1. "Read the Bill... Read the Bill" Remember that chant from August 2009? Well, apparently most of the new members of Congress, including our own Congressman Mike Fitzpatrick, have not read the bill or even any of the dozens of readable and accurate summaries of it (such as are on our web site). They and he claim they are in favor of several health reform ideas, like insurance competition, eliminating pre-existing conditions, and controlling costs, and yet they pretend these are not in the ACA already and they offer nothing specific as alternatives. If they actually understood the law, they would realize most of what they want is there and they could simply try to modify what they don't like.

"The next fiction is the idea that there exists some market-based reform that would operate immaculately free of intrusive government regulation. If consumers are to exercise real leverage on insurance vendors, they have to understand the choices they face. That demands that the range of plans be limited to a manageable number, that marketing of insurance plans be highly regulated and that objective literature written in plain English must be available to customers. It also demands extensive risk adjustment of premiums and subsidies for those who cannot afford the full cost of health insurance. All of this will require heavy government involvement. Come to think of it, each of those steps is part of the health law." Click here.

"Many economists say the effects on jobs are likely to be modest. Most large companies already provide health benefits to employees. And many small businesses will be exempt from penalties if they fail to do so.

While employers often pay premiums for their employees, economists say, the cost of health benefits is, over time, generally passed on to workers, through reductions in wages or other compensation. But employers cannot reduce the wages of people earning the minimum wage.

Thus, the Congressional Budget Office says, the new law "will probably cause some employers to respond by hiring fewer low-wage workers," or by using more part-time and seasonal workers.

But Democrats say that if the law provides coverage to more than 30 million currently uninsured people, as intended, it will increase demand for medical services, thus creating new job opportunities in the health care industry."

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2. The Impact of Repeal on Our District The minority staff in the House Committee on Energy and Commerce issued a series of reports in January on the impact for each state if the ACA were to be repealed. For example, repeal would:

• Rescind consumer protections for 502,000 individuals who have health insurance through their employer or the market for private insurance.
• Eliminate health care tax credits for up to 18,100 small businesses and 102,000 families.

You can get a copy of the one for PA (or NJ) Click here. One might argue that reports are "biased," but the facts seem pretty straight forward, showing the numbers of people who would lose coverage or subsidies, insurance protections, and the number of small businesses adversely impacted. Unless some other reform bill with comparable coverage and subsidy rules were quickly enacted by the Republicans, these consequences would be real and severe.

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3. Don't Know Much About Government... Kaiser Family Foundation released a poll showing that 22% of Americans incorrectly believe the Affordable Care Act has been repealed. The attempt to repeal of the health reform law was only voted on by the House of Representatives. The Democratic controlled Senate has not brought up the legislation for a vote and President Obama said he would veto any repeal legislation if the House bill managed to get through the Senate.

Maybe one reason that so many are misinformed is the media coverage of issues relating to the law. An example is the reporting on the five major rulings to date of lawsuits brought against the law. Note that the Washington Post had zero news articles on the latest federal judge's ruling. See coverage graph below...

Share with kids and friends the video "Schoolhouse Rock-How a Bill Becomes Law" Click here.

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4. Defenders of the ACA Win Serious Debate by a Landslide A formal debate in January in New York City, part of a series of public issue debates called "Intelligence Squared," saw defenders of the ACA not only winning the debate, according to audience votes. But they persuaded many doubters to become supporters of the bill.

At the beginning of the debate, 17% of the audience agreed with the motion, Repeal Obamacare, 47% were against it, and 36% were undecided. After the debate, 72% were against repeal, 22% were for it, and only 6% remained undecided. In other words, positions tightened up and most of the initially undecided came out supporting it.

The winning team included Jonathan Cohn, a senior editor at the New Republic, and Paul Starr, a professor of sociology and public affairs at Princeton University and co-founder and co-editor of the American Prospect magazine. The side arguing for the motion included Douglas Holtz-Eakin, president of the American Action Forum and a former director of the Congressional Budget Office and director of domestic and economic policy for the John McCain 2008 presidential campaign and John Shadegg, a former Republican representative from Arizona.

