It's not that pesky gay marriage problem that's the Supreme Court's biggest issue this term. It's who the next appointee will be.

After all, Justice Ruth Bader Ginsburg is getting up there in years and if President Barack Obama is re-elected, she might consider retiring so Obama can choose the next justice.

And, according to Stephen Colbert, Obama will probably appoint "a gay polar bear" if any of the current justices resign.

But, only if that polar bear "votes liberally," according to CNN's legal analyst Jeffrey Toobin, who recently appeared on Colbert's show.

Above The Law first posted the pair's tête-à-tête, in which Toobin theorized Chief Justice John Roberts shocked the country and upheld Obamacare because he didn't want his court to get up in the "maelstrom of politics."

Watch the full interview, courtesy of Above The Law:

DON'T MISS: Justice Scalia Blew Off A Reuters Reporter's Genius Question About Health Care >

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Remember the big flap about the Supreme Court ruling on the Affordable Healthcare Act (AKA – Obamacare – ACA)? The issue that made the headlines was that the Supremes ruled that ACA was legal, provided that the penalty for not having health insurance was collected as a tax.

This is a big deal as the penalty ($700 a year per person) was supposed to be the discipline that forced people to go out and buy their own insurance. One either acquires health insurance, or they pay a price.

The CBO took a look at this last week (link). The results surprised me. The reality is that few people will end up paying the penalties. So the basic premises of ACA is actually a fraud.

CBO estimated that there will be 30Mn uninsured in 2016 when ACA goes into effect. Of that 30Mn, the following groups will be excluded from paying the penalty:

1)   Undocumented workers.

Really? But that is 10Mn people; a third of the problem!

2)   Religious Beliefs

Huh! What religion is that? If it gets you out of paying taxes, I want to join!

3)   Native Americans

Okay, after all, it is their land. 

4)   Individuals and families with low incomes.

I can live with this. But isn’t this where we are today? Poor people don’t have health insurance today, and they don’t have to pay any fines. In 2016 they will still have no insurance, and they won’t have to pay any fines. What has been accomplished?

5)   Anyone who does not file federal income taxes.

This is directed to those with income of less than $10k per year (same as #4), but there are an awful lot of people who don’t file taxes who are making much more than the minimum amounts. Most waiters and bartenders would fall into this group.

6)   Individuals who can’t afford the cost of health insurance.

The annual cost of health insurance must be less than 8% of an individual’s income for the penalties to apply. What is this new insurance policy going to cost? If the answer is $250 per month (too low in my opinion) it means that anyone with an income less than $37,500 is excluded. If the cost of that Ins. policy is $500 a month(a more reasonable estimate), then anyone who has annual income of less than $75,000 would be excluded.

With these carve outs the number of individuals who would be subject to the penalty falls to 6Mn (80% drop). But it gets worse:

Among the uninsured individuals subject to the penalty tax, many are expected to voluntarily report on their tax returns that they are uninsured and pay the amount owed. However, other individuals will try to avoid payments.

Oh boy! How many of the remaining 6Mn will “voluntarily” pay the penalty, and how many will seek to “avoid” it? At least half will avoid it. There is not much risk of getting hit by the IRS if one’s income is < $75,000. The IRS does not have the manpower to chase after those who “avoided” the penalty. The CBO recognizes that the actual amount of fees collected is subject to:

the ability of the Internal Revenue Service (IRS) to administer and collect the penalty.

The only people who are going to end up paying are those who have something to fear from an audit.

Households with income that exceeds $60k are estimated to constitute aboutone-third of people paying penalties and to account for about two-thirds of the receipts from those penalties.

The CBO reckons that Uncle Sam will collect about $8Bn a year in fees. This money will be used to offset some of the costs of the uninsured. The Penalty is also the “stick” of ACA that forces people to get insurance by one means or another. I see it differently:

-       Post the introduction of ACA there will still be 30Mn people without insurance. These people will still get sick or injured; they will continue to be a drag on everyone else.

-       The fees/taxes that are supposed to provide discipline and revenue for ACA will accomplish very little. I will be amazed if the penalties total more than $2Bn a year (peanuts). There will still be 30Mn people without insurance, and they will get sick (not peanuts).

-       The Administration and Congress have cooked up a deal that got amended by the Supremes that will result in a great new opportunity for people to cheat on their taxes. Millions will take advantage.

-       ACA is a wealth redistribution program. ACA will create more TAKERS; the PAYERS will foot the bill.

++

Mitt probably lost any chance he had with the election with is words about the “other” 47%. But the fact is the country is divided between Takers and Payers. The CBO head, Doug Elmendorf had this to say about the dilemma the country faces:

Formidable? I would say impossible.

Four years from today the Taker – Payer ratio will exceed 50%. The argument then will be the same as it is today. In order to pay for the cost of government, taxes will have to be much higher than the historical norm. But the necessary higher taxes will drag on the economy, and growth will be far less than potential. Sub-par growth means high unemployment and low tax receipts. The vicious debt spiral will continue.

Where does this lead us? Elmendorf’s thoughts:

The conclusion is that we are headed into a crisis, and when it happens we will not have the resources available to fight that crisis off. What kind of plan is that?

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Seeking to soften his image, Mitt Romney has this week taken — again — to touting the health care reform law he enacted as governor of Massachusetts, saying it illustrates his “empathy and care about the people of this country.”

While running for president in 2008, and the following year while the Affordable Care Act was still being crafted, Romney was actively evoking ‘Romneycare’ as a model for federal health reform. All that changed after President Obama signed the law in March 2010, at which point repeal became the Republican Party’s raison d’être. Romney quickly latched on to the cause.

That’s when the relationship between the now-Republican nominee and his signature achievement as governor grew complicated. Here’s a timeline.

April 12, 2006: Birth of Romneycare

Massachusetts Gov. Mitt Romney signs health care reform into law.

February 2, 2007: ‘Model for the nation’

Preparing to run for president, Romney touts Romneycare in a Baltimore speech. “I’m proud of what we’ve done,” he says. “If Massachusetts succeeds in implementing it, then that will be a model for the nation.” He repeats this message in multiple media appearances throughout his presidential run.

January 5, 2008: ‘I like mandates’

In a Republican primary debate, Romney defends Romneycare and its individual mandate. “I like mandates. The mandates work,” he says. “If somebody — if somebody can afford insurance and decides not to buy it, and then they get sick, they ought to pay their own way, as opposed to expect the government to pay their way.” He continues to echo this message.

