More than one in five Americans are now enrolled in the federal Medicaid program, according to new data released by the Center for Medicare and Medicaid Services on Wednesday.

Enrollment in the Medicaid and Children’s Health Insurance Program topped 65 million through April, the month after the end of the first open-enrollment period of the Affordable Care Act.

Overall, since the beginning of the implementation of the Affordable Care Act, Medicaid enrollment has exploded month by month. More than 1.1 million people enrolled in April. And from October through March, which coincided with the Affordable Care Act's open-enrollment period, more than 6 million joined the Medicaid and CHIP programs. This marked about a 10.3% monthly increase from the average monthly enrollment in the months preceding.

Twenty-six states and the District of Columbia expanded their Medicaid programs as part of the law known as "Obamacare," and enrollment in the program increased in both states that did and did not expand.

States that expanded Medicaid saw a 15.3% increase in the program's rolls, and non-expansion states also grew their enrollments by a modest 3.3%.

The latter phenomenon is what's known as the "woodwork effect"— when individuals who were eligible for Medicaid become aware of it because of increased outreach and attention toward healthcare, as would be expected with the implementation of a major health-law overhaul.

In May, Avalere Health released an analysis showing Medicaid enrollment had grown in 17 of the 26 states that did not expand the program. The Obama administration's analysis displayed that it had grown in 18 of those states. 

Leading enrollment in the states that have expanded Medicaid were led by Oregon, West Virginia, and Nevada, three states who saw their Medicaid rolls jump by about 40%.

The Obama administration noted, however, that many circumstances could have influenced the uptick in sign-ups other than the healthcare law kicking into effect. This is because it's difficult to count Medicaid enrollment on a month-to-month basis, given the fact people's eligibility depends on factors like their income, their children's ages, and whether or not they're pregnant. 

"It is important to note that multiple factors contribute to the change in enrollment between April 2014 and the July-September 2013 baseline period, including but not limited to changes attributable to the Affordable Care Act," the Department of Health and Human Services said in a statement.

Separate from the Medicaid expansion, more than 8 million people signed up for coverage through private insurance exchanges established by the Affordable Care Act through April, surpassing the Obama administration's original goals. 

(H/T Vox)

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U.S. companies added 217,000 jobs in May, according to the Bureau of Labor Statistics — and a decent chunk of them came in the healthcare industry. 

The healthcare industry added 34,000 jobs last month, which amounts to twice its average monthly gain over the prior 12 months. A significant portion of that number came from the ambulatory healthcare services sector, which includes increases in physicians' offices, outpatient care centers, and home healthcare services.

With the uptick, the healthcare industry has added jobs in 131 consecutive months. The last time the sector lost jobs was in July 2003.

Dan Diamond, the managing editor of the Daily Briefing, also points out that 100,000 jobs have been added in the healthcare sector over the first five months of the year, and the industry is on pace to add more than 230 jobs this year

Still, May's healthcare sector growth amounted to less than 3%. And overall, jobs growth in the healthcare sector has been remarkably consistent on a year-over-year average. Former OMB Director Peter Orszag tweeted this chart:

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Sylvia Mathews Burwell, who was confirmed by the Senate on Friday as the new secretary of the Department of Health and Human Services (HHS), played a weird role in one of the most notorious moments of the Whitewater scandal: the suicide of Vince Foster.

In 1993, Burwell was a staff director at the National Economic Council. Foster, a central character in the Whitewater controversy, was the deputy White House counsel at the time of his death and a former law partner of Hilary Clinton. 

On the night of Foster's suicide, Burwell somehow ended up with the garbage from Foster's office trash bin.

She later testified before a Senate committee that "on her own she went through trash in Foster's office and found no suicide note but only routine credit card receipts, schedules and news summaries," according to a Reuters article from 1995.

The New York Times reported at the time that "Ms. Mathews had also managed to retrieve a [different] special bag of garbage containing classified and sensitive papers that was usually destroyed by the Secret Service. The contents of the bag were never examined by anyone to see if Mr. Foster had left anything in it that might shed light on his state of mind. Ms. Mathews said that she got the bag from the Secret Service and began looking briefly through it, when she discovered that it contained all of the classified garbage from the West Wing."

Two decades later, it's still unclear exactly why Burwell had the trash or what her role, if any, was in the scandal. 

When we asked HHS for comment, a spokesperson called us back with several questions of his own: "What is your story? What does this have to do with HHS?" he asked. "What does this have to do with what happened today? Why is this newsworthy?"

HHS later declined to provide a statement on the incoming secretary's version of events. "No comment," the HHS spokesperson told us via email.

Burwell's predecessor at HHS, Kathleen Sebelius, is leaving the agency after the botched rollout of the Affordable Care Act. She has also taken heat for refusing to testify before Congress on more than one occasion. Burwell won the Republican vote by promising to be more transparent and responsive than Sebelius.

This post has been updated with more information from HHS.

SEE ALSO: Meet Sylvia Burwell, Obama's Next Pick For Secretary Of Health And Human Services

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A Virginia state senator is set to resign on Monday after cutting a deal with Republicans, a stunning move that gives the state GOP the upper hand in an ongoing fight over the state's budget and an expansion of the Medicaid program under the Affordable Care Act.

Democratic state Sen. Phillip Puckett will step down on Monday, news first reported by The Washington Post. According to the report, Puckett's resignation leads the way for him to get a job as deputy director of the state tobacco commission and for his daughter to be confirmed for a state judgeship.

It also means Republicans now have a 20-19 majority in the state Senate, something that could stall an expansion of the Medicaid program in the middle of an increasingly tenuous, partisan fight over the state budget.

Puckett's office confirmed he will make the announcement on Monday but declined to discuss specifics of the deal that reportedly led to his resignation — a deal some characterized as "bribery."

A furious Gov. Terry McAuliffe, a Democrat, called the situation "unacceptable."

"I am deeply disappointed by this news and the uncertainty it creates at a time when 400,000 Virginians are waiting for access to quality health care, especially those in Southwest Virginia," McAuliffe said.

"This situation is unacceptable, but the bipartisan majority in the Senate and I will continue to work hard to put Virginians first and find compromise on a budget that closes the coverage gap."

Virginia's government is rapidly veering toward a shutdown if neither side budges from its Medicaid position before July 1. McAuliffe says an expansion must be part of the new budget, while Republicans have so far resisted his calls.

Virginia is one of 24 states that has not expanded the Medicaid program under the law known as Obamacare. McAuliffe campaigned on a promise to change that.

The state's Medicaid office estimates that as many as 400,000 Virginians would be eligible for Medicaid coverage under a possible expansion. According to a study from The Commonwealth Institute, a supporter of the expansion, more than 20,000 of those people could come from Puckett's district alone.

More than 6 million people nationwide have enrolled in the Medicaid and Children’s Health Insurance Programs since the law has begun being implemented.

Puckett's resignation gives Republicans an outright majority in the state Senate. The previous 20-20 split gave Democrats a de-facto majority, since Virginia's lieutenant governor would cast a tie-breaking vote. Virginia's Republican-controlled House is staunchly opposed to an expansion of Medicaid.

In his statement, however, McAuliffe offered a reminder that three moderate Republican state senators had offered sentiments of support for Medicaid expansion. Their votes could theoretically make Republicans' majority obsolete.

This post has been updated.

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Last year, the widening partisan split over the Affordable Care Act produced the first federal government shutdown in 17 years. Almost one year later, Virginia's state government is on a collision course that could cause that state's first-ever shutdown. 

Like the federal shutdown, the law known as Obamacare is to blame for the bickering in Virginia, which has become a national political bellwether.

Virginia's Democrats, led by freshman Gov. Terry McAuliffe, and Republicans have engaged in an increasingly partisan and nasty fight over the past few months over an expansion of the federal Medicaid program under the Affordable Care Act. The dispute has come to a head because Virginia must pass a budget by July 1 to avoid a shutdown. 

McAuliffe and the state Senate, which up until this week was narrowly controlled by Democrats, have bickered with the Republican-controlled House of Delegates in Virginia over the expansion, which the governor says could expand coverage to as many as 400,000 Virginians.

But late Sunday, Virginia Republicans effectively teamed up with one Senate Democrat and threw the debate for a loop. State Sen. Phillip Puckett is set to resign on Monday, a move that led some Democrats to accuse Republicans of "buying" Senate control. 

Puckett's resignation leads the way for him to get a job as deputy director of the state tobacco commission and for his daughter to be confirmed for a state judgeship. Depending on how you look at it, it's politics at its worst — or best.

"Republicans I've talked to are chortling," Larry Sabato, founder and director of the University of Virginia Center for Politics, told Business Insider. "They think it's one of the cleverest things they've done."

"And yet," he added, "one of them asked me, 'Do you think Democrats would not have done the same thing if they had the opportunity?' And of course they would have. It's yet another reason people hate politicians."

The developments give Republicans 20-19 majority in the state Senate, meaning they now hold the upper hand in the budget battle and the Medicaid fight.

All of this maneuvering comes back to Obamacare. Republicans will now control both the House of Delegates and the Senate, and McAuliffe may be backed into a corner. 

The Affordable Care Act provides resources for states to expand Medicaid after a landmark Supreme Court decision in 2012 said states could decide on expansion for themselves. So far, 26 states and the District of Columbia have expanded Medicaid to cover people below 133% of the poverty line — about $15,500 in annual income for an individual and about $31,700 for a family of four. Virginia is one of a handful of states still actively debating whether to expand the program.