A transcript and video are available at http://www.intelligencesquaredus.org.

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5. They're Only Experts – What Do They Know?! A Harris Interactive survey sponsored by the Commonwealth Fund and the journal Modern Healthcare of 203 health care opinion leaders (health care executives, and policy experts) in January found that over 90% "believe the general direction set by the Affordable Care Act is appropriate, with nearly seven of 10 favoring implementing the law with little or no change."

But what do they know? We're sure the average voter and those members of Congress elected to repeal the law know so much more than these folks about health insurance, the health care delivery system, and how other countries cover 100% of their population at half the cost that we pay. Isn't it great that in this country voters and politicians are so humble and eager to learn the facts in order to make objective decisions? Click here.

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6. Dysfunctional America: If You Can't Repeal, Defund Instead You would think that once a law is passed, it would definitely be implemented, unless it's later repealed. But, no, not in the good old dysfunctional USA. Here you can keep the law but just cut off funding so it can't be implemented, or the implementation goes poorly, leaving a sour taste in the mouths of citizens. According to the Robert Wood Johnson Foundation (RWJF):

"In addition to pursuing full repeal of the Affordable Care Act (ACA), congressional Republicans are seeking to block various sections of the law or cut off funding for key provisions. In February, House Republicans approved nine amendments that would block health reform funding as part of a spending bill for the remainder of fiscal 2011."

A March 2 RWJF analysis reviews several approaches that opponents of the ACA are attempting to undertake:

• Repealing and replacing, which would replace the ACA with alternate health reform;
• Repealing specific provisions, such as the individual mandate, the prohibition on states to reduce Medicaid eligibility and the employer mandate;
• Blocking regulations;
• Holding hearings to rally support for alternate reforms; and
• Defunding implementation of the ACA.

Click here.

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7. Full-Court Press At half-time now, the score stands at 3 to 2 in favor of Team Obama. As a Feb. 26th New York Times editorial observed:

"The latest ruling, by Judge Gladys Kessler of the Federal District Court for the District of Columbia, provides a reasoned analysis of why appellate courts and ultimately the Supreme Court ought to uphold the law.

The crucial issue is whether a requirement that almost everyone obtain health insurance in 2014 or pay a penalty can be imposed by Congress under the powers granted to it by the Constitution, especially the power to regulate interstate commerce.

The two judges who found the law unconstitutional concluded that Congress cannot regulate "inactivity" - the failure to purchase health insurance - as if it were an "economic activity" that affects interstate commerce. But Judge Kessler rightly noted that when people without insurance become sick and seek care, the costs are usually shifted to other participants in the health markets, to federal and state governments, and to taxpayers.

She called it "pure semantics" to argue that people who choose to forgo health insurance are not "acting," especially given the economic impact on others.

However, in a blow to supporters of the reform law, Judge Kessler sided with all of the judges who have considered the issue and ruled that Congress could not rely on its power to raise taxes for the general welfare to justify requiring people to buy insurance or pay a penalty. She argued from the bill's legislative history that Congress did not intend for the penalty to operate as a tax."

But the Spoilers are looking for a comeback in the second half. Thus Florida Judge Roger Vinson, who ruled against the ACA back on January 31, issued a stay on his own ruling. But he really sought to speed the process by conditioning the stay on the Justice Department's pursuit of an expedited appeal, which he ordered filed within seven days.

"The sooner this issue is finally decided by the Supreme Court, the better off the entire nation will be," wrote the judge..." according to a March 3 New York Times article. Click here.

Vinson was the only judge to declare the whole act unconstitutional, while the other judges ruling against it only cited the coverage mandate.

