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The latest news on Obamacare from Business Insider

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    john g roberts

    Now that the Supreme Court has given its narrow blessing to the Affordable Care Act, the big question is whether it will deliver the benefits that its proponents promise. Unfortunately, as it is now constructed, the plan will backfire causing fewer healthy people to buy insurance, raise premiums for those who do, destroy employment opportunities, cripple the health insurance industry, and weaken the economy.

    In order to guarantee insurance to all, regardless of age, health or pre-existing conditions, the framers of the plan concede that it is essential that the young and healthy (who are less likely to be heavy users of health care) pay into the insurance pool. The surplus generated from their premiums compensates for the money lost to those receiving more in services than they pay in premiums (e.g. older people and those with medical conditions). But the ACA has given these healthy people a “Get out of Jail Free” card that many of them are sure to play.

    Most healthy young people know that they are losing money to insurance providers, at least in the near term. This is the nature of insurance. They pay to prevent costly exposure to an unlikely event. And just as homeowners wisely pay for fire insurance even if they don’t expect their homes to burn down, it is practical given the high cost of medical care that healthy young people buy insurance.

    But,the ACA makes it illegal for insurance providers to deny coverage to anyone for any reason. This allows healthy people to dropinsurance until they actually need it without incurring any risk. To counteract these new free rider incentives, the law imposes “no insurance” penalties (also defined as taxes by the Supreme Court).

    The problem is that these “penaltaxes” (for lack of a better word) are insufficient to the task. In fact, Chief Justice John Roberts ruled the law constitutional precisely because the burdens were not high enough to compel behavior. (In other words, he thought the law was constitutional because it will be ineffective.) The numbers support his arguments.

    On average, in 2010, a typical healthy young person paid at least $2,500 per year for insurance (for a plan that would still involve significant out of pocket expenses). In some areas of the country, premiums were more than twice as high.

    When the program takes effect in 2014 the penaltaxes will be the greater of $95 or 1% of household income. A single person earning $40,000 per year who chooses to go uninsured would then be subject to a $400 penaltax. The decision would be an easy one: drop the insurance, incur the penaltax and pay for any medical services out of pocket.

    Even in 2016, as the penaltax increases to the greater of $695 or 2.5% of household income, it will still not make sense for many people to buy insurance. The penaltaxes are capped at levels that equal the full cost of an average health plan. So at no time are even high income individuals worse off financially for not buying insurance. In addition, the IRS’ ability to actually collect these penaltaxes is limited to garnishing income tax refund checks. If an individual is not getting a refund, the IRS is impotent.  

    The law places no requirements for businesses with fewer than 50 employees to offer insurance. So when younger workers realize the benefits of dropping insurance, they will naturally gravitate to savvy businesses that offer higher pay instead of insurance. This will drain more premiums from the insurance pools. 

    In contrast, the burdens placed on employers with more than 50 workers are complex, onerous and unpredictable. Those that don’t offer insurance would be subject to substantial (and open ended) penalties if at least one employee receives an insurance tax credit or a government subsidy to an insurance exchange.

    If they do offer insurance, they will also be subject to substantial (and open ended) penalties if the plan fails to cover 60% of employee health expenses, or if premiums for any employee are more than 9.5% of family income.  It has been left wholly unexplained how employers are supposed to accurately determine these triggers which involve knowledge of family income, not just employee income.

    Smaller employers will look to avoid these headaches by staying below the 50-employee threshold. Though it should be obvious, there is plenty of evidence to support this. French law involves significant regulatory requirements for businesses that have more than 50 employees.  As a result, there are currently2.4 times more French companies that have 49 employees than there are with 50. Incentives for businesses to stay small will hurt the economy and will further shrink the numbers of people paying into the health insurance pools.  

    Employers will also be incentivized to avoid hiring lower paid workers who would be more likely to trigger the penalties tied to household income. As a result, many small companies will likely look to replace lower rung employees with temps, automation or outsourcing, further raising the barrier to workforce entry for lower skilled workers.  The unemployable workers will qualify for free health insurance, further draining the system.

    Unless the penaltaxes are raised significantly, far too many needed premium payers will drop out.  As they do, the only way for insurance companies to recoup the lost revenue will be to raise premiums for the customers who remain.  As the gap between the relatively low penaltaxes and the high cost of health insurance premiums increases, so too will the incentive to drop coverage. This self-reinforcing dynamic will render the entire plan non-viable.

    It is a foregone conclusion that the Obama Administration and its congressional allies are already planning to raise the penaltaxes. Although such increases would render the plan unconstitutional if they compel behavior, according toRobert’s analysis, I do not expect the Supreme Court to ever rule on this case again. The Court has a history of opening small cracks in the Constitutional barn door for the bureaucratic horses to stampede. 

    Unless we can summon the political will to repeal the poorly conceived law, we should all brace for higher health care costs, many more layers of impenetrable federal bureaucracy, a significantly weaker economy, diminished employment opportunities, and lower living standards.

    Peter Schiff's new book, The Real Crash: America’s Coming Bankruptcy – How to Save Yourself and Your Country is now available. Order your copy today

    For in-depth analysis of this and other investment topics, subscribe to Peter Schiff's Global Investor newsletter. CLICK HERE for your free subscription. 

    This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. Please feel free to repost with proper attribution and all links included.