McAuliffe campaigned on a promise to expand Medicaid, which had been resisted by then-Republican Gov. Bob McDonnell. However, Republicans have nearly a two-thirds majority in the House of Delegates. And, as Sabato explained, the only way most of them can lose is through a Republican primary in which they are not viewed as conservative enough.

"This is really about Obamacare," Sabato said of the dispute. "Forget about Medicaid."

What happens now? There are three immediately foreseeable solutions. The first, as McAuliffe contended is still possible Sunday night, is the Senate still passes a budget funding Medicaid expansion. Three moderate Republicans have expressed support for the expansion, but "they can be persuaded," Sabato said. The new developments, meanwhile, have energized the party as a whole. 

If the Senate does manage to pass a budget with the Medicaid funding, it would mean a standoff between Republicans in the House and Senate Democrats, with McAuliffe backing Democrats. 

Another potential outcome is that Republicans, emboldened and unified by the power play, could refuse the expansion in both the House and Senate. It could leave McAuliffe with no choice but to blink, unless he is prepared to take on the uncertain political and legal future of a potential shutdown. 

But McAuliffe has also been preparing for a potential third option. According to The Washington Post and confirmed by a source with knowledge of his deliberations, McAuliffe has looked into whether he has the ability to bypass the legislative process altogether and expand Medicaid by executive order. But whether he has the legal authority to do so is unclear, and it is clear the move would cause a political firestorm. 

McAuliffe said only Sunday night that he was "disappointed" by Puckett's move, touting the fact three Republican senators have offered sentiments of support for the expansion. 

"I am deeply disappointed by this news and the uncertainty it creates at a time when 400,000 Virginians are waiting for access to quality health care, especially those in Southwest Virginia," McAuliffe said in a statement.

"This situation is unacceptable," the statement read, "but the bipartisan majority in the Senate and I will continue to work hard to put Virginians first and find compromise on a budget that closes the coverage gap."

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Sylvia Mathews Burwell is taking over the leadership of the Department of Health and Human Services (HHS) from Kathleen Sebelius, and the two women had very different career trajectories to the cabinet-level position. 

Kathleen Sebelius started her career with the government of the State of Kansas. As the below chart of her employment timeline shows, Sebelius slowly worked her way up through the ranks of the state government and was eventually elected governor. She also had some experience in the the healthcare industry as the state insurance commissioner. HHS Secretary was the first position that she held at the federal government level.

Sylvia Mathews Burwell's career path has been the opposite of Sebelius's.

Burwell spent 11 years working in different roles for the federal government, most recently as the director of the Office of Management and Budget. But she's not a career bureaucrat.

As the below chart shows, Burwell has spent almost an equal amount of time working in the private sector for both the Bill & Melinda Gates Foundation and the Wal-Mart Foundation. In these roles, she worked on some global and domestic health-related projects, but she has little direct experience working in the healthcare industry aside from serving on the board of the University of Washington Medical Center (which is not included in the chart below).

The New York Times notes that President Obama's decision to nominate Burwell "places a relative outsider at the helm of one of the government's largest bureaucracies."

But that might have been part of her appeal. Burwell "works hard to be seen as a practical manager rather than an ideologue,"observes Elise Viebeck of The Hill.

In her nomination hearing before the Senate Finance Committee, Burwell sought to bridge gaps with Republicans and admit the flaws of the rollout of the Affordable Care Act. Sebelius, meanwhile, was criticized for her lack of transparency, particularly with her refusal to testify before Congress on failed aspects of the rollout.

And since reigning in healthcare spending continues to be be a priority in Washington, Burwell's economic policy background and private sector experience appealed to legislators on both sides of the aisle.

In the end, Viebeck notes, Burwell's confirmation process was "unusually smooth."

SEE ALSO: New Obamacare Boss Has Ties To One Of The Weirdest Moments Of The Clinton Whitewater Scandal

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Minnesota has seen its uninsured rate plunge by more than 40% since the implementation of the Affordable Care Act, according to a new study released this week. 

The study, released by researchers at the University of Minnesota, provided the first look at Obamacare's effect on a single state's insured rate. It found that the number of uninsured in Minnesota fell from 445,000 (about 8.2% of the population) to about 264,500 (about 4.9% of the population).

The decrease is similar to the effects in Massachusetts after similar healthcare reforms were implemented there in 2006. It's a larger increase than the Congressional Budget Office has projected for the entire United States — a drop from 54 million under previous law to 42 million under the Affordable Care Act.

"Our findings on the change in the number of uninsured are consistent with national reports of early ACA impact, and with research on the impacts of Massachusetts reforms implemented in 2007 which are quite similar to the access expansion provisions included in the ACA," the researchers wrote in a summary of their report.

Thus far, there have only been imprecise studies taken on the uninsured rate after the end of Obamacare's first open-enrollment period. The Obama administration has said 8 million people nationwide gained coverage through private insurance exchanges established by the law, while more than 6 million people have enrolled in the federal Medicaid program since October.

The authors of the study said their findings were consistent with a number of national polls and studies showing a drop in the uninsured rate, including a Gallup survey that showed a drop in the uninsured rate to 13.4%, the lowest the company has ever recorded.

Medicaid expansion was the main driver of the plunge in Minnesota's uninsured rate. Enrollment in Medicaid and MinnesotaCare, a state healthcare program for the working poor, was responsible for 20.6% of the growth in coverage, or about 155,000 Minnesotans. Meanwhile, enrollment by individuals in private plans jumped by 36,000. 

Here's a chart showing the breakdown in insurance gains:

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In late April, the Bureau of Economic Analysis released an advance estimate of first-quarter GDP that had one noticeably eye-popping statistic— spending on healthcare grew 9.9%, the biggest percent change in more than three decades.

Those numbers were questioned by former OMB Director Peter Orszag and others, because the data didn't quite square. With healthcare spending surging but employment growing at a steady year-over-year pace, could there really be an absurd boom in healthcare productivity?

A month and a half later, we have a more definitive answer. And it appears healthcare spending didn't explode as high as the BEA's advance estimate had suggested. 

On Wednesday, the Commerce Department released its quarterly services survey (QSS), which provided a few important points of data. Healthcare and social assistance spending, overall, plunged 2%. Revenue for hospitals (-1.3%), medical labs (-6.4%), and outpatient care (-3.6%) all fell in the first quarter of 2014 when compared to the final three months of 2013.

Even year-over-year, the increase in health spending was only 3%. If that holds throughout the year, it would continue the four-year trend of healthcare spending growing at a historically low pace.

The numbers suggest healthcare spending growth will continue at a relatively slow pace. But it's likely that because healthcare spending didn't grow as much in the first quarter, GDP will be revised down even further than its already-anemic growth. 

"That’s just surprisingly low," Charles Roerhig, director of the Altarum Institute’s Center for Sustainable Health Spending, told the Kaiser Family Foundation. "This confirms the skepticism that has been expressed about the acceleration" suggested in earlier data.

Orszag was among the first to convey that skepticism. His argument: For spending to have exploded with healthcare employment growing at an average pace, it would mean an incredible boom in in healthcare productivity.

"It would mean that somehow we're able to produce so much more health care with each worker, in a dramatic fashion, starting magically with the fourth quarter of last year," Orszag said in May. "OK, maybe? It's just not really plausible. If all of this were real, it would mean that suddenly, magically, health-care workers have become a lot more productive."

On Wednesday, Orszag posted a chart on Twitter (below) showing the recent advance healthcare spending data doesn't square with the QSS data released Wednesday. He suggested it likely means healthcare spending will be revised downward.

Kaiser president Larry Levitt predicted the same thing. But though health cost growth continues a relatively steady, slow pace, it likely means GDP will also be revised down from a -1% growth. Barclays and UBS both slashed their GDP projections to -2% growth, meaning the economy will have contracted.

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In his days as a salesman pitching his healthcare law to the American public, President Barack Obama often said it would not cost much more than a monthly cell-phone bill. 

For many people, that has turned out to be true, according to new data released by the Department of Health and Human Services on Wednesday. The report found people receiving subsidized health insurance plans are paying $82 a month, on average, for their premiums.

On average, individuals who selected health plans from the federal marketplace saw their premiums slashed by about 76% through the federal subsidies, reducing their monthly premiums about $346 to $82. After tax credits, almost 70% of the approximately 5.4 million people who signed up for plans through exchanges run by the federal government will pay less than $100 a month. And 46% are paying less than $50 a month, HHS said.

The report did not measure the premiums of insurance purchased through state-based marketplaces and federal officials told reporters they didn't have that data. Still, it provides the most comprehensive look at the effect of subsidies during the first open-enrollment period of the Affordable Care Act. 

Federal officials said the data proves the law is working.

"What we’re finding is that the Marketplace is working. Consumers have more choices, and they’re paying less for their premiums," newly confirmed Health and Human Services Secretary Sylvia Mathews Burwell said.

People are eligible for tax credits if they make more than the federal poverty level — about $11,670 for a single person in 2014, or about $23,850 for a family of four — but less than four times that amount. HHS said 87% of the 5.4 million people who signed up through the federally run exchanges selected plans with tax credits. About 2.4 million people signed up through the 15 exchanges run by individual states and the District of Columbia.