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8. Conflict of Interest? Well, Recuse Me! Concerned that the various legal challenges to the ACA will end up being decided by a close vote in the Supreme Court, Democrats have written to ask Supreme Court Justice Clarence Thomas to recuse himself from the case. Thomas has financial ties to organizations that have lobbied heavily against the ACA. See letter here: Click here.

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9. Pennsylvania - Pittsburgh in the West and Philadelphia in the East and Alabama in the Middle As with several other states, the new Republican legislature in PA is working on legislation that would stop implementation of the ACA in our state. According to Pennsylvania Health Access Network, "State Representative Matt Baker (Wellsboro), the new chair of the House Health Committee, has sponsored House Bill 42, the "Freedom of Choice in Health Care Act," which recently passed in committee and may soon be voted on in the House and Senate. The legislation is a virtual carbon copy of a model bill written by the American Legislative Exchange Council, a right-wing think tank." The proposed bill would allow people to disregard the coverage mandate so that they have the freedom to be freeloaders off of everyone else paying into the system.

As PA Health Access notes, the bill is a waste of time and taxpayer money. "... H.B. 42, if passed, will undoubtedly go straight to the courts and be declared unconstitutional, because a state legislature does not have the authority to order state agencies not to comply with federal law, as this bill does." Please press your state representatives to vote against this bill when it comes up. Click here.

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10. Cost = P x Q x N Princeton economist and internationally renown health care expert Uwe Reinhardt keeps reminding us that the way to understand health care costs is actually quite simple. The formula is: prices times quantity/quality of services times number of covered individuals. U.S. health care costs are 50% to 100% higher than in other advanced countries and yet we do not cover 1/6th of our population. The quantity and quality of care is roughly similar. So the real difference is in the prices we are charged. Hospitals and doctors (especially specialists) charge much higher rates here (plus their overhead is higher) than in other countries. To get serious about cost control, this is where we have to look.

According to an article by Matthew Coffina on the Morningstar investment website, highlighting a lecture by Reinhardt:

"Comparing the U.S. to other developed countries, the average price for a normal childbirth in the U.S. was around $8,400 in 2010. In Germany, it was $2,100. In France, it was $3,800. And just across the border in Canada, it was $2,300. An appendectomy cost $13,100 on average in the U.S., compared to $2,600 in Switzerland, $6,500 in Australia, and $3,800 in Canada. The average cost of Lipitor was $129 in the U.S., compared to $78 in Germany and $33 in Australia."

Click here.

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11. Compliance With Prescriptions and Other Treatments – a Huge Cost Savings Opportunity According to NEHI, a health research organization, poor adherence in taking prescribed medication "results in up to $290 billion annually in medical expenses." Read about the innovative ways pharmacologists and others are trying to address this problem and cut costs. Click here.

A Feb 28 New York Times online-only article profiles a related program in New York City, modeled off of PACT, "Prevention, Access to Care and Treatment. PACT is part of Partners in Health — a nongovernmental group famous for its work in Haiti, Rwanda and elsewhere. Part of Partners' strategy is to use people from the community who are paid a stipend to visit patients, watch them take their pills and support them." The program has shown success where most other programs fail – getting patients to take their medications and change bad health behaviors. The key is regular and personal contact with patients, which doctors haven't been able to do ever since "managed care" started limiting their ability to spend more than a few minutes with each patient.

Treatment compliance is perhaps the most difficult part of the healthcare chain to link together. We could cover everyone with high quality care but if people don't do their part, costs will still stay unacceptably high. "About three-quarters of patients do not keep appointments for follow-up care. In one study of diabetes patients, only 7 percent were compliant enough with their treatment plans to control the disease. Even people at grave and immediate risk do not always take their medicines: a quarter of kidney transplant patients in one study did not take their medicines correctly, putting them at risk for organ rejection." Click here.

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12. President Obama Supports Flexibility on How States Implement Reform According to a March 1 editorial in the New York Times:

"The president told the nation's governors on Monday that he supported a bipartisan bill -- sponsored by Senators Ron Wyden, Democrat of Oregon, Scott Brown, Republican of Massachusetts, and Mary Landrieu, Democrat of Louisiana -- that would allow states to fashion solutions right from the start of full-scale reform in 2014, rather than waiting until 2017, as the law requires.

