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Does Medicare Impoverish the Disabled?

In my new book, Medicare Victims: How the U.S. Government’s Largest Health Care Program Harms Patients and Impairs Physicians, I examine how the disabled fare with Medicare’s cost sharing.

One disabled woman that I interviewed for the book was Francine English, who is now, sadly, deceased. For her, the problem was Medicare’s cost sharing.  For example, Medicare Part B requires beneficiaries to pay 20 percent of any treatment; Medicare pays the other 80 percent.  Most seniors on Medicare have some type of supplemental insurance, often called Medigap, that covers the cost sharing.  But it’s expensive, and if you’re like Francine who was getting about $10,000 annually from Social Security Disability Insurance, you’re not able to afford the premiums.  At the time I interviewed her, Medicare’s cost sharing had caused her to run up about $2,000 in medical debt.

One of the things I found most interesting while researching this book is that there doesn’t appear to be any research on the amount of medical debt incurred by the disabled who are on Medicare.  It would seem to be a prime area for research.  You have patients who are often quite ill, need a lot of health care, and often don’t have the means to pay for Medicare’s cost sharing.   But no one, apparently, had looked at this phenomenon. Thus, I had no way of discussing the extent of the problem.

The best I could do was to examine whether there were a lot of disabled people on Medicare who had trouble accessing care because of the cost sharing.  As a I noted in Tuesday’s blog post, there is a lot of evidence that disabled people on Medicare do have trouble accessing care because of cost.  Thus, if there are a lot of disabled patients who don’t access care because of cost, it would likely follow that there disabled patients who run up a lot of debt because they do seek care.  

Unfortunately, I don’t have a good explanation for what is arguably the biggest problem most overlooked by health care researchers at least in regards to Medicare.  Perhaps it has something to do with the fact that the vast majority of health care researchers are liberals and, as such, probably have little interest in digging into the shortcomings of government programs.  But that’s just a theory.

Nevertheless, it is an area that should be thoroughly researched because it’s quite possible that Medicare may impoverish some of our most vulnerable citizens by saddling them with medical debt.


Medicare’s Victims is available at Amazon, Barnes & Noble, Lulu, and iBookstore


Government Interferes with the Religious Liberty of Christian Colleges

After the recent U.S. Supreme Court ruling on same-sex marriage, many Christians expressed concern that the decision might result in government interference with the religious liberty of Christian institutions.  As it turns out, federal ObamaCare mandates are doing that already.

My alma mater, Wheaton College, just lost a court challenge related to ObamaCare’s emergency contraceptive mandate.

Wheaton’s community covenant requires all students and faculty to “uphold the God-given worth of human beings, from conception to death.”  

ObamaCare, on the other hand, requires that the College’s health insurance company cover all contraceptive measures, including those methods that destroy a fertilized ovum after sexual intercourse — methods that many Christians consider to be abortifacients.

Apparently, our right to freedom of religion is not as important as our right to cheaply dispose of our unborn children.


Medicare Helps the Disabled--Or Not

As noted in an earlier blog post, the leftist Commonwealth Fund is publishing a series of papers this month under the heading “Medicare at 50 Years.”

The first report released under this series is entitled, “Medicare: 50 Years of Ensuring Coverage and Care.”  The Executive Summary of the report claims, “there is a lot to celebrate. For 50 years, Medicare has accomplished its two key goals: ensure access to health care for its elderly and disabled beneficiaries, and protect them against the financial hardship of health care costs.”

But as one gets a bit deeper into the report, the achievements of Medicare change:  “In its first 50 years Medicare has unquestionably achieved its two basic goals: to ensure that Americans 65 and older have access to health care, and to protect them and their families from severe financial hardship from medical bills.”  Note that protecting the disabled are no longer part of the achievements.

I’m not sure why the discrepancy.  I can say that the second statement is far more accurate.  Due to Medicare’s cost-sharing—Medicare Part B, for instance, requires beneficiaries to pay 20 percent of the cost of most services—many disabled people on Medicare have trouble accessing care.  While many seniors have some sort of supplemental policy (often called “Medigap) that pays for most of the cost sharing, the disabled are often too poor to be able to afford monthly Medigap premiums.  Indeed, about 20 percent of the disabled on Medicare lack supplemental coverage as opposed to eight percent of seniors.

The data shows that the disabled on Medicare have a harder time paying for care.  Thirty-three percent of the disabled report major or minor problems paying for care versus about 13 percent of the elderly. A paper from the mid-1990s found nearly three times the number of disabled on Medicare reported not getting health care as the elderly.  Seventy-one percent of the disabled cited cost as the major factor.  Another study found that as a result of having higher rates of putting off or not getting care, the disabled experienced higher rates of stress and anxiety, physical pain, and the worsening of a medical condition or problems that eventually required medical attention.

None of these studies, naturally, appear in the Commonwealth Fund report.  I’ll have some more about how the disabled fare on Medicare Thursday, including what I think is the biggest problem most overlooked by health care researchers.

For now, you can read more about the disabled an Medicare in chapter 3 of my book, “Medicare’s Victims: How the U.S. Government’s Largest Health Care Program Harms Patient and Impairs Physicians.”  Here are the ordering options:

Paperback at, $14.99.

Kindle at, $6.99.

ePub at, $6.99.

ePub at iBookstore, $6.99.

I’d be remiss in not noting that Barnes & Noble is selling the paperback version for only $11.99.  The economist in me realizes that the 20 percent cut in price means demand for the book is lagging.  The writer in me can’t help but suffer a blow to his ego.


