Friday, July 3, 2015





Why Is ObamaCare So Confusing and Complicated?


Talk to anyone, and they will tell you never have they found anything so confusing and complicated as ObamaCare. Why is this?

The simple reason is that the ACA is federal bureaucracy run amuck.

A second reason is administrative incompetence with the proliferation of agencies, programs, forms, and rules and regulations .

A third reason is that government must account for every penny and satisfy multiple constituencies. As Jonathon Oberlander, a health care analyst at the University of North Carolina, explained in the December 9 New England Journal of Medicine , “The law is not a single program, It is a collection of mandates, public insurance expansions, and regulations that affect difference groups of Americans in different ways, at different times.” It means different things to different people.

A fourth reason is that it keeps changing to adjust to its flaws and to evolving political realities. Since the law was enacted, it has undergone 54 changes.

Here is a list of changes compiled and explained by Grace Marie Turner in a July 1 article in Forbes Magazine

“By our count at the Galen Institute, more than 54 significant changes have been made to the Patient Protection and Affordable Care Act since it was enacted in 2010 – at least 34 that the Obama administration has made unilaterally, 17 that Congress has passed and the president has signed, and three by the Supreme Court.

Our latest count has added two more changes made by the Obama administration contrary to statutory language, and one rewrite of the law’s text from the latest U.S. Supreme Court decision. Our latest additions:

Extension of credits to people receiving employer-sponsored coverage. Section 1511 of the ACA instructs the Labor Department to issue regulations requiring businesses with more than 200 employees to automatically enroll their employees in any health benefits plan offered by the employer. Section 36B correspondingly denies credits to employees covered by an employer plan. IRS regulations contradict the statutory language and allow credits to taxpayers when they are automatically enrolled in employer minimum essential coverage. Treasury implicitly acknowledges there is no statutory authority for its regulatory change. (May 23, 2012)

Illegal use of exchange grants. CMS issued guidance saying that states operating their own exchanges can use money from federal grants to do outreach and education to increase enrollment, even though the ACA stipulates the grants are to be used only to set up exchanges. (June 8, 2015)

The law doesn’t mean what it says: In King v. Burwell, the U.S. Supreme Court overruled the plain meaning of the ACA to limit tax credits to people living in states that created their own exchanges and instead allowed tax credits for insurance purchased through federally-facilitated exchanges as well. (June 25, 2015)

The court:

Allowing tax credits through federal exchanges: The latest change to the law was made by the U.S. Supreme Court on June 25, 2015, in King v. Burwell when it ruled that the law doesn’t mean what it says. The court ruled 5-4 that the spirit of the law’s goal to expand coverage, not the actual language, allows tax credits to flow through federal exchanges, despite seven instances in the law only allowing credits to citizens in states that set up their own exchanges.

This is the third change to the law made by the court. Three years ago, the Court determined that the law doesn’t mean what it says in calling the penalty for not purchasing health insurance a “tax” and deciding that Medicaid expansion could be optional for the states, in contradiction of the explicit language of the statute.

The administration:

Illegal use of grant money: The Center for Medicare and Medicaid Services issued guidance June 8, 2015, that allows states with their own health insurance exchanges to use money from federal grants for marketing and outreach.

The statute stipulates that the grants must be used to establish the exchanges. The CMS guidance expands allowable use of the establishment grants after January 1 to include “outreach and education, including in-person assistance, to support increasing total enrollment” to levels needed “for the viability of the marketplace.”

Double trouble for employers: The latest research about implementation of the Affordable Care Act by Andy S. Grewal, an associate professor at the University of Iowa College of Law, finds that Obama administration regulations are allowing taxpayer subsidized health insurance for some people receiving employer-sponsored coverage, in violation of the statute.

He described the regulatory changes he has uncovered while comparing regulations to the statute in testimony before the Senate Judiciary Subcommittee on Oversight on June 4, 2015.

Grewal explained that the ACA provides tax credits to U.S. citizens with incomes between 100 and 400% of the Federal Poverty Level (FPL). However, IRS regulations were written to extend credits to citizens below 100% FPL in some cases.