The catch is that a state's plan must cover as many people as the federal law does, provide insurance that is as comprehensive and affordable, and not increase the deficit."

"Alternative approaches might include replacing the mandate to buy insurance with a system to automatically enroll people in health plans, reformulating tax credits for small businesses and low-income individuals to encourage near-universal coverage, adopting such liberal approaches as a single-payer plan or a public option, and even moving all or part of the enrollees in Medicaid into new health insurance exchanges."

Unfortunately, the proposed bill to amend the ACA is not likely to pass since it would have to gain majority votes in both houses and the Republicans in the House campaigned to kill the bill rather than let it be improved. Click here.

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13. Medicaid Funding Governors, especially Republicans, are pushing back on the ACA's requirements to upgrade their Medicaid programs, by increasing benefits and expanding eligibility. These governors say they would prefer the federal money to help pay for most of the expansion comes to them in the form of block grants, so they have more flexibility to tailor their programs.

According to the Associated Press: "GOP governors want control of the purse strings and leeway to rewrite coverage and payment rules. So far President Barack Obama has turned them down, but he may be forced to give some ground if negotiations to reduce federal debt get serious later this year." Many governors also "would probably put most Medicaid recipients in some kind of private insurance," rather then continue with a state-run single payer program.

Despite the complaints, the AP article notes that "Washington will cover about 95 percent of the cost for those who would be newly entitled to Medicaid: childless adults with incomes just over the poverty line. States will save money because those people won't turn up in emergency rooms without the means to pay. Over time, the federal share would drop to 90 percent." Click here.

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14. "Let Them Eat Cake": Corbett Bids Adieu to PA's AdultBasic Care Pennsylvania made national headlines on March first, but not in a good way. The new Republican governor and legislature let the "adultBasic" program lapse due to lack of funding. As the New York Times reported on March 1st, "41,467... Pennsylvanians who had been covered by adultBasic, a state-subsidized insurance program for the working poor that Gov. Tom Corbett shut down on Monday in one of the largest disenrollments in recent memory." Any other coverage alternative will be far more costly, and less comprehensive. Most such individuals do not qualify for Medicaid, which now covers primarily women and children, not single adults. They also do not qualify for the state's high risk pool, which requires that someone be uninsured for at least 6 months.

The program was originally funded through tobacco settlement money and then through funds contributed by PA's nonprofit Blue Cross Blue Shield organizations. Continuing the program for another year would have cost $56 million, or a mere 1% of the Blues cumulative surpluses of $5.6 billion, as of the end of 2009. Gotta hoard those "nonprofit" bucks for a rainy day! Click here.

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15. Franz Kafka vs. the US Health Care System You know who normally loses on this one. But if you "enjoyed" Franz Kafka's infuriating struggles with bureaucracies, you must read the series of four blogs by Case Western Reserve University physics professor, Mano Singham, regarding his routine physical and colon screening. I too (George Faulkner) had a similar experience here in PA about two years ago—not nearly as bad, but then being in the business, I was able to pre-empt the problems before I got stuck with bills I should not have paid.

To cut to the chase, in order to correct a procedure coding error and reverse charges for expenses that should have been covered by the insurance plan as routine, Singham, "had to make 17 phone calls to the hospital's billing office, 15 calls to my doctor's office, 9 calls to the insurance company billing office, and 4 calls to the radiologist's billing office." And some politicians want to replace Medicare and Medicaid with insurance plans alone (see next story). May they have some of these experiences! Click here.

