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The latest news on Obamacare from Business Insider

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    Harry Reid

    Democratic Senate Majority Leader Harry Reid might have saved Obamacare by going "nuclear."

    Last November, Reid pushed the button on the so-called "nuclear option," dramatically changing Senate filibuster rules to get more of President Barack Obama's judicial and executive nominees approved. Reid's rule change allowed Obama's nominees to be approved by a simple majority vote rather than with the support of 60% of senators, which prevented the Republican minority from blocking the president's picks.

    And it turns out, Reid's maneuvering might become the White House's most effective weapon as it faces the most serious legal challenge to the Affordable Care Act in more than two years.

    "It's the first big case where the effects of the nuclear option could be felt," one Senate Democratic aide told Business Insider last week.

    Here's how Reid's senatorial nuke could theoretically save Obamacare. Last week, a three-judge panel on the D.C. Circuit Court ruled that a 2012 IRS regulation that implements key subsidies under the law is invalid, in the case of Halbig v. Burwell. The decision has the potential to affect more than five million people who have been given tax credits when purchasing health insurance through the federal exchange.

    But the Department of Justice is appealing the panel's decision, requesting an "en banc" review by the full D.C. Circuit Court. The math for the Obama administration is better in this situation — the court splits 7-4 in favor of Democratically appointed judges, because of Reid's rule change. Because of this breakdown, legal experts believe the D.C. court will reverse the Halbig decision if it grants the en banc review.

    Reid's decision to go nuclear came after Obama mounted an unusual public campaign to get three of his judicial nominees appointed to the U.S. Court of Appeals for the D.C. Circuit. After months of threats, Reid responded to the president's push by instituting the rules change. Those three D.C. Circuit Court judges have since been confirmed — and they're the reason there's a Democratic majority on the court that would most likely reverse the Halbig decision in the en banc review.

    "Adding Democratically appointed judges who are less enamored of a literalist approach to statutory interpretation makes it much more likely that the court will take the case en banc," Nicholas Bagley, a law professor at the University of Michigan and contributor to The Incidental Economist, told Business Insider, adding, "The nuclear option thus matters a great deal for the moment."

    The D.C. Circuit Court, considered the second-most powerful court in the nation after the Supreme Court, is of particular importance to Obama's second-term agenda — and his legacy. The court has a vast jurisdiction over the federal government and thousands of regulations, rules, and executive actions from more than 400 administrative agencies. The Halbig case is viewed as the most significant case yet to potentially come before the new D.C. Circuit Court's split. 

    In fact, some opponents of the president's signature healthcare law believe Reid's decision to go nuclear was specifically designed to protect Obamacare from legal challenges.

    "There has been speculation they did that because of Halbig," Michael Cannon, the director of health policy at the Cato Institute and one of the key architects of the Halbig lawsuit, told Business Insider in an interview on Friday. 

    "I have no basis for evaluating those claims and that speculation, other than to say that adhering to the law as written would prove such a threat to the law itself and the goals of Senate Democrats and the president. These lawsuits are probably reason enough for them to pull the trigger on the nuclear option."

    The D.C. Circuit Court's decision in Halbig v. Burwell wasn't the only recent ruling in a legal challenge to Obamacare that could prove crucial to the law's future.

    Last Tuesday, the same day Halbig was announced, the Fourth Circuit Court of Appeals in Virginia came to the opposite conclusion and ruled the regulation allowing subsidies for people buying health insurance through federal exchanges was valid. These dueling rulings mean Reid's work to fill the D.C. Circuit with Democratic judges could prevent the challenges to the regulation on subsidies from reaching the Supreme Court, which is far less predictable and is divided 5-4 in favor of Republican appointees. 

    If the full D.C. Circuit Court panel reverses the Halbig decision, it will be in agreement with the Fourth Circuit Court ruling. In this case, legal experts say, the Supreme Court would be much less likely to step into a situation in which there is no dispute at the lower-level courts.

    Reid Obama HugHowever, all of Reid's maneuvering doesn't guarantee the legal challenges to Obamacare won't make it to the Supreme Court. And, as Bagley put it, the rule changes "won't make a lick of difference" if the case goes to the higher court. 

    Therein lies the caveat: If the case does reach the Supreme Court, all bets are off, because it will be up to an unpredictable court. But for now, Reid has made the odds of the law's survival in the federal-court system a little better.

    Jonathan Adler, a law professor at Case Western Reserve University in Ohio and another conservative legal scholar behind the Halbig challenge, acknowledged that Reid and Obamacare supporters may think the nuclear option gave them a win. However, he also argued the ultimate outcome was still uncertain.  

    "Sen. Reid certainly thinks the nuke option helps the government, and in a case this politically charged it might," Adler said. "I guess we'll see."

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    Barack Obama smile

    Projected premium increases for health insurance in the individual market have averaged about 7.5% in 27 states measured so far plus the District of Columbia, according to a new report from PricewaterhouseCoopers.

    Though the projections widely vary from state to state, the average increase is far less than the doomsday scenarios from certain health industry officials — and critics of the law, who said premiums could "double" or even "triple" in certain parts of the country in the second year of the Affordable Care Act.

    The map below, from PwC, shows the wide variety so far of premium hikes that insurers have submitted to state regulators:

    Obamacare map

    Health insurance premiums rise every year. But former Secretary of Health and Human Services Kathleen Sebelius told Congress earlier this year she was hopeful premium increases would grow more slowly than they had in the past.

    According to a study released by the Commonwealth Fund, which supports the Affordable Care Act, individual health insurance premiums rose by more than 10% on average in the three years before President Barack Obama signed the Affordable Care Act into law.

    In 2008, according to the study, premiums grew by an average of 9.9%, by 10.8% the following year, and by 11.7% in 2011. According to the study, there was also considerable variation across states. For example, in 2008, premiums increased by about 3% in Iowa, compared with about 20% in Connecticut. 

    The firm Avalere released a report in June projecting premiums would rise about 8% for an average 40-year-old, non-smoker.

    Over at The New Republic, Jonathan Cohn explains some of the likely reasons for the premium hikes. First and foremost is how actively state officials have worked in implementing the law. California, for example, has reported a weighted average increase of 4.2%. It's generally seen as a bellwether for the law as a whole, and state officials have been eager to implement it.

    Officials Florida, on the other hand, have actively opposed the law. The Republican-led state government has not expanded the federal Medicaid program under Obamacare. And in 2013, Florida Gov. Rick Scott signed a law in 2013 that significantly rolls back the state's authority to review rate increases. Last week, Florida Blue, Florida Blue, the state’s largest health insurer, said it would increase premiums by an average of 17.6% for Obamacare plans.

    "No one can claim in good conscience that a 10 percent rate increase or more would signal the advent of something new and unprecedented," said Greg Mellowe, policy director of consumer group Florida CHAIN, told Kaiser Health News. "For years, this was standard practice in Florida."

    SEE ALSO: We Just Got More Good News About The 'Biggest Fiscal Development' Of The Past 3 Decades

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    Three Doctors Surgeons In Scrubs Washing Hands

    The primary reason for the incredible slowdown in healthcare spending growth has been due to a sluggish economy, according to a new study from Northwestern University researchers.

    The study, published in Health Affairs this week, suggests that as the economy continues to pick up steam, healthcare costs will also likely grow at higher rates than they have been for the past few years.

    The primary driver of future debt and deficits in recent projections has been the growth of federal healthcare spending, something that has alarmed economists as a wave of baby boomers retires and more people are added to the Medicare and Medicaid rolls. 

    But over the last four years, healthcare spending has grown at a historically slow rate. Economists have credited the Affordable Care Act in part, as well as other reforms. But according to the new study, the recession and struggling economy together accounted for around 70% of the slowdown in healthcare spending.