Medicare's Victims: Order Your Copy!

Finally!  Today is the official release of my book, Medicare’s Victims: How the U.S. Government’s Largest Health Care Program Harms Patients and Impairs Physicians!

It is available at, both paperback ($14.99) and Kindle ($6.99).

For those of you who have an eReader other than Kindle (i.e., it uses an ePub file) you can purchase the book at ($6.99).

UPDATE: It is also available at iBooks ($6.99).

I’ll be doing my first interview for the book today on the Bill LuMaye show, at about 3:15 Eastern time.

Finally, here are some excerpts from David Catron’s review of Medicare’s Victims at the American Spectator:

And what about the seniors who constitute the vast majority of Medicare beneficiaries? Surely, considering the enthusiasm with which single-payer advocates push Medicare-for-All, seniors fare better than the disabled. In fact, seniors endure countless hardships pursuant to the regulatory and reimbursement snarl in which they and their doctors find themselves immured by Medicare. It is in the care of seniors that the bureaucrats most brazenly substitute their judgment for that of health care professionals. The magnitude of this travesty is difficult to appreciate unless one has witnessed, as I have, a doctor violently slam down the phone after being told by Medicare that a septuagenarian suffering with congestive heart failure fails to “meet criteria” for an inpatient admission.

The perversity with which Medicare applies these criteria beggars belief. One of the stories Hogberg relates is that of a dialysis patient who had suffered kidney failure after a bout with cancer. He suddenly grew ill one morning and was rushed to a nearby ER where the doctors were informed in minute detail of his health status: “Frank needed dialysis, but under Medicare’s rules, he couldn’t receive it at a hospital unless he was an inpatient.” Like the patient noted above, he failed to “meet criteria.” Thus, he and his doctors were forced to wait until his condition deteriorated far enough to satisfy Medicare. At length he had a seizure, whereupon he was finally admitted and received dialysis: “Frank briefly recovered, but the damage was done.” Within a few months he died.

….Hogberg does not, however, despair of reforming the program. This brings us back to his proposal to give Medicare’s beneficiaries control over how the money is spent. Is it crazy to give Medicare funds directly to patients? Well, as Hogberg points out, this is precisely how Social Security works: “Beneficiaries receive their checks… each month and then have complete discretion over how to spend it.”

Hogberg would do away with Medicare parts A and B and replace them with “a Basic Account and a Major Medical Account.… The amount in these accounts will be renewed every year.” The idea is that beneficiaries should purchase health care the same way they buy other goods and services. The plan is obviously far too detailed to fully flesh out in this space, and any reform of Medicare has profound political implications, but Hogberg’s ideas are eminently sensible. Medicare’s Victims hits the shelves today. It’s well worth a read for anyone with a desire to understand how Medicare actually works.

Read it all.


Medicare and the Gila Monster Threat!

Apparently, the deadline to test the new ICD-10 system with Medicare has just passed.

If you’re wondering what “ICD-10” is, don’t worry …actually you should worry, for reasons I’ll explain in a bit.

Anyway, ICD stands for International Classification of Disease.  It is a system of diagnostic codes that physicians use to let Medicare and every other insurance provider know what the patient is being treated for. Depending on the diagnosis, ICD codes are from three to seven digits in length. So, if a physician sees a new patient and he diagnoses him with anemia, he would use the ICD code 280. If it is a more serious type of anemia, like Plummer-Vision Syndrome, the ICD code used would be 280.8.

The U.S. is still using ICD version 9, which has about 18,000 codes.  In October, the Centers for Medicare & Medicaid Services will switch over to ICD-10, which has about 80,000 codes.

If you think dealing with over four times as many codes is going to add considerably to the costs of running a physician’s practice, you’re right.  According to John Grimsley and John S. O’Shea, M.D. of the Heritage Foundation, “the potential cost of productivity loss [could] be anywhere from $8,500 to over $1.6 million per practice per annum…depending on practice size.” Of course—and here is why you should be concerned—the more resources that physicians have to spend dealing with codes mean less resources that will be spent treating patients.

While the cost of complying with ICD-10 will fall on all physicians, it is likely to fall hardest on primary care physicians, a topic I examine in my forthcoming book, Medicare’s Victims: How the U.S. Government’s Largest Health Care Program Harms Patients and Impairs Physicians. (“Squeezing every last bit of book promotion out of this blog, aren’t we?” — the Wife.) 

One of the physicians I interview, Dr. Juliette Madrigal-Dersch, explains it this way:

When you are a primary care physician, you are going to see a much wider variety of illnesses. If you are a specialist you are going to see a much more finite number of illnesses, especially if you are, say, an orthopedic surgeon who does primarily knees, probably 90 percent of all your codes are going to be the same five codes. As opposed to primary care, you never know what’s going to walk through the door. You could get something very rare. And now you have to be so specific with the codes. You have to code for “fall from uneven ground,” or “fall from tractor.”


Indeed, the ICD-10 codes have become something of a laughingstock.  If it can be coded, it probably is in ICD-10.  For example, there are codes for a bite from one of these guys:

The Gila Monster is found primarily in the Southwest United States and Mexico.  And there must be an epidemic of Gila Monster bites!  How else to explain the fact that there are 13 ICD-10 codes for having this guy clamp down on your hand?  Indeed, it is so serious that physicians may need to practice coding for Gila Monster bites.  One of the codes, T63.111, “should only be used for training or planning purposes.”