Here's a look at the average affect of subsidies on the five different categories of insurance plans offered through the federal marketplaces, which are labeled with "metal level;" Bronze, Silver, Gold, Platinum, and Catastrophic:

While Obamacare is clearly helping some people lower their premiums, what's less clear from the report is the cost of these subsidies to the federal government. Federal officials refused to speculate on subsidies' cost now that the law has gone into effect.

The Congressional Budget Office estimated in April the federal government would spend about $12 billion in subsidies and related spending — numbers that are projected to rise to $29 billion and $62 billion over the next two years as more people sign up. Calculations from The Los Angeles Times suggest the pricetag for subsidies is about $11 billion — and could amount to close to $16.5 billion if state subsidies are dished out comparably.

An HHS official said the department hopes to have that information "later this year."

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Healthcare spending plunged in the Bureau of Economic Analysis' latest estimate of first-quarter GDP growth, accounting for two-thirds of the revision that tumbled overall growth to -2.9%.

In the BEA's first estimate of first-quarter growth, healthcare spending was projected to explode by 9.9%. It was subsequently revised to 9.1%. But the latest estimate had healthcare spending plunging to -1.4%.

"So much for the BEA's initial view that the start of Obamacare triggered a surge in spending on healthcare,"Pantheon Macroeconomics' Ian Shepherdson said. "The press release offers no detail on what triggered this massive revision."

So what triggered that massive revision? The BEA told Business Insider the revision was based on a new set of data from the Commerce Department's quarterly services survey.

That survey provided a few important data points: Healthcare and social assistance spending, overall, plunged 2%. Revenue for hospitals (-1.3%), medical labs (-6.4%), and outpatient care (-3.6%) all fell in the first quarter of 2014 when compared to the final three months of 2013.

A BEA spokesman said the agency had previously used "information on Medicaid benefits and on ACA insurance exchange enrollments as well as other available data" to determine the spending increase.

"These data sources suggested a relatively large increase in health care spending. Based on these data sources, we had assumed that ACA related effects boosted consumer spending on healthcare services by about $37 billion for 2014Q1 (in current dollars). The QSS data now available does not show this same increase," the spokesman said.

Among the first to convey skepticism about the BEA's initial estimate was Peter Orszag, the former OMB director. His argument: For spending to have exploded with healthcare employment growing at an average pace, it would mean an incredible boom in in healthcare productivity.

"It would mean that somehow we're able to produce so much more health care with each worker, in a dramatic fashion, starting magically with the fourth quarter of last year," Orszag told Business Insider in May. "OK, maybe? It's just not really plausible. If all of this were real, it would mean that suddenly, magically, health-care workers have become a lot more productive."

Orszag recently posted a chart on Twitter (below) showing the BEA's initial advance estimate didn't square with the QSS data released Wednesday. He suggested at the time it likely meant healthcare spending will be revised downward.

Though analysts suggested the data was subjected to revision, few could've predicted such an incredible swing. Jason Furman, the chairman of the White House's of the Council of Economic Advisers, said it's the biggest revision in roughly 30 years.

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When I first moved to San Luis Obispo, I thought I’d go back to my native Wisconsin after I finished my degree at Cal Poly. More than 40 years later, I can’t imagine ever leaving. This place, once named the happiest city in America, has given me everything, including a good living as an insurance agent and regional sales manager.

Part of my job is to understand the complicated, and I’ve never come across anything as complicated as the Affordable Care Act. As I studied it after its passage in 2010, I began to worry about how the law’s one-size-fits-all approach would work in a semi-rural county where the major industries are agriculture, tourism, and government.

I became concerned that no one here in San Luis Obispo could explain the law to me. And when I trained insurance agents on the law, I saw their eyes glaze over. New and experienced agents couldn’t make sense of the subsidies, plan eliminations, limited enrollment periods, and new taxes. Many agents chose not to participate in the new system, or to get certified to sell policies through Covered California.

I saw all this confusion as an opportunity—to give back to my community and to educate the individuals and businesses that have been so loyal to me and my insurance agency, even after I turned it over to my wife and went to work in management at Anthem Blue Cross. So I left that management position—and a salary and great benefits—and decided to take on the task of educating our community on healthcare reform.

Getting the word out through traditional advertising was beyond my financial means. So I began meeting with people from local institutions and found that my most promising partners were hospitals. I prepared elaborate presentations about the risks and rewards of Obamacare.

Hospital staff and executives were as puzzled as anyone else about the impact of the law and had a financial interest in public education. I offered to provide that education and, in turn, the hospitals agreed to use their media and community contacts to spread the word about my willingness to educate people on the subject.

The invitations started to pour in. I gave joint presentations with the county health department on the Medi-Cal expansion that’s part of Obamacare. I spoke at the chamber of commerce, the rotary, and other service and community organizations. Many churches in the region offered the use of their rooms and did outreach. Through word of mouth, I had gained enough momentum to launch a public campaign.

I launched the campaign last June—four months before open enrollment for Obamacare was set to begin—with the help of the health department, hospitals, churches, and other community organizations. My first seminars at Sierra Vista Regional Medical Center and Twin Cities Regional Medical Center were attended by about 50 people each, about half of what I expected.

Most of the people who attended were either fearful of losing their Medicare coverage or community leaders who had insurance but were trying to understand the new law. Very few people who the law was designed to help—the uninsured—showed up.

Even after we modified the ads to attract young people and those without coverage, very few members of our target population attended. By the enrollment launch in October, I had conducted 23 publicly advertised seminars in every corner in San Luis Obispo County, but the total attendance was only 500.

Given this lack of engagement, and the considerable confusion, I worried about the launch of the Affordable Care Act. And unfortunately, the botched rollout made it clear that San Luis Obispo was not unique: Many people in state and federal governments who were in charge of rolling out the new law did not understand it either.

I found it particularly frustrating to hear officials describe the process as easy. Peter Lee, executive director of Covered California said that using the website would be as easy as “buying a book on Amazon or a pair of shoes on Zappos.”

Public statements were made about how small businesses could buy the same plans as large corporations, see their insurance prices fall, and get tax credits for offering coverage. These statements have proven to be untrue. Even worse, they made my local efforts at public education much more difficult.

As we now know, the Covered California website—while better than the federal exchange site and other state exchange sites—was only marginally functional for the first three months. Clients who turned to the phone often found the lines jammed; those who got through waited for two hours or more. People were extremely frustrated.

Even after all those months of work and public education, I couldn’t do much to help people. We agents were getting the runaround, too. First, we were told to use the website, which was unreliable. In December, we were told to use paper applications, but the fax lines were often down. Then we were told that Covered California didn’t have the capacity to enter the faxed information into the system and that we would have to enter it ourselves.

Communication between Covered California and the insurance companies was very poor. Many people who tried to sign up didn’t realize that Covered California was just a conduit for collecting information and validating income before an application was turned over to the insurance company to generate an invoice.

There were long delays and repeated requests by Covered California for information that we had already submitted for clients. Numerous time extensions were issued, some of which Covered California did not honor. A client would be promised coverage effective January 1 but instead would be issued coverage a month later.

The Good News

The good news is that final enrollment numbers in California exceeded expectations. People with a pre-existing medical condition can now buy individual coverage at standard rates. The expansion of Medi-Cal has made coverage more affordable to low-income people, and the subsidies helped many people buy higher benefit plans at low premiums.

There were a few rewarding moments: the 64-year-old cancer patient without coverage who I pushed through the system so she could start cancer treatment within days of January 1. The widow who attended one of my seminars who cried when I showed her that she would have very low premiums and good benefits.

Unfortunately, such stories were the exception in my experience. Most of the people I worked with were already insured. They were reapplying to obtain lower premiums through the subsidies—beneficial, but not an expansion of coverage. Less than 20 percent of the folks I enrolled were uninsured. Other local agents I know experienced the same thing.

I’m also not seeing the choice and competition among health plans that was supposed to happen. In San Luis Obispo County, only two companies were available to individuals through Covered California: Blue Cross and Blue Shield, both of which previously dominated the market.

Before Obamacare, there were three other small plans and dozens of options and prices. There are only four options offered under Covered California and, in many cases, my clients are actually paying more. And, because the reimbursement rates remain so low, some physicians won’t accept the new plans. Healthcare coverage is an illusion if no one will provide you with care.

It wasn’t any better for my business clients: the Small Business Health Options (SHOP) exchange only included Blue Shield and Health Net. The law only offered the much touted tax credit to businesses that went through the exchange, but many other carriers—and the most desirable plans—were offered outside the exchange.

After these last few years of studying and working with the law, I’m convinced that Obamacare was well-meaning but attempted to do too much, too fast. Of course, the continuous opposition and repeal attempts have hampered progress, but the lack of preparation and confusion is still inexcusable.

I remain worried about whether major problems will be addressed by the next open enrollment, which has been delayed until November 15. I continue to see clients whose information still has not been updated, or whose applications for insurance are listed as “pending”—even though they were approved months ago.

The forms and website need to be clarified, so people don’t make mistakes. There’s still too much confusion out there. But, as an eternal optimist, I will continue to try to educate my community on how to deal with this ever-changing, but very important, legislation.

Michael Framberger has been in the insurance field for 36 years, holds numerous educational designations, and is a certified wellness speaker. He is the author of Get Happy, Get Healthy, Be Wealthy: It's Your Choice!, as well as numerous articles on health and wellness.