July 30, 2009: Adopt my plan, Mr. President

The national health care debate is raging. Romney takes to USA Today to call on Obama to embrace the tenets of Romneycare. “Obama could learn a thing or two about health care reform from Massachusetts,” he writes, making the case for an individual mandate: “Using tax penalties, as we did, or tax credits, as others have proposed, encourages ‘free riders’ to take responsibility for themselves rather than pass their medical costs on to others.”

The federal law enacted in March 2010 includes the three core planks of Romneycare: guaranteed insurance coverage, an individual mandate and subsidies to help people afford to buy their own policies on a regulated exchange.

March 30, 2010: ‘Different as night and day’

Reading the tea leaves, Romney proceeds to channel his party’s calls to unwind Obamacare and insists that it’s different from his plan.

“People often compare his plan to the Massachusetts plan,” he tells the Boston Globe. “They’re as different as night and day. There are some words that sound the same, but our plan is based on states solving our issues; his is based on a one-size-fits-all plan.”

After initially calling for partial repeal, Romney champions the GOP’s push to fully repeal the Affordable Care Act, describing it as both unconstitutional and damaging to the nation.

May 12, 2011: No apology

Weeks before announcing his presidential bid, and under pressure from conservatives to disavow his greatest political accomplishment, Romney gives a speech defending his law but vowing never to impose it on the nation. “Our plan was a state solution to a state problem and his plan was a federal power grab,” he says.

“I also recognize a lot of pundits are saying I should stand up and say this whole thing was a mistake,” he says at the University of Michigan. “But there’s only one problem with that: It wouldn’t be honest. I, in fact, did what I felt was right for the people of my state.”

June 12, 2011: Obamneycare

One day after his Republican primary opponent Tim Pawlenty derisively conflated the two laws with the moniker "Obamneycare," Romney defends his version in a debate.

“If I’m elected president I will repeal Obamacare,” he says. “And also, on my first day in office … I will grant a waiver to all 50 states from Obamacare.”

Romney proceeds to avoid mentioning Romneycare for the rest of the primaries, but holds the line on the federal-state distinction each time he’s asked about it.

September 15, 2011: ‘One of my best assets’ against Obama

During a Republican primary debate in South Carolina, Romney explains how he will respond to Obama’s contention that he isn’t a credible critic of the Affordable Care Act.

“That will be one of my best assets if I’m able to debate President Obama,” he says, “as I hope to be able to do by saying, ‘Mr. President, you give me credit for what you’ve tried to copy in some ways. Our bill dealt with 8 percent of our population, the people who aren’t insured and said to them, if you can pay, don’t count on the government, take personal responsibility. We didn’t raise taxes, Mr. President. You raise taxes $500 billion. We didn’t cut Medicare.’”

December 7, 2011: ‘It’s not even perfect for Massachusetts!’

Looking to shore up his primary position, Romney puts more distance between himself and his Massachusetts law than ever before. In an interview with the Washington Examiner’s Byron York, he says he actually had serious concerns about his own bill. As for how many other states should mimic his signature law, he replies: “In its entirety, not very many.”

“It’s not even perfect for Massachusetts,” he says. “At the time we created it, I vetoed several measures and said these, I think, are mistakes, and you in Massachusetts will find you have to correct them over time. But that’s the nature of a piece of legislation of this nature. You’ll see what works, what doesn’t, and you’ll make the changes. But they have not made those changes, and in some cases they made things worse. So I wouldn’t encourage any state to adopt it in total.”

June 28, 2012: Upheld

The Supreme Court upholds the Affordable Care Act, and by now Romney has locked up the presidential nomination. “Our mission is clear,” he says. “If we want to get rid of Obamacare, we’re going to have to replace President Obama.” He does not mention Romneycare.

August 8, 2012: Romneycare revival

Accused in a vicious pro-Obama group’s ad of being responsible for the death of a woman by making decisions at Bain that cost her her health care, the Romney campaign seeks to soften his image by saying the Massachusetts law would have covered her.

“Obviously it is unfortunate when anyone loses their job,” says Romney spokeswoman Andrea Saul on Fox News. “To that point, you know, if people had been in Massachusetts under Gov. Romney’s health care plan they would’ve had health care.”

Conservatives threw a fit, unleashing a torrent of criticism at their nominee’s campaign, with some fearing that Saul’s remarks would cost him the election. The criticism, it turns out, would not silence the campaign’s embrace of the law.

August 26, 2012: ‘Very proud’

Fending off Democratic claims that Republicans are waging a “war on women,” Romney says he’s “very proud” that his Massachusetts law gave health care to many women.

“I’m the guy who was able to get all the health care for all the women and men for my state,” he says on Fox News. “They were talking about it at the federal level. We actually did something and we did it without cutting Medicare and without raising taxes.”

September 8, 2012: I like parts of Obamacare — but not exactly

In an interview on NBC, Romney briefly signals support for two key provisions in Obamacare — guaranteed coverage for preexisting conditions and letting young people remain on a parent’s policy until 26, which were also included in Romneycare.

“I’m not getting rid of all of health care reform,” he says. “Of course there are a number of things that I like in health care reform that I’m going to put in place.”

Soon, his campaign clarifies that he wasn’t expressing solidarity with the Affordable Care Act, but was reiterating support for different versions of the ideas. In the case of preexisting conditions, he wants laws protecting those who have maintained continuous coverage, but not first-time buyers. And he says insurers will adopt the under-26 provision on their own.

September 26, 2012: ‘Empathy and care’

Under fire again from the Obama campaign for his taped remarks deriding 47 percent of Americans as freeloaders, Romney cites Romneycare in a national TV interview as evidence of his compassion for ordinary people.

“Don’t forget — I got everybody in my state insured,” he says on NBC. “One hundred percent of the kids in our state had health insurance. I don’t think there’s anything that shows more empathy and care about the people of this country than that kind of record.”

On the same day, Romney touts Romneycare in a guest article for the New England Journal of Medicine contrasting his vision for health care reform with Obama’s. “Each state will have the flexibility to craft programs that most effectively address its challenges — as I did in Massachusetts,” he writes, “where we got 98 percent of our residents insured without raising taxes.”

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SAN JOSE, Costa Rica — Sitting in blue scrubs in a hospital room, plastic surgeon Christian Rivera ponders a potential sea change for this Central American country’s private hospitals, triggered by health care reform in the United States.

That’s because his profession thrives on uninsured US citizens looking for cheaper care abroad. So what happens to medical tourism when US President Barack Obama’s Affordable Care Act grants almost all US citizens health insurance by 2014? Rivera hopes he has a positive answer.