Here is a table listing the other 12 codes: 

This leads to a number of questions.  First, are there are lot of people who get bit by a Gila Monster more than once?  Second, is it correct in assuming that the “intentional self-harm” codes are there because a lot of people use this type of lizard to attempt suicide?  Finally, how do you assault someone with a Gila Monster?  I don’t know the answers to those questions, but I sure am glad that ICD-10 includes codes for them.

Now, here is the part where you come in.  ICD10Data is a search engine for ICD-10 codes.  I want you to go there, and type in any animal or object (like a lamp post or sink) that you can think of, and see if the ICD-10 has a code for it.  If it does, go back to the Facebook page that led you to this blog post, and in a comment tell me what animal or object you found a code for.

After all, what else are you going to do with your Fourth of July weekend?


Paid Parental Leave Shouldn't Be Mandatory

Should paid parental leave be mandatory in the United States?  Horace Cooper with the National Center for Public Policy Research and Elizabeth Peters with the Urban Institute discussed this issue on Al Jazeera America’s “Inside Story with Ray Suarez” on June 30, 2015.

“I’ve got no problem if an employer decides that a great way to retain employees for long term is to take [paid parental leave] on,” says Cooper. “I have a problem with, if that turns out not to be cost-effective for an employer, telling them, ‘You’re gonna do it anyway.’”


Donald Trump, the Clintons and Marijuana

How are Donald Trump, Bill and Hillary Clinton and marijuana linked to each other?

They were all topics of discussion June 28 on WHUT’s “New View with Ed Gordon,” and topics covered with zeal by our own adjunct fellow Horace Cooper.

Recent remarks by Donald Trump during his announcement of his presidential candidacy, considered by many to be racist and anti-immigrant, were played over and over again by the media. But Cooper questions whether the media is playing fair.

Bill and Hillary Clinton “honored and acknowledged Confederate Day for the eight years that they served as governor and first lady,” noted Cooper on public television’s “New View With Ed Gordon.” “Now, very little coverage of that. This, very prominent coverage. I find it curious.”

Also, in states where marijuana has been legalized, should employers be able to fire employees who use marijuana in their free time? Cooper says the issue comes down to whether the U.S. Supreme Court “is going to give us and recognize a constitutional right to use recreational drugs in our free time.” 


Earlier in the program, Cooper was adamant that people of all racial backgrounds need to be part of any healthy discussion about race.  He also discussed what the recent Supreme Court rulings say about the makeup of the Court.

“New York Times analysis of this [Supreme Court] term suggests that it may be among the most liberal… in about fifteen years.  Clearly a number of these decisions that came down aren’t going to comport with the the narrative that it’s a right-wing Court,” said Cooper.  “I want us to understand therefore that it’s not clear that just because someone was named by one president… that we know for sure how they are going to come down.” 


Medicare's Innovation Center Will Be Captured by Big Medical Providers

The Commonwealth Fund is publishing a series of papers this month under the heading “Medicare at 50 Years.”  Yesterday the Fund released a paper under this series entitled “Medicare Payment Reform: Aligning Incentives for Better Care.”  In it, the authors note that ObamaCare “has created the Center for Medicare and Medicaid Innovation, which is developing and testing new models to improve the quality of care provided to Medicare beneficiaries while reducing spending.”

The Center for Medicare and Medicaid Innovation (CMMI)—something created by ObamaCare—has a bevy of new “payment models” that it is trying on Medicare: the initiatives for Accountable Care Organizations which include the Pioneer Program and the Medicare Shares Savings Program; the Comprehensive Primary Care initiative; the Multi-Payer Advanced Primary Care Practice demonstration; and the Bundled Payments for Care Improvement initiative.

The results* of those programs are not particularly relevant to this post.  Rather, what is striking about the paper the Fund released yesterday is that there is not a hint of skepticism that a bureaucracy like CMMI is capable of innovating.  Indeed, they conclude that the “ultimate goal is to transform the delivery of care for everyone, improving patient outcomes and care experiences, preventing avoidable hospitalization, and lowering costs.

Here’s a more likely outcome: regulatory capture.  Regulatory capture “is the process by which regulatory agencies eventually come to be dominated by the very industries they were charged with regulating.”  

Over time, the bigger medical providers such as hospitals, skilled-nursing facilities, large physician practices—basically any group that can afford a lot of D.C. lobbyists—will begin making “proposals” for innovation that will benefit them while making it harder for their smaller competitors to survive.  The bureaucrats who work at CMMI will be all too happy to accommodate the big medical providers because they will be accommodating their future employers. The people at CMMI will develop knowledge and skills that will be very helpful to big medical providers wanting to get their proposals accepted by CMMI.  And, of course, the big medical providers will pay much better than the government.

The end result will be one that stifles innovation.  As John Goodman states in his book Priceless:

Successful innovations are produced by entrepreneurs, challenging conventional thinking—not by bureaucrats trying to implement conventional thinking. There are lots of examples of successful entrepreneurship in healthcare. There are very few examples of successful bureaucracy. Can you think of any other market where the buyers of a product are trying to tell the sellers how to efficiently produce it?

Any upstart medical provider who has developed a more cost-effective way to treat patients—and one that threatens the way the big medical providers do things—will likely never see his idea adopted by CMMI.  The big medical providers will use their clout with CMMI to stymie it.