SEE ALSO: Here's Why The GDP Report's Healthcare Spending Estimate Was Such A Disaster

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A rather interesting shockwave came across the newsfeeds this week. I was actually doing a TV interview when the host announced that GDP was down 2.9% for the first quarter. There was not much else I could do but note that that was a really bad, ugly, terrible, not very good number. But I had no real basis, without any facts in front of me, by which to understand why the revision was so extreme. Sure, we were all expecting a pretty large revision, but what we got was the worst decline in five years and the largest downward revision since recordkeeping began. Later, a quick perusal of the data on the BLS website revealed the culprits: exports and healthcare spending.

Last year I was one of the very few who suggested that the implementation of Obamacare could cause a recession (see more below). Such a suggestion was universally dismissed by all right-thinking economists, and for very good reasons based in sound economic theory, I might add. But sometimes the real world neglects to adhere to our models and theories, and that was my concern.

While I doubt we’ll see a recession – classically understood as two quarters in a row of negative GDP – this rather large bump in the road offers a number of teaching opportunities. This week’s letter will look at the actual numbers; and then, rather than try to spin the numbers to fit some preconceived political agenda, we will examine what actually happened in the spending data and why. And while it may surprise some of you, I actually think a few good things did happen, things I find encouraging.

Anytime I write about healthcare it’s controversial, and I expect this letter will be received that way as well. However, as I (and many others) have clearly established, the healthcare system in the United States is massively dysfunctional. We are simply spending too much money on healthcare and are on a path to spending an unsustainable amount of money by the end of the decade. Things are going to change no matter what. The Affordable Care Act (ACA or Obamacare) was one way to try to address the problem. The majority of the country now feels this might not have been the best way, but that really doesn’t make any difference. It is going to be the basic law for another three to four years. My job, at least in this letter, is not to discuss policy but rather the economic effects of the policies we have chosen to implement, and what those effects may mean for our investment portfolios.

GDP Shocker: a Drop of 2.9%!

First, let’s look just at the facts as given to us by the BLS. US Q1 GDP Q/Q was revised much lower, to -2.9% on an annualized basis, down from the -1.0% previously reported (which itself was revised lower from the +0.1% initially reported) and well below the expected decline of -1.8%. How did we go from barely positive to down 2.9%?

When the BLS gives us its first estimate of previous-quarter GDP, it is forced to use models based on previous trends until the actual data comes in. This is why we get two monthly revisions and in future years will get even further revisions. (Sidebar: don’t you wish the US Bureau of Labor Statistics could be as good as their Chinese counterparts? The Chinese never have to revise their numbers. Obviously they are very good at this type of thing.)

And we all know that assumptions will sometimes bite you in the derrière. Look at this chart of projected healthcare spending from the original release of first-quarter GDP data in April. Notice that the projected spending was almost double what it had been just the previous quarter and over four times the previous year’s average. I’m not quite certain how trend models got to that number, but then I’m not a mathematician. In any event, here’s the chart, courtesy of Zero Hedge:

Now fast-forward to last week’s revision and notice that the healthcare spending number has dropped from the previous quarter, not doubled. In fact, it dropped an enormous 6.4%. Rather than contributing 0.62% to GDP is it did in the fourth quarter of 2013, in Q1 2014 it subtracted 0.16% from GDP growth.

Just for the record, here are the actual numbers from the BLS data. Roughly 2/3 of the negative revision in Q1 GDP was from healthcare spending, and the rest was from falling exports and rising imports (from an accounting standpoint, imports are a negative in figuring GDP).

I want us to look quickly at two charts to get some historical perspective on growth in the US. The first is GDP quarter by quarter for the last seven years. Notice that only two quarters ago we had a 4.1% positive quarter. During the 19 quarters since the current expansion began in June 2009, the economy has grown at an annual rate of 2.1%, compared to the 4.1% average in every other expansion since 1960.

In fact, rather than the comfortable +3% from 1950 through 2000, growth fell to +1.9% for the entire decade of the aughts and has not risen appreciably above that in the last four years. Here is a chart showing the rolling four-quarter average for GDP growth since 1980. With last quarter’s negative revision included, we’ve only grown 1.6% for the last 12 months. Dude, who stole my productivity?

The New Normal of Healthcare Spending

On October 6, 2013, I penned a rather lengthy discussion of the economic impact of the Affordable Care Act. I still think it was one of the better pieces I have written. You can read it here. I offered an analysis of what healthcare will look like within a few years. Essentially, we are moving to a three-tiered system. Somewhere between 3 to 5% of people will have what is coming to be known as concierge care, another 20% or so will have what we think of as traditional insurance, and the remaining 75% will get by with some form of government-mandated and -controlled healthcare (with high deductibles and increasing costs).

I titled the letter I wrote back in October “The Road to a New Medical Order.” Business Insider, which posts my letter each week (a surprising number of people think I actually write for them, which is fine by me, I guess) generally tries to come up with impactful and somewhat controversial headlines to attract readers. Their headline over my piece was “Obama Care Will Change Everything – And I Think It Might Cause a Recession.” And yes, buried deep in the article I did write:

When I am asked what keeps me up at night about our economy, my ready answer for the past few months has been the unknown transition costs associated with the ACA. I hope Jack Rivkin is right and that the transition to Obamacare proves to be just another Y2K. I truly believe that healthcare will be significantly better in 10 years, largely due to advances in technology, but also as we streamline our healthcare delivery. So I’m a long-term optimist, though I have to confess that, in the short term, which would be through the last half of 2014, I am quite concerned that dislocating 1 to 2% of the economy could be enough to push us into recession. I have nothing factual to base that on – no inverted yield curve, no evident bubble getting ready to burst – so I will stop far short of a prediction. Let’s just say that these issues need to be right up front on our radar screens. And it wouldn't hurt to keep our fingers crossed.

Let’s run through a quick summary of my analysis then – which is the same as how I see things today. We are going to reduce the amount of money we spend on healthcare by around 1% of GDP a year for the next four years, or about 5% per year in actual reductions. While right-thinking economists will point out that that money will be spent elsewhere, and they are correct, my concern was – and it is evidently turning out to be pretty correct – that the transition will be messy. I simply do not believe that you can change the “plumbing” of how healthcare dollars are spent, totally change the incentive structure, and demand more service for 20% fewer dollars while reducing the number of workers at hospitals, without serious short-term dislocations. Like we saw last quarter.

Will all this wash out over the next few years? Absolutely. We are not on some permanent healthcare spending death march where quarter by quarter healthcare spending will keep dropping. It is just, to borrow a phrase from my friend Mohamed El-Erian, that we are entering into a New Normal of Healthcare Spending. And eventually that money that we are not spending on healthcare will get spent on something else, and those people that are not employed in the healthcare industry will find other jobs or end up taking less pay for doing the same job. But it is the turmoil created in the midst of that process that is going to create some ups and downs in the economy (more on that later).

I have regular conversations with numerous friends about what’s happening in the healthcare world, as I think that is where the real action is. For an economist, this is a wonderful experiment in incentive structures. And if you are an economist worth your salt, you know that economics is all about incentives. Individuals have an incentive to maximize their healthcare services and reduce their actual out-of-pocket expenses. Healthcare businesses have an incentive to make sure that expenses don’t exceed revenues. And the ACA is nothing if it is not an enormous incentive-changing machine.

Jack Rivkin sent me a note yesterday detailing a conversation he had recently with a healthcare provider. (I’ll remove names, just in case.)

Had a great 3 hour dinner discussion in Chicago three weeks ago with the head of the … Hospital. He realizes he’s at the bottom of the food chain but is very excited about what is happening. First dinner with him was three years ago when he was just beginning. He’s substantially changing the mix of his work force. That includes doctors who are now employees, not independent business folks. He has made the switch to outcomes-oriented medicine and is looking to become his own insurance company where he believes the big ripoff has been taking place. You should hear what he has to say about Blue Cross/Blue Shield and the people running it. He is tired of getting paid for procedures as opposed to outcomes, e.g., [he’s] down from using 7 different types of hip replacements to 3, based on those with the best long-term success. The doctors were told you either switch to what we have chosen or find another hospital. Actually “fired” some doctors when the data showed what a high rate of repetition [their] patients had.

That complaint about insurance companies is showing up a lot. Here’s a section from a great little article by Jake Novak at CNBC called “An Obamacare bailout? Insurers already got one!”

Whether the ACA has actually helped more citizens than it's hurt has turned into a partisan war of statistics. That war will be waged for years to come. While I believe the new law will ultimately hurt more people than it helps, I realize those on the other side of the political spectrum will never agree with that assessment.

So let's not have that fruitless argument.

Instead let's focus on something the two major political camps can agree on, even if it is something that will make both of them very angry. Based on the non-partisan, hard numbers, the big winners in Obamacare America are… drumroll please… the insurance companies!

Yes, those greedy, heartless, bureaucratic, and anti-competitive health-insurance companies that President Obama kinda sorta blamed for his mother's death and Republicans blasted for seeking a bailout, and doctors accused of interfering with their medical judgment are all still alive and kicking in the 2014 world of the ACA.

Of course, insurance companies would simply argue that they’re playing by the rules and that they’re having a really difficult time making profits. Most insurance plans under Obamacare are going to rise significantly in cost later this year or next year.