In June, the US Supreme Court declared the core of the reform constitutional. Republican presidential candidate Mitt Romney, if elected, has vowed to repeal it. At the same time, overseas medical tourism representatives are searching for ways to benefit under the new law, often called “Obamacare.”

That name started out as a favorite pejorative for critics who deride what they see as a central pillar of Obama’s agenda for big government control. But now the law’s supporters have adopted the word for legislation they believe brings Americans closer than ever to universal health care.

But other changes could be under way. Some experts predict a doctor shortage and longer hospital waits in the United States. They also foresee insurance companies extending coverage for Americans’ international medical bills. If all this is true, medical tourism will have a healthy future.

US patients obtain health care treatment in foreign countries well below US rates. Treatments include dental implants, hip and knee replacements or bariatric surgeries. Americans also go abroad for more complicated procedures such as heart operations and cancer treatment, or alternative therapies such as stem cell treatment unavailable at home.

Estimates vary on the size of the medical tourism industry. In December 2010, consulting firm Frost & Sullivan put the industry’s global worth at $78.5 billion. Patients Beyond Borders, a consultancy for consumer information on the sector, put it at $15 billion, counting 5 million patients worldwide in 2011.

Estimates for how many of the patients were American vary too: from 550,000 to 1.6 million.

In the developing world, many doctors now work like Rivera. Physicians and surgeons train at top US medical schools, return to their homeland — whether in Mexico, Central or South America, or Asia — and provide nimble treatment to anyone who can afford their care.

The economic benefits extend far beyond the doctor’s office. In Costa Rica, patients fly in to fill hospital beds, hotel rooms and spots in tour groups all on the same trip. They tend to stay longer and spend six times as much money than the average tourist, according to Promed, a Costa Rican nonprofit association representing the private health sector. American patients often bring the family, and spend their recovery at a beach resort or in a lodge in the rainforest.

In 2010, Costa Rica attracted 36,000 medical tourists — primarily US and Canadian citizens — who spent $295 million in the country, according to Promed.

Those commanding numbers underline why it’s crucial for countries to understand the intricacies of Obamacare — and how to take advantage of it.

“One drop of business from the US is a tsunami for the Costa Rica economy,” Rivera says.

David Vequist researches medical tourism at the University of the Incarnate Word in San Antonio, Texas. He estimates that a little more than 1 million US citizens seek health care abroad each year.

The American population is getting older, fatter and sicker, he said. The US has a doctor shortage even while the country extends coverage to 30 million citizens. The Association of American Medical Colleges says the United States could have a deficiency of more than 62,000 doctors by 2015.

If demand cannot be met, Vequist said, patients with the means to travel abroad will do so to obtain immediate care.

He predicts a slight drop in patients traveling abroad in the first two years of reform, and then an increase starting around 2015.

Some US businesses already persuade employees to travel for treatment. Medical tourism experts see that becoming more common in the future. With incentives like deductible waivers, the plan saves money for the insurance company, the business and the employee.

The health care reform does not cover many of the industry’s most popular procedures, such as dental work, which accounts for an estimated 40 percent of medical tourism. Elective surgeries and operations not offered in the United States, including stem cell treatment and experimental drugs, will not be affected by the reform.

Countries like India, a medical tourism leader in the developing world, could face more of an obstacle since many Americans visit Indian hospitals for heart surgery and other procedures covered by US health insurance. Few will travel halfway around the world to get cavities filled.

Jonathan Edelheit, who runs the Medical Tourism Association, a Florida-based trade group, is bullish about the industry’s prospects in the face of the Affordable Care Act.

“Consumers are more educated than ever before on quality,” Edelheit told GlobalPost. “And when they find it they’ll travel wherever they have to."

He calls the law merely “insurance reform,” since it does little to slow the rising costs of pharmaceuticals or medical devices. The fines for opting out of insurance ($95 in 2014 and $695 in 2016) are too weak, he said, so young people will choose not to be covered, further straining the system.

The Congressional Budget Office estimates 1 percent or roughly 4 million people will opt out and pay the fine instead of buying health insurance by 2016.

Glenn Cohen, a Harvard law professor who studies medical tourism, notes that in 2006, Romney, then the Massachusetts governor, overhauled the state’s health care system. Hospital wait times have not increased dramatically. The longest wait comes in primary care, averaging 45 days, according to a recent report by the Massachusetts Medical Society. Specialty care wait times are shorter. Better access to a doctor has helped improve patient wellness and disease prevention, thus reducing costly emergency room visits.

The severity of the doctor shortage likely will depend on the state. According to 2008 data by the Kaiser Family Foundation, Massachusetts has one of the highest primary care physician-to-patient ratios in the United States, with more than 1.5 doctors per 1,000 people, similar to most of the Northeast. However, states in the Mountain West and the South have far lower ratios.

The legislation includes some incentives for becoming a primary care doctor, but whether it fills the gap could mean a world of difference for countless international clinics.

Yet the government could choose to put limits on coverage for care in foreign countries, particularly if it sees problems with liability, quality and lack of transparency in their health sector.

There is no official global regulatory body overseeing medical tourism.

The closest thing perhaps to a hospital standard-bearer is the US-based Joint Commission International. It has accredited more than 200 hospitals and clinics in three-dozen countries that follow specific norms for quality and safety.

That helps health providers stand out among the competition.

Latin America and southern Asia held an advantage of lower costs over places like South Korea, Japan, Taiwan, Israel and Europe. Experts believe Latin America’s proximity to the United States, and the US’s large Hispanic population, will give the region an edge over Asian competitors after the reforms take place.

Yet Rivera worries Costa Rica could lose out to other major destinations. The surgeon is urging the Costa Rican government to promote clinics along with other traditional tourism hotspots in international advertisements.

“When you talk about Costa Rica the average American tourist thinks about jungle, rivers, volcanoes and birds,” Rivera says. “They don’t think about surgeries.”

Read the original article at GlobalPost

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Critics say moderator Jim Lehrer let President Obama and Mitt Romney walk all over him in the first presidential debate, but because Lehrer let the candidates go long on their answers, and because both are technocratic candidates, the debate had a surprising level of substance.

If the debate had been snappier and zingier, pundits would be wailing about the terrible superficiality of American politics. Instead, Romney and Obama gave the fact-checkers a whole bunch of stuff to sort through.

Here are the arguments and the facts of three big policies they debated:

Taxes

What'd they say?