Also, Section 36B of the ACA grants credits to some non-citizens with low-incomes only if they are themselves lawfully present in the U.S. and cannot obtain Medicaid coverage. IRS regulations, however, contradict the statute and allow subsidies if “the taxpayer or a member of the taxpayer’s family is lawfully present in the United States,” and “the lawfully present taxpayer or family member is not eligible for the Medicaid program.”

In the latest addition to our list, he finds the IRS regulations allow persons to obtain premium tax credits when they are automatically enrolled in an employer plan, again in violation of the language of the Affordable Care Act.

Section 1511 of the ACA instructs the Labor Department to issue regulations requiring businesses with more than 200 employees to automatically enroll their employees in any health benefits plan offered by the employer. Section 36B correspondingly denies credits to employees covered by an employer plan.

IRS regulations contradict the statutory language and allow credits to taxpayers when they are automatically enrolled in employer minimum essential coverage. Treasury implicitly acknowledges there is no statutory authority for its regulatory change.

“It’s hard to get worked up over extending tax credits to our nation’s poorest, but the unfortunate structure of the ACA may lead to controversy,” he writes. “Under Section 4980H(a), a business can face severe penalties if it fails to offer health insurance coverage and even one of its employees receives a premium tax credit. Thus, the invalid extension of the tax credit, even when made to a sympathetic individual, can trigger adverse consequences.”

He highlights “the pitfalls associated with Treasury’s failure to recognize limits on its administrative authority.” The Supreme Court’s ruling in King v. Burwell embolden the administration to continue its illegal rampage.

The Galen Institute has been cataloguing the major changes made to the ACA. Prof. Grewal’s newly-uncovered finding and the latest Supreme Court decision bring our count to 54, including the 34th change made by the administration without statutory authority

Thursday, July 2, 2015

ACA at 5 Years: Standoff

An assessment of the ACA at 5 years would not be complete without acknowledging the effects of the law on the relationship between the American people and their government and the balance of power within our society.

David Blumenthal, MD, et al, “The Affordable Care Act at 5 years,” New England Journal of Medicine, June 18, 2015

As the July 4 Independence Day celebration approaches, it is time to admit the Patient Protection and Affordability Act (ACA) is a standoff between progressive and conservative elements in American society. For some, the ACA protects and makes care more affordable. For many, the opposite holds true.

Progressives can lay claim to successes: passage of the ACA, protection for those with pre-existing illnesses , insurance coverage of 16-17 million of the previously insured 2012 reelection of the President, and survival of two Supreme Court challenges.

Conservatives can point to the continuing unpopularity of the ACA, increased premiums and deductibles of many in the middle class, limiting of choice and individual freedoms, mandated financial penalties on individuals and businesses with slowing of the economy, and intrusions on the prerogatives of the states.

The result has been a standoff – the refusal of progressives to budge on the moral issue of greater coverage for all, and the insistence of conservatives that the ACA is anti-capitalistic and anti-choice. For the rest of President Obama’s term the ACA is “here to stay,” and after 2016, if Republicans win, the ACA may well be repealed or replaced by a market-based plan.

In the interim,

progressive strategies for reform – reducing Medicare hospital –acquired conditions and readmissions, paying for value for hospitals and physicians, bundling payments , ending or minimizing fee-for-service, and promoting accountable care organizations and transforming primary care into a team-based enterprise will be at play.


On the conservative side, Republicans will chip away at ACA funding, seek to end taxes on medical innovation companies. repeal the Independent Payment Advisory Board, and change the rules of the Employer Mandate by extending the period at which penalties for coverage kink in from 30 to 40 hours.


During this period, those enrolling in health exchanges and Medicare will increase, many millenials will prefer to pay penalties to not having a health plan, nearly half of the remaining 33 million uninsured will pay cash or barter for care, physician shortages (now 28,000 at the VA) will mount, more physicians will turn away those on Medicaid, Medicare, and health exchange plans, and ObamaCare-inspired high deductible plans will drive a consumer revolution towards direct cash, negotiated, competitive care.