Again, we find out something about incentives. It should be no surprise that a significant number of people with serious health issues who had no insurance have now signed up for the new healthcare programs. Lanhee Chen on the BloombergView site sees it this way:

At its base, the data show that people insured through the law’s exchanges have higher rates of serious medical conditions. Of the enrollees who have seen a doctor or other health-care provider in the first quarter of this year, 27 percent have significant medical problems, including diabetes, cancer, heart trouble and psychiatric conditions. That rate is substantially higher than that for patients in nonexchange market plans over the same period. And it’s more than double the rate of those who were able to hold onto their existing individual market insurance plans after President Barack Obama was forced to allow them to keep them.

This outcome should not surprise anyone. The law’s one-size-fits-all regulatory regime, which requires insurers to offer coverage to all comers and prohibits pricing of coverage based on an applicant’s health status, was bound to increase the number of relatively sicker people purchasing insurance through the exchanges. Moreover, Obama’s executive action, which effectively allowed many people who had individual market plans to remain in them through at least 2016, bifurcated the insurance markets such that healthier people remained in the plans they already had, while relatively sicker patients were left to acquire coverage through the Affordable Care Act’s exchanges.

Some of the bad risk in the exchanges has been offset by the enrollment of relatively healthy people who acquired coverage because of the law’s generous subsidies. Yet the numbers make clear that the exchanges remain a haven for those who may consume more medical services than others. (Bloomberg)

The ACA is going to be enormously contentious, as the rules are conflicting as to how insurers can make up their losses. President Obama would like to do it one way that he thinks is allowed within the rules, but there are many in Congress who think that’s a bailout for insurance companies and is against the rules. However it plays out, the ACA is going to cost someone, whether it’s taxpayers or those buying insurance, a great deal more money than initially budgeted. And the insurers will continue to be everybody’s favorite whipping boy.

As an aside, I find it an enormously intriguing idea that a healthcare hospital group is seriously thinking about setting up its own insurance company. You gotta love America, 100 different experiments going on at once. Some of them are sure to be game changers.

Why Healthcare Spending Went Down

My contacts in hospitals and elsewhere in the healthcare industry confirm that healthcare spending was down dramatically (though perhaps not quite the 6.4% in the data) in the first quarter. These same sources suggest that healthcare spending has rebounded during the second quarter. The first week of June was actually the best week ever for one major healthcare provider, but the overall trend is still for somewhat lower healthcare spending than last year.

So what happened in the first quarter? Evidently, several things. Number one, if you haven’t noticed, the deductibles for most of the ACA programs were quite high, often running as much as $5000 (which, for what it’s worth, is the deductible on my own insurance program – buying a lower deductible is significantly more expensive than simply paying the higher deductible. Go figure.)

The high deductibles were a shock to many people who were used to more-traditional health insurance. They postponed some services and started looking for transparency of pricing for the more expensive services. It is no longer uncommon for a patient to ask for a prescription for an MRI that they can take to another provider across the street who will charge them half of what the hospital provider will. If you’re paying it out of pocket, you begin to pay attention to what you’re paying. I think we should applaud that increase in transparency.

To those points, Dr. Toby Cosgrove, CEO of Cleveland Clinic, recently noted:

The entire healthcare system will have less money coming into it – we are taking costs out, so will all hospitals.... Obamacare is accelerating the process.... but this is due to transparency of costs and consumer[s] with high-deductible plans. This is a huge social experiment involving almost 18% of GDP and 100% of people... this will take four to five years to shake out.”

Further, there were a lot of people who didn’t get Obamacare insurance in the first few months and had to wait until March or April for their insurance to kick in. Other people have lost their insurance inexplicably because insurers are losing control of their internal management systems amid all the turmoil. People are postponing what they can until their insurance kicks in or gets reinstated. Apparently, some of this has gotten sorted out in the second quarter, and healthcare spending is on a trajectory to the “new normal,” which may eventually be about 20% less than what we spend today.

Muddle Through Economy Redux

I still think the next shoe to drop may be in the third and fourth quarter when hospitals begin to realize that they have significant cash-flow problems. Estimates are that we have about 10% too many hospitals, and the creative destruction of the new healthcare system is going to relieve us of that excess. Only the strong and well-managed will survive. This is of course going to create turmoil in the whole healthcare employment world, etc., etc.

Further, Obamacare is the largest middle-class tax increase in history. Yes, enrollees are getting healthcare for their additional expenditures, but you get extra government services for an increase in regular taxes. Call it a premium or call it a tax, it still amounts to a reduction in disposable income for individuals and families. Tax increases have a negative effect on the economy equal to roughly three times their actual amount. We have gone over that research numerous times.

And that negative effect doesn’t come all at once but is actually spread out over about three years, so the Obamacare taxes will still be creating a headwind to growth this year and next.

Further, although the president has postponed some of the “features” of the ACA, such as the business mandates, they are going to kick in eventually. We’ve already seen a rather large rise in temporary employment as employers shed full-time employees so they don’t have to cover their insurance. We’re going to see more such unintentional consequences, because that’s just where the incentives are. This will of course create even more headwinds for growth and productivity.

We would have to achieve 3% GDP growth in each of the next three quarters simply to average 2% for 2014. If you go back and look at the chart on US real GDP growth, you will notice that we haven’t grown that consistently since the recovery began in 2009. GDP growth has been rather noisy.

We are at best in a slow-growth Muddle Through economy. And the problem is that consumers are getting hammered from all directions: incomes are roughly flat and core expenses are rising.

Returning to the BLS GDP report, we see that inflation was 1.3% in the first quarter as measured by personal consumption expenditures (PCE). One of the “checks and balances” I like to look at when thinking about PCE is what the Dallas Federal Reserve calls the “trimmed mean PCE inflation rate.” Basically they take all the components of inflation in the PCE (which is the Fed’s preferred measure of inflation) and remove the “outliers” (trimming them off, as it were) to smooth out the noise. And sure enough, when you go back and look at the one-month PCE inflation rates for the first quarter, 1.3% seems to be close enough for government work. But then when you look at the chart of what’s happened since then, you see a rather sharp rise in PCE. If that inflation shows up in the BLS statistics next quarter, in their first measure of Q2 GDP (which we will see in late July), it could reduce overall real GDP growth by about 1%. Just saying.

Sidebar: It is all well and good for Janet Yellen to talk about how noisy inflation is and therefore ignore it, but in the things that you and I buy there are what economists call “inelastic” items, which means that we have to buy them no matter what the price – things like food and gas and healthcare. We can talk about whether the overall inflation rate for the entire economy is low, but for the mass of consumers in the middle, inflation is running considerably higher than 1.3%.

All this is to say that while I don’t think the US will fall into an “official recession” next quarter, we are extremely vulnerable to “exogenous shocks.” If either China or Europe has a serious problem, or the price of oil increases dramatically for this or that geopolitical reason, then, with the economy flying barely above stall speed, it wouldn’t take much to push us into a recession. We need to have our antennae up in a world where the biggest bull market seems to be in complacency.

Let’s wrap this session up with a cautionary note from my friend Rich Yamarone (aka Darth Vader)

According to the latest data from the Bureau of Economic Analysis, there has never been a time in history that year-over-year gross domestic income has been at its current pace (2.6 percent) without the U.S. economy ultimately falling into recession. That’s more than 50 years of history, which is about as good as one could ever hope for in an economic indicator.

Stay tuned.

The Frontiers of Life Extension Science

Since we are on the subject of healthcare, let me throw in an additional “bonus note” that my friend Pat Cox, who writes Transformational Technology Alert for Mauldin Economics, sent out to the readers of his free technology updates. Pat and I have regular discussions about the latest discoveries on the very cutting edge of technology and especially biotechnology. This is one of the things that keeps me optimistic, because I think that in 10 to 15 years technology will have totally transformed our healthcare delivery systems and significantly reduced the cost in the system, because we will be healthier and there will be cures for some of the most expensive diseases – we’ll actually be fighting back against the ravages of old age. At least that’s my hope as I approach my 65^th birthday in a few months.

So let’s look at this fascinating and rather optimistic piece of research that Pat has come across. (More and more, biotechnology is coming to resemble the science fiction that I read.) By the way, if you like what you read, you can subscribe to get his regular updates for free at this link.

By Patrick Cox

In the article below, I discuss work on the frontiers of life-extension science, including the importance of growth differentiation factor 11 (GDF11), and my friendship with the brilliant writer Robert Heinlein.

There’s an obscure reference to me in Robert Heinlein’s (RAH) book To Sail Beyond the Sunset. It came about due to something I said to him in the home he built in Bonny Doon, California. RAH had asked me to write an article about him and his soon-to-be-published book, The Cat Who Walks Through Walls, for the Wall Street Journal.

So I chose the wine, and his wife Ginny cooked several meals that day as the conversation extended into the morning hours. Pixel, the cat that inspired the book title, was there as well. If you’re interested, I'm pretty sure the article I wrote can be found online if you search for my and his names.

The Cat Who Walks Through Walls is interesting for several reasons. One is that it may be viewed as a sequel to Heinlein's The Moon Is a Harsh Mistress, though it also continues story lines found in The Number of the Beast. As such, one of the main characters in the book is Lazarus Long, who first appeared in Methuselah’s Children. As the name of that book implies, it involves extremely long-lived characters.

Heinlein gave two explanations for his characters’ longevity. One was selectively bred genetics. The other was periodic blood transfusions from very young donors.