Obama and Romney spent several minutes debating whether Romney's tax plan features a $5 trillion tax cut. Obama said, "Romney’s proposal that he has been promoting for 18 months calls for a $5 trillion tax cut, on top of $2 trillion of additional spending for our military. And he is saying that he is going to pay for it by closing loopholes and deductions. The problem is that he’s been asked over 100 times how you would close those deductions and loopholes, and he hasn’t been able to identify them." Obama continued that "independent studies" said the only way Romney could implement his plan and not increase the deficit is by increasing taxes on the middle class — the average family with kids paying $2,000 more. "It’s — it’s math. It’s arithmetic."

Romney responded that he would not cut taxes in a way that increased the deficit. "There’s no economist that can say Mitt Romney’s tax plan adds $5 trillion if I say I will not add to the deficit with my tax plan." He continued, "I will not under any circumstances raise taxes on middle-income families… Now, you cite a study. There are six other studies that looked at the study you describe and say it’s completely wrong. I saw a study that came out today that said you’re going to raise taxes by $3,000 to $4,000 on middle-income families… I want to bring the rates down, at the same time lower deductions and exemptions and credits and so forth, so we keep getting the revenue we need."

What are they talking about?

This was one of the moments when the candidates seemed to forget they were talking to an audience that was larger than "people who read a lot of political blogs." The study Obama was referring to was by the Tax Policy Center. (Obama's reference to "math," too, seemed to be a nod to Jon Stewart's praise of Bill Clinton's math in his Democratic National Convention speech.) TPC's study, released August 1, found that Romney can't achieve all his tax goals with the tax plan he's offered. Romney wants to cut marginal tax rates, eliminate the alternative minimum tax, and pay for that by getting rid of some tax deductions, so that in the end, middle class taxes don't go up, and the deficit doesn't increase. But TPC found that killing the deductions won't save enough money to make up for the price of tax cuts. So TPC found that to avoid increasing the deficit, Romney has to increase taxes on the middle class. 

But there have been others who say Romney's plan is possible — Harvard's Martin Feldstein found that if Romney raises taxes on those making more than $100,000 a year, instead of $250,000 a year.

Who's right?

PolitiFact rates Obama's claim as half-true, but says a reason Obama can make his claim is that Romney hasn't offered enough details. Obama's $5 trillion number comes from adding up TPC's estimated yearly cost of Romney's plan — $480 billion — over 10 years. "But Obama is right in pointing out that Romney has yet to specify what tax breaks he would change," PolitiFact says.

What about the "six studies" backing Romney up? FactCheck.org says there are five, but two were blog posts, and none were nonpartisan. One one of these studies was done by someone who wasn't advising Romney — Harvey Rosen, who worked on George W. Bush's Council of Economic Advisers. But Rosen's analysis rests on the idea that cutting taxes will grow the economy an extra 3 percent. There isn't much evidence to back that up — after Bush's tax cuts, real gross domestic product grew by an average of a little more than 2 percent.

Health Care

What'd they say?

Obama said that since Obamacare was passed, sure, health care premiums have gone up, but "they’ve gone up slower than any time in the last 50 years. So we’re already beginning to see progress." He said under Romney's plan, "there’s no indication that that somehow is going to help somebody who’s got a pre-existing condition be able to finally buy insurance. In fact, it’s estimated that by repealing Obamacare, you’re looking at 50 million people losing health insurance…"

Romney countered that "preexisting conditions are covered under my plan. Number two, young people are able to stay on their family plan." He said Obamacare is too expensive, because the Congressional Budget Office has said Obamacare will cost $2,500 a year more. In 2008, Obama promised to lower the cost of insurance by $2,500 per family.

What were they talking about?

How insurance companies can get out of paying for some medical conditions now and under Romney's plan, and how much insurance costs per month.

Who's right?

Health care spending, not health insurance premiums, has grown at a slower rate, FactCheck.org says. But credit goes to the bad economy, not Obama, for the slower growth in health care spending. As for premiums, Obamacare "was responsible for a 1 percent to 3 percent increase last year because of more generous coverage requirements."

As for pre-existing conditions, The New Republic's Jonathan Cohn says he was jumping out of his chair at this part of the debate. Romney said "number one, preexisting conditions are covered under my plan." But that's only for people with continuous coverage — that means people who've never gone without insurance. But it's the people who've gone without insurance who are at the greatest risk for losing coverage.

Medicare and Medicaid

What'd they say? 

Romney accused Obama of cutting $716 billion from Medicare, and promise to restore it. Romney preempted an expected Obama attack line, saying that while Obama says the cuts are just to eliminate fraud and abuse, they're actually cutting how much doctors and hospitals get reimbursed, which means fewer will accept Medicare patients.

Obama countered that Romney would make even bigger cuts to the program in the long run by offering vouchers, eventually costing old people $6,000 a year more, and further down the line, crippling Medicare until it faces "collapse."

What are they talking about?

The $716 billion Obama cuts is in the plan offered by Paul Ryan, too. FactCheck.org explains that the cuts are not to benefits, and in some cases give incentives for better care — if hospitals have too many re-admissions, they lose money. "Hospitals agreed to these cuts because they knew, at the same time, they would likely see an influx of paying patients with the Affordable Care Act’s insurance expansion," The Washington Post's Sarah Kliff explained in August.

Romney wants to offer old people on Medicare the option of getting a subsidy to buy private insurance. Obama argues that the size of the voucher won't grow as fast as health care costs, so seniors will be able to get less and less care.

Who's right?

PolitiFact says the $6,000 figure Obama cited is based on an older plan offered by Paul Ryan. "The current plan, while it caps overall growth in Medicare spending, is slightly more generous in how fast it allows subsidies to grow as health care costs increase," the site says. It's possible the increased cost is as little as $800 a year, but the new plan hasn't been fully analyzed. FactCheck.org says that while cuts to the growth of Medicare is necessary to extend the life of the program, it's true that Medicare’s chief actuary, Richard Foster, testified last year that 15 percent of providers who take Medicare patients would become unprofitable, a figure Romney alluded to.

But Romney's plan has problems, too. His promise to restore the Medicare cuts, The New Republic's Cohn says, poses some of the same problems as his tax plan. "Either Romney can’t restore the Medicare dollars as he says or he’s not living up to his promises on deficit reduction," Cohn writes. In August, The New York Times' Jackie Calmes reported that Romney's promised restoration of the cuts would have the curious result of actually raising out-of-pocket costs by $342 a year over the next decade. That's because if Medicare pays more to doctors, seniors' co-pays are higher, too.

