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Newsletter, What's Going On, December 21, 2010

Senate Republicans last week successfully defeated an omnibus spending bill that would have funded the government through the end of the current fiscal year (October 2011). To avoid a government shutdown, the new plan is to pass a continuing resolution that funds the government at the current level through March 4, 2011.  (The Wonkbook) “Funding for the new healthcare reform law is noticeably absent from a bill to keep the government running through March 4, after Republicans objected to an earlier proposal because they said it funded reform.

The continuing resolution (CR) provides a small increase of $1.16 billion over fiscal 2010 levels, but does not fund reform law measures included in an earlier, comprehensive spending proposal.”  The Hill

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The Massachusetts Division of Health Care Finance and Policy (MA DHCFP) has released the results of its 2010 household insurance survey. It’s very good news, and to tie it into current news, it continues to show the value of an individual mandate. “[N]ot only does Massachusetts continue to have the highest health insurance coverage rate in the nation, but that our state has seen gains even through an economic recession.  This year, more than 98 percent of Massachusetts residents have health insurance. These results are astonishing.  Some of the most exciting news is related to children and elderly adults, as the survey found that virtually all Massachusetts children have health insurance (99.8 percent) and nearly all elderly adults are covered (99.6 percent).”

POLITICO Pulse notes: MASS. KIDS GET UNIVERSAL COVERAGE W/O MANDATE- While everyone marveled at Massachusetts' 98.1 percent insurance coverage for adults, they overlooked an even more impressive stat. The Bay State has 99.8 percent coverage for kids, who are NOT required to carry insurance (the MA individual mandate only applies to 18 and up). How'd they pull off near-universal coverage without the all-important mandate? Brian Rosman of Health Care for All Massachusetts credits the state's Medicaid expansion (up to 300 percent FPL for children) as playing a big part. But there was also an "aggressive outreach campaign" from both the state and community-based groups at work. And, last but not least, Rosman concedes that the mandate, albeit not requiring child coverage, did play an important role. "There's a cultural factor at work," he says. "There's a general expectation set up by the individual mandate that everybody is going to have coverage.

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Checking In With Dr. Robert Kocher On Who Might Stay Uninsured In Spite Of The Individual Mandate   […] But even if the mandate takes effect in three years, experts acknowledge that some people are certain to still be without coverage. These consumers may have been confused by the system, caught between programs or simply opt to pay the mandate's penalty (that is based on a percentage of income and begins at a minimum of $95 for an individual in 2014 but grows to at least $695 by 2016). Nonetheless, they will fall into a category known as the "residually uninsured" and make up what's been called the "outlaw market." Even during the year's congressional debate, there was much speculation about how big this group might be and whether the result could undermine the push to spread risk and make health coverage more affordable and accessible.  Kaiser Health News.    Quoting from the same interview, the Incidental  Economist writes, “Depending on what you believe about these factors leads you to a large range for how many people will be residually uninsured. In some scenarios, that pool may be as large as 30 to 40 million people.”  (emphasis added).

As you plan your year-end giving, please keep us in mind.

40% of the people who are eligible for free Medicaid don’t sign up. Darshak Sanghavi, writing in Slate (and based on a NEJM article) examines why. “Some of them may have their priorities wrong, but many don't. The real problem is that state governments are trying to save money by keeping eligible people off the insurance rolls. In 2007, Health Affairs reported that fully one-third of all eligible but uninsured children had been booted out of Medicaid or SCHIP after being enrolled in the prior year. Some states make people file yearly or twice-yearly applications in order to stay covered, with in-person interviews and demands for a birth certificate. (Imagine being asked to retake your driver's test twice every year.) Make an error on your paperwork or forget an appointment and your kid automatically loses coverage. 

“It's clear why states might have worked against enrollment in the past, but according to the new law, the federal government will cover almost all the costs of people who are newly eligible for Medicaid. The states won't be on the hook for the millions of names that might soon be entered in the books, yet they're fighting the expansion of Medicaid benefits nevertheless. (Fourteen have sued to stop it.) So why are some state governments hell-bent on denying free care to needy people when it will hardly cost them a thing?  (n.b.  The federal government will cover the direct cost of care of the new Medicaid eligibles till 2016; states will be responsible for paying for the administrative cost of the millions of newly Medicaid insured.) 