My forthcoming book, Medicare’s Victims, contains an example like this.  Chapter 9, titled “The Big Hospital Lobby” examines how general hospitals used their clout with Congress to stop the spread of smaller physician-owned specialty hospitals. Some excerpts of that chapter can be found at the Atlas Society’s website.

In the long run, the CMMI will become an agency dedicated to preserving the status-quo in Medicare.  True innovators will need not apply.

*The Accountable Care Initiatives have had, at best, mixed success so far, while the Comprehensive Primary Care Initiative has failed to achieve any significant cost savings or quality improvement.  The other programs are too young to have any measurable results.  


Why Sen. Bernie Sanders' "Medicare-for-All" Won't Work

Senator Bernie Sanders (D-VT) recently said, “…we have to move toward a Medicare for all, single-payer system.”

For years now “Medicare-for-All” has been the rallying cry for single-payer advocates.  It is, if nothing else, shrewd marketing.  Medicare is very popular with the American public.  For example, a Harvard School of Public Health 2013 survey found 72 percent of respondents had either a very favorable or somewhat favorable opinion of Medicare.  What better way to promote single-payer than to rename it after a popular program?

However, you will seldom see advocates of Medicare-for-All explain exactly why Medicare is so popular.  In other words, presumably Medicare is popular because it functions well, but why does it function well?  

The closest such advocates come is an explanation like this:

[Medicare-for-All] would replace today’s welter of private health insurance companies with a single, streamlined public agency that would pay all medical claims, much like Medicare works for seniors today.

But surely a program like Medicaid has those qualities too, yet Medicaid is lousy and, hence, far less popular.  After all, you don’t see the left calling for “Medicaid-for-All.”  

Furthermore, wouldn’t it be useful for all public health care programs to know why Medicare works so well?  Presumably if we understood what it was about Medicare’s structure that caused it to work well, we could then shape programs like Medicaid in a similar way so that they function much better.

As I explain in chapter two of my forthcoming book, Medicare’s Victims, Medicare’s success is based not on anything in Medicare’s structure, but on political power. Seniors, Medicare’s main population, have a great deal of political power—the ability to influence Congress—when it comes to Medicare policy. 

For starters, seniors vote at higher rates than the population at large in both presidential and non-presidential elections. For example, here are the voter turnout rates of those ages 65-74 versus all ages in 2010 and 2012:


Seniors receive good coverage from Medicare because their voting behavior gives them political clout. If they have serious problems with Medicare, it won’t be long before members of Congress hear about it. In turn, members of Congress know that to maximize the support they receive from seniors means keeping seniors satisfied with their Medicare coverage and, if possible, expanding the benefits they receive under Medicare. 

Not only do seniors vote, because so many live in retirement communities and visit senior centers, they are easy to organize should the need arise.  Exactly how many retirement communities there are in the U.S. is not known. However, retirement communities that include medical facilities like nursing homes—known as Continuing Care Retirement Communities—number about 2,000. Senior centers—places where seniors can gather for socialization and support—number about 11,000.  With that degree of political power, seniors are seldom denied the services they want in Medicare.

Groups that lack such political power tend not to fare as well under Medicare.  For example, there are roughly 9 million disabled people on Medicare.  Yet to get on Medicare, most disabled people have to endure a two-year waiting period.  Furthermore, the disabled on Medicare have, on average, more difficulty accessing and affording medical care than seniors.  The reason is that the disabled vote at much lower rates than seniors and are not nearly as easy to organize.

Political power (or the lack of it) also goes a long way in explaining why Medicaid is a lousy program.  Medicaid is the government health care program for the poor. The poor vote at some of the lowest rates of any group in our country.

So, would a system of Medicare-for-All improve health care for the poor?  Would it, as one pundit recently claimed, “improve healthcare for tens of millions, perhaps even hundreds of millions, of Americans”?  Well, unless Medicare-for-All changes the voting habits of the poor, then no, it wouldn’t.  

Members of Congress want to get reelected, and they will cater to those groups who are important to that goal and neglect groups that are not.  Thus, under a system of Medicare-for-All health care resources will tend to go toward groups that have political power, such as seniors and the relatively well-to-do.  Those without such power will lose out.


Medicare's Victims: Available One Week from Today

My book, Medicare’s Victims: How the U.S. Government’s Largest Health Care Program Harms Patients and Impairs Physicians, will be available next Monday, July 6.  You can pre-order now at  Both paperback and Kindle versions are available.

In the coming days I’m going to blog about some of the themes in the book.  For today, I’m going to leave you with the description of the book and the praise it has received from John C. Goodman:

Summary: In Medicare’s Victims, you’ll read the intimate stories of patients and physicians who have struggled with Medicare, and then you’ll learn how the particular Medicare policy has caused their plight. The patients who are victims of Medicare are often the sickest of the sick, whether it is the disabled who are on Medicare’s two-year waiting period; seniors who fell into Part D’s donut hole; or patients who are harmed because they receive too much treatment or not enough. The physicians who are victims are ones who struggle to provide the best care for their patients while Medicare’s reimbursement system, in effect, punishes them for it. They all tend to have one thing in common: lack of political power. For example, people who are seriously ill are relatively few in number. As such, they do not have the numbers necessary to impact elections. Further, people who are ill are generally not engaging in the networking, meetings and other activities necessary to form effective political organizations. Thus, Congress seldom feels the pressure to change the policies that harm these people. In the end, you’ll learn how we can reform Medicare so that patients and physicians are put in control of their own medical decisions and, thus, will be much less likely to be victimized.