    "By exploiting regional variations in the severity of the slowdown, we determined that the economic slowdown explained approximately 70% of the slowdown in health spending growth for the people in our sample," wrote the study's authors — David Dranove, Craig Garthwaite, and Christopher Ody.

    "This suggests that the recent decline is not primarily the result of structural changes in the health sector or of components of the Affordable Care Act, and that — absent other changes in the health care system — an economic recovery will result in increased health spending."

    Add the Northwestern study to a growing list of divergent analyses on the topic. Last year, researchers at Harvard University concluded the economy was not primarily responsible for the healthcare spending slowdown, providing evidence the trend could continue. The Kaiser Family Foundation found, however, that the economic downturn was responsible for about 77% of the health spending slowdown.

    The Northwestern study relied on different methodology and techniques to arrive at its conclusion. It analyzed data from the Health Care Cost Institute of 47 million Americans who had employer-sponsored health insurance. 

    The researchers compared healthcare spending trends from 2007-09 and 2009-11 in metropolitan areas that were hit particularly hard by the recession (like Las Vegas) and those that weren't (like Dallas). It found that in places like Las Vegas, in which there was a 5.6% employment-to-population decline from 2009-11, health spending only grew 5.4% from 2007-11. In Dallas, which saw a 3% employment-to-population decline, healthcare spending exploded by 28%.

    Here's a chart showing that effect:

    Healthcare spending

    In their conclusion, the researchers warn their study does not mean spending will automatically increase, as reforms contained in the Affordable Care Act and elsewhere in the healthcare system could offset future growth. 

    There are also a couple of caveats — even if only 30% of the slowdown is due to reforms, that's still a significant development.

    Peter Orszag, the former director of the Office of Management and Budget, also pointed out a potential flaw — it only addresses people who have employer-sponsored insurance, and not Medicare. Medicare has seen extremely slow cost growth since the Affordable Care Act was passed — enough to extend the projected life of its major trust fund by at least 13 years.

    "What this study doesn't address is Medicare, where the deceleration can't be explained by the economy," Orszag said in an email. "That's why I keep harping on Medicare as a better indicator of potential structural change than either total or commercial spending — Medicare is not strongly influenced by the economy and its enrollment is growing gradually, not in a step-function as the exchanges and Medicaid eligibility ramp up." 

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    Antonin Scalia

    Subscribers to a particularly stringent legal theory pose the greatest challenge to the Affordable Care Act (ACA), better known as Obamacare, Jeffrey Toobin writes in The New Yorker

    Opponents have pointed to one line in the law's text stating that healthcare subsidies are to be made available through exchanges, or marketplaces, "established by the State." But since many states never created their own online healthcare exchanges, the Obama administration created a federal exchange at to serve individuals in those states.

    Some members of the legal community who agree with a legal theory known as textualism are arguing that the federal exchange is not authorized because the law only explicitly mentions state exchanges. In a victory for textualists, the U.S. Court of Appeals for the D.C. Circuit ruled in a 2-1 decision in July that ACA health insurance subsidies are invalid in 36 states with federal health insurance marketplaces.

    The textualist theory, championed by U.S. Supreme Court Justice Antonin Scalia, stresses that courts should interpret laws based solely on their text, regardless of the true intention of legislators who passed the laws in the first place, The New Yorker reported. Critics of textualism, like chief judge on the second circuit Robert A. Katzmann, argue that when a law's text is ambiguous judges should then consider the greater picture of what legislators in Congress have said in debates and committee reports. But Scalia is against any such interpretation beyond the text of the law itself.

    "As a textualist, Justice Scalia totally rejects reliance on legislative history or legislative intent,"wrote Claremont McKenna College Professor Ralph A. Rossum in his essay titled, The Textualist Jurisprudence of Justice Scalia. "He invariably criticizes his colleagues for turning to committee reports, or even floor debates, to ascertain what a law means." To Scalia and textualists like him, judges should "interpret the text alone and nothing else. The law should be understood to mean what it says, and say what it means," Rossum added.

    The benefit of the textualist theory, in Scalia's eyes, is that it prevents judges from being impacted by bias that can plague politically-charged issues like the Affordable Care Act. "Now the main danger of the Constitution — or, for that matter, in judicial interpretation of any law — is that the judges will mistake their own predilections for the law," said Scalia in a 1988 address at the University of Cincinnati. 

    SEE ALSO: The Story Of Why One Of America's Most Renowned Judges Is Feuding With Antonin Scalia

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    The historic slowdown in healthcare spending growth over the past few years will come to an end in 2014, according to a new report from actuaries at the Centers for Medicare and Medicaid Services (CMS) released Wednesday.

    For year, primary driver of future projected debt and deficits has been the growth of federal healthcare spending, something that has alarmed economists as a wave of Baby Boomers continues to retire and more people are added to the Medicare and Medicaid rolls. 

    But over the past four years, healthcare spending has grown at a historically slow rate — a credit to reforms in the Affordable Care Act and elsewhere, as well as a sluggish economy. The spending slowdown has lasted longer than many experts predicted.

    But by 2023, spending on healthcare will amount to about 19.3% of the nation's economy, according to the new CMS report, which was published in the journal Health Affairs on Wednesday.

    The report projects spending on healthcare will increase about 6% each year from 2015-23, a marked increase from below 4% in each of the past four years. The increase, however, is slightly lower than the historical average growth of 7.2% annually from 1990-2008, a fact the Obama administration emphasized in calling the report "encouraging."

    Overall, spending on healthcare will rise more than 1% faster than GDP.

    The chart below shows the growth rate of national health expenditures vs. the growth of GDP. The arrow signifies the point upon which the slowdown will end:

    Health spending

    The actuaries said the primary drivers of the tick upward in healthcare spending would be increased coverage under the Affordable Care Act's expansion of the federal Medicaid program, an aging economy that keeps adding itself to the Medicare and Medicaid rolls, and an improving economy.

    The actuaries estimated that in total through private insurance plans and through Medicaid expansion, more than 17 million people would be added to insurance rolls and Medicaid by the end of next year.

    "The period in which healthcare has accounted for a stable share of economic output is projected to end in 2014, primarily because of the coverage expansions of the Affordable Care Act," the report read.

    By 2023, national healthcare spending will total about $5.2 trillion, the report said, an increase from $2.9 trillion over the previous decade.

    Some observers were quick to point out some hidden positives in the report that were rather obscured by its top lines. The actuaries' estimate of healthcare spending in the year 2019, for example, is now more than $500 billion lower than what it was four years ago, Kaiser Family Foundation senior vice president Larry Levitt pointed out on Twitter. And Medicare spending growth is projected to peak in 2020, as the swath of Baby Boomers retiring begins to taper off.

    The White House said the long-term trends on healthcare spending growth remain "encouraging." In an analysis, Jason Furman, the Chairman of the Council of Economic Advisors to President Barack Obama, said that if even one-third of the current slowdown in healthcare spending persists, it would save Americans nearly $1,200 on average.

    "These savings would ultimately accrue to Federal and State governments in the form of lower costs for health care programs like Medicare and Medicaid and to families in the form of higher wages and lower out-of-pocket costs," Furman wrote.

    Health care spending

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    Barack Obama tan suit

    A federal appeals court in Washington has ordered a review of a case involving a major challenge to the Affordable Care Act, raising hopes among the law's supporters that the law would ultimately prevail.

    The order means the full U.S. Circuit Court of Appeals for the District of Columbia will hear Halbig v. Burwell, a case on which a three-judge panel ruled 2-1 in favor of the plaintiffs in June. The 2-1 decision threw out an IRS regulation that implements key subsidies for health insurance under the Affordable Care Act, allowing millions of low-income people to afford insurance.