“The answer lies in a little discussed provision of the law that aims to simplify enrollment into Medicaid. The law's architects realized that giving away insurance wouldn't be enough; they also wanted to force states to deal with the people who were already eligible for free care but had been squeezed out of the system. According to the new rules, you may soon be allowed to sign up for Medicaid via the Web, without any of those repeated in-person interviews. (Some states might start enrolling people into Medicaid automatically, just like how Medicare kicks in when people start collecting Social Security checks.) That's a problem for states with low enrollment rates now. The federal government may be ready to pay for all the newly eligible people on Medicaid, but the states must cough up half the costs for all the previously eligible people who are added to the rolls under the simplified system.” 

And…In her latest Kaiser Health News column, Nina Owcharenko writes: "Recent coverage of the proposals offered by President Obama's debt commission managed to gloss over a huge issue that is adding to the nation's deficit -- Medicaid. The impact of this federal-state partnership program on the country's long-term fiscal future is just as real and consequential as Medicare and Social Security. Plus, Medicaid also adds to the financial burdens on states' budgets" (12/15). Read the column

Medicaid isn't perfect, but there aren't better solutions out there, Jonathan Cohn writes in KHN and The New Republic.  (Recall that Cohn was the author of “Sick”, the book popular a couple of years ago) 

And…CQ HealthBeat: Health Care Legal Challenge Spotlight Turns To Medicaid Next 
In a Florida courtroom on Thursday, the 20 states fighting the health care law will attack its expansion of the nation's Medicaid program -- a sweeping provision that extends health coverage to millions of needy American adults (Norman, 12/14).  Kaiser Health News.  The judge’s questions sounded as if he might rule against the mandate but in favor of leaving Medicaid changes in the new law as they are. 

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From Chris Weaver of Kaiser Health News: (via the Incidental Economist.)  Medicare patients in Fort Myers, Fla., were more than twice as likely to receive hip replacement surgeries in 2005 and 2006 as their counterparts across the Everglades in Miami, according to a finding by Dartmouth Health Atlas researchers. [...]   But, before you blame such inconsistencies on America’s money-driven health system, take a look at Britain’s effort to anglicize the Dartmouth work: Doctors in some areas such as the college town of Oxford do one type of hip replacement at rates up to 16 times greater than in places like London, according to a November atlas by the National Health Service.   The British atlas is surprising because “doctors are not by and large paid on a fee for service basis in the NHS,” Angela Coulter, director of global initiatives for the Dartmouth Atlas-associated Foundation for Informed Medical Decision Making, said at a Salzburg Global Seminar session this week. “It illustrates the fact… that doctors tend to favor the treatments they’re trained to provide,” even when money isn’t a factor. Most British doctors get salaries rather than payments for each procedure like their American colleagues.  Variations in the way doctors treat patients are “independent of the way health care’s organized and financed,” Dr. Jack Wennberg, the godfather of Dartmouth’s variation research, said in an interview here Thursday, noting that his work uncovered similar patterns in Britain and Norway in the 1970s.

Please note the planning meeting.  Details below.

Dr. William Hsiao, who’d been planning alternatives for health care in Vermont including a state single-payer plan, has made a public status report on progress toward developing his proposal, saying that reform won’t be quick or inexpensive.  He’s projecting a 12 year implementation, and estimates that his proposal will lose him a number of friends.  His report is due out on January 19, to be open for comment for two weeks, then subject to his revision for two more weeks before presentation in final form in February.   (I’ve found very few news stories of the status report that I could summarize and hyperlink for this newsletter.  Surely there will be others in the next day or so to watch out for.)  

Serious, detailed consideration of what might happen…really…if the individual mandate were invalidated. 

Art Sutherland passed along a superb article appearing in this week’s issue of the Journal of the American Medical Association describing the moral and legal basis for the assertion that health care is a human right.  Extended discussion of international treaties and compacts, a number of which the United States has not signed.  I’ll hyperlink to an extract of the article; full text is available at that site for a fee.  And I’ll hyperlink to Art’s email address…perhaps he can forward a copy of his email with the article embedded in it. 