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Election fever

Health care defined Barack Obama’s first term. It may determine whether he wins a second

THE economy is the election’s main issue, but health care is its most incendiary. According to Democrats, Mitt Romney and Paul Ryan, his running-mate, want to disembowel Medicare, the elderly’s sacred public health programme, and slash Medicaid, its programme for the poor. According to Republicans, Mr Obama’s reforms of 2010 trample on states’ rights, steals billions from Medicare and will shove America off a fiscal cliff.

Despite the hyperbole, the fight over health care is vital. Nearly 18% of America’s GDP is spent on health. Millions of baby-boomers are retiring; the young are developing chronic disease as never before. It is unclear that America can care for them without going bankrupt. The future health of America’s economy and citizens depends on reforms made now.

The two candidates offer two very different choices. If Mr Obama is re-elected, he will implement his vast law in full, moving America significantly further towards universal health coverage. Mr Romney would transform Medicare and throw "Obamacare" in the bin. The fight over health helped oust Democrats from the House of Representatives in 2010. It may determine the presidential election, too.

Mr Obama’s law covers everything from menus to electronic health records, though its most prominent reforms will not come into effect until 2014. Controversy has centred on the law’s "individual mandate", the requirement to buy health insurance or pay a fine. The mandate tries to end the free-riding that occurs when the uninsured receive free care at hospitals, which pass the costs to everyone else in the form of higher fees. It is also a tool to offset the cost of insuring the very ill. Mr Obama’s law requires insurers to cover those with pre-existing conditions from 2014, without unduly raising their rates. If cheap, healthy young people must have insurance, their premiums will help pay for the cost of insuring the ill.

Mr Obama also sought a big extension of Medicaid. Previously, states were required to cover only specific groups of the poor, such as pregnant women. Mr Obama’s law extended Medicaid to all those with incomes of up to 138% of the federal poverty level--$23,050 for a family of four. Washington would pay for all of the expansion in 2014, falling to 90% by 2020. Those who do not qualify for Medicaid but who cannot afford insurance--those with incomes between 100% and 400% of the federal poverty level--will get tapering subsidies to buy insurance on new health exchanges. Run by states, these markets will let individuals compare and buy insurance products. In all, the law was meant to expand coverage to 32m Americans who lacked it.

States challenged the reform within minutes of it being signed into law. They argued that Congress could not force Americans to buy insurance. But in June the Supreme Court upheld the law. The decision was not a complete victory for the Democrats. The court held that Congress must make the Medicaid expansion optional. Telling states to expand the programme or forgo all aid amounted to unconstitutional coercion.

The ruling was a huge relief for the White House, but it did not solve Mr Obama’s problems. Most important for his political survival, the law is still divisive. According to a Kaiser Family Foundation poll in late September, 45% of voters approved of the reform and 40% opposed it.

Then there is the thorny task of implementation. The Supreme Court’s decision on Medicaid is a headache. The very poor are particularly vulnerable--if states choose not to expand Medicaid, more than 11m uninsured would qualify for neither Medicaid nor the subsidies on the new health exchanges. The exchanges themselves are uncertain. Only 19 states and Washington, DC, have taken steps toward creating them. By far the biggest threat to the reforms, however, comes from the fact that Americans may choose to elect a president who wants to throw them out.

Mr Romney makes a very odd crusader against Obamacare. The reform is modelled after the one that he passed in Massachusetts. Nevertheless, he has vowed to "repeal and replace" the law. Whether he could actually do so is debatable. He would probably offer states waivers from the law (some would not accept), then try to repeal the law in its entirety. If he wins the presidency, there is a good chance that the Republicans will also take the Senate. It is highly unlikely, however, that they will win 60 seats or more, so Democrats would surely filibuster attempts at repeal. Mr Romney may try to scuttle parts of the law through "reconciliation", a process usually reserved for budget measures, which requires a simple majority vote.

Even if Mr Romney were to repeal the law, it is unclear what he would replace it with--or if Congress would have the appetite to replace it at all. Mr Romney’s governing philosophy is that Washington’s role should shrink, with states and the private sector leading reform instead. He offers a few further sketches. Like congressional Republicans, he favours letting insurers sell products across state lines. He wants tax breaks for individuals who buy insurance on their own.

Turning his back on everything he did in Massachusetts, Mr Romney has few plans to expand coverage. He would gut Mr Obama’s Medicaid provisions, the state exchanges and their accompanying subsidies. Mr Romney would instead give states a set amount of money for their Medicaid patients, to contain spending. Confusingly, in September he said he would keep parts of Mr Obama’s law, such as guaranteed coverage for the sick. He did not explain that the guarantee would be only for those previously insured. Mr Romney’s plans are thus pretty muddy. More clear is his vision for one of America’s most popular programmes: Medicare.

Silver power

Medicare is beloved by America’s most powerful voting bloc. The elderly turn out in higher numbers than any other group. In Florida, the most important swing state, those 65 and older comprised 22% of voters in 2008. There is the pesky fact, however, that Medicare is blatantly unaffordable. America spent $549 billion on it in 2011. The cost of services continues to rise, and baby-boomers are now entering the programme en masse. The question is how to lower spending without committing political suicide. Messrs Obama and Romney offer two very different answers.

Mr Obama’s health law cuts Medicare costs in two main ways. First, it reduces federal payments to hospitals, doctors and insurers. Second, it creates an Independent Payment Advisory Board. The controversial, appointed board must suggest cuts to keep Medicare growth below that of nominal GDP plus one percent. These cuts would automatically become law unless Congress makes equal ones through another mechanism.

In addition to these two rather blunt tools, Mr Obama is using Medicare to test better ways to deliver and pay for care. To date, America has rewarded doctors for the quantity, rather than quality of their services. Companies are slowly trying new schemes; Mr Obama’s law accelerates this. New "accountable care organisations", for example, reward those that provide good care to Medicare patients while keeping costs down.

Mr Romney presents a radically different vision. Mr Obama makes top-down cuts, while encouraging experimentation. Mr Romney says he trusts market competition to transform Medicare, praising the plan of his running-mate. Mr Ryan wants to give the elderly vouchers to spend on insurance. He initially suggested scrapping Medicare entirely. In a plan presented in December with Ron Wyden, a Democratic senator, he proposed letting the elderly put their subsidy toward either a private plan or traditional Medicare.