    It was a rare step for the D.C. Circuit Court, and it diminished the near-term prospects the Supreme Court would become involved in the case.

    "The D.C. Circuit rarely grants en banc review. The fact they did here is testimony to the devastating effect this misguided decision would have had on millions of Americans and the fact that the decision is wrong on the law,"Timothy Jost, a law professor at Washington and Lee University and a supporter of the law, told Business Insider.

    The Halbig lawsuit is viewed as having the potential to cripple Obamacare in the 36 states where the federal government provides subsidies for low-income people to buy health insurance.

    The plaintiffs in the case argue the way the law was written does not allow for subsidies to be provided by the federal government, pointing to a statute that says subsidies should be issued to plans purchased "through an Exchange established by the State under Section 1311" of the Affordable Care Act. Section 1311 establishes the state-run exchanges. But plaintiffs say the law does not permit subsidies in federal exchanges, according to Section 1321 of the law.

    The three-judge panel in July was comprised of two Republican appointees and one Democratic appointee. But the Obama administration has better math with a full, 13-judge panel, which is comprised of eight Democratic and five Republican appointees. Three of President Barack Obama's appointees to the court have been confirmed by the Senate after a rules change in the past year.

    "The full D.C. Circuit will hear Halbig, an important and welcome next step in the process of the Halbig case," a senior Obama administration official told Business Insider.

    "The 2-1 decision of the panel was wrong, and we are confident that the full court will recognize that the text of the statute, the clear intent of Congress, and common sense all demonstrate that premium tax credits are available to Americans in every state – as a unanimous panel of the Fourth Circuit has already concluded."


    In a separate ruling hours after the D.C. Circuit Court panel handed down its Halbig decision in July, the Fourth Circuit Court of Appeals gave the law a unanimous victory in a similar challenge and upheld the federal government's ability to distribute subsidies.

    The plaintiffs in that case are appealing directly to the U.S. Supreme Court. But if, as expected, the D.C. Circuit Court issues a different ruling in concurrence with the Fourth Circuit, the Supreme Court may not step into a situation where the lower courts are in agreement.

    "We'll now see whether the D.C. Circuit will apply longstanding principles of statutory interpretation or will acquiesce to the administration's request that it be allowed to ignore the plain text of a duly enacted law,"Jonathan Adler, a law professor at Case Western Reserve University in Ohio and a conservative legal scholar behind the Halbig challenge, told Business Insider.

    "We're this not about the [Affordable Care Act], this would really be an easy case."

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    Obama Affordable Care Act Obamacare

    A hacker breached the federal website in July and uploaded malicious software, federal officials said Thursday.

    The breach, which was first reported by The Wall Street Journal, was discovered last week. No personal data was taken, but the break-in has raised concerns months ahead of the start of another open-enrollment period.

    The Department of Health and Human Services briefed congressional staff Thursday on the breach, believed to be the first successful hack of the federal health-insurance exchange where millions of people signed up for private plans late last year and early this year.

    "Today, we briefed key congressional staff about an intrusion on a test server that supports," HHS said in a statement. "Our review indicates that the server did not contain consumer personal information; data was not transmitted outside the agency, and the website was not specifically targeted. We have taken measures to further strengthen security."

    An HHS official told Business Insider the breach was discovered on Aug. 25 when a department security team noticed an anomaly in the system security logs of one of the server's systems. HHS leadership and its Inspector General's office were "quickly notified and assisted in assessing this incident," the official said.

    The FBI and Department of Homeland Security were also called in to investigate the attack.

    The official said was not specifically targeted in the hack, which could mean it was part of a broader effort to discover vulnerable spots across government-agency and private-sector websites.

    "The commonplace malware uploaded on the test server was designed to launch a 'denial of service' attack against other websites when activated and not designed to exfiltrate [personally identifiable information]," the official said.

    The HHS official said the breach wouldn't have any effect on the second period of open enrollment, which is scheduled to begin Nov. 15.

    SEE ALSO: An Amazing Healthcare Revolution Is Happening In Maryland — And Almost No One's Talking About It

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    The uninsured rate in the US plunged to its lowest level since 1997, a new government survey found, partly reflecting the implementation of certain elements of the Affordable Care Act.

    Though other studies have shown a sharp decline in the uninsured rate since the law's full implementation, the Centers for Disease Control and Prevention's survey provides the gold-standard estimate and the first official government look at the uninsured since the start of the year.

    During the first three months of the year, according to the new data, the uninsured rate fell to 13.1%. That was a 1.3% drop from the first quarter of last year, reflecting a decline of 3.8 million uninsured in the country. Both numbers are the lowest on record since 1997, when the CDC began tallying the uninsured through this type of survey.

    The decline in both the uninsured rate and the overall population does not reflect a late surge in enrollment at the end of March and in early April, when millions signed up for private health insurance toward the end of the law's first open-enrollment period. That means subsequent tallies will likely show the uninsured rate plunging even further.

    The percentage of adults aged 18-64 who lacked insurance fell to 18.4% from 20.4% on a year-over-year basis, while the percentage of children fell to 6.6%. Much of the decline in adults 18-64 came from adults aged 19-25, whose uninsured rate fell almost 6 percentage points.

    "The overall picture is clear: the Affordable Care Act is working and well on its way to ensuring that all Americans have access to high-quality, affordable health care," the White House's Jeanne Lambrew and Matt Fielder wrote in an analysis of the numbers.

    Here's a chart from the CDC that breaks down the number of uninsured:

    CDC uninsured

    And this chart from the White House shows a the decline by age group:

    Uninsured rate

    Other independent studies have also provided evidence that the law is having a dramatic effect on the uninsured rate. Gallup has attributed the lowest uninsured rate it has ever recorded to the Affordable Care Act's implementation. A RAND Corp. study showed the uninsured rate dropping nearly 5 percentage points. And a Commonwealth Fund study showed the rate plummeted by nearly one-quarter during a nine-month stretch in which the law was fully being implemented.

    Overall, the CDC found that 165.6 million people were insured under private plans. Among working-age adults 18-64, 17.1% were insured through public programs, and 65.6% had private coverage. had public health insurance, 65.6 percent had private coverage.

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    The health of people in the United States is plagued by conundrums.

    We spend more on healthcare than any other developed nation, yet we lead far shorter lives. A baby born on American soil is the most expensive in the world, yet our newborns have a lower chance of surviving past infancy than those born in eight other developed nations. The Affordable Care Act has made health insurance more accessible to the poor, yet bills for medications and basic hospital procedures remain strikingly high.

    Here are 11 charts that show in embarrassing detail some of the many shortcomings of our healthcare system.

    1. Americans don’t live as long as we should.

    In terms of overall life expectancy, the United States ranks 26th out of 34 Organization for Economic Cooperation and Development member countries. Americans enjoy fewer years than Slovenians and Koreans, living just a tad longer than Czechs and Chileans, who used to rank far behind us. life expectancy at birth

    2. But our country spends far more on healthcare and drugs than any other developed country.

    Nearly a fifth of America’s gross domestic product goes toward healthcare spending, putting us above the Netherlands, France, Germany, Canada and Switzerland, where actual health outcomes are much better.

    health care spendingdrug spending overall

    3. Many of us die from diseases that don’t have to be fatal.

    Americans are more likely to die from asthma than people than in Brazil or Costa Rica, even though the disease is equally prevalent in those countries.

    Asthma death rates

    4. Americans with certain treatable diseases are more likely to end up in a hospital — and more likely to die.

    We send more adult asthma sufferers to the hospital to be treated than any other developed country, coming in just under the Slovakian Republic. The soaring cost of asthma medication in the US (a Qvar brand inhaler, for example, costs 18 times more in the US than it does in Greece) is partially to blame for this problem, but access to preventative care also plays a role. Uninsured asthma patients are far more likely to die in the hospital than those with insurance. asthma hospital admission rates

    5. Our life expectancy varies by skin color.

    In 2009, the average black American could expect to live to just 75, the same life expectancy white Americans enjoyed 30 years earlier in 1979. Today, Black Americans remain far more likely than white Americans to die from heart disease, cancer and diabetes, according to the Centers for Disease Control and Prevention.