The standoff will continue, at least after the 2016 elections and for indeterminate time thereafter. What may evolve is a two tier system, one paid, delivered, and run by government run, and the other in the private sector.
ObamaCare: Cost to Taxpayers of Health Exchange Subsidies

Now that the Supreme Court has ruled that 6.7 million people will continue to receive federal health exchange subsidies, it’s time for a little math.

These 6.7 million people receive $362 a month in subsidies.

Multiple $362 by 12, and that comes to $4344 per year.

Multiply $4344 by 6.7 million and you get $29 billion per year.

Add 2.5 million subsidized people now on state health exchange subsidies to the 6.7 million, and you arrive at the figure of 9.2 million now on federal and state subsidies.

Multiple 9.2 million by $4344, and it comes to $40 billion.

Take into account, that ½ of America’s 320 million citizens pay no income taxes, and that leaves 160 million taxpayers paying the $ 40 billion.

Divide $40 billion by 160 million, and you get $2500 per taxpayer per year.

President Obama has 18 months to go in his term. Multiple $2500 by 1 ½ (18 month/12 months) and that amounts to $3750 per taxpayer per subsidized patient on federal and state exchanges for the rest of his 2nd term.

Monday, June 29, 2015

A Funny Thing Happened on the Way to the Health Care Forum



Democrats and liberals rejoiced. The nation had embraced tolerance on social issues.

Republicans celebrated. They were now free to pursue economic and national security problems without being labeled bigots.

In Charleston, South Carolinians demonstrated what true Christianity is all about – love and forgiveness rather than hate and bigotry.

To further end the charges of Southern bigotry, the politicians of South Carolina vowed to take down the Confederate flag from the state capitol grounds and put it a museum. Mississippi and Alabama public officials made similar vows. For the South, this was a healing time.

Jonathon Martin of the New York Times (“As Left Wins, GO.P. Reflects”) wrote, “ A cascade of events suggests that 2015 could be remembered as a Liberal Spring: the moment when deeply divisive and consuming questions or race, sexuality and broadened access to health care were settled in quick succession, and social tolerance was cemented as a cornerstone of American public life.”

Which brings me to the definition of tolerance, “A fair and objective attitude towards those whose opinions differ from one’s own: freedom from bigotry."

These days far too often, resistance to mainstream liberalism is labeled “bigotry,” which politically correct circles is defined as “stubborn and complete intolerance of any freed , belief, or opinion that differs from one’s own.”

While acknowledging that the country had become more tolerant and, in some ways, culturally liberal, many Republicans contend that America is still receptive to a more conservative approach approach on economics and social security.

Obama says it’s here to stay. But it will need fixing. Last week the Republican House overwhelming passed a bill repealing the Medical Innovation Tax and the Independent Patient Payment Board. These repeals await a Senate vote. And the GOP says it will still repeal ObamaCare if it wins in 2016. And it says it will seek to passed a market patient-centered plan in 2017 0r 2018 after it repeals ObamaCare with its individual and employer mandates . In the meantime, it will chip away at ObamaCare by denying funding, prevent he bailout of insurers who lose money on subsidies, and softening the employer mandate on comapies with over 50 employees.

In an editorial today “The Fight for Health Care Isn’t Over,” the Times acidly comments on this and GOP efforts in 21 states resisting Medicaid expansion, “The Republicans, gripped by irrational hostility (italics mine) to helping the poor, would rather hurt the uninsured and damage their state economies by refusing federal money. Federal money always comes with strings attached - loss of control, compliance with federal regulations, and unforeseen expenses.