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    doctor walking patients waiting

    Visits to primary care physicians can result in unnecessary trips to the hospital, according to a recent study that challenges the main arguments of Obamacare.

    Under the president's healthcare plan, which was recently upheld by the Supreme Court, more Americans would have access to preventative care and screening.

    The idea is that taking care of conditions early can prevent costly treatments later on.

    But while primary care if useful in some cases, it's often wasteful and unnecessary, according to a study by Robert Kaestner and Anthony T. Lo Sasso at the University of Illinois.

    Despite being central to Obamacare, there was previously no research to suggest that primary care actually prevents hospital stays later, Kaestner and Lo Sasso write.

    The researchers studied healthcare claims from more than 900 different firms in the U.S.

    Here's what they found:

    "Estimates indicated that greater outpatient spending was associated with more hospital admissions and greater inpatient spending. Moreover, we presented evidence that the increase in hospital admissions associated with greater outpatient spending was for conditions in which it is plausible to argue that the physician could exercise more discretion—treat “aggressively”. Thus, the positive association between outpatient spending and inpatient spending we “supply sensitive” and largely without substantial health benefit."

    While some people benefitted from going to a primary-care physician for preventative care, the vast majority didn't and ended up spending more money.

    DON'T MISS: The Tea Party Will Love Justice Thomas' Obamacare Dissent >

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    Andrea SaulMitt Romney spokeswoman Andrea Saul appeared on Fox News' America's Newsroom this morning to hammer the controversial ad from a pro-Obama SuperPAC that blames Romney for the death of a steelworker's wife.

    But in defending Romney, she veered way off message, explaining that if the steelworker, Joe Soptic, had lived in Massachusetts, he and his wife would have been able to get health insurance under Romney's health-care reform legislation. 

    Here's what she told Fox anchor Bill Hemmer, via Think Progress

    SAUL: To that point, you know, if people had been in Massachusetts under Governor Romney’s health care plan, they would have had health care. There are a lot of people losing their jobs and their health care in President Obama’s economy.

    Now conservatives are freaking out about it. Conservatives' main gripe with Romney all the way back to the primary season was his implementation of Obamacare on a state level and the thought that he would be an ineffective messenger on repealing the president's legislation.

    Influential conservative blogger Erick Erickson tweeted this afternoon that Saul's slip-up may have been the moment that cost Romney the election:

    Romney Obama tweet

    As governor of Massachusetts, Romney implemented health-care legislation that features the same individual mandate provision of President Barack Obama's legislation that has come under constant fire from conservatives since it passed in 2009.

    Romney has, however, repeatedly stated that his health care legislation that featured the individual mandate would not be effective as a national model.

    Watch Andrea Saul's interview below (her healthcare comment comes around the 1:20 mark):

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    Andrea Saul

    Add influential conservatives Rush Limbaugh and Ann Coulter to the crowd of conservatives dismayed about Romney campaign spokeswoman Andrea Saul's off-message comments on Fox News this morning. 

    Limbaugh said on his radio show that Saul flubbed the proper response to a controversial pro-Obama super PAC ad. Meanwhile, Coulter went on Hannity tonight and suggested that Saul should be fired.

    Earlier today on Fox News, Saul said that if the steelworker, Joe Soptic, had lived in Massachusetts, he and his wife would have been able to get health insurance under Romney's health-care reform legislation.

    Limbaugh suggested it would not play well with the base — some of whom have already said it could cost Romney the election — even comparing it to the campaign's lack of vocal support for "Chick-fil-A Appreciation Day" last week

    From the transcript:

    From the sound of this, they don't know, at the Romney campaign, what the purpose of this ad was and how it took root. They apparently don't know that the Obama campaign ran an ad accusing Romney of murder, essentially. Stephanie Cutter is backing it up. The woman did die. Romney got rich.  He closed the plant.  Husband lost the job.  Wife got sick and died.  Romney made out like a bandit. 

    Well, she'd-a had health insurance if she lived in Massachusetts.  You couple that with there was a lack of understanding or desire to join the Chick-fil-A day?  I mean, that's your base out there.

    Coulter went a step further. Coulter condemned the ad, but she saved her harshest criticism for Saul. 

    "Anyone who donates to Mitt Romney — and I mean the big donors — ought to call Mitt Romney and say if Andrea Saul isn’t fired and off the campaign tomorrow, they are not giving another dime. Because it is not worth fighting for this man if this is the kind of spokesman he has to respond to this by citing health care in Massachusetts."

    There’s no point in you doing your show, there’s no point in us going to the convention and pushing for this man if he’s employing morons like this. This ad is the turning point, and she has nearly snatched victory from the jaws of defeat. She should be off the campaign.”

    Watch video of Coulter here (the good part starts around the 5:55 mark):

    Limbaugh added that it would be a potential "gold mine" for the Obama campaign. Conservatives' main gripe with Romney as a nominee has been his health-care legislation dubbed "Romneycare," and they thought that he would be an ineffective messenger on repealing the president's legislation. Romney, though, has repeatedly said his model should not be applied nationally.

    "That's a potential gold mine for the Obamaites, because they can say, 'Well, yeah, and Romneycare's the foundation for our plan, Obamacare,' which they are already out there saying," Limbaugh said.