    Racial life expectancy

    6. It’s too easy to opt out of vaccinations, leading to new cases of preventable diseases.

    Low vaccination rates can lead to outbreaks of diseases like measles and Hepatitis B, especially among susceptible populations such as the young and the elderly. A handful of wealthy southern California schools have lower vaccination rates than South Sudan— a troubling trend that extends to New York City private schools as well.

    Hep B vaccination rates

    7. American doctors spend very little time with patients.

    In comparison to physicians in the Czech Republic, New Zealand, France and Israel, doctors in the US spend far less time consulting with patients and do a far worse job explaining to them what’s wrong.

    doctors spending time w patients

    8. Life-saving prescription drugs cost a fortune.

    The US spends a huge chunk of its budget on pharmaceutical drugs. Unlike other countries, whose governments regularly haggle with pharmaceutical companies to reduce drug prices, Medicare is forbidden from engaging in such negotiations. This is why a cancer drug like Gleevec, which costs about $1,000 in New Zealand and Canada, costs an average of $6,214 in the US. Even the common pain medication Celebrex, which runs for $51 in Canada, can cost anywhere from two to nine times that amount in the US.

    Cancer drug cost

    Pain med cost

    9. Standard lab tests are far pricier, too.

    An MRI in the US, for example, can cost 10 times as much as it would in Switzerland.

    MRI costs


    10. American babies are the most expensive in the world.

    Giving birth in the US — including hospitalization and a normal delivery — costs an average of $10,002, nearly five times more than the cost of birth in Argentina or Spain.

    Cost of child birth

    11. Yet babies born in the US are far less likely to survive past infancy than babies born in many other developed countries.

    In 2004, the latest year that data are available for all countries, the US ranked 29th globally in infant mortality, with the same rate of infant death as Slovakia and Poland.

    Infant mortality

    SEE ALSO: Babies Are More Likely To Die In Detroit Than In Mexico

    Read more: One Blockbuster Drug Explains A Lot About Our Out-Of-Control Healthcare Costs

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    Doctor surgeon surgery scrubs

    New data revealing the payments doctors and teaching hospitals received from drug companies and device manufacturers was made available online on Tuesday, the Centers for Medicare and Medicaid Services announced.

    The data include 4.4 million payments made to 546,000 physicians and 1,360 teaching hospitals between August and December of 2013. The payments — which include speaking fees, consulting fees, ownership stakes, and more — total $3.5 billion.

    The data release is part of a the Open Payments program, created by a section of the Affordable Care Act called the Sunshine Act that was designed to shed some light on the huge amounts of money exchanged between pharmaceutical companies and healthcare providers — money that may affect doctors' decisions about their patients.

    "Research has shown that physician–industry relationships do influence prescribing behavior," Eric G. Campbell wrote in the New England Journal of Medicine soon after the law was proposed. The idea behind the Sunshine Act is that making such relationships public may eventually make them less ubiquitous and in turn save the healthcare system money.

    Still, financial relationships between physicians and drug and device companies "do not necessarily signal wrongdoing," Shantanu Agrawal, a deputy administrator at the Centers for Medicare & Medicaid Services, emphasized on a call with reporters. "The data does not identify which financial relationships are beneficial, and which might represent conflicts of interest."

    The current data release, the first in a series, is also incomplete. It only includes data for the last five months of 2013, so if your doctor received a payment earlier in the year, that would not show up. In addition, records were anonymized if there was any confusion about the identity of the doctor in question, e.g. if two doctors had the same name and it couldn't be resolved which one received the payment in question. That means 40% of records don't yet reveal who was actually paid.

    Finally, payments that involved products not yet approved by the FDA were excluded at the companies' request, to protect trade secrets or active research. (That data — 199,000 payments in all — will eventually be included, either in four years or after FDA approval.) Another 9,000 records have been withheld because the information in them was disputed by physicians or hospitals.

    Soon, the site will include more user-friendly search and analysis tools to help patients explore the data. Officials at the Centers for Medicare and Medicaid Systems have promised that a full twelve months of data, including all physicians' names, will be released in 2015.

    How To Look Up Your Doctor

    With all those caveats in mind, you can go ahead and look up your doctor on the new Open Payments site to see what you can learn. (N.B.: The site seemed to be overloaded on Tuesday afternoon.)

    Here's how.

    1. Go to and click on "Interact."

    open payments

     2. Click through to "Access Data Explorer Tool."

    open payments

    3. You'll see a list of available data sets. The one that includes identifying information about doctors is the first (and most popular) on the list. That's the one you want.

    open payments

    4. The fastest way to search for your doctor is to use the "Find in this Dataset" search box. But you may have better results creating a filter by clicking on the dark blue button in the second row. That will let you specify more details like your doctor's first name, last name, and payments

    In any case, you'll have to scroll to the right to see the dollar the amount of each payment received.

    Keep in mind that this data is incomplete and may contain errors and that finding your doctor in this database is not evidence of any wrongdoing.

    We'd recommend cross-referencing information from the new database with a query on the Dollars for Docs site, a ProPublica project that includes payments from some of the largest drug companies from 2009-2013.

    This article was updated with more information about how to query the database.

    SEE ALSO: How To Find Out If Your Doctor Is Trustworthy

    Don't miss: The Case Of The Brooklyn Therapist With A $4 Million Medicare Claim Gets Even Stranger

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    Barack Obama Syria airstrikes

    A federal judge in Oklahoma has struck down an IRS regulation that provides subsidies under the Affordable Care Act, giving more ammunition to challengers aiming to deal a potentially crippling blow to the law known as Obamacare.

    At issue in a number of legal challenges around the US is whether the Affordable Care Act allows for the federal government to provide subsidies to individuals buying health insurance on the federal exchange. U.S. District Judge Ronald White ruled that subsidies provided through the federal exchange are invalid.

    "The court holds that the IRS Rule is arbitrary, capricious, an abuse of discretion or otherwise not in accordance with law ... in excess of statutory jurisdiction, authority, or limitations, or short of statutory right ... or otherwise is an invalid implementation of the ACA," White wrote.

    The Oklahoma judge's ruling in the case, brought by Oklahoma Attorney General Scott Pruitt, agrees with one handed down by a three-judge panel on the US Court of Appeals for the District of Columbia in July. The Obama administration appealed that ruling, and the full bench of the appeals court will review the case. The Fourth Circuit Court of Appeals' ruling in a similar case backed the Obama administration.

    White stayed his ruling pending appeal, meaning that Obamacare subsidies from federal exchanges will keep flowing. The Obama administration plans to appeal the decision to the 10th Circuit Court of Appeals.

    "The district judge in the Oklahoma case made a decision that is inconsistent with the text of the statute, the clear intent of Congress, common sense, and the Fourth Circuit panel’s unanimous contrary ruling on the same issue," a Department of Justice spokesperson told Business Insider.

    The plaintiffs in the various cases across the country argue the way the law was written does not allow for subsidies to be provided by the federal government, pointing to a statute that says subsidies should be issued to plans purchased "through an Exchange established by the State under Section 1311" of the Affordable Care Act. Section 1311 of the law establishes the state-run exchanges. But plaintiffs say the law does not permit subsidies in federal exchanges, according to Section 1321 of the law.


    Supporters of the challengers said White's ruling on Tuesday will make it more likely the Supreme Court will have to step in to resolve the issue.