A Funny Thing Happened on the Way to the Health Care Forum

A Funny Thing Happened on the Way to the Health Care Forum
A funny thing happened this week after the Supreme Court OKed federal subsidies and gay marriage.
Democrats and liberals rejoiced that the nation had embraced tolerance on social issues. Republicans celebrated that they were now free to pursue economic and national security problems without being labeled bigots. In Charleston, South Carolinians demonstrated what true Christianity is all about – love and forgiveness rather than hate and bigotry.
To further end the charges of Southern bigotry, the politicians of South Carolina vowed to take down the Confederate flag from the state capitol grounds and put it a museum. Mississippi and Alabama public officials made similar vows. For the South, this was a healing time.
Jonathon Martin of the New York Times New York Times ( “As Left Wins, GO.P. Reflects”) wrote, “ A cascade of events suggests that 2015 could be remembered as a Liberal Spring: the moment when deeply divisive and consuming questions or race, sexuality and broadened access to health care were settled in quick succession, and social tolerance was cemented as a cornerstone of American public life.”
Which brings me to the definition of tolerance, “A fair and objective attitude towards those whose opinions differ from one’s own: freedom from bigotry.
These days far too often, resistance to mainstream liberalism is labeled “bigotry,” which politically correct circles is defined as “stubborn and complete intolerance of any freed , belief, or opinion that differs from one’s own.”

“While acknowledging that the country had become more tolerant and, in some ways, culturally liberal, many Republicans contend that America is still receptive to a more conservative approach approach on economics and social security.
Obama says it’s here to stay. But it will need fixing. Last week the Republican House overwhelming passed a bill repealing the Medical Innovation Tax and the Independent Patient Payment Board. And the GOP says it will still repeal ObamaCare if it wins in 2016. And it says it will seek to passed a market patient-centered plan in 2017 0r 2018 after it repeals ObamaCare with its individual and employer mandates . In the meantime, it will chip away at ObamaCare by denying funding, prevent he bailout of insurers who lose money on subsidies, and softening the employer mandate on comapies with over 50 employees.
In an editorial today “The Fight for Health Care Isn’t Over,” the Times acidly comments on this and GOP efforts in 21 states resisting Medicaid expansion, “The Republicans, gripped by irrational hostility (italics mine) to helping the poor, would rather hurt the uninsured and damage their state economies by refusing federal money

Saturday, June 27, 2015

Headline Hunting for Supreme Court Impact on ObamaCare

I’ve gone hunting for headlines to see how media is responding to Supreme Court upholding federal health exchange subsidies.

Left-leaning publications are joyous. Right-tilting media are either furious with Chief Justice Roberts or happy Republicans are now free to pursue repeal.

Here is a sample of today’s headlines.

“Supreme Deliverance for Republicans,” Fox News



“Twisted Logic of John Roberts Ruling,” New York Post



“ Health Law Nightmare is Just Beginning,” National Interest



“Health Care Ruling a Landmark Victory for White House,” Real Clear Politics




“ No Easy Road for Health Law: Troubles Remain: Still Highly Unpopular with Significant Structural Issues,” Politico



“Krauthammer: No Question GOP Will Repeal if They Win”


“Supreme Court Allows National Health Care Subsidies,” New York Times

I was particularly interested in what the headlines were in the Wall Street Journal, long a harsh critic of ObamaCare. Here are 11 WSJ headlines and subheadings.

“High Court Saves Health Law: Justices in 6-3 Ruling Uphold Provision of Obama’s Signature Program; Republicans Vow To Continue Fight.



“Roberts Charts Own Path: Frustrated Conservatives Again”





“Insurers and Hospitals Breath Sign of Relief”



“Ruling Caps a Week of Wins for the President

“Decision Pushes Health Care to Fore of GOP Campaign”



“Companies to Take Aim at Law’s Fees”



“Disputed Ruling Has Long Backstory”



“ObamaCare Debate Begins Anew”



“The Political John Roberts: The Chief Justice Again Rewrites ObamaCare to Save It”



“ObamaCare Wins One, America Loses”



“Antonin Scalia Dissents

There you have it. For some, Supreme Court ruling is a resounding victory. For others, it is a Pyrrhic victory, destined to last only until 2016, if Republicans win. For most, ObamaCare’a structural problems still lurk - soaring premiums and deductibles, unpopularity among public, losses of choice of doctors and health plans, and negative impact on economic growth.. The decision is good in short term for Obama, uninsured, hospitals, and insurers. But it is bad in many respects for some people who want prompt access to care they need, from a doctor, hospital, and health plan they choose, at a price they can afford.