Praise: David Hogberg has produced a tour de force. He has identified Medicare’s hidden victims and explained why bureaucracy, price-fixing, suppression of the marketplace and unwise regulations all combine to deny millions of patients the high quality, low cost medical care they should be receiving. I know of no other place where you can find a more comprehensive treatment of Medicare’s worst problems. This is must reading for everyone in health policy. —John C. Goodman, President of the Goodman Institute


How Will the Pope's Position Affect the Poor and the Presidential Election?

How will Pope Francis’s climate change encyclical impact the world’s poorest citizens? And will it affect the upcoming presidential election? Bonner Cohen of the National Center for Public Policy Research and Bill Galston of the Brookings Institution had a thoughtful conversation about the possibilities in their June 24 appearance on the Al Jazeera America program “Inside Story with Ray Suarez.”

“Millions of Catholics live in parts of the world which are very vulnerable,” noted Cohen. “What we really don’t want to do, I think, is impose policies that would deny these people access to electricity or make their access to electricity more difficult.  That’s where I think the Pope has to be very very careful here, because if he favors policies that will ultimately put some of the good things about the modern life out of the reach of the most vulnerable, he will ultimately wind up perpetuating poverty and putting himself behind policies that will lead to shorter life expectancies, and that’s not something I think any of us want.”

So how will presidential candidates respond to Pope Francis’s climate change encyclical, and will it matter? 

Cohen expects the Republican candidates “to say, ‘Listen, we need to be very careful in going about this, because first of all, do no harm.  Don’t impose policies that ultimately hurt people, denying them access to the many amenities of modern ingenuity that have our lives much more livable than our parents, grandparents and great-grandparents could possibly have imagined.’

“On the Democratic side,” Cohen continued, “you will probably see the Pope’s words evoked many many many times.”

However, will all of this even matter in the presidential election?  Cohen notes that Pew Center surveys indicate that American voters see climate change as last priority.


Horace Cooper Rumbles with Thom Hartmann on Trade, Trans Fats, Climate Change and Women's Health Funding

On June 17, Horace Cooper held back no punches as part of “The Big Picture Rumble” on the RT Network. Host Thom Hartmann moderated the panel that also included Bryan Pruitt of and TJ Helmstetter of the Progressive Change Campaign Committee.

Flabbergasted that congressional Republicans were supporting President Obama’s controversial trade bill, liberal host Hartmann asked the panel why, and Cooper bluntly responded: “It turns out Trade Promotion Authority is a positive good in and of itself and we are happy, we are HAPPY, to see the President of the United States embrace that concept.”

Next topic: the FDA’s recent ban of trans fats.  While the show’s liberals thought this issue was a no-brainer, Pruitt noted that industry was already making the move toward healthier food without requiring a mandate, and Cooper pointed out that this ban will likely have an economic impact. “The problem is that you’re targeting an industry and making them bear all of the costs while we claim to spread out the benefits to all of society,” Cooper noted. “That’s how you kill jobs.”

Does the Pope’s new encyclical on climate change promote policies that help — or hurt — the poorest in the world?  Cooper says the truth isn’t what you might expect: “Poor people are disproportionately impacted by climate change regulation policies.  They are overwhelmingly going to be the front line of those harmed by these policies.”

On the issue of women’s health funding, Cooper said there’s a quick solution for those wanting to protect that budget line item: “This problem will go away if Planned Parenthood and the other abortuary operators decide that they’re no longer going to do that and they’ll just stick to STD testing, they’ll stick to cervical screenings and the like, and then you won’t have this problem… We are funding abortion mills all across this country and Americans… don’t support them.”


Justice Scalia May Be Snarky, But He's Also Quite Correct

Justice ScaliaJustice Scalia

The Washington Post's Wonkblog staff, in an article published at 10:33 AM today, says Associate Justice Antonin Scalia "may have already won for snarkiness" in his dissent in the Obamacare case handed down today.

It is amusing that the Post published this mere minutes after the decision was handed down, making it impossible for the Wonkblog staff to have read the entire decision and opinions. I suspect they went straight to Justice Scalia's dissent and read little, if anything, else.

So Justice Scalia wins for snarkiness in the Post's eyes not just for today, but apparently for his entire tenure at the high court.

Regardless, the article is worth reading, as it quotes a page and a half of Scalia's very on-point opinion, saving readers the need to read less perceptive justices before getting to Justice Scalia.

Or you could just read Justice Scala below. If you don;t have time for all of it, read the part at the end I put in bold. Justice Scalia is a good man. We need more like him.

Today's opinion changes the usual rules of statutory interpretation for the sake of the Affordable Care Act. That, alas, is not a novelty. In National Federation of Independent Business v. Sebelius, 567 U. S. ___, this Court revised major components of the statute in order to save them from unconstitutionality. The Act that Congress passed provides that every individual "shall" maintain insurance or else pay a "penalty." 26 U. S. C. §5000A. This Court, however, saw that the Commerce Clause does not authorize a federal mandate to buy health insurance. So it rewrote the mandate-cum-penalty as a tax. 567 U. S., at ___ - ___ (principal opinion) (slip op., at 15 - 45). The Act that Congress passed also requires every State to accept an expansion of its Medicaid program, or else risk losing all Medicaid funding. 42 U. S. C. §1396c. This Court, however, saw that the Spending Clause does not authorize this coercive condition. So it rewrote the law to withhold only the incremental funds associated with the Medicaid expansion. 567 U. S., at ___ - ___ (principal opinion) (slip op., at 45 - 58). Having transformed two major parts of the law, the Court today has turned its attention to a third. The Act that Congress passed makes tax credits available only on an "Exchange established by the State." This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.