    Listen to the Limbaugh's clip below, courtesy of The Daily Rushbo:

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    In posts about the Ryan pick, I’ve argued that if we in the commentariat and the media get this right, the American electorate could have a salutary debate on the role of government.  But, I stressed, that’s a big “if.”

    We particularly need an eagle-eyed media to cut through the inaccurate and misleading stances that show up with increasing frequency around this time.

    A classic, for example, is the one I talked about with Rachel Maddow last night: the claim that President Obama is “destroying Medicare” by reducing its growth rate to the tune of $700 billion in the Affordable Care Act.

    Rep Ryan has precisely the same cut in his budget. The difference is what they do with the savings.  As I noted on Rachel, the ACA uses those savings to cover the uninsured, along with these other services, noted by Jon Cohn:

    Obamacare puts the money back into the pockets of people who need help with their medical bills. A portion of the money is earmarked for children and non-elderly Americans, who, starting in 2014, will become eligible for Medicaid or receive tax credits to offset the cost of private insurance. A smaller, but still significant, portion of the money is for seniors. It helps them pay for prescription drugs, by filling the “donut hole” in Medicare Par D coverage. It also eliminates out-of-pocket costs for annual wellness visits, some cancer screenings, and other preventative services. Those benefits have actually started already: In the first six months of this year, according to the Department of Health and Human Services, more than 16 million seniors took advantage of the free preventative care provision.

    I also found this piece to be an excellent review of the issue, stressing a very important dimension of the ACA’s Medicare savings:

    None of these reductions were financed by cuts to Medicare enrollees’ eligibility or benefits; benefits were improved in the ACA. Cuts were focused on hospitals, health insurers, home health, and other providers. Except for insurers, all the affected groups publicly supported the reductions to help finance the ACA’s expansion in health insurance to about 32 million uninsured Americans.

    This is in stark contrast to the Ryan proposed cuts, supported by House Republicans, which are largely used to lower taxes on the most affluent.

    Finally, remember that these and other measures in the ACA actually extend the life of the Medicare HI trust fund and reduce its budget shortfall by a factor of five (see the last section of Paul’s piece here, the part on Medicare not going bankrupt).

    What we have here is stark proof that it’s going to take real vigilance to have the discussion we need to have in this country about the role of government in our lives—in this case, in the lives of retirees who depend on guaranteed benefits under Medicare.

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    After the Obamacare ruling, the National Retail Federation said requiring retail employers to offer healthcare would be devastating to the industry.

    Since the ruling in June, big businesses including Papa John's have weighed in and complained about the costs of providing employees with benefits.

    But there's one major retailer that does offer most employees affordable healthcare: Costco.

    Leon Kaye at TriplePundit describes Costco's policies:

    "Walk into any Costco and look at the name tags. Chances are you will read the phrases “since 2002,” “since 1999” and “since 1995.” Costco workers get paid very well compared to their counterparts at chains including Walmart. In fact, employees working on the floor can make a salary that reaches the mid-$40,000 range; not bad for someone who starts working for the company out of high school.

    And while the vast majority of Costco’s employees are not unionized (most of those are legacy employees from Price Club that the Teamsters represent), over 80 percent have competitively priced health insurance plans.

    The outcome includes more productive workers, lower turnover and for what it’s worth, relatively high job satisfaction."

    Costco certainly has more resources than small businesses, which the NRF said would suffer most from the SCOTUS ruling.

    But the Costco anecdote certainly provides food for thought on how retailers should treat their employees.

    DON'T MISS: Luxury Companies Are Getting Hammered Because They're Losing Two Big Cash Cows>

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    romney portrait

    On June 21, 2005, Massachusetts governor Mitt Romney, now the Republican candidate for President, gave a speech at the John F. Kennedy Presidential library advocating for a new, controversial healthcare law he wanted passed in the state.

    The bill was controversial with some conservatives because it was going to try to lower the cost of health care by requiring all citizens to buy health insurance.

    This was called an "individual mandate."

    Even some of Romney's aids wondered: should a government be able to require its citizens buy anything?

    But after the speech, Romney spoke with the press and told them that, actually, the individual mandate is "the ultimate conservative ideal."

    Michael Kranish and Scott Helman report on the moment in their excellent book, the Real Romney: 

    Romney delivered his speech, publicly backing an individual mandate for the first time. He told reporters afterward, “No more free riding, if you will, where an individual says, ‘I’m not going to pay, even though I can afford it.’ ” He called it “the ultimate conservative idea,” saying that people “don’t look to government to take care of them if they can afford to take care of themselves.”

    Eventually, Romney's health care bill – and the mandate – were passed into law. Romney was so proud of this accomplishment that he asked his portraitist to include a copy of the bill in his official portrait. It's next to the picture of his wife in the portrait above. You can see the gold caduceus on the bill's cover.

    These days, Romney opposes Barack Obama's successfully passed health reform law, the Affordable Care Act, aka "Obamacare,"  which also has an individual mandate. Romney says he opposes it on the basis that it is a solution that should not be imposed on the federal level.

    We learned all this reading The Real Romney, a deeply reported and informative book by Michael Kranish and Scott Helman. You should read if want to know about the guy whom half the country wants to be our next president. Pre-order the up-coming, updated, paperback version here. Or buy the Kindle edition.

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    One of Republican presidential candidate Mitt Romney's campaign promises is that he will do everything he can to repeal the Affordable Care Act, aka "Obamacare."