POLITICO notes that many states (including Alabama) that oppose the health care reform and are suing for it to be overturned are also moving ahead quietly to establish insurance exchanges called for under the act.  “The exchanges, which will be web sites similar to Orbitz or Expedia where people can buy insurance, emphasize the GOP-friendly concepts of consumer choice and competition. Republicans are embracing them quietly even as they loudly fight other aspects of the law in federal court.”  The Wonkbook.  

“The Kaiser Foundation has a timeline for implementation of provisions of the Affordable Care Act, specifically including those that go into effect on January 1, 2011.

This is said (by POLITICO) to be the best site for the legal documents relating to all of the litigation over the ACA.  

Would health care reform work without an individual mandate?  Norman Orenstein, the American Enterprise Institute, writing in Roll Call.  

There’s a wonderful piece in the New York Times reprinting the arguments used way back in history against social security, Medicare, child labor laws, women’s suffrage and a number of other issues.  (Incidental Economist).  

The Small Business Majority is pretty proud of its support of the Affordable Care Act. 

Arizona has an ongoing problem, a willingness to deny life-saving transplants to some of its citizens on Medicaid in the interest of saving money.  There’s been no progress toward resolving the problem, but there’s intelligent commentary, here, which, among other things, contains a quotation from Rudolph Virchow that I hadn’t heard before.  Physicians, Virchow said, are the natural attorneys for the poor.  

McClatchy/The Sacramento Bee: More Middle Income Families Going Without Health Insurance 
As more Americans lose health coverage because of unemployment, the latest snapshot of the uninsured reveals a grim picture: It's not just the poor and unemployed who now go without health insurance. About a third of California's uninsured had family incomes of more than $50,000 a year in 2009, according to the California HealthCare Foundation (Calvan, 12/17).  Kaiser Health News. 

Key Point:  “But as Republicans smelled serious opportunity in the midterm elections, they didn't let facts get in the way of a great punchline. And few in the press challenged their frequent assertion that under Obama, the government was going to take over the health care industry.  PolitiFact editors and reporters have chosen "government takeover of health care" as the 2010 Lie of the Year. … The phrase is simply not true.”  And what is most unsettling is despite the fact that this was disproven by many non-partisan sources, according to Politifact:  • The phrase appears more than 90 times on Boehner's website, GOPLeader.gov.

• It was mentioned eight times in the 48-page Republican campaign platform "A Pledge to America" as part of their plan to "repeal and replace the government takeover of health care."

• The Republican National Committee's website mentions a government takeover of health care more than 200 times. 

Checking In With Dr. Robert Kocher On Who Might Stay Uninsured In Spite Of The Individual Mandate   […] But even if the mandate takes effect in three years, experts acknowledge that some people are certain to still be without coverage. These consumers may have been confused by the system, caught between programs or simply opt to pay the mandate's penalty (that is based on a percentage of income and begins at a minimum of $95 for an individual in 2014 but grows to at least $695 by 2016). Nonetheless, they will fall into a category known as the "residually uninsured" and make up what's been called the "outlaw market." Even during the year's congressional debate, there was much speculation about how big this group might be and whether the result could undermine the push to spread risk and make health coverage more affordable and accessible.  Kaiser Health News.    Quoting Dr. Kocher from the same interview, the Incidental  Economist writes, “Depending on what you believe about these factors leads you to a large range for how many people will be residually uninsured. In some scenarios, that pool may be as large as 30 to 40 million people.” 

WISCONSIN DEVELOPS EXCHANGE PROTOTYPE- The Wisconsin Office of Health Care Reform has released a prototype website for the health exchanges to provide consumers a hint at how they will purchase coverage after 2014. A similar small business exchange prototype is in the works. The office is asking for consumer feedback. The site 

In case you missed it ...Low pay, long hours and concerns that government isn't reimbursing services enough is driving doctors to consider new careers, but in this case, it's not the American primary care physician, worried about the doc fix and considering leaving the Medicare system. It's Czech doctors this time around, and they're threatening to emigrate if the government doesn't pay them more. One gastroenterologist with 10 years under his stethoscope works 80-hour weeks and makes only enough rent a modest apartment and buy food. Physicians have taken to protesting by riding around town in a specially marked-up ambulance--its front reads "Pay doctors more than a street sweeper. Keep us here!" and its back reads: "Thank you, we're leaving."  ACP Internist.  