    "It's certainly reassuring to see another court take the text of the statute seriously," said Jonathan Adler, a law professor at Case Western Reserve University in Ohio and a conservative legal scholar behind the Halbig challenge. 

    "That another court reaches this result shows that even if the DC Circuit reverses Halbig, that will not resolve the underlying dispute. This decision likely makes eventual Supreme Court review more likely."

    Timothy Jost, a law professor at Washington and Lee University and a supporter of the law, told Business Insider, said it's likely the Supreme Court would wait until the appeal at the 10th Circuit to see whether there would be a split in decisions at the appellate-court level.

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    Marco Rubio Ron Johnson

    Senate Republicans are gearing up for a fight over the Affordable Care Act in the lame-duck session of Congress — and it could set up a replay of last year's federal government shutdown.

    Sen. Marco Rubio (R-Florida) sent a letter to House Speaker John Boehner (R-Ohio) on Wednesday that was also signed by 13 other Republican senators. In the letter, Rubio and the other senators urged Boehner to use the stopgap spending bill to prohibit "unappropriated and unauthorized funds" from going toward a risk-corridor program in the healthcare law.

    The stopgap spending bill needs to be passed by Dec. 11 to avert a government shutdown. This means there could be another shutdown showdown Congress is in session during the month between the midterm elections and the deadline if Boehner uses the strategy outlined in Rubio's letter.

    "We must act to protect Congress’ power of the purse and prohibit the Obama administration from dispersing unlawful risk corridor payments providing for an Obamacare taxpayer bailout," the senators wrote.

    Republicans have charged the risk-corridor program could serve as a potential "bailout" of insurance companies. The "risk corridors" in question aim to make it easier for insurance companies to transition to the new health-care system, largely by making it less financially risky for them to sell new insurance plans on the government exchanges established by the Affordable Care Act. 

    The risk corridors are a temporary program that expire in 2016. Until then, the risk corridors are set up so that the government would compensate insurance companies that have bigger costs than they expected while transitioning to the new system. This provision is designed to protect insurers that see an especially unhealthy pool of customers and end up with higher claims than expected. 

    The program exists because, under an unprecedented overhaul of the federal healthcare system, insurers' cost of providing health insurance to an expansive new slate of customers was hard to predict.

    The Department of Health and Human Services has said the risk-corridor program's payments are "user fees," and the administration has the authority to oversee the program and its funds. However, a recent decision from the non-partisan Government Accountability Office, which the Republican senators pointed to in their letter, held that the funds for the risk-corridor program must be appropriated by Congress.

    "Without that appropriation, any money spent to cover insurance company losses under the risk corridor program would be unlawful," the senators wrote. "... Unfortunately, President Obama and his administration have exhibited their intent to disregard the law and ignore the Constitution."

    The other signatories on the letter were Republican Sens. Ted Cruz of Texas, Mike Lee of Utah, Rand Paul of Kentucky, John McCain of Arizona, John Barrasso of Wyoming, David Vitter of Louisiana, Mike Enzi of Wyoming, James Inhofe of Oklahoma, Jeff Sessions of Alabama, Deb Fischer of Nebraska, John Boozman of Arkansas, Pat Roberts of Kansas, and Tom Coburn of Oklahoma.

    Barack Obama tense

    Democrats immediately pounced on the letter, calling it reminiscent of the playbook that led down the road to the first federal government shutdown in 17 years in October 2013. But the goals for Republicans this time would be much smaller. Last year, they sought to defund all discretionary spending for Obamacare. This fight is aimed at taking away funds from just a single program.

    "The latest Republican shutdown threat proves the GOP learned nothing from last year’s Tea Party tantrum that cost the U.S. economy $24 billion and 120,000 jobs," said Drew Hammill, a spokesman for House Minority Leader Nancy Pelosi. "It’s time for Speaker Boehner to stop monkeying around and put an end to the reckless shutdown talk."

    Boehner's office declined to comment on the letter. A White House spokesman did not respond to a request for comment.

    The result of the elections could add another wrinkle into the potential battle — particularly if Republicans retake control of the Senate. If Republicans flip enough seats to gain a majority on Election Day, it could encourage the more conservative Republican flanks in both chambers of Congress.

    But Senate control could also be unknown on Election Day. There could be December and January runoffs in Georgia if neither candidate in each race gets more than 50% of the vote on Election Day. If that's the case, then Republicans might be more inclined to back off of a similar fight that led to major damage for the GOP brand last time around.

    SEE ALSO: Democrats Just Got Some Horrible News From New Polls

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    Marco Rubio immigration

    Fourteen Republican senators have written a letter to House Speaker John Boehner that sets stage for a budget showdown ahead of a government-funding deadline in December. The possibility has started to ruffle feathers in Washington weeks before the midterm elections and sparked fears of a government shutdown.

    In the letter, which was spearheaded by Sen. Marco Rubio (R-Florida), the senators urged Boehner to prohibit any "unappropriated and unauthorized funds" from going toward a risk-corridor program of the Affordable Care Act. It could open the door to a replay of last year, when bickering over the healthcare law led to the first federal government shutdown in 17 years. 

    A Senate Democratic leadership aide who spoke to Business Insider suggested Rubio, who is expected to launch a White House bid in 2016, was trying to compete with another likely presidential hopeful, Sen. Ted Cruz (R-Texas), who was widely seen as the architect of the last shutdown.

    "The Rubio strategy seems like he’s trying out-Cruz his probable 2016 primary challenger," the aide said. "I’m not going to predict whether it will succeed because Republicans have done crazier things."

    The stopgap spending bill needs to be passed by Dec. 11 to avert a shutdown and keep the government funded. 

    Republicans have charged the risk-corridor program could serve as a potential "bailout" for insurance companies. The "risk corridors" in question aim to make it easier for insurance companies to transition to the new health-care system, largely by making it less financially risky for them to sell new insurance plans on the government exchanges established by the Affordable Care Act. 

    The risk corridors are a temporary program scheduled to expire in 2016. Until then, the risk corridors are set up for the government to compensate insurance companies that have bigger costs than they expected while transitioning to the new system. This provision is designed to protect insurers that see an especially unhealthy pool of customers and end up with higher claims than they predicted. 

    This program exists because, under Obamacare's unprecedented overhaul of the federal healthcare system, insurers' cost of providing health insurance to an expansive new slate of customers was hard to predict.

    The Department of Health and Human Services has said the risk-corridor program's payments are "user fees" and the administration has the authority to oversee the program and its funds. But a recent decision from the non-partisan Government Accountability Office, which the Republican senators pointed to in their letter, held the funds for the risk-corridor program must be appropriated by Congress.

    Because of the decision, some Republicans who oppose the risk corridors think the best way to prevent them is to block their funding in the stopgap spending bill. This forces Democrats to either abandon the program or face the prospect of another shutdown if the stopgap bill is unable to pass.

    "Without that appropriation, any money spent to cover insurance company losses under the risk corridor program would be unlawful," the senators wrote in their letter to Boehner, adding, "Unfortunately, President Obama and his administration have exhibited their intent to disregard the law and ignore the Constitution."Ted Cruz

    "We must act to protect Congress’ power of the purse and prohibit the Obama administration from dispersing unlawful risk corridor payments providing for an Obamacare taxpayer bailout," the senators wrote.

    A consensus is emerging, however, that Republicans would most likely only take this path if they fail to win a Senate majority. Insiders doubt they would move on the strategy if they know they will have a Senate majority on Election Day since they would be in a position to eliminate the risk corridors without a budget battle.

    However, control of the Senate may remain unknown immediately after Election Day due to the potential for lengthy runoffs in Georgia and Louisiana. In this scenario, it's also unlikely Republicans would want to risk a high-profile confrontation with the potential for a shutdown. The GOP's image brutally suffered after last year's 16-day shutdown, which means lawmakers would be reluctant to provoke a similar fight if voters are heading to the polls for decisive runoffs. 