Beginning in 2022, beneficiaries could buy insurance on a new "Medicare Exchange". They would keep the savings if a plan cost less than their voucher and pay the extra if a plan cost more. Competition would supposedly contain costs. If it did not, the Ryan-Wyden plan would cap growth at the rate of nominal GDP plus 1% (Mr Romney has yet to endorse this cap).

Ironically, Mr Ryan and Mr Obama each favour health exchanges, but Mr Obama hates the idea for the elderly and Mr Ryan would scrap the idea for the rest. Nevertheless, the candidates’ plans for health reveal a clear ideological gap. Mr Romney would shrink Washington’s role in health care, capping costs while leaving innovation to the states and the private sector. Mr Obama believes that a big package of reforms--expanding insurance, improving preventive care, testing new ways to deliver services and squeezing payments to hospitals--will improve America’s fiscal and physical health.

The debate is simplified on the trail. Republicans have attacked Mr Obama’s health policies for years. On Medicare, Democrats can now thrash Mr Romney and Mr Ryan with equal gusto. Republicans say that they will save Medicare and accuse Mr Obama of stealing $716 billion from the programme. Democrats declare that Republicans would "end Medicare as we know it", forcing beneficiaries to pay for more health costs themselves. What is more, the $716 billion-worth of cuts is mostly for hospitals and insurers; the savings will extend Medicare’s solvency.

Interestingly, attacks on Obamacare seem to be increasingly ineffective. Polls in September showed voters still closely divided over the new health law, but they think Mr Obama is better equipped to improve American health care. On Medicare, in particular, voters favour the president. The issue that doomed Democrats in 2010 might even help them in 2012 after all.

Democrats declare that Republicans would "end Medicare as we know it"

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Supreme Court Chief Justice John Roberts voted to uphold “Obamacare” not only because he believed the law’s individual mandate is constitutional under Congress’ taxing powers, but because, as the head of the court, he understood the political ramifications of striking it down, legal commentator Jeffrey Toobin said in remarks Sunday at The New Yorker Festival.

“John Roberts is not an associate justice, he’s a chief justice. And he takes that role very seriously.

He is the institutional voice of the Supreme Court. He is the custodian of the court’s public reputation. Roberts understood the political peril that would come by making the ‘Obamacare’ case the third in a trilogy, with Bush v. Gore in 2000, Citizens United in 2010 and ‘Obamacare’ in 2012,” said Toobin, a staff writer for The New Yorker and a senior legal analyst at CNN.

After the court’s oral arguments in March, Toobin famously predicted the individual mandate — and potentially the entire law — would be struck down. In April, he stood by that claim in an interview with TPM. On Sunday, Toobin joked about the embarrassment he felt after the court proved him wrong. It looked — “to me, at least” — like the court was going to strike down the law, Toobin said, adding that court watchers should take the justices’ comments at face value.

In his new book, “The Oath: The Obama White House and the Supreme Court,” Toobin writes that Roberts changed his vote during the deliberations, bucking the conservative members of the court and siding with the liberal justices to uphold the law. Roberts wanted to avoid making the “Obamacare” case the latest in a series of highly partisan cases with the five conservative justices ruling against the four liberals, Toobin said Sunday. In making their case, the conservative justices “overplayed their hand,” Toobin said, by calling for the entire law to be thrown out — a result that would have been an “extreme, draconian step.” That caused Roberts to pause, and he “found a way out” with the taxing power argument, Toobin added.

All that being said, Toobin cautioned against the assumption that Roberts will strike a moderate chord in the court’s current term, which kicked off earlier this month and is expected to cover affirmative action, gay marriage and voting rights cases. “John Roberts has not discovered his inner moderate,” Toobin said. “I don’t think we should expect this one vote to signal any sort of change in his judicial philosophy. … “Do not expect a new John Roberts. Expect the conservative he has always been.”

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Last month I got a job that pays well enough that I will owe federal income taxes. This 
means that for the first time in my life, Governor Mitt Romney actually cares about me.
 In my first two decades, I was a student.

I only worked part-time jobs that didn't earn
 me enough money to qualify for payment of federal income taxes. Though hundreds
 of dollars came out of my paychecks over the years for federal payroll taxes, I was such 
a lucky ducky because I didn't have to pay any federal income taxes. This also meant 
I could only vote for President Obama.

But now that I have graduated and found a 
well-paying job, Mitt Romney actually deems me worthy of voting for him! This is so 
exciting!



There's no way I'm going to let an opportunity of voting for an experienced businessman
 like Mitt Romney go by. It's not like I get a chance to vote for a multi-millionaire every day.


And now that I qualify to be one of his supporters, all I have to do is take a look at his 
policy agenda and past record to see if he qualifies to be my president. That shouldn't be
 so hard, should it?



I thought I'd start by looking at tax policy, since Governor Romney himself seems 
to care so much about who pays taxes. On Mitt Romney.com, I found a whole page
 dedicated to his tax plans. According to this page, Romney wants to lower taxes to spur
 economic growth while still raising enough revenue to keep the federal budget deficit
 from increasing. This seemed like a good general principle, so I scrolled all the way to 
the bottom of the page past many paragraphs attacking President Obama's record on 
taxes in order to get to the details of Romney's plan.



But the details didn't add up, quite literally. Romney specifies that he wants to cut
 federal income taxes for everyone who currently pays them by twenty percent. He also
 wants to eliminate something called the Death Tax (on Wikipedia, it rerouted me to
 a page for the Estate Tax), and maintain current tax rates on interest, dividends and 
capital gains except for those whose incomes are under $200,000 (like me!), who 
will see taxes on those kinds of earnings eliminated altogether. That all sounds like it
 could help me, but nowhere on the page does the Romney campaign explain how it
 will accomplish its second goal, which is to lower all these taxes without increasing the 
federal budget deficit, since Romney says he thinks it is far too high already.



Because I couldn't find the answer on his website, I started to look at news websites 
to see if Romney had cleared this up in a campaign speech or interview of some kind.
 It turns out, he believes the best way to lower federal income taxes by twenty percent
 without increasing the deficit is to eliminate all those loopholes and deductions mucking
 up the tax code. That makes perfect sense, since taxes are so complicated at this point 
that Romney can't even find where he put all his tax returns from before 2010.