Perhaps the Patient Protection and Affordable Care Act will attain the enduring status of the Social Security Act or the Taft-Hartley Act; perhaps not. But this Court’s two decisions on the Act will surely be remembered through the years. The somersaults of statutory interpretation they have performed (“penalty” means tax, “further [Medicaid] payments to the State” means only incremental Medicaid payments to the State, “established by the State” means not established by the State) will be cited by litigants endlessly, to the confusion of honest jurisprudence. And the cases will publish forever the discouraging truth that the Supreme Court of the United States favors some laws over others, and is prepared to do whatever it takes to uphold and assist its favorites. I dissent.


Rush Limbaugh 1, Pope Francis, 0 - But Why?


Rush Limbaugh, at the end of the first hour of his June 22 show:

It's not just climate change for the Pope. The Pope has now said that the weapons manufacturers cannot call themselves Christians, yet he wondered why the allies did not bomb the railroads leading to the concentration camps. I'm not kidding you here.
Regrettably, Rush really isn't kidding. The Pope is saying it can be immoral not to use weapons, but it is immoral to make them.

How can it be immoral to make something if it is immoral not to use them afterward?

As a condition of employment, the Swiss Guards who guard popes are required to be Roman Catholics. They also are trained in the use of weapons and are prepared to use them.

Does Pope Francis believe his guards are bad Catholics because they are prepared to use weapons to protect his life?

Pope Francis apparently has chosen to speak out on public policy without first developing consistent views.

I think his decision to do so is unfortunate. On the matter of guns, he comes across as confused and even hypocritical. This does no benefit to the Pope nor to his cause (gun control?).

Pope John Paul II and Pope Benedict earned the respect of tens of millions, if not hundreds of millions, of people, to the tremendous benefit to the Catholic Church specifically and to Christianity and to the world in general. Is Pope Francis about to squander it?


Project 21's Kevin Martin Commends SC Governor Nikki Haley for Pressing for Removal of Confederate Battle Flag

Kevin MartinKevin Martin

Project 21's Kevin Martin is praising South Carolina Governor Nikki Haley's decision to push for removal of the Confederate Battle Flag from that state's capitol grounds:

I commend South Carolina Governor Nikki Haley for making the courageous call for the removal of the Confederate Battle Flag from the capitol grounds in Charleston.

As a Southerner myself, I have become accustomed to seeing the Confederate Battle Flag in and around the South over the years. For some, it is about their heritage. For others, with racist views, it is a tool and symbol of intimidation. For many Black Americans, the Confederate Battle Flag is a reminder of the Dixiecrat South that was resistant to the equal treatment of Blacks in America.

Dylann Roof was one of those people who thought he could use the Confederate Battle Flag as his own personal tool of intimidation. He took his racist hatred even further when he entered Emanuel AME Church with the intent to gun down innocent Black worshippers in cold blood in an action he thought would spark the race war he desired.

Mr. Roof must now sit in his jail cell with the realization that he only brought the people of Charleston and South Carolina further together in unity. That unity has lead many in South Carolina to realize that now is time to remove the Confederate Battle Flag from the capitol grounds.

Like Governor Haley, I realize a way to discredit people like the reprehensible Mr. Roof is to take away the symbols that inspire them. There will be those who see this as a partisan political victory and others as a partisan political defeat. I say to both that we cannot allow this racist to divide us. We must remember the victims of Emanuel AME Church first and foremost. If we allow partisanship to drive what is right and what is wrong, people like Mr. Roof are the real winners.

As I am a veteran, Southerner and American, freedom of expression has always been near and dear to my heart. If you are proud Southerner with ancestors who fought in the civil war, feel free to fly the flag of the Confederacy, but also remember that the Confederate Battle Flag has been hijacked over time by racists like Dylann Roof, and that, for many Black Americans, the battle flag is a symbol of resistance to our equal treatment in the South by the civil rights era racist Dixiecrats.

We are all Americans at the end of the day and we will heal from this latest mass shooting by an individual who was motivated by hate, but unless we remain united once the dead have been buried and the mourning is over then we have handed victory to people like Mr. Roof.

Removing the Confederate Battle Flag from the capitol grounds of Charleston is a first step forward in the direction of unity.


Medical Records: Got Privacy?

Twila Brase is a public health nurse and the founder of the Citizens’ Council for Health Freedom.  CCHF specializes in protecting medical privacy and in ways to opt out of ObamaCare and other government programs.  (For example, check out CCHF’s website called ITSMYDNA.ORG.)

In the below interview Brase explains how privacy is at great risk due to ObamaCare and HIPAA, how our medical records could be used in the future to deny us care, and what she means by our health care system needs a “Wedge of Freedom”.  It’s about a half hour long, but well worth your time.



Health Care Odds & Ends: ObamaCare Exchanges One Problem For Another

1. First the “Front End” of the ObamaCare website was a problem.  Now the “Back End” is.  The Office of Inspector General for the Department of Health and Human Services released a report stating that the Center for Medicare & Medicaid Services “did not effectively ensure the accuracy” of $2.8 billion in exchange subsidies.  That’s bureaucracy-speak for “a lot of subsidies went to people who shouldn’t have received them.”