    Democrats have already taken notice of Rubio's letter and have attempted to frame it as a strategy that could lead to a scene reminiscent of last year's shutdown. 

    "Washington Republicans have already shown that they’re willing to shut down our government and hurt the middle class if they think it will help advance their ideological agenda," Josh Schwerin, a spokesman for the Democratic Congressional Campaign Committee, told Business Insider. "That’s why the choice is so clearly between Republicans who will use shutdowns as leverage or Democrats who want to jumpstart the middle class."

    How likely it is Republicans will follow through on the strategy depends on who you ask. Democrats consider it a real possibility. Other analysts, observers, and aides think Rubio's letter is more about trying to both raise his personal profile and the profile of the risk-corridor program.

    Goldman Sachs economist Alec Phillips speculated in a recent note that Republicans taking back the Senate would lead to an increase in fiscal confrontations between congressional Republicans and the White House ahead of key deadlines to fund the government and raise the debt ceiling.

    "The result is likely to be less predictability regarding the process surrounding major fiscal deadlines. Since the confrontation between House Republicans and the White House over the debt limit in 2011, markets have gradually become inured to fiscal brinksmanship, as these debates have started to follow a predictable pattern," Phillips wrote.

    "If Republicans win majorities in both chambers as polls currently suggest they might, that pattern seems likely to change, which could lead to renewed uncertainty ahead of future fiscal deadlines."

    One Republican Senate aide, while refusing to comment on the potential strategy, told Business Insider, if Republicans take back the Senate, party leadership would be better served separating risk corridor-related legislation from the stopgap spending bill.

    The aide described GOP-authored risk-corridor legislation as something that could attract some Democratic votes and pass both chambers. That way, Republicans will have put Obama, who would be forced with a decision about whether to sign or veto the bill, in a bit of a corner without flirting with a potential shutdown.

    GOP leadership in both chambers, the aide told Business Insider, should prioritize "demonstrating the kind of competence" the aide said has not been seen from current Senate Majority Leader Harry Reid.

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    ObamacareU.S. insurers planning to sell 2015 Obamacare health plans expect at least 20 percent growth in customers and in some states anticipate more than doubling sign-ups.

    In interviews with Reuters, half a dozen privately held and non-profit health insurers around the country say they are expecting this growth based on interest from potential customers they are hearing about through their call centers, sales forces and brokers.

    With the start of enrollment barely two weeks away, their assessment is dramatically different from a year ago, when it was unclear how many Americans would apply for the brand new insurance and income-based subsidies offered under President Barack Obama’s healthcare law.

    Despite crippling technology issues with the website, more than 7 million people signed up for Obamacare plans in 2014.

    In Florida, Jason Alford, sales director at Health First Health Plans Inc, expects to more than double customers in Affordable Care Act compliant plans from the 4,400 it signed up this year.

    "We've just talked to so many people in the market who for one of 5 or 6 different reasons didn't enroll in 2014. We had many folks call this summer who really don't understand the open enrollment period. They are calling in August to sign up for a plan because they think it's all-year enrollment," he explained.

    When the three-month enrollment period opens on Nov. 15, it will be a critical juncture for insurers who need to build profitable businesses that can stand up as government financial supports to insurers who sell these plans decline in the next two years.


    Aimed at extending health insurance to 25 million people, the law has been controversial for its cost to taxpayers and the changes it has spurred in coverage. Millions of individual plans were canceled for 2014 and some employers stopped insuring part-time workers.

    Support for the law tends to fall along political lines and has waned overall, polls say. Public support fell to 40 percent in 2014, from 44 percent in 2012 and 42 percent in 2010, Harvard researchers said this week.

    The exchanges have become a big business for insurers like Aetna Inc and WellPoint Inc, who enrolled hundreds of thousands of new customers last year. UnitedHealth Group Inc, barely on the exchanges in 2014, will be in two dozen states. These insurers have not discussed 2015 forecasts.

    There is political importance for Obama as well. The Congressional Budget Office expects 13 million people to buy exchange plans in 2015 and 24 million in 2016. If those numbers materialize, it will make it even more difficult for Republicans and other foes to uproot the embattled law.

    healthcareInsurers would not say whether they agreed with CBO forecasts, but many interviewed by Reuters have doubled or tripled staffing to handle applicants. Some saw customer calls up 30 percent in October. Only those with qualifying events such as job loss can buy insurance outside the regular enrollment period.

    In Pennsylvania, where Medicaid is being expanded, Independence Blue Cross hopes to add about 30,000 new customers to the 165,000 it signed up for 2014 plans.

    "We're thinking pretty positive. Last week we saw our call center activity increase 31 percent from a call volume standpoint versus the previous few weeks," Brian Lobley, a senior vice president at Independence Blue Cross in Pennsylvania, said in an interview.

    Lobley is seeing growth at a slower pace than CBO suggests because some customers may qualify for benefits under Medicaid when the state makes it available for more residents.

    In Texas, one small insurer predicts growth of 15,000 to 40,000 more customers from the fewer than 500 it signed up last year.

    Non-profit insurer Community Health Choice Inc in Houston priced premium rates too high and was mostly shut out in 2014, said Daisy Morales, vice president of marketing. This year, with more competitive premiums, it expects to win new customers by gaining market share and because of forecasts for growth in the state. The insurer foresees one million new sign-ups in Texas in addition to the more than 700,000 who enrolled in 2014.

    "It's not like we're starting from scratch, like we were last year," Morales said.


    (Reporting by Caroline Humer; additional reporting by David Morgan in Washington; editing by Gunna Dickson)

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    The number of Americans without health insurance hit an all-time high in 2006. Nearly 44 million people (close to 17% of Americans) lacked even the most basic coverage, meaning they'd have to pay full price for any health treatment, from annual checkups to prescription medications.

    Data from previous years showed the numbers were following a worrisome trend.

    health insurance 1978 07

    By 2010, as the number of uninsured continued to rise (even while the percentage of Americans without insurance held steady), it was clear America had a problem.

    In many states, the numbers were far more dismal. Across Nevada, Texas, and several other southern states, more than 22% of the population lacked health insurance. (These numbers vary slightly depending on the data used; the maps below use the Gallup-Healthways Well Being Index.)

    Here's what 2010 looked like, in a visualization created by @MetricMaps:

    map insured americans 2010

    Today, more Americans have health insurance than ever before.

    Since the Affordable Care Act went into effect, an additional 10 million people who would have previously had to pay full price for any health treatment can now afford an annual checkup, eye glasses, or birth control pills.

    map insured americans 2014

    Four million of them are young people between 19 and 25.

    In states that embraced the ACA's planned expansion of Medicaid, the government health care program for the poor, the number of uninsured fell by nearly 40%.

    A wide swath of Western states, including California, Nevada, and Washington saw the number of their residents with insurance climb sharply. Texas (which opted out of participating in the Medicaid expansion along with several other states, mostly in the South), is now the only state where more than 22% of the population lacks coverage.

    In total, an estimated 3.6 million Americans who would have likely received Medicaid coverage under the new rules remain uninsured today because they live in states that opted out of the Medicaid expansion.

    While the population of uninsured Americans seems to be shrinking, the Affordable Care Act itself is far from perfect. Dozens of glitches in the online system of enrollment likely prohibited hundreds from signing up — only six people actually managed to enroll in Obamacare the first day the system rolled out. The law also raised the cost of health insurance for some people who already had private coverage because it forced insurers to provide more benefits and to cover people with pre-existing conditions.

    Regardless, the Affordable Care Act was created in part to increase the number of Americans with health insurance. And it's undoubtedly achieved that goal.