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16. "But At Least It's a For-Profit Bureaucracy" Speaking of insurance companies (and don't forget intricate coding and billing systems, dozens of network discount arrangements, and millions of plan design variations), according to the Associated Press, "House Budget Committee Chairman Paul Ryan, R-Wis., is testing support for his idea to replace Medicare with a fixed payment to buy a private medical plan from a menu of coverage options." Instead of cutting back on the 14% average higher payments to insurance companies for Medicare Advantage plans, or reducing the rate of increase in payments to some high-paid specialists, opponents of the ACA (including our own Rep. Mike Fitzpatrick) would rather give us a voucher and let us loose in the insurance jungle.

According to Ryan's proposal, "Under Ryan's plan, current Medicare recipients would get to stay in the program. People within 10 years of eligibility — ages 55 to 64 — would also go into Medicare. But those now 54 and under would get a fixed payment from the government when they become eligible at age 65."

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17. Medicare Advantage – Still not a Good Deal Sure, some folks love Medicare Advantage plans. Who wouldn't, given the extra 14% average subsidy the federal government gives them, thanks to the previous Bush administration and Republican Congress. But a new Government Accounting Office (GAO) study reconfirms that they are not a good deal for the taxpayer. According to a House subcommittee press release, the report found:

• "One out of every three MA enrollees is in a plan that spends less than 85 percent of their projected Medicare payment on medical expenses, which means more than 15 percent of their projected Medicare payment goes to overhead and profit.
• The more market concentration there was in a given area, the higher the insurance companies' bids and subsequent costs to Medicare and taxpayers were."

Click here.

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18. "Canadians Live Longer Than Americans - Universal Health Care Blamed" That's the headline on the Feb. 4 science news website Machines Like Us, citing a 2010 study in Population Health Metrics on U.S. vs. Canadian health care. The study found that Canadians live 2.7 more years of "perfect health" than Americans do, despite similar demographics, as a result of better access to health care, thanks to their universal system with generally no co-pays. But at least we pay less for health insurance—oops, make that twice as much—and we have so many more choices—in insurance companies. Click here.

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19. Massachusetts Health Reform Program Update Massachusetts, the state that led the way in health care reform under then Gov Mitt Romney "announced comprehensive health care payment and delivery reform legislation designed to control rising health care costs and improve patient care." Massachusetts has near universal coverage of its citizens, but costs continue to rise at an unsustainable pace.

This new proposal, announced by Governor Deval Patrick, aims to address high costs by getting providers and insurance companies to use bundled payments rather than the traditional fee-for-service approach which encourages excessive utilization. It also include malpractice reforms, such as "a 180-day cooling off period before a malpractice suit can be brought, and also a provision that would make apologies by doctors inadmissible as evidence in lawsuits," according to the following article: Click here.

Read here also: Click here.

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20. Boo! Public Option Surfaces in Connecticut This one bears watching. The state of Connecticut, where many insurance companies are headquartered, is debating including a public option in their state health exchanges. Click here.

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21. Consensus on a Change to the ACA for Small Businesses Senate has voted to repeal one part of the ACA, the 1099 provision, a tax-reporting requirement that the Senate Finance Committee inserted during the debate in 2010 to raise revenue to help pay for the law. Both Democrats and Republicans have since wanted to remove this part of the law, due to complaints that it would be too burdensome for small businesses. The House will take up the issue next. It is expected to pass and be signed by President Obama. Click here.

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22. Patients Can Control Their Hospital Visitors As of January 21, 2011, all hospitals who participate in the Medicare or Medicaid programs must now allow all patients to put whomever they choose on their visitation list and no longer limited to only the traditional "family." This is very meaningful for gay and lesbian partners. Click here.

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23. Benefiting Women The Department of Health and Human Services has a new web page dedicated to the new rights and benefits for women in the ACA. Bookmark and pass the link on to others. Click here.

The next issue will update the various single-payer bills introduced in some states and Congress. We will also report on the Accountable Care Organization ground rules that the Center for Medicare and Medicaid Services (CMS) will soon introduce.

Your generous donation allows us to continue to bring you health care reform implementation updates and analysis. Please support our work today.

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