The Washington Examiner notes:

In late 2013, when was a useless, glitchy mess for members of the public, government officials had another, less-noticed problem on their hands.

Everyone knew — many from experience and many from the news coverage — that the website the government had built to connect Americans with subsidized insurance policies did not work very well on the front end for months after its launch. The dirty secret, though, was that the back-end of the site had not even been built — the part that was supposed to make sure subsidies were set properly and insurers received payments on behalf of each customer.

Congress noticed this even then, and asked Health and Human Services Secretary Kathleen Sebelius about it in a December 2013 hearing. She reassured members that it would be up and running eventually, and added, “There’s a manual workaround for virtually everything that isn’t fully automated yet.”

Only now it is becoming clear how inadequate the agency’s preparations had been.

Yeah, about $2.8 billion worth of inadequacy.

2. Of the people who faced higher insurance costs due to ObamaCare, only 1 in 5 received a subsidy. Ed Haislmaier at the Heritage Foundation notes that while the “stated purpose [of the exchange subsidies] was to help more low-income individuals purchase health insurance, the subsidies also served to mask the significant health insurance premium increases that would inevitably result from the law’s new insurance benefit requirements and regulations.  For instance, if a 45-year-old received $540 annually in subsidies, he may not realize that the premium for the lowest-cost health insurance plan in his area actually had increased by $600 a year thanks to Obamacare regulations—because the government was paying most of that additional cost.”

The problem is that “the design of the subsidies also created one of the Affordable Care Act’s biggest inequities. Namely, the number of people getting the new subsidies is only a small subset of the much larger number of people whose coverage is subject to the law’s new requirements that drove up health insurance premiums.”  ObamaCare “regulation increased health insurance costs for 20.9 million covered by individual or small-employer group policies in the 34 states affected by King v. Burwell. Of those, 18 percent received an offsetting subsidy and 82 percent did not.”

Hope and change!

3. 41 percent of people on the exchanges who were previously insured would like their old insurance back.  The Foundation for Government Accountability (FGA) has released an extensive survey of people who have insurance on the ObamaCare exchanges.  Turns out, all is not as rosy as ObamaCare supporters claim.  (I know, what a shocker.)  For example, most people did not purchase a plan on the exchange because it was cheaper:


And about 4 in 10 would like to have their old policy back:


The survey also asked, “ObamaCare outlawed many health insurance plans that were available before 2014. If Congress re-opens the law, should they allow people to buy the types of plans that used to be sold before 2014?”


The FGA survey has loads of good stuff. When you get time, take a look.


ObamaCare Premium Hikes for 2016—Ignore Them at Your Own Risk

Today the National Center is releasing my latest National Policy Analysis entitled “ObamaCare Premium Hikes for 2016—Ignore Them at Your Own Risk.”

It examines in depth the requested premium increases for individual policies on the ObamaCare exchanges for 2016 that were released via the federal website “Rate Review” back in early June.  The release of this data garnered a lot of attention, since many of the requested increases were very high.  This elicited a response from ObamaCare supporters that can be best summarized as:

At Mother Jones, Kevin Drum said not to worry, that “we’ve all seen this movie before.” Drum claims these are just rates that insurers are requesting. A “few months from now, the real rate increases—the ones approved by state and federal authorities—will begin to trickle out,” he wrote. “They’ll mostly be in single digits, with a few in the low teens. The average for the entire country will end up being something like 4-8 percent.”

Well, this is something we’ve seen before.  The problem, as this table shows, is that it is getting worse:

There were 121 policies with requests for premium hikes above double digits in 2015, while there are 231 in 2016, an increase of almost 91 percent.*  For 2016 there are 26 policies with requests for hikes over 40 percent, and 12 over 50 percent.  There were none in 2015.

And Drum will probably be disappointed if he thinks state and federal regulators will reduce the rate increases for 2016.  Of the 38 exchanges examined in the NPA, only Kansas, Oregon, Texas and Washington did not approve all of the rate increases insurers requested for 2015. And only one policy was denied the requested rate increase in each of those states.

In short, the rate hikes for 2016 represent the beginning of the death spiral for the ObamaCare exchanges. Read more here.

*Initially said 46 percent.  Sorry for the error.


Ambulance Transport and Medicare's Victims

On July 6, I have my first book coming out entitled Medicare’s Victims: How the U.S. Government’s Largest Health Care Program Harms Patients and Impairs Physicians. One of the main themes of the book is that patients and physicians who struggle with Medicare usually lack political power.  In other words, they lack the ability to influence Congress to make changes in Medicare policy that would help them.

There are many reasons why they lack political power, but a big one is that they simply lack the numbers.  That is, there are too few of them to have any impact at the voting booth or to hire lobbyists to lobby on their behalf.

Case in point is a new program that Medicare has launched in New Jersey, Pennsylvania and South Carolina to cut down on the cost of non-emergency ambulance transports.  Unfortunately, the crack down has put some patients like Robert Browning, who genuinely need the ambulance ride, in a tough situation.

Browning is bed-ridden with leg wounds and needs an ambulance transport to the Community Medical Center for weekly treatment.  Browning now has to get approval from the Centers for Medicare & Medicaid Services (CMS) before Medicare will pay for an ambulance ride.  Browning gets his ambulance rides from Abba Medical Transportation.  Unfortunately, he is one of 20 patients who “whose claims were denied, and [Abba] had to stop transporting most of them, officials said. They couldn’t understand the reason; at times it seemed like they couldn’t get patients approved no matter how much documentation they provided.”