    But Romney hasn't always been so opposed to the ideas behind "Obamacare," such as the act's requirement that all individuals buy health insurance.

    While he was governor of Massachusetts, Romney's own signature legislation was a healthcare reform act built around the idea of an individual mandate. In 2005, Romney even called it "the ultimate conservative idea." In materials from his 2008 campaign for President, Romney cited reports that the bill had "newly insured" some 300,000 people.

    In fact, Romney was so proud of this legislation that he insisted his official governor's portrait include a copy of the bill.

    We learned all this reading The Real Romney, a deeply reported and informative book by Michael Kranish and Scott Helman. You should read if want to know about the guy whom half the country wants to be our next president. Pre-order the up-coming, updated, paperback version here. Or buy the Kindle edition.

    Here's the portrait. You can see the bill on Romney's desk, next to a picture of his beloved wife. It has that snake-and-wings medical symbol called a caduceus embossed on its cover:

    Mitt Romney's Portrait has the healthcare bill in it

    Here's a detail:

    Romney's healthcare bill

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    Mitt Romney

    At the beginning of a press conference Thursday in South Carolina, presumptive Republican nominee Mitt Romney announced that he was going to simplify the debate on Medicare — and he brought a whiteboard in to do it.

    “I know there’s an effort by some people to try and bring as much confusion to the topic of Medicare as possible,” Romney said of the campaign that has been waged back and forth in the last two days between his campaign and that of President Barack Obama. 

    “But I want to bring as much clarity as possible. So I’ve prepared a small chart here, which will describe differences in our respective plans for Medicare.”

    The press conference ended up being more noteworthy for a different topic — Romney's tax returns. But the whiteboard lesson he gave to reporters served as one of the weirder moments on the campaign trail. 

    Moreover, it didn't quite accomplish the mission it set out to do. He didn't offer many specifics to advance his policy plan forward. He offered pretty much no new information. In the end, it wasn't nearly as simple as the three words that ended up on Romney's plan: "No change" and "Solvent."

    Here's Romney's whiteboard. It's set to four simple columns: Obama and Romney on top, seniors and the next generation on the side.

    Romney writes that there would be "no change" to seniors under his Medicare plan. He messes up the Obama side for a second...

    There it is. Romney writes that Obama cuts Medicare by $716 billion for seniors.

    Politifact pretty handily debunks this claim that Obama "robbed Medicare to pay for Obamacare." In short, there is little in "cuts" to beneficiaries. The cuts come largely from how much the program pays to providers. Here's Politifact's summary:

    What kind of spending reductions are we talking about? They were mainly aimed at insurance companies and hospitals, not beneficiaries. The law makes significant reductions to Medicare Advantage, a subset of Medicare plans run by private insurers. Medicare Advantage was started under President George W. Bush, and the idea was that competition among the private insurers would reduce costs. But in recent years the plans have actually cost more than traditional Medicare. So the health care law scales back the payments to private insurers.

    See the rest of the story at Business Insider

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    On Tuesday, we showed you an effective first punch on Medicare from the Romney campaign in a television ad buy. The Obama campaign answered on Friday with its own ad, entitled "Facts." 

    The ad will air in eight crucial swing states — New Hampshire, Virginia, North Carolina, Florida, Ohio, Iowa, Colorado and Nevada. A notable exception is Pennsylvania, which has a growing population of aging seniors.

    The Obama ad relies heavily on a non-partisan study from AARP, which supported the Affordable Care Act. AARP concluded that Obamacare "cracks down on Medicare fraud, waste and abuse" and "expands the number of people eligible for free preventive and wellness benefits."

    "And the Ryan plan? AARP says it 'would undermine' Medicare and ‘could lead to higher costs for seniors,'" the Obama ad says. 

    An item of note in the ad is the narrator using the term "Obamacare," which President Barack Obama has been trying to turn into a positively connoted term on the campaign trail.

    Romney campaign spokeswoman Andrea Saul already responded to the ad, saying "President Obama’s new ad ‘Facts’ gets the facts wrong." She continued, laying out the basic theme of Mitt Romney's whiteboard presentation on Thursday.

    Watch the full Obama ad below:

    Now watch the Romney ad >

    And check out Romney's whiteboard presentation to reporters on Thursday >

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    Barack ObamaWINDHAM, N.H. — President Barack Obama today used his harshest attack line yet on Mitt Romney and Paul Ryan's Medicare plan, warning a New Hampshire crowd here that they would not be able to "count on health care" under the Romney-Ryan plan.

    The words were the sharpest attack yet in a fiery campaign speech here to a packed crowd of 2,300 in Windham High School's gymnasium. Obama added a personal warning to his usual stump speech, which claims that Romney and Ryan would "end Medicare as we know it."

    "My plan has already extended the life of Medicare by nearly a decade," Obama said. "Their plan would put Medicare on track to be ended as we know it.

    "It would be an entirely different plan — a plan in which you could not count on health care because it would have to be coming out of your pocket. That’s the real difference between our plans on Medicare." 

    It was a day in which Obama saved his deepest criticism for Ryan, newly added to the Republican ticket as Romney's running mate last weekend. Later in his speech, he hit the Romney-Ryan ticket on taxes, saying that Romney would pay only 1 percent in taxes under Ryan's plan. That comment drew a sharp rebuke from the Romney campaign. 