    Here's the 2008-2014 action in all its GIF glory:


    SEE ALSO: 11 Charts That Should Make People Embarrassed Of The US Healthcare System

    DON'T MISS: Obama Just Took A Big Victory Lap On Obamacare

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    Barack Obama

    President Barack Obama predicted on Friday that Republicans would stop calling the Affordable Care Act by its colloquial name, "Obamacare," sometime in the next decade because the American public will eventually view it as a success.

    "No matter how many times Republicans threaten to repeal this law, we're going to keep it in place — because it's working. Not only is it covering more people, not only is it protecting women and people with preexisting conditions from discrimination, but it's actually been part of the trend that's lowering health care inflation," Obama said during remarks Friday at Rhode Island College in Providence.

    "We're actually saving money because the system is getting smarter and there’s more preventive care instead of emergency care, and we're changing how health care is delivered. Which is why I’m pretty sure that in 10 years they're not going to call it Obamacare anymore. Republicans will be like, oh, I was for that, yes. That's how that works."

    After he laid down the market, an audience member shouted they would "remember" that Republicans were vehemently opposed to the law. 

    "You’ll remember though. You’ll remind them," Obama said.

    Republicans coined the term "Obamacare" during the debate over the law. Obama eventually embraced the term during the 2012 presidential campaign, saying he does "care — that's why we fought so hard to make it happen." Indeed, polls have shown that calling the healthcare law "Obamacare" makes it significantly less popular than "the Affordable Care Act."

    A common belief among supporters of the law is that it will be viewed in a much more positive light down the road, after Obama leaves office and benefits of the law kick in for more and more Americans. Right now, though, it remains unpopular — an average of six October polls shows the majority of the American public still opposes the law.

    Obama hasn't been shy on touting the law's successes on the campaign trail, saying earlier this month that more than 10 million people — 26% of the uninsured in the country — had gained access to health insurance in the first year of the law.

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    A man looks over the Affordable Care Act (commonly known as Obamacare) signup page on the website in New York in this October 2, 2013 photo illustration. REUTERS/Mike Segar

    WASHINGTON (Reuters) - After years of trying to repeal Obamacare, Republicans are planning a new strategy to eliminate some of the law's most unpopular provisions by using targeted legislation with the potential to attract enough Democratic votes to reach President Barack Obama's desk.

    First they have to pick up the six seats they need for a U.S. Senate majority in Tuesday's midterm elections, which would give the party control of both congressional chambers for the first time since 2006.

    With opinion polls showing the odds for Senate control increasingly in their favor, Republicans are exploring a series of efforts to repeal some of Obamacare's taxes and penalties on businesses.

    The Affordable Care Act, Obama's signature domestic policy achievement, aims to reduce the number of uninsured Americans by offering subsidized private coverage to lower income Americans and by extending Medicaid program for the poor.

    But the law has been a target for constant Republican attack since Congress enacted it in 2010, when both chambers were controlled by Democrats. Republicans view it as an unworkable expansion of big government that will only raise healthcare costs while hurting businesses, job growth and the economy.

    A Republican-controlled Congress would still be expected to kick off in January with separate bills to repeal the entire law, as well as the penalty for individual Americans who fail to obtain health coverage and the federal subsidies for low-income people enrolled in private Obamacare health policies.

    Senate Republican Leader Mitch McConnell came under fire from conservatives critics last week after saying the party was unlikely to have the 60 Senate votes, out of 100, needed to repeal the law with standard legislation. A McConnell spokesman said his position had not changed: a Republican-controlled Senate would still see a full repeal vote and McConnell remained committed to undoing the law's funding provisions through a special parliamentary process requiring only a simple 51-vote majority.

    But with a White House veto of such measures all but certain, Republicans hope to move on quickly to legislation capable of drawing enough Democrats to surmount the Senate's legislative hurdles and put pressure on Obama to acquiesce, lawmakers and aides said.

    Chief among Republican targets is the ACA's employer mandate, which requires businesses with at least 50 full-time workers to offer health coverage to their employees or pay a penalty. Also on the hit list are the law's definition of "full time" as any employee who works 30 hours a week or more, provisions that compensate health insurers for market losses and an excise tax on medical devices, including the machines that produce CAT scans and magnetic resonance images.

    "There's consensus that we need to tear down the most destructive parts of the law that are hurting people and are hurting our economy. And there's proven bipartisan support for some of our ideas," said Senator John Barrasso of Wyoming, an orthopedic surgeon and a leading Republican voice on healthcare.

    Employer requirements and taxes have also been the subject of intense lobbying by the business community, including medical device manufacturers, while risk provisions that seek to reduce insurer losses have become a favorite target for Tea Party-backed conservatives who warn of a looming government "bailout" for the insurance industry.

    Some measures have won support from senators in both parties, including Republican Orrin Hatch's budget resolution amendment last year to repeal the excise tax on medical devices. That measure was blocked from a later floor vote by Democratic leaders.

    There also could be room for negotiations between parties once the repeal efforts run their course. Democratic Senate aides say they have talked to Republican aides about compromises including streamlining reporting requirements for employers and replacing the tax penalty with an incentive for firms to offer health coverage to workers.

    Both parties could add proposals to tweak Obamacare to broader pieces of legislation, such as a budget or appropriations bill.

    "That is the old fashioned way of passing legislation. You pull together a bunch of things that could have gone separately, you find a way to pay for them and you get enough people to hold their noses and vote for it,” said Joe Antos of the conservative American Enterprise Institute.

    (Reporting by David Morgan; Editing by John Whitesides and Frances Kerry)

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    Barack Obama

    Tuesday night's landslide Republican victories in the midterm elections are being hailed by the GOP as a referendum on President Barack Obama. And the results could end up putting a dent in his signature legislative achievement.

    Republicans who now control the Senate plan to chip away at the Affordable Care Act, and they believe they have a chance to push public opinion even further against the law with stepped-up public oversight. And at the state level, the law's supporters suffered setbacks to their hopes of Medicaid expansion in more states.

    When all is said and done, Republicans will likely have a 54-46 majority in the Senate next year — which, going into Tuesday night, was one of the best-case scenarios for the party. The party will likely pick up at least two governor's seats, including flipping Democratic strongholds in Maryland, Massachusetts, and Illinois. 

    It could mean a weakened Obamacare at the federal level and a stalled push to expand Medicaid in states that have so far resisted.

    There's still "not much evidence that the ACA was at the center of this election," Larry Levitt, the senior vice president of the Kaiser Family Foundation, told Business Insider. "But with a Republican majority in the Senate, tweaks to the law will move ahead."

    Of Medicaid expansion, he added: "It doesn't seem like there are much prospects for the Medicaid expansion to spread after these results."

    Mitch McConnell

    The Republican Holy Grail — a bill that repeals the Affordable Care Act — will see its best chance for passage next year, but it would face a certain presidential veto.

    But while there will likely be a full vote in the Senate to repeal the entire healthcare law, according to senior Republican aides who spoke to Business Insider, the overall GOP strategy will likely be to chip away at parts of the law in bills that could make it to the president's desk.

    Some areas they could target include the law's tax on medical devices and the Independent Payment Advisory Board — which some Republicans have infamously labeled a "death panel," but whose launch has been delayed amid slowing healthcare cost growth. Other possible actions include tweaks to the so-called employer mandate of the law, which has been delayed twice, as well as the individual mandate that requires most Americans to purchase health insurance.

    One item Republican House and Senate aides think is likely to make it to Obama's desk — and potentially get his signature — is a bill to repeal Obamacare's tax on medical devices. A similar amendment, championed by Sen. Orrin Hatch (R-Utah), who is in line to become the next chair of the Senate Finance Committee, passed by a 79-20 vote in 2013.