Of course, we’re talking about science fiction, so nobody really believed that young blood could extend lives. If they had, it would have certainly been a simple hypothesis to test. In fact, 73 years after Methuselah’s Children was serialized in Astounding Science Fiction, the experiment was performed last month at the Stanford University School of Medicine – using mice.

Interestingly, the senior author of the Stanford blood study, Tony Wyss-Coray, PhD, noted that the experiment could have been done 20 years ago. Actually, it could have been done long before that. The procedure was relatively simple.

The team gave 18-month-old mice components of blood from 3-month-old mice eight times in 24 days. Then they gave the aged mice a kind of rodent IQ or memory test, which showed significant improvements.

The overview of the study, published in the journal Nature, states:

As human lifespan increases, a greater fraction of the population is suffering from age-related cognitive impairments, making it important to elucidate a means to combat the effects of aging. Here we report that exposure of an aged animal to young blood can counteract and reverse pre-existing effects of brain aging at the molecular, structural, functional and cognitive level. Genome-wide microarray analysis of heterochronic parabionts – in which circulatory systems of young and aged animals are connected – identified synaptic plasticity–related transcriptional changes in the hippocampus of aged mice.

In other words, the brains of the older mice given transfusions of plasma (the cell-free portion of blood from the young mice) did not simply perform better, they exhibited physical signs of a reversal of aging. Clearly, this is a pretty big deal. To reiterate the last sentence of the summary: “Our data indicate that exposure of aged mice to young blood late in life is capable of rejuvenating synaptic plasticity and improving cognitive function.”

Many of the stories about the Stanford study focused on the likelihood that specific factors in the young blood responsible for the rejuvenation can probably be isolated and used on their own. A prime suspect is the protein expressed by the growth differentiation factor 11 (GDF11) gene. GDF11 protein production decreases with age; prior research has shown that it has rejuvenating effects in parts of the body other than the brain.

I’ve written several times in my weekly alerts, for example, about the Amy Wagers and Richard Lee Harvard experiment. Reported in Cell, it showed that age-related damage to heart muscle in older mice will reverse when GDF11 proteins are transferred from younger mice. This is of enormous interest to researchers because, as you probably know, heart muscle does not normally regenerate in older animals.

It’s not surprising, therefore, that Wyss-Coray is the cofounder of Alkahest, a biotech startup exploring the possibility of commercializing some therapy based on his experiments. I don’t think that Alkahest is likely to be the leader in this field, however.

The reason is that therapies based on the Wyss-Coray experiments would be less than optimal. If you are given an exogenous dose of a naturally occurring protein, it tends to upset the regulatory axis that balances all the interactive and complex forces at work in our bodies.

I’m convinced, therefore, that there are better ways to restore rejuvenating GDF11 to youthful levels. One way is to introduce youthful stem cells, engineered from the patient’s own induced pluripotent stem cells (iPSCs), which express GDF11 at high levels.

Induced Pluripotent Stem Cells

One of the most exciting developments in modern medicine is the creation of induced pluripotent stem (iPS) cells. As it happens, I’ve had skin cells taken from inside my left arm transformed into iPS cells by one of the companies in our portfolio. Those iPS cells are identical to the embryonic stem cells that I came from. Because they have my DNA, there’s no chance of immune rejection, which is one of the advantages they have over cells derived from embryonic stem cell lines.

My iPS cells were then engineered to become youthful heart muscle cells. Based on animal experiments, we have every reason to believe that those cells would become part of my body and repair any damage that my heart may have suffered. Here’s a shot of my youthful cardiomyocytes beating in the lab.

Those same iPSCs, however, could also be engineered to become the type of cell, already developed and patented, that produces high levels of GDF11. Placed into my circulatory system, they would replicate and produce their rejuvenating proteins permanently. This would eliminate the need for periodic transfusion or pills. Another method, owned by a different company in the portfolio, is to put DNA plasmids engineered to express GDF11 into a group of cells so that they permanently produce the protein.

This type of therapy is inevitable. Friends of mine who keep track of high-end anti-aging clinics tell me that extremely wealthy clients are paying for youthful blood transfusions right now. The cost, they tell me, is astronomical. Superior results, however, could be attained using induced pluripotent stem cells or DNA vaccines for far less money.

It’s ironic that most ancient cultures and religions seemed to treat young blood as a sacred symbol of power and life. Historically, there are many stories about victors and vampires who drank blood to acquire youth and strength. Ancient instincts were correct, however, in that youthful, healthy blood does have power, as the ancient kings and warlords of mythology believed.

There’s a race going on right now to see who delivers that power and life first. As Dr. Wyss-Coray noted in the paper about his experiment, “As human lifespan increases, a greater fraction of the population is suffering from age-related cognitive impairments, making it important to elucidate a means to combat the effects of aging.” Personally, I suspect that Alzheimer’s and other sources of cognitive impairments will be cured in the next decade. The human desire for increased health and time, however, is limitless, so we’ll continue to follow these life-extending biotechnologies closely as they develop.

(To learn more about Pat’s Breakthrough Technology Alert and other Mauldin Economics publications, click on this link, where you will find an offer to subscribe to all of our publications at a significant discount. This is a permanently low price, and the offer will go away after Monday.)

The Strategic Investment Conference Presentations

The first group of presentations and select videos from the 2014 Strategic Investment Conference is now available! Videos of two of our most popular speakers, Kyle Bass and David Rosenberg, are available, as well as numerous other presentations and summaries. If you are a Mauldin Circle member, you can access the videos by going to www.altegris.com to log in to your “members only” area of the Altegris website. Upon login, click on the “SIC 2014” link in the upper-left corner to view the videos and more. If you have forgotten your login information, simply click “Forgot Login?” and your information will be sent to you.

If you are not already a Mauldin Circle member, the good news is that this program is completely free. In order to join, you must, however, be an accredited investor. Please register here to be qualified by my partners at Altegris and added to the subscriber roster. Once you register, an Altegris representative will call you to provide access to the videos, presentations, and summaries from selected speakers at our 2014 conference.

Nantucket, New York City, Maine, and San Antonio

What would be considered a normal schedule for me would see me doing all of the above-named cities in less than a month, rather than according to my current travel schedule, which lets me spread them out over three months! I will be in Nantucket at a private conference in the middle of July, then in New York July 13-16. Then, as always, I (along with my son Trey) will be in Grand Lake Stream, Maine, the first Friday in August. I think this will be my eighth annual summer expedition to northern Maine and Leen’s Lodge for David Kotok’s big to-do. Then in the middle of September I will join a number of friends and a great roster of speakers at the Casey Research Conference in the Hill Country outside of San Antonio. I’m sure there will be other trips here and there, but I am anticipating being at home a little more for the next few months.

One of the benefits of being home is that I can get into a regular routine at the gym. I and a partner are working with a personal trainer at the gym in our building. His training style is a little different for us and has me doing things that I quite frankly haven’t thought about doing in 40 years. Wind sprints, steps, all sorts of novel ways to torture the body and get your heart rate up, and yes, old-fashioned weights now and then. This morning he introduced me to boxing gloves. The last time I had on boxing gloves, I was a sophomore in high school when our gym coach had us put on gloves and I went into a ring for about three minutes. I took them off with a vow to never touch them again. It was an exhausting three minutes trying to avoid getting pummeled. At least this morning the big brute wasn’t hitting back, but it was quite the workout. I really do need to get in better shape.

I’m cooking for a group of friends and family, so I need to hit the send button and get the prime rib started. Have a great week.

Your wishing I could avoid the healthcare system altogether analyst,

John Mauldin, Editor
subscribers@mauldineconomics.com

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The Supreme Court on Monday dealt a setback to the Affordable Care Act, ruling that employers with religious objections can refuse to pay for contraception.

In a 5-4 decision handed down by conservative justice Samuel Alito, the court sided with arts and crafts chain Hobby Lobby over the federal government. The decision could lead to other challenges from for-profit corporations who seek to refuse coverage for other medical procedures at odds with religious beliefs. 

Supporters of the ACA's mandate called it a big setback to the law and to women's health in general. Opponents hailed the win as a victory for religious liberty. 

"Today’s Supreme Court decision makes clear that the Obama administration cannot trample on the religious freedoms that Americans hold dear," said Senate Minority Leader Mitch McConnell, who was among 15 members of Congress who filed an amicus brief in the case.

"Obamacare is the single worst piece of legislation to pass in the last 50 years, and I was glad to see the Supreme Court agree that this particular Obamacare mandate violates the Religious Freedom Restoration Act."

The rule at stake under the health-care overhaul is a provision in the Affordable Care Act that requires all new health insurance plans to pay for contraceptives. The issue is whether for-profit corporations — in this case, the lead plaintiff Hobby Lobby Inc. — can refuse to provide all or some contraceptive services on the grounds they are owned by religious families.

Both Hobby Lobby, an arts and crafts chain, and Conestoga Wood Specialties, which makes wood cabinets, challenged that the birth-control mandate was unconstitutional because it violates the Religious Freedom Restoration Act. They said the requirement to cover contraceptives like Plan B and Ella violates their religious liberty, since they equate use of the drugs to abortion.

In the majority opinion of the court, Alito emphasized its ruling was narrow in scope: 

"As this description of our reasoning shows, our holdingis very specific. We do not hold, as the principal dissentalleges, that for-profit corporations and other commercialenterprises can 'opt out of any law (saving only tax laws) they judge incompatible with their sincerely held religious beliefs.'