    But in a week in which the conversation on the campaign trail has been dominated by Medicare, Obama hit the Republican ticket hardest on the subject. 

    :The latest thing they’ve been trying is to talk about Medicare," Obama said. Now, you would think they would avoid talking about Medicare, given the fact that both of them have proposed to voucherize the Medicare system. But I guess they figure the best defense is to try to go on offense. 

    "So, New Hampshire, here is what you need to know:  Since I have been in office, I have strengthened Medicare. I have made reforms that have extended the life of the program, that have saved millions of seniors with Medicare hundreds of dollars on their prescription drugs."

    Meanwhile, on the Republican side, Ryan appeared at a campaign stop in Florida with his mother, a 78-year-old Floridian who Ryan said has been on Medicare for 10 years. Ryan charged Obama with "raiding Medicare" to "pay for Obamacare."

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    barack obama

    The CBS/New York Times/Quinnipiac poll of three crucial swing states released Thursday morning reveals that President Barack Obama is so far winning the battle between campaigns on Medicare. 

    The poll found that in Florida, Wisconsin and Ohio — three key battlegrounds — voters trust the president to do a better job with the system. This could prove significant, because after the economy and health care in general, Medicare ranks as the third most important issue for voters in all three states, according to the poll. 

    Obama has at least 8-point leads on the issue in all three states. He leads Romney 51-42 in Wisconsin; 51-41 in Ohio; and 50-42 in Florida, the state with a large population of seniors currently enrolled in Medicare.

    The poll suggests that this is largely due to the fact that most voters don't want to see their Medicare benefits reduced. In all three states, at least 74 percent of voters surveyed said the benefits of Medicare are worth the costs.

    At least 59 percent of voters in all three states preferred Medicare to continue as it is rather than shift to a voucher-type system, as Mitt Romney and Paul Ryan have proposed. And a large chunk of voters would not support any cuts to Medicare benefits — even if it meant a reduction in the federal budget deficit.

    The Social Security and Medicare Trustees say Medicare is on track to be bankrupt by 2024.

    But even though the president scores high on Medicare, voters don't give him the same level of trust on health care in general. By double-digit margins, voters in all three states think the Affordable Care Act will harm them rather than help them.

    Now, here are two scary charts for Mitt Romney >

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    Mitt Romney

    Two and a half weeks ago, Romney campaign spokeswoman Andrea Saul prompted a flurry of conservative outrage in defending Mitt Romney's signature health care law he passed as governor of Massachusetts.

    On Sunday, Romney himself defended the law, saying he was "very proud" of the legislation known as "Romneycare" during an interview with Fox News' Chris Wallace. The remark came in response to a question from Wallace about the controversy stirred by Missouri Rep. and Senate candidate Todd Akin's recent comments on rape, pregnancy and abortion.

    Romney cited his health care law as an example of how he has protected health care for women.

    "First of all, with regards to women’s health care, look, I’m the guy that was about to get health care for all of the women — and men — in my state," Romney said. "They’re talking about it on the federal level, we actually did something. And we did it without cutting Medicare and raising taxes."

    "So you’re saying, 'Look at Romneycare?'" Wallace interjected.

    "Absolutely. I am very proud of what we did, and the fact that we helped women and men and children in our state. And we did it without cutting Medicare. … And then with regard to contraceptives, of course Republicans, myself in particular, recognize that women have a right to use contraceptives. There is absolutely no validity whatsoever to the Obama effort to try and bring that up."

    Conservatives got rather upset the last time the Romney campaign brought up Romneycare to defend something. One even said it could have been the moment Romney lost the election. They generally don't like the law in general, considering it to be an implementation of Obamacare on a state level.

    Here's video of Romney's remarks (the relevant part starts around the 1:30 mark):


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    President Obama and doctorsLawmakers in D.C. may truly be committed to improving America's health-care system. But according to actual physicians, our leaders are going about it all wrong.

    Want real health reform that is in the interest of you and your family? Don't make the same mistake that Washington did. In formulating ObamaCare, the politicians listened to lobbyists, policy wonks, academics, health theorists, regulators, and occasionally to each other.

    But they failed to listen to the people who actually care for patients: Doctors. Granted, the lobbyists for physician groups were at the table, but not the doctor him or herself. Ironic, isn't it? Especially when it's the doctor who has the daily responsibility of directly caring for the patient.

    Go ahead, ask your physician at your next visit what she or he thinks of current Washington-directed reform and its impact on the doctor-patient relationship. What you hear will likely surprise you, because it will likely be markedly  different from what you hear from Washington. The policy theorists are simply too far removed from the reality of front-line patient care. Health reform, whether via the implementation of ObamaCare or the GOP's "repeal and replace" plan, should no longer ignore the input and counsel of experienced, front-line, practicing doctors.

    Here is a sampling of what my own internist, who has taken care of thousands of patients over the past 20 years, shared with me:

    Frist: We hear the electronic health record (EHR) will solve much of what ails our health sector. 

    Doctor: The EHR is not the savior of the medical system. In fact, it is effectively destroying the relational aspect of the art of medicine. Instead of talking with a patient and hearing her "story," we are being relegated to looking at a computer screen and pointing/clicking during the visit.  I know there are long-term benefits to an EHR,  but most internists who value the art of medicine will tell you it is killing the "story." And it is expensive. Physicians with EHRs see 15 to 30 percent fewer patients (and work later into the night). And yet with ObamaCare, we will be asked to take care of an additional 30 million patients.  

