the insurance companies. Without a public option, this bill is a major failure and unlikely to be fixed in the future, as so many Obama supporters claimed, or be replaced if SCOTUS declares the bill unconstitutional.

This is huge in so many ways, to many for a non medical professional like myself to break it all down.

New Insurance Rules: Free Preventive Health Care