But I wanted to know which specific loopholes and deductions he wanted to eliminate,
 since if I ever want to buy a house I might really need something like the mortgage tax
 deduction. So I watched a Fox News interview with Romney's sharp-looking running
 mate, a fellow Wisconsinite by the name of Paul Ryan, who said that Romney would 
eliminate tax deductions starting with people at the higher end. Whew, I thought. That
 shouldn't affect me, since I don't make that much money. Then he declined to name
 which deductions a Romney administration would eliminate because he didn't have
 time to go through all the math. I understood why he said this because television is a
 medium better suited for images than arithmetic. However, I thought if all it took was a 
little math to divine the Romney tax plan, I was up to the challenge.



It turns out the math is less complicated than you would think, though probably still
 too much for a channel like Fox News. According to the non-partisan Tax Policy Center, 
cutting federal income tax rates by twenty percent would save all households with
 income above $200,000 a grand total of $251 billion every year. That's a lot of money!
 However, that money has to come from somewhere if it's not going to add to the deficit.



Ryan said it would come out of deductions, so I took a look at how much all those 
deductions for high income individuals are actually worth. And I had to keep in mind 
that Romney's website promised to keep tax rates steady on all earnings from interest,
 dividends, and investment. But adding up all those deductions together less any
 deductions for savings and investment equals less than $165 billion. That's almost
 $100 billion less than the value of the twenty percent tax cut high-income households
 would be getting. I realized that the reason the plan details on Romney's website didn't 
add up is because they simply couldn't. Even if Romney did eliminate all those pesky deductions, the wealthy would still get billions in tax cuts.



This money has to come from somewhere. It either will increase the deficit, or people 
like me will have to pay higher taxes, or federal spending will be cut. Because Paul Ryan 
and Mitt Romney don't want to go into detail about the arithmetic, I can't really guess 
what will happen. I thought maybe I could get a better sense of what might happen if 
I vote for Romney by looking at his record in government and business. Boy, if trying
 to figure out his policy agenda was difficult, understanding his record was positively 
confounding.



One concern I had about Mitt Romney was his staunch opposition to Obamacare,
 since I currently benefit from the part of that law that allows young people to stay on
 their parents' health insurance policy until the age of 26 (this makes sense when you
 work at a tech start-up that can't yet afford extensive health insurance benefits for
its employees). But then I found out that Obamacare actually modeled its regulate-
mandate-subsidize approach to health care reform on a very similar plan that was 
passed in Massachusetts when Mitt Romney was governor. How could Mitt Romney 
have signed health care reform into law while praising it as a model for the nation and then
 later excoriate the President of the United States for actually using it as a model for the 
nation, insisting that if he became president, he would repeal it?



Unfortunately, whether it’s climate change, reproductive rights, auto bailouts, or even his own proposed tax and regulation policies, the story is the same: Romney has switched sides on many of the most important issues of our time, then declined to give a coherent explanation as to why. In fact, in some cases he actually denies that he ever changed his position despite crystal clear video evidence to the contrary. Between this unsettling tendency to switch positions without providing a reason, and a consistent reliance on vague assertions with contradictory details when it comes to discussing a policy agenda on his website and in his speeches, I have come to the following conclusion:



I have no idea what Mitt Romney would do if he became President of the United States.



He has taken a lot of stances that I disagree with, both those that would make life
 more difficult for me personally like repealing Obamacare, and others like eliminating reproductive rights which would hurt immeasurably the women I count as friends and family. But prior to taking these stances, he held the opposite ones. Who is to say which set of beliefs are really his?



I made some sense of this when I thought back to what Mitt Romney had said about 47 percent of Americans: They pay no federal income taxes, and therefore they are reliant on the government.  According to his logic, I had become less dependent on the government when I started earning enough to pay federal income taxes, and therefore more important for him to reach since I was taking responsibility for my life.



But when I looked at Mitt Romney's own tax returns, I found out that he earns tens of millions of dollars annually but pays federal income taxes on a vanishingly small portion of that money. Because of the government's special tax treatment for investment income — that is money that you earn from what you own rather than what you actually do — Mitt Romney pays income taxes on almost none of his income. By contrast, I pay federal income tax on all of my income. Therefore, using his own logic, I am less dependent on the government, and more personally responsible than Mitt Romney himself because the government hands him preferential tax treatment that I don’t receive.



Romney's total lack of clarity about his own preferred policies reflects a discrepancy between what he says and who he is. I simply cannot vote for such a man, since at a bare minimum I think the President of the United States should demonstrate some semblance of knowing his own mind.

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Today the Federal Reserve said the US economy is undergoing a moderate recovery.

Anil Makhija, a professor at the Fisher College of Business, presented this morning at GE's Middle Market Summit about what a huge role mid-sized firms have played in the recovery.

The sector — which is defined as firms with revenues between $10 million and $1 billion — grew employment by 3.8 percent last year, versus 2.5 percent in small and 0.8 percent in large firms; and it created a 41 million net jobs through the crisis.

Makhija shared his PowerPoint presentation with us, and we also briefly caught up with him over the phone.

"The most important thing is the middle market indicator," he tells us. "It's been the engine of growth and continues to outperform large firms. In our last Q3 survey, S&P 500 companies are growing only at 1.5 percent, compared to 3.7 percent for mid-sized firms."

There are now nearly 200,000 mid-sized firms in the U.S., and they're spread across the country and all industries. "They're mostly privately held, not under pressure of the next quarterly report, and can take the long-term perspective," he says. "The middle market has been growing even though industry [e.g., manufacturing] has been weak."

They've played the biggest role in the recovery, he says, but just haven't gotten as much attention for it: "One reason is that small firms have informal government supports. Large firms have deep pockets and are in the public eye. There's no advocacy and no easy data."

Although these firms have been growing in recent years, their global and overall economic outlook is negative. "If you look at revenue expectations, if there’s a recovery, it’s a tepid one," he says. "The rate of growth is respectable, but it’s been declining. ... When you see this dropping off of expectations, ask why. Some of the challenges these firms are dealing with are government actions. Health care costs have been on top of their lists. Then there's uncertainty about government action, like the fiscal cliff."

Makhija's report also shows that mid-sized businesses are holding onto more cash and not investing and hiring as much as they were back in Q1 and Q2. "These firms are very diversified across industries, all around the nation and are good barometers for the economy as a whole."

Now check out Dr. Makhija's PowerPoint presentation >

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It’s election season, and we’re sure you’ve been hearing a lot about the rising cost of health care.

Medical spending in the United States is rising faster than inflation and has nearly doubled in the last decade. The U.S. government is trying to tackle that problem, and through the Affordable Care Act, dubbed “Obamacare,” they’ve begun changing the way they pay hospitals for Medicare patients.