"Nor do we hold, as the dissent implies, that such corporations have free rein to take steps that impose 'disadvantages ... on others' or that require 'the general public [to] pick up the tab.' And we certainly do not hold or suggest that 'RFRA demands accommodation of a for-profit corporation's religious beliefs no matter the impact that accommodation may have on ... thousands of women employed by Hobby Lobby.

"The effect of the HHS-created accommodation on the women employed by Hobby Lobby and the other companies involved in these cases would be precisely zero. Under that accommodation, these women would still be entitled to all FDA-approved contraceptives without cost sharing."

Amid high-profile controversy two years ago, the Obama administration crafted exemptions for religious-affiliated organizations and other nonprofits. At issue was whether a for-profit corporation has religious rights under the Constitution, furthering the debate over so-called corporate personhood.

In addition to whether for-profit corporations could claim religious exemptions, the Supreme Court also wrestled with two other questions: Does the birth-control mandate of the ACA "substantially burden" the exercise of religion? And if it does, does the government have a compelling interest to do so?

Some of the liberal-leaning justices worried during oral arguments in March that a favorable ruling for Hobby Lobby could lead to more challenges of the law, including provisions that cover blood transfusions or vaccinations. The four liberal justices — Justices Elena Kagan, Sonia Sotomayor, Ruth Bader Ginsburg, and Stephen Breyer — dissented on Monday. Justices Antonin Scalia, Clarence Thomas, and Anthony Kennedy, along with Chief Justice John Roberts, joined Alito in the majority opinion.

This is the most significant Obamacare-related case argued before the Supreme Court since the high court upheld the law's individual insurance mandate two years ago, in the heat of the 2012 presidential election. In that decision, Roberts cast the deciding vote to preserve the heart of the law and the way for which it is paid.

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In perhaps the biggest case of its term, the Supreme Court ruled Monday that "closely held," for-profit corporations like Hobby Lobby Inc. cannot be compelled to pay for employees' contraception if they object on religious grounds. 

So, what is a closely held corporation? 

The Internal Revenue Service has spelled it out in plain terms in a Q&A on its website. Generally, it fits two descriptions:

• Has more than 50% of the value of its outstanding stock owned (directly or indirectly) by five or fewer individuals at any time during the last half of the tax year; and
• Is not a personal service corporation.

According to the IRS, more than 90% of all businesses in the U.S. fit the definition of "closely held," a statistic House Minority Leader Nancy Pelosi cited in her denunciation of the decision. 

"Although the Court restricted their ruling to ‘closely-held’ companies, this ruling will immediately affect the lives of millions of women across the country. Over 90% of America’s businesses are ‘closely-held,’ including such large employers as Koch Industries and Bechtel," Pelosi said in a statement.

"Women should not be forced to jump through extra hoops to secure the fundamental health care they need.  Allowing employers and CEOs to limit the health care available to employees is a gross violation of their workers’ religious rights. It’s just not her boss’s business. No employer should have the right to limit the health choices of its employees, male or female."

Publicly traded companies, while making up a smaller share of businesses overall, account for almost half of employment in the U.S. Still, closely held companies comprise 52% of the American workforce, according to a 2002 study from New York University.

Conservative Justice Samuel Alito, who wrote the 5-4 majority opinion in the case, took pains to emphasize that the court's decision was narrow in scope. 

From the decision:

"We do not hold, as the principal dissent alleges, that for-profit corporations and other commercial enterprises can 'opt out of any law (saving only tax laws) they judge incompatible with their sincerely held religious beliefs.'

"Nor do we hold, as the dissent implies, that such corporations have free rein to take steps that impose 'disadvantages ... on others' or that require 'the general public [to] pick up the tab.' And we certainly do not hold or suggest that 'RFRA demands accommodation of a for-profit corporation's religious beliefs no matter the impact that accommodation may have on ... thousands of women employed by Hobby Lobby.

"The effect of the HHS-created accommodation on the women employed by Hobby Lobby and the other companies involved in these cases would be precisely zero. Under that accommodation, these women would still be entitled to all FDA-approved contraceptives without cost sharing."

Alito also added the decision would not give for-profit companies an opening to prevent coverage of other, non-contraceptive benefits — though nothing is stopping potential future lawsuits. 

"This decision concerns only the contraceptive mandate and should not be understood to hold that all insurance-coverage mandates, e.g., for vaccinations or blood transfusions, must necessarily fall if they conflict with an employer’s religious beliefs," Alito wrote.

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The White House on Monday said President Barack Obama disagreed with the Supreme Court's decision that closely held corporations cannot be forced to pay for employees' contraception if they object on religious grounds. At his daily briefing with reporters, White House press secretary Josh Earnest said the ruling put women's health in danger. 

"Today's decision jeopardizes the health of women that are employed by these companies," Earnest said, noting the "constitutional lawyer in the Oval Office disagrees" with the 5-4 decision. 

Earnest also said the president will work to ensure women who work at companies affected by the ruling are covered for contraception. 

"We will work with Congress to make sure that any women affected by this decision will still have the same coverage of vital health services as everyone else," said Earnest.

When asked if Obama would look at executive actions if Congress doesn't act, Earnest said it's too soon to tell. 

"We'll consider whether or not there's some opportunity for the president to take some sort of action that would mitigate this decision," Earnest said. 

Obama's use of executive actions has come under fire from conservatives. Last week, House Speaker John Boehner announced his plan to sue Obama over executive orders. 

In the 5-4 decision handed down by conservative justice Samuel Alito, the court sided with arts and crafts chain Hobby Lobby over the federal government. The decision could lead to other challenges from for-profit corporations who seek to refuse coverage for other medical procedures at odds with religious beliefs. 

Supporters of the ACA's mandate called it a big setback to the law and to women's health in general. Opponents hailed the win as a victory for religious liberty. 

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WASHINGTON (Reuters) - Online insurance marketplaces created under President Barack Obama's signature healthcare law are struggling to verify whether Americans who applied for government subsidies to purchase health insurance are actually qualified to receive them, a federal watchdog agency said on Tuesday.

The Department of Health and Human Services Office of the Inspector General said in two reports that some "internal controls" were ineffective in verifying eligibility at the marketplaces run by the federal government, California, Connecticut and some other states.

To qualify for insurance subsidies, applicants must enter income data, Social Security numbers and other information into the online systems. The maximum household income to qualify for a subsidy is four times the federal poverty level, or about $94,200 for a family of four, and subsidies increase as income levels fall.

"The deficiencies in internal controls that we identified may have limited the marketplaces' ability to prevent the use of inaccurate or fraudulent information when determining eligibility of applicants for enrollment in qualified health plans," the inspector general said.

The reports mark the second potential setback in two days to the 2010 healthcare law after the U.S. Supreme Court on Monday limited its mandate to provide universal contraception coverage for women.

The HHS inspector general's findings prompted fresh complaints from Republicans in Congress, whose attention in recent weeks had been redirected to other issues in the runup to November's mid-term elections.

"When Obamacare was passed, its chief architects told us they would have to pass the bill to find out what was in it," said Senator Orrin Hatch, the top Republican on the Senate Finance Committee. "Today's report confirms what we knew was not included: safeguards to protect hard-earned taxpayer dollars from an incompetent bureaucracy."

The California marketplace had difficulties verifying citizenship and lawful presence, while the federal marketplace had difficulty verifying Social Security numbers, the inspector general said.

A companion report found that the federal and some state insurance marketplaces were unable, in their early months of operation, to resolve most inconsistencies between applicants' self-supplied information and data received through other federal sources, most commonly citizenship and income levels.

Under the Affordable Care Act, applicants whose incomes are below certain levels can qualify for taxpayer subsidies for health insurance purchased on the exchanges.

The federal marketplace was unable to resolve 2.6 million of 2.9 million inconsistencies as of the first quarter of 2014, because of systems not fully operational from October through December last year.

"These inconsistencies pertained to citizenship, national status, and lawful presence; income and employer-sponsored minimum essential coverage," the inspector general said.

On Monday, the Supreme Court ruled 5-4 that owners of private companies can object on religious grounds to an Affordable Care Act provision that requires insurance covering certain kinds of birth control for women, but this applies only to a number of small family or closely held companies. It means perhaps several thousand female employees who receive health insurance from these firms may have to obtain some forms of contraception coverage elsewhere.

(Reporting By David Lawder; editing by Gunna Dickson)

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The Affordable Care Act, or Obamacare, is wreaking havoc with our view of the American economy.

This year, every revision of gross domestic product – our measure of GDP – has provided a new read on what Obamacare is doing for the economy. Initially, the health insurance program appeared to give an enormous boost to healthcare spending in the US, indicating that Americans were rushing in droves to sign up.

Most recently, US healthcare spending for the first quarter of 2014 went from unbelievably strong to unbelievably weak. "The near-record setting 9.9% increase in health spending shown in the advance Q1 report has been revised to a 1.4% decline," Goldman Sachs analysts summed up in a report today.

The downward revision in itself was not a surprise to most analysts. The size was.

"The revision to Q1 was even larger than we expected," admitted Goldman Sachs analysts.

Spending on health services has been a bit of a roller coaster over the last several months. The report also found that personal income and spending data for April and May show "nearly flat real growth in health spending".

There might be a few reasons for this back and forth in healthcare spending, says Goldman.

1. Hoping to avoid insurance disruptions related to Affordable Care Act, some Americans probably scheduled their elective and less urgent procedures in the last few months of 2013.