Now, Browning has to pay $250 out of pocket for each ride.  ”’We’re paying for it now,’ Kathie Browning said. ‘I don’t have a choice.’”

Some background:  Medicare pays for ambulance rides to the hospital and other facilities for patients who are confined to their beds and cannot be moved in a wheelchair. However, some ambulance companies seem to be abusing the service (and, perhaps, some patients are too). The cost of non-emergency ambulance transports have skyrocketed in some states.  In California, such transports rose 554 percent from 2002-2011.  In New Jersey, it rose 144 percent.  So, last year, CMS began a pilot project to eliminate such abuse.

But as happens with so many government efforts to root out fraud and abuse, those with genuine need get caught up in the net meant to catch the fraudsters.  That appears to be what has happened with Browning.

My guess is that this program will eventually expand beyond the three states in the pilot project, and patients like Browning will suffer.  The reason?  Well, here’s how Alide Walker, billing manager for Abba, put it: “I feel like they’ve been given the word, ‘You need to save money,’ and they’re saving money on the backs of patients that don’t have a voice for themselves.”

That’s correct.  There are no groups lobbying for Medicare patients who are having trouble getting access to non-emergency ambulance rides.  Nor are these patients likely to ever be a force at the voting booth.  I don’t have any hard statistics, but my guess is there are maybe a few thousand people like Robert Browning who are on Medicare at any given time in the U.S.  Spread that out accross 50 states and 435 House Districts, and it’s almost negligible.

Because the sick usually lack political power, they are unable to change government policy that causes them harm.  And that’s one of the biggest problems of any government health care system.


Ban Flavored E-cigarettes?

Tobaccocigarettee cigDPCW

Cities and states around the country are considering banning the sale of flavored e-cigarettes. The city of Minneapolis, for instance, is considering legislation on the issue this week. In my letter to the bill’s sponsors I explain why doing so would actually undermine public health.

Dear Council Members Gordon and Yang,

I am writing to share my perspective with you on the legislation under consideration that would, among other things, ban the sale of most flavored e-cigarettes at almost all retailers. 

I’m a senior fellow at the National Center for Public Policy Research, where I analyze policy related to public health issues. I’ve testified on these issues at the United Nations, at FDA scientific meetings, and at state and local legislative hearings.

My concern regarding this legislation is that a ban on the sale of flavored e-cigarettes in almost every retailer where adult smokers buy their products-  would have the unintended consequence of undermining, rather than protecting, public health. 

The Health Department’s report on the legislation completely ignored the potential benefits of e-cigarettes as a method of harm reduction. The idea is that smokers, especially those that have had a hard time quitting, would find e-cigarettes a viable alternative to smoking. Flavors play an important role in helping adult smokers transition from smoking to using e-cigarettes.

E-cigarettes often contain nicotine, but do not produce the myriad deadly chemicals from combustible cigarettes, and are as such dramatically less harmful.

In fact, the FDA’s top tobacco regulator, Mitch Zeller, explains that there is a “continuum of risk” among different nicotine containing products.

Mr. Zeller told the Robert Wood Johnson Foundation’s New Public Health, “The other example is if at the end of the day people are smoking for the nicotine, but dying from the tar, then there’s an opportunity for FDA to come up with what I’ve been calling a comprehensive nicotine regulatory policy that is agency-wide and that is keyed to something that we call the continuum of risk: that there are different nicotine containing and nicotine delivering products that pose different levels of risk to the individual.


Zeller explained that, “Right now the overwhelming majority of people seeking nicotine are getting it from the deadliest and most toxic delivery system, and that’s the conventional cigarette. But if there is a continuum of risk and there are less harmful ways to get nicotine, and FDA is in the business of regulating virtually all of those products, then I think there’s an extraordinary public health opportunity for the agency to embrace some of these principles and to figure out how to incorporate it into regulatory policies.”

In other words, the FDA is aiming to use regulatory policy to move people down the continuum of risk. The city of Minneapolis should endorse the Obama administration’s approach and seek policies that further, rather than undermine, the FDA’s science-driven policy. 

Any analysis of the e-cigarette market will show that flavored e-cigarettes- flavors other than the flavors regularly found in cigarettes- are very appealing to adult smokers who are switching to e-cigarettes. 

This explains why, in its proposed “deeming regulation,” the FDA has so far resisted suggestions to restrict the sale of flavored e-cigs to adults, for this very purpose. 

The FDA is currently doing pattern of use -or PATH - studies- to determine how e-cigarettes are being used in the real world- and to determine the role of flavors on helping people move to lower risk products. The FDA is correct to evaluate the science and use it to develop appropriate regulations to protect public health- before regulating. I encourage the council to do the same.

The council should consider other means to achieve the intended and laudable result- reducing underage tobacco and e-cigarette use.  For instance, more effective enforcement on the current state-wide ban on sales of e-cigarettes to minors would be a more narrowly tailored way to prevent underage use of all tobacco products and e-cigarettes. Doing so would minimize the unintended consequence of removing flavors which appeal to adult e-cigarette users who are reducing their harm by no longer smoking cigarettes.

I’d be happy to discuss this with you in more detail if you are interested.


Jeff Stier

Senior Fellow, National Center for Public Policy Research

Director, Risk Analysis Division 

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