    We are told that increased government regulation and monitoring will reduce waste.

    Unnecessary regulations and increased paperwork are drowning us and reducing quality of care. We have allowed just "one more thing" to be added over and over again. The camel's back is now breaking. I have never seen physicians as depressed and stressed in my 20 years of practice. At each visit, I am required to tell the government whether the patient I am seeing had a flu shot last winter! Please help me understand how that improves care. I know the many quality metrics (i.e.: check this box) mean well, but they are having the opposite effect.  They are diminishing quality because they (the boxes) become the focus of each visit, rather than the human interaction.   

    But increased documentation in charts and billing surely improves value to the patient?

    Hardly. We are now working with 17,000 diagnosis/billing codes — absolutely ridiculous. There are nine codes for abdominal pain (right upper, left upper, right lower, left lower — you get the idea). And the government has recently increased the number of codes from 17,000 to 155,000.   The bottom line — 300 codes would probably cover everything. It could be printed in a four-page leaflet, not three large volumes. It is unnecessarily complicated and it does absolutely nothing to improve patient care.  

    Doesn't more careful documentation with the required codes help eliminate fraud?

    That's ridiculous. It is just the opposite. The actual diagnosis/billing codes have nothing to do with fraud. The EHR creates the appearance of a perfectly prepared note. In truth, it simply makes it easier to copy and paste from note to note. The note is filled with unnecessary information, making the truly pertinent information hard to find (and therefore negatively impacts patient care). The nice-looking, "electronic documentation"  in the EHR opens the door for the unethical doctor to game the system and get away with it. It just makes it easier for them to upcode and not get caught. Fraud is skyrocketing while the EHR provides the cover.  

    But Washington tells us that "evidenced-based medicine" is the surest way to better outcomes.  

    Quality care comes from a careful, professional analysis of a clinical situation that leads to a correct diagnosis and treatment for the particular patient at hand. Quality care will never be found by mindlessly marking boxes or following algorithms that are at the heart of what is being called "quality measures and evidence-based medicine."  

    What stands between you and caring for the patient? 

    The paperwork is overwhelming — nursing home admission forms, medical device forms, diabetic supply forms, home health forms, insurance records requests for "additional information." Everyone has their form that must be completed. All forms roll downhill and the internist is the final resting place. Regulations requiring more needless paperwork mean less time for patients.

    The law in Washington is that your reimbursement is to be cut every year. But you seem to be working harder than ever. 

    Reimbursement for our services continues to decline, because overhead costs rise. I am very blessed. I am paid well. But I have not seen a raise in 13 years. While CEOs, managers, administrators, benefit managers, and insurance executives see regular raises and bonuses. Physicians in our clinic feel fortunate that our pay has not declined. Yet our workload is so much heavier than it once was. Not because of patient volume, but because of the higher expectations of patients, the higher complexity of medical care, and the excess "stuff" that we are being required  to do.  

    I'm told the primary care shortage of 40,000 doctors over the next 10 years can be met by non-physicians. 

    The suggestion that non-physician practitioners can fill the primary care needs of the American people is simply false. Their training, knowledge base, and ability to form a complete differential diagnosis is limited. The press often proclaims that nurse practitioners can replace doctors.  There is a role for the NP and we need to support that role. But to suggest that someone with two years of training can provide equivalent care to that of a physician who, after college, has spent four years in medical school, three to four years in residency (working days and nights), and who, each day, makes hundreds of decisions for which he or she is ultimately responsible is not only wrong, it disrespects the training and ability of the physician. Remember, quality care is not measured by patient satisfaction surveys, but instead, by the ability to properly diagnose and treat a patient.   

    So... we're not moving in the right direction with health reform? 

    At the age of 49, I feel that the practice of the art of medicine is becoming impossible, even for those of us who live for the chance to care for others. Our goal should never be to cure disease. Instead, our goal should be to heal people. The direction of our present system is negatively impacting the ability of good doctors to try and heal people. We must remove the growing distractions and be allowed to spend time with each unique patient and their "story." We need to ask of each regulation or mandate that "seems" to sound so good: How will it impact the doctor-patient relationship? It is now, and will always, be within this relationship that healing occurs and true quality care is found.  


    Those are the words of one, but they are the sentiment of many. Ask and see.

    And what is interesting is that this sort of conversation from the front-line would never make it  all the way up to my office when I was majority leader of the U.S. Senate. The existing, overly restrictive filters of Washington lobbyists and bureaucracy simply don't allow such real-life information to flow all the way up to the legislator.

    So for the next round of reform, let's make sure we don't ignore the insights of real-life doctors. Let's make sure this time around they are at the table. 


    Dr. William H. Frist is a nationally acclaimed heart transplant surgeon, former U.S. Senate Majority Leader, the chairman of Hope Through Healing Hands and Tennessee SCORE, professor of surgery, and author of six books. Learn more about his work at

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    Barack ObamaCHARLOTTE, N.C. — Rod Snyder, the president of Young Democrats of America, doesn't hesitate when asked the No. 1 thing his organization pitches as a reason to convince young voters they should re-elect President Obama this November. 

    "The single most important accomplishment of President Obama in his first term was the passage of the Affordable Care Act," Snyder said in Charlotte this week, where the College Democrats of America held a multi-group press conference in advance of the 2012 Democratic National Convention.