    "I think the med-device tax and some other little areas would be the best place to start, because that is the 'possible,'" a senior GOP aide on the Senate Finance Committee told Business Insider of Republicans' pursuit of Obamacare-related legislation in the next session of Congress.

    Republicans could also take aim at so-called risk corridors in the health law, a potential battle that some Republican senators have already begun discussing as part of a potential funding fight that leads down the road to a federal government shutdown.

    The "risk corridors" in question aim to make it easier for insurance companies to transition to the new healthcare system, largely by making it less financially risky for them to sell new insurance plans on the government exchanges established by the Affordable Care Act.

    But Republicans have charged the program amounts to a "bailout" for insurance companies, and a bill targeting the provision is something they think could attract Democratic votes to get past a 60-vote filibuster firewall. 

    "Why not just do it separately?" one Republican aide said when asked about the possibility of tying funding for the risk-corridor program to the continuing resolution, which keeps the government funded and needs to be passed by Dec. 11 to prevent a shutdown.

    If Republicans tackled the issue of risk corridors in a separate bill, senior aides said, it would simplify messaging and make some Democrats more likely to jump on board.

    In general, Senate Republicans will look to follow the House GOP Obamacare playbook of the past four years. They plan to use their subpoena powers to full effect and hold more oversight hearings on the healthcare law.

    Some of the issues those potential hearings will focus on include money Republicans claim has been wasted on state insurance exchanges that ended up converting to the federal marketplace, the security of and state-exchange websites, and the process for verifying people's incomes to receive subsidies for health insurance.

    The potential political boon is palpable.

    "Being in the minority, we don't have the ability to call a hearing and to get the witnesses that we'd want," the GOP Finance Committee aide said of Republicans' status in the current Congress. "I think oversight of Obamacare would be something you'd see a lot more of" in the next one.

    Scott Walker

    Meanwhile, on the gubernatorial side, Levitt said the most likely chance for movement on Medicaid expansion would be in Alaska, where independent candidate Bill Walker is leading Republican incumbent Sean Parnell.

    There is also the potential for "backsliding" in states like Arkansas — where Republican Asa Hutchinson won a seat currently governed by a Democrat. Arkansas features a "private option" as an alternative to Medicaid expansion, but it has always only been narrowly popular. 

    Democrats also hoped strong candidates in the Florida, Georgia, Kansas, Maine, and Wisconsin gubernatorial races would win and work toward expanding Medicaid. But all five of those candidates lost. 

    "It's hard to imagine those Republican governors opposed to the expansion getting religion based on these results," Levitt said.

    Levitt, however, said the intensified battles to come on the law are normal for major healthcare legislation. And he doesn't expect any changes to become law that get to the heart of the Affordable Care Act.

    "For the foreseeable future, the law remains intact. We're now maybe entering a stage where — in some ways, it's surprising it's taken this long where Republicans try to move the law in a more conservative direction," Levitt said.

    "This is normal. This has been happening for years in Medicare and Medicaid. But programs themselves remain intact."

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    A triumphant Speaker John Boehner (R-Ohio) came out firing on Thursday, taking shot after shot at President Barack Obama just two days after Democrats were routed in the midterm elections.

    "If the president continues to act on his own, he is going to poison the well. When you play with matches, you take the risk of burning yourself. And he's going to burn himself if he continues to go down the path," Boehner said.

    Boehner's warning came in reaction to Obama's vow to enact immigration reform measures through executive action by the end of the year. Obama repeated the executive action promise at his own press conference on Wednesday.

    "I've made it clear to the president that if he acts unilaterally — on his own, outside of his authority — he will poison the well, and there will be no chance for immigration reform moving in this Congress. It's as simple as that," Boehner said.

    In another sign of expected tension between Congress and the White House, Boehner also made it clear he plans to move to repeal Obama's signature healthcare reform law.

    "Obamacare is hurting our economy. It's hurting middle class families. And it's hurting the ability for employers to create more jobs. And so the House I'm sure at some point next year will move to repeal Obamacare," he said. "Now, whether that can pass the Senate, I don't know. But we're going to pass it."

    Boehner went on to cast doubt on Obama's claim to have heard the voters' message on Election Day.

    "The president said, 'I listened to what happened Tuesday night.' Really?" Boehner asked.

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    Barack Obama

    The Supreme Court on Friday agreed to take up a new challenge to the Affordable Care Act, a move that will again thrust the law into a high-profile battle before the high court.

    The Supreme Court's move is somewhat surprising, considering there is still no split in the lower, circuit courts. But the high court agreed to hear King v. Burwell, a case in which the Fourth Circuit court upheld an IRS rule that extends the distribution of health insurance subsidies to states served by the federal insurance marketplace.

    The challenge to the law is viewed as having the potential to cripple Obamacare in the 36 states where the federal government provides subsidies for low-income people to buy health insurance.

    It has the potential to affect more than 5 million low-income Americans who currently receive subsides. One analysis projected that if challengers' efforts were successful, it would spike premiums by 76% for the people who currently receive subsidies.

    The plaintiffs in the case argue the way the law was written does not allow for subsidies to be provided by the federal government, pointing to a statute that says subsidies should be issued to plans purchased "through an Exchange established by the State under Section 1311" of the Affordable Care Act. Section 1311 establishes the state-run exchanges. But plaintiffs say the law does not permit subsidies in federal exchanges, according to Section 1321 of the law.

    The White House called the lawsuit "another partisan attempt to undermine" the law.

    "The ACA is working. These lawsuits won’t stand in the way of the Affordable Care Act and the millions of Americans who can now afford health insurance because of it. We are confident that the financial help afforded millions of Americans was the intent of the law and it is working as Congress designed," White House press secretary Josh Earnest said.

    "This lawsuit reflects just another partisan attempt to undermine the Affordable Care Act and to strip millions of American families of tax credits that Congress intended for them to have. We will continue to ensure that every American has the peace of mind of having access to affordable insurance. We are confident that the Supreme Court will recognize both the clear reading of the entire law, and the certain intent of Congress in crafting it."

    In early September, the U.S. Circuit Court of Appeals for the District of Columbia agreed to rehear the case, taking away a split between the circuits. A three-judge panel had thrown out the subsidies as invalid, but now the full, 13-judge panel will rehear the case. The math on the full panel is much better for the administration, as it consists of eight Democratic-appointed justices and just five who are Republican-appointed.

    Timothy Jost, a professor at the Washington and Lee University School of Law and supporter of the law, told Business Insider the law is now in "very dangerous territory."

    "This is highly unusual. The Supreme Court doesn't usually just take away cases from circuit courts where there's no circuit split, which I think sends a signal that politics might be driving this — not legal analysis," Jost said. "So I think that's bad. It doesn't look good that this could be a politically driven decision."

    The other interpretation one could read from the Supreme Court's move, he said, is that it wants to get past the case now rather than have it linger for another year — or more.

    "We're going to have to decide this case sometime, and we might as well get it done now, rather than leave it open for perhaps another year," he said of the justices' possible thinking. "If that's the case, then it's possible that certainly five and maybe more of the judges could vote to uphold the law."

    Supporters of the challengers, meanwhile, took it as a good sign for their case.

    "The Supreme Court has the opportunity to reaffirm the principle that the law is what Congress enacts, not what the Administration or others wish Congress had enacted with the benefit of hindsight," Jonathan Adler, a law professor at Case Western Reserve University in Ohio and a conservative legal scholar behind the Halbig challenge, told Business Insider.

    The new case represents the most high-profile challenge to the law since the 2012 case aimed at the so-called individual mandate of the law. The Affordable Care Act mostly survived that challenge, but the Supreme Court also gave states the option of choosing whether they would expand Medicaid under the law.

    This post has been updated with comment from the White House.

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