The Ryan-Rivlin Medicare Reforms are currently getting a lot of favorable press on the right.  Ezra Klein analyzes them scathingly…mostly as a renamed and distorted form of Obamacare.  

State-based programs that help spread the word about Medicare benefits will have to increase beneficiaries' awareness about benefits of the healthcare reform law in order to get federal grants next year, the Medicare agency announced Thursday.   The Hill. 

Bob Doherty, at the ACP Advocate, notes the Irony: A GOP-appointed judge rules that a GOP idea, recently embraced by a Democratic president who a few years ago campaigned against it, is unconstitutional, possibly paving the way for a government-run program. 

(Reuters) - The Justice Department said on Tuesday it intends to appeal to a U.S. appeals court a ruling by a judge in Virginia declaring a key part of President Barack Obama's landmark healthcare law unconstitutional. (POLITICO Pulse) - MULTI-STATE LAWSUIT ARGUMENTS HEARD- Judge Roger Vinson says he'll rule "as quickly as possible" on the lawsuit against health reform brought by 20 states and the NFIB. (The read: mid- to late-January) He had a lot of questions for both parties about what would limit Congress's power if the individual mandate is kept intact and sounded skeptical that the decision not to purchase health insurance is activity that can be regulated, which would advance the states' case. But he seemed to agree with the federal government that states can easily leave the Medicaid program if they want to, citing public comments from several Republican governors suggesting they might do so in the wake of reform. The oral arguments bring "Lawsuit week," as PULSE has dubbed it, to a close 

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Thursday, December 16, 2010.  @5:30 PM.  Third Thursday happy hour (social gathering), at 801 Franklin (Huntsville).   Rescheduled this month.   Wednesday, December 22.  5-7 PM.  Happy hour, Westin Hotel, Bridge Street, Huntsville to greet Linda Haynes Lieb and Tom Lieb who’ll be in town for a brief visit.  

Tuesday, December 28.  7 PM.  Planning Committee meeting for planning coalition meetings...where to meet, what topics to discuss.  Wally Retan’s home, 3105 Warrington Road, Mountain Brook.  Anyone with ideas of what we might discuss, where we ought to meet is welcome.  Very, very welcome.  Directions: On Hwy 280, at the south end of the Birmingham Waterworks, turn onto Overton Road at the flashing yellow light.  Drive 1.6 miles.  At the Locksley Fire Station, 25 yards short of a stoplight, turn left onto Locksley Road.  Drive 0.6 miles.  At Warrington Road, a cross road,  turn right.  3105 is the house on the right next to the house on the corner.  

Wednesday, December 29, 2010.  Lunch, (social gathering) Nothing but Noodles, Village on Whitesburg Shopping Center, 4800 Whitesburg Drive, Huntsville.  Wednesday before each monthly meeting. 

Sunday, January 2 (?),  7PM CDT.  Healthcare-NOW monthly activist phone call. Please use this Dial-in Number 1-218-862-1300 and Conference Code 441086. To mute and unmute the line, please hit *4.

Monday, January 3, 2011 @ 5:30 PM.  North Alabama Healthcare for All Monthly Meeting —Huntsville/Madison County Public Library, 901 Monroe Street  (downtown).  The meeting is in Room AB, on the first floor. After you enter the library’s front door, turn right towards the auditorium.

Thursday, January 6, 2011, 7 PM.  Debate: “That the US Supreme Court will Declare the Individual Mandate Unconstitutional by midnight October 31, 2011.”  David Carpenter vs. (to be determined…where are Republican attorneys when we need them?)  Main meeting room, Emmett O’Neal Library, 50 Oak Street, Mountain Brook.  Brief business meeting precedes the debate, at 6:30 PM, same place.  


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