    "If you point to one major policy accomplishment for young people, it's the Affordable Care Act, and that's what we try to highlight as much as possible."

    It's an interesting selling point for what has been a contentious piece of legislation. But the law is popular with young people because of one specific provision, which allows them the opportunity to stay on their parents' plan until the age of 26. 

    The Romney campaign scoffs at the notion of Obamacare being a selling point for young people. Campaign spokeswoman Amanda Henneberg told Business Insider in an email that an emphasis will be placed on consumer choice, and she hinted that the 26-and-under option would remain available in a Romney-Ryan administration.

    "Gov. Romney will institute reforms that expand choice and competition, and allow individuals to own their own insurance," Henneberg wrote. "As a result, each family will be able to choose the health care plan that is right for them, including one that covers young adults up to age 26, and many insurers have already announced that they will continue to offer such plans. By repealing Obamacare, Gov. Romney will also be giving the American people a $1 trillion tax cut."

    Throughout this campaign — but especially since the decision — one of Romney's recurring lines that always draws the most cheers is that he will "repeal and replace Obamacare" as president

    But it remains to be seen whether the campaign's message on health care will stick with young voters, after the Obamacare provision has already allowed more than 3 million people the ability to stay on their parents' plans that wouldn't previously have been able to under former law. 

    Snyder is betting against it.

    "Young people have historically been among the most under- or uninsured age group in the whole country," Snyder said. "He was addressing that very specifically through that bill."

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    Mitt Romney

    Growing numbers of conservatives are starting to sound a little bit panicked about Republican presidential nominee Mitt Romney's lack of policy details — specifically, by his refusal in recent days to delve into specifics with his health care and tax plans.

    When asked about taxes on Sunday, for example, neither Romney nor his running mate Paul Ryan would point out a single deduction or loophole they would close.

    And this morning, The Wall Street Journal editorial board, one of Romney's staunchest media allies, was left to explain the Republican presidential nominee's health care policy.

    The Journal's editorial board seemed flabbergasted over Romney's flub on health care policy during his Sunday appearance on Meet The Press, when the candidate said there were certain elements of the Affordable Care Act he would keep in place as president. He later walked back on the comments, which only added to the overall confusion. 

    The Journal was thus forced to speculate about what Romney could have said instead:

    "Based on our reading of Mr. Romney's policies, he should have said something like this: 'I support President Obama's goal of making sure sick people can get insurance. But the wrong way to solve this problem is a new entitlement we can't afford, a vast increase in government control over medicine, and drastic health-care chances for the other 300 million Americans.'

    "Mr. Romney could then explain that he wants the market for individual insurance to work better by imitating the current system for large businesses. People who are covered by their employers are already protected form price shocks or losing their insurance if they become ill."

    The editorial proceeds to slam Romney, writing that his position "seems to be that he can win the election without having to explain the economic moment or even his own policies."

    And a new ABC News/Washington Post poll indicates that these fears are warranted.

    The poll shows that 63 percent of voters surveyed believe Romney has not been specific enough about policy detailscompared with just 31 percent that think he has. 

    President Obama scored much better, with voters about evenly split on whether he's provided enough policy details.

    Here's a look at how he and Romney compare on the issue of policy specifics:

    Mitt Romney Obama

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    “I’m not getting rid of all of health care reform. Of course there are a number of things that I like in health care reform that I’m going to put in place,” the Republican nominee said on NBC’s “Meet The Press.”

    “One is to make sure that those with preexisting conditions can get coverage.”

    His campaign later told TPM he wasn’t signaling a shift in policy and was instead referring to his existing stance in favor of protections on preexisting conditions only for those with continuous insurance coverage — not for first-time or returning buyers.

    “He has a comprehensive reform plan; for instance, his own plan will deal with preexisting conditions but not in the same way that Obamacare does,” a campaign aide said.

    Details of Romney’s plan are scant. For months he has sought to paint himself as supportive of helping people with preexisting conditions. But he’s caught in a predicament: enacting a robust guarantee would require maintaining other major market-driven provisions in the Affordable Care Act in order to be financially viable — which is unacceptable to the Republican base. But supporting a weaker policy would invariably leave many sick Americans out in the cold.

    The Republican nominee’s remarks Sunday served to position him favorably on the issue, but his campaign’s clarification to reporters later affirmed that he still supports the scaled-back policy he unveiled earlier this summer.

    “So let’s say someone has been continuously insured and they develop a serious condition,” Romney explained on the campaign trail in June. “And let’s say they lose their job or they change jobs, they move and they go to a new place. I don’t want them to be denied insurance because they’ve got some preexisting condition.”

    Current law has some protections for sick people in between jobs, but few for those who buy insurance on the individual market. The ACA provision takes effect in 2014.

    Although Romney also signaled sympathy for a part of the law that permits young people to remain on a parent’s policy until 26, he was singing a different tune months ago. In July, he told the Toledo Blade that he doesn’t believe that coverage guarantee be required of insurance companies.

    “That’s already in the marketplace,” he said. “United Health Care and others are offering that product, so it’s voluntary. It does not require federal legislation. It’s already in the market.”

    In response to Romney’s remarks, Obama campaign spokeswoman Lis Smith said voters should not trust the Republican candidate to save or replace any provision in the law.