2. With patients switching to new insurance plans – more insurance disruption – payments to healthcare providers might have been delayed. As a result, they might be counted among healthcare spending in the second quarter.

3. Timing. The rolling deadlines for Obamacare kept rolling past the traditional financial cutoffs for measuring economic activity. "Many enrolees waited until the 31 March enrollment deadline, which meant in most cases they began to receive benefits only in April or even May," notes Goldman. The healthcare.gov did see a surge of visits and sign-ups in the weeks leading up to the enrolment deadline. In fact, about 900,000 additional enrolees signed up for a plan in the first two weeks of April after they had trouble signing-up by the original 31 March deadline.

4. As always, blame the weather. In this case, the culprit may be "a milder than usual flu season". If you didn't get sick, maybe you hurt the economy by spending less on healthcare.

5. Personal spending. "It is possible that the difference is due to other private-sector forces (eg employer-sponsored insurance or out-of-pocket spending) that are harder to observe on a month-to-month basis," explains the Goldman report.

As number of the health plans sold through the Affordable Care Act exchanged came with high deductibles that the consumers have to meet before their plans kick in, out-of-pocket spending could definitely play a role. Especially, since in the beginning of 2014, both doctor and hospital spending were running at more than twice their pre-Obamacare trend, according to Ian Shepherdson, chief economist at Pantheon Macroeconomics.

So what's next? More revisions.

"[T]he estimates could simply be revised higher once the Quarterly Service Survey data for [the second quarter of the year] becomes available in September," says Goldman. Quarterly Service Survey provides estimates of revenue and expenses for select industries, one of which is healthcare.

This article originally appeared on guardian.co.uk

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The Supreme Court ruled earlier this week in Burwell v. Hobby Lobby that closely held corporations can refuse on religious grounds to pay for contraception as mandated by the Affordable Care Act. Previously, only churches and religious nonprofits had exemption from the health law's contraception mandate.

The Fortune 500 companies that had actively voiced support for the landmark 2010 Citizens United case, which ruled that corporations have a First Amendment right to free speech, were notably absent from this debate over a corporation's right to free expression of religion, as Slate reported earlier this year.

That might be because the Hobby Lobby ruling will do more harm than good to corporate America. Here are three reasons why.

Corporations Might Have An Identity Crisis

A corporation is not a person. It is an abstract legal entity that is separate from the individual owners and shareholders that comprise it.

Legally, corporations can do things that a person can do, like enter into contracts or pay taxes. The Hobby Lobby case entered into murky territory regarding the rights and responsibilities of a corporation: Can a corporation have religious beliefs like an individual person?

The ruling doesn't say that the corporation itself has religious beliefs, but it allows the corporation to avoid compliance with federal law based on the beliefs of its owners/shareholders. This muddies the traditional legal definition of a corporation, which separates the corporate entity from the individuals who own and manage it.

The Court's decision also has the potential to complicate corporate governance, according to an amicus brief filed by the U.S. Women's Chamber of Commerce and the National Gay & Lesbian Chamber of Commerce. The brief argues that religious discussions could create a new source of conflict among shareholders, potentially pushing out those with minority views.

Even in the best case scenarios, corporations may be forced to invest time and money figuring out how to navigate new questions about their "official" religious expression.

The Cost Burden Could Shift To Taxpayers And Insurers

With employer-sponsored health insurance, both the employer and the employee pay for the employee's health benefits. The employer negotiates a per-employee premium with the insurance company and the employee pitches in by also paying monthly premiums and co-payments for office visits and prescription medications.

The Affordable Care Act mandated that all insurance plans need to cover certain FDA-approved contraception methods. Even though the Court's Hobby Lobby decision means the company doesn't have to pay for contraception through its employer-sponsored health insurance plans, many of the company's employees may still want access to the birth control that they legally have a right to.

What does that mean? Either the government or health insurance companies will have to pick up the tab.

For religious organizations that are already exempt from the mandate, the insurance company basically eats the cost. The onus is on the insurer to notify women in the health plan that it will be "providing them separate no-cost payments for contraceptive services for as long as they remain enrolled," according to a press release from the Department of Health and Human Services.

No word on what happens if a private insurer is religiously opposed to contraception, but the other option, proposed by Supreme Court Justice Samuel Alito, is that the government provides the contraception free of charge.

Paying For Contraception Costs Way Less Than An Unintended Pregnancy

The U.S. government already shoulders a tremendous burden when it comes to paying for both family planning and unintended pregnancies (when a woman becomes pregnant even though she wasn't planning to).

The government spent $12.5 billion on births resulting from unintended pregnancies nationwide in 2008 through publicly funded programs like Medicaid, according to a report from The Guttmacher Institute.

Currently about 3.4 million, or half of pregnancies in the United States each year are unintended, and the rates are highest among low-income and minority women. Contraception plays a significant role in reducing unintended pregnancies.

The Guttmacher Institute reports notes that two-thirds of women who are at risk of getting pregnant take birth control "consistently and correctly." The at-risk women who do not use birth control, meanwhile, account for more than half of all unintended pregnancies. While some people may voluntarily forego contraception, the population of women who do not use birth control may well grow on the heels of the Hobby Lobby decision.

Making it more difficult for women to obtain contraception won't make them less likely to need it, but it may make them less likely to use it — or less likely to seek employment at whatever company chooses to make things more complicated.

Given that the average woman spends three decades trying to avoid an unintended pregnancy, the widespread access to contraception mandated by the ACA — and hobbled by this latest decision — was designed as a way to reduce costs for individuals and taxpayers as a whole.

The financial effect of the decision on businesses won't be known for some time, and that's part of the problem. "The court, I fear, has ventured into a minefield," Supreme Court Justice Ruth Bader Ginsburg warned in her dissent, noting that the decision was "bound to have untoward effects."

It's no wonder corporate America is not lining up behind Hobby Lobby to applaud.

SEE ALSO: Supreme Court Says Small, Private Companies Don't Have To Provide Contraception

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This week, in the Hobby Lobby case, the Supreme Court ruled that a religious employer could not be required to provide employees with certain types of contraception. That decision is beginning to reverberate: A group of faith leaders is urging the Obama administration to include a religious exemption in a forthcoming LGBT anti-discrimination action.

Their call, in a letter sent to the White House Tuesday, attempts to capitalize on the Supreme Court case by arguing that it shows the administration must show more deference to the prerogatives of religion.

"We are asking that an extension of protection for one group not come at the expense of faith communities whose religious identity and beliefs motivate them to serve those in need," the letter states.

The Hobby Lobby decision has been welcomed by religious-right groups who accuse Obama of waging a war on religion. But Tuesday's letter is different: It comes from a group of faith leaders who are generally friendly to the administration, many of whom have closely advised the White House on issues like immigration reform. The letter was organized by Michael Wear, who worked in the Obama White House and directed faith outreach for the president's 2012 campaign. Signers include two members of Catholics for Obama and three former members of the President’s Advisory Council on Faith-Based and Neighborhood Partnerships.

"This is not an antagonistic letter by any means," Wear told me. But in the wake of Hobby Lobby, he said, "the administration does have a decision to make whether they want to recalibrate their approach to some of these issues."

Last week, the administration announced it would issue an executive order banning federal contractors from discriminating on the basis of sexual orientation or gender identity, a reform long sought by gay-rights groups. Such an order would essentially impose on contractors the provisions of the proposed Employment Non-Discrimination Act, which passed the Senate but hasn't been taken up by the House. 

But the text of the order has not yet been released, so it is not known whether it will include a religious exemption. (A White House spokesman declined to discuss the order.) ENDA, the proposed federal legislation, does include such an exemption: It specifically does not apply to a broad array of faith-based organizations, from churches to religious-service groups to religious newspapers, meaning those groups could still decline to hire gay or transgender people if they believe it conflicts with their faith. The exemption was included despite fears from some LGBT activists that it could constitute a license to discriminate.

Balancing religious freedom with other concerns, be they gay rights or health-care mandates, is difficult, said Stephen Schneck, director of the Institute for Policy Research and Catholic Studies at Catholic University and a signatory to the letter. The faith community simply wants to make sure its side is heard and respected as the administration tries to thread this delicate needle.

"It would be nice if we had just a little bit more leverage," said Schneck, a onetime cochair of Catholics for Obama. "I am a very strong supporter of LGBT rights, and I am really excited about the prospect of extending provisions against discrimination in federal contracts. But I am also aware that this is an issue that provokes real differences among some of the most important religious organization on the front lines of providing care for the poorest and most vulnerable." Those groups, he said, need to be allowed to work with the government while following the dictates of their faith.

To these religious leaders, Hobby Lobby ought to prompt the White House to reexamine the way it weights religious rights against other priorities. Liberals opposed to the decision, on the other hand, argue it creates a slippery slope to more and more carve-outs from important legislation for claims based on faith. This executive order could be the next battleground for those competing points of view.

Religious Exemption Letter to President Obama

SEE ALSO: Barack Obama Got Destroyed At The Supreme Court

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One of the big criticisms of Obamacare was that it would discourage job creation, because employers would find the cost and "uncertainty" too burdensome.

Welp, that's not happening.

Here's a look at average monthly job growth, via Deutsche Bank's Torsten Slok. Up until this year, job growth average between 174,000 and 194,000 jobs per month.

This year after today's great report? A massive jump to 231,000 jobs per month.

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