    “Mitt Romney has only one health care plan: to repeal Obamacare,” Smith told TPM. “And if he had his way, insurance companies would once again be allowed to discriminate against Americans with pre-existing conditions, charge women higher premiums than they charge men for the same coverage, and kick kids off their parents’ plans when they graduate from college or high school. His promises today should be seen for what they are: a cynical attempt to mislead the American people on the devastating impact his policies would actually have.”

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    Extreme Shopping

    Retailers are still freaking out over Obamacare.

    The National Retail Federation recently went in front of a congressional panel to voice its concerns, and it used some strong language to try to change minds.

    Here's what NRF VP and employee benefits policy counsel Neil Trautwein said:

    Our nation cannot afford for the ACA to stumble out of the starting gate.

    "A cascade of last-minute regulations will create confusion and thus could encourage more employers to back out of coverage.

    "We are trying to help prevent what threatens to become a regulatory train wreck.”

    The NRF does support "effective implementation" of the Affordable Care Act, even though it's against the law itself.

    What it's particularly concerned with are the delays in getting things done. It feels that retailers won't have time to deal with what's to come.

    NOW SEE: Three Ways Obamacare Could Change Retail Forever >

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    Employer outlays for workers’ health insurance slowed from a 9 percent jump last year to less than half that — 4 percent — this year, according to a new survey from the Kaiser Foundation. Good news?

    Our political class believes it is. The Obama administration attributes the drop to the new Affordable Care Act, which, among other things, gives states funding to review insurance rate increases.

    Republicans agree it’s good news but blame Obamacare for the fact that employer health-care costs continue to rise faster than inflation. “The new mandates contained in the health care law are significantly increasing the cost of insurance” says Wyoming senator Mike Enzi, top Republican on the Senate health committee.

    But both sides ignore one big reason for the drop: Employers are shifting healthcare costs to their workers. (The survey shows workers contributing an average of $4,316 toward the cost of family health plans this year, up from $4,129 last year. Many are receiving little or no employer-provided coverage at all.)

    Score another win for American corporations — whose profits continue to be robust despite the anemic recovery — and another loss for American workers.

    Those profits aren’t due to a surge in sales. Exports are down (Europeans, Japanese, and Chinese are all pulling in their belts) and American consumers don’t have the dough to buy more.

    The profits are largely due to lower corporate costs, especially when it comes to their payrolls. Employer-provided health and pension contributions are shrinking, and the real median wage continues to drop.

    High unemployment has given companies more bargaining leverage over their workers, who have to accept lower real pay and benefits or risk losing their jobs.

    When it comes to health insurance, employees increasingly have to choose between health-insurance policies with sky-high premiums or with sky-high co-payments and deductibles. And since they can’t afford the former they’re opting for the big co-payments and deductibles – or no insurance at all.

    The result is fewer visits to the doctor and less use of other medical services.

    This is a new trend, and it comes despite the Affordable Care Act (which hasn’t been fully phased in). And it wouldn’t be worrisome if we were seeing too much of doctors before, and using up medical resources we didn’t need.

    But it’s worrisome if it means less preventive care, or health problems going untreated until they become chronic illnesses or crises.

    Healthcare costs do have to be better controlled. They now claim 18 percent of our entire economy. But the best way to control them isn’t by cutting back care. It’s by wringing inefficiencies out of the system.

    Our healthcare system wastes 30 cents of every dollar spent on health care, according to new calculations by the well-respected Institute of Medicine. Much of it is wasted on repeated tests, and a huge portion wasted on paperwork – between doctors and hospitals and specialists and insurers, to justify expenditures by one group to be paid by another.

    A single-payer system would be far more efficient. 

    So back to my original question. Is the dramatic slowdown in employer health-care costs good news? It all depends. If we and our families are in good health, or we’re high earners who can afford good health coverage without big co-payments and deductibles, or if we own lots of shares in companies showing higher profits because they’re trimming pay and benefits – or we’re in all three categories – it’s probably good.

    But if we’re none of these, it might not be good news – especially if it means we’re getting less care than would otherwise keep ourselves and our families healthy. 

    At the least, if we’re concerned about the health and well-being of all Americans, we need to find out much more before we celebrate.

    Read more posts on Robert Reich »

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    Justice Antonin Scalia

    When Supreme Court Justice Antonin Scalia spoke to a group of law students and reporters Monday night, he made it clear he wouldn't talk about past cases or anything currently before the court.

    But that didn't stop a Reuters' reporter from trying to slip in a question about health care.

    And we've got to say, he took a pretty creative approach.

    Scalia vehemently opposed the health care ruling in June, which upheld the mandate that most Americans hold health insurance or pay a penalty.

    So Monday night a reporter asked Scalia how he felt about a mandate from 1790 that required mandatory health care for all seamen.

    And while the rather cantankerous justice who says he rules based on the text of statutes and not on legislative history first refused to answer the question, he couldn't keep his mouth shut for long.

    Requiring merchants to insure seamen, who often acted as militiamen in the 1700s, is quite different from the current mandate that affects all Americans, according to Scalia.

    But, the reporter argued, both the 1790 mandate and the current one place a burden on American citizens.

    "Congress imposes a lot of burdens on the citizenry," Scalia fired back.

    DON'T MISS: Justice Scalia Flipped Out Last Night When People Asked Why The Court Was So Political >

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