On October 1, hospitals started receiving federal funding based on a “pay-for-performance” model (more on that later). To put it simply, hospitals will get more money if they adhere to what the government considers good medical and patient care practices, and less money if they don’t. The Congressional Budget Office estimates that Obamacare overall will reduce the growth in Medicare costs by $716 billion over the next ten years.

A change sounds very appealing, but what’s so different about this system from the old system? Does it have larger ramifications for the economy? And really, if we aren’t actually working in hospitals or are currently patients, why should we care?

The Problem With Medicare (and Most Health Care)
Medicare is essentially a form of government health insurance mostly for people who are 65 and older (it also takes care of people of any age with a disability or with end-stage renal disease). It pays at least a fraction of your medical costs and prescriptions directly to your doctor or hospital and is one of the largest health insurers in the world–it accounts for 17% of U.S. health spending and one-eighth of the federal budget.

Physicians and their hospitals were being reimbursed by Medicare (and private insurance companies) according to the procedures they performed and drugs they prescribed. According to this system, called fee-for-service, they were paid more if they performed more numerous or more expensive procedures. This wasn’t a universally popular approach: Many health policy analysts felt that this incentivized doctors to perform bigger or unnecessary procedures and raised costs without improving patient care.

Another problematic aspect of the system: Medicare Advantage, which is a plan that allows you to go through a private insurer (at additional cost) to receive Medicare benefits. It’s estimated that Medicare Advantage was the most costly element of the plan and cost the government about 14% more money than standard Medicare plans–but patients on every Medicare plan paid for it with increased premiums.

The money Medicare was shelling out for this flawed system was largely financed by taxpayers, through payroll taxes, taxes on Social Security benefits and interest on trust fund assets, and it was no pittance–in 2010, Medicare covered roughly 47 million patients and spent $523 billion.

How Obamacare Proposes to Improve Incentives and Care
Now, as part of President Obama’s plan for health care reform (“Obamacare“), the solution to misaligned incentives is what’s called the pay-for-performance model, which pays hospitals more not for the procedures they perform or drugs they prescribe, but instead:

Rewards hospitals financially for adhering strictly to established procedures, which reduce medical errors and the costs to fix them. For example, hospitals can be penalized if they don’t immediately provide medication to a patient having a heart attack.

Pays hospitals more for providing exemplary patient care, as measured by patient surveys.
Offers preventive services such as checkups for free. A checkup that catches any illnesses in the early stage is much cheaper than treating a full-blown disease that only got caught when it was more developed.

Nearly two-thirds of the $716 billion in savings will come from the new way of paying private insurers through Medicare Advantage and from the rules around medical procedures.

But the purpose of measuring patient care through surveys is focused more on improving patient care than cutting costs–this year, only $1 billion will be doled out as incentives to hospitals who distinguish themselves. Next year, double that amount will be doled out as an incentive for outstanding patient care and adherence to procedure.

Are Patient Surveys an Effective Measure of Care?
Already, the surveys aren’t so popular with hospitals. Because they aren’t exactly known as places of cheer, and because patients so often disagree with or dismiss their doctor’s advice, some doctors and administrators feel that the surveys aren’t a reliable representation of patient care. “You go to Disney for a great vacation experience,” Dr. Rhonda Scott tells The Wall Street Journal. “You go to Ruth’s Chris for a great dining experience. Do you think it is a great experience when I tell you that you have stage-four cancer and you may be dead in three months?”

RELATED: Big News! No More Co-Pays for Birth Control

Hospitals also worry that variables–like a high-traffic emergency room whose long waits breed grumpy patients–will negatively affect their scores and therefore, their payouts. But officials say that the surveys focus on clear and effective communication, something that any hospital should be able to provide, and that the evaluations are adjusted for demographic differences so that hospitals aren’t penalized simply for taking on patients with more serious health issues.

How Do the New Policies Affect You?
As far as patients go, it’s fair to expect that things might be a little different in many hospitals from now on. The Journal reports that many facilities getting low patient satisfaction ratings are implementing changes to fix that–things like flat screen TVs, having nurses visit every hour instead of every two and having room cleaners ask patients if they missed anything.

But don’t expect that every hospital visit from now on will end with a survey. Many hospitals are only required to ask the opinions of 100 people per year (larger hospitals will complete more surveys), and are audited to make sure they aren’t hand-picking respondents to guarantee good reviews. Aside from that, the new program should lead to two things–better patient care and lower Medicare costs … which hopefully leads to a third thing: less cost to the taxpayer, or at least more efficient use of taxpayer funds (AKA your money).

Medicare is one of the biggest health insurance providers to experiment with realigning incentives, so if the experiment is a success in terms of saving money and improving patient care, it isn’t far-fetched to think that other insurers might adapt that model. So keep an eye on the news: Your own insurance may be changing in the next few years.

Now see what Obamacare will cost you now that it's passed > 

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I expected this presidential race to tighten up, so why should I find that fact so dispiriting?

At least two reasons come to mind.  First, the stakes are high.  If Romney/Ryan win and really do:

–pass another massive trickle down tax cut on top of making the Bush tax cuts permanent;

–repeal Obamacare, voucherize Medicare, and block grant Medicaid and food stamps;

–deregulate financial markets and environmental protections;

–push through budgets that spend a lot more on defense and a lot less on public goods, including education;

…the nation will be a lot worse off for it.  I understand that they won’t have a free legislative hand to wreak such havoc, but new administrations tend to get quite a bit of what they want, and even half of the above agenda would be terrible.

I and others have written a lot about that.  Here, I’d like to think a bit about the second reason the current moment feels so unsettling: facts, policy analysis, pragmatic compromise, even common sense and simple math seem less relevant in this election cycle than in any in my lifetime.

That’s not for lack of such analysis.  I and many, many others offer tons of fact-based policy analysis, and many of us—Krugman and the Wonkbook team are especially noteworthy—try to do so in ways that are intelligible and go down easily.  But I fear we are mostly writing for each other, our converted fans, and mindless opposition trolls.

It’s no great insight to point out we’re stuck in an age of truthiness, where fact checking has been relegated to a section in the paper.  It’s also an old saw to knock folks making this argument as egg-heads who don’t get the gut—the Drew Westin critique that Democrats lose when they go for the brain instead of the heart.  [Though I must admit I was struck when I read a passage this week from a New Yorker article citing the political scientists Gerber and Green on persuading non-voters to vote: “We do not see much evidence that what you communicate matters.”]

I’m sure that’s all true but it’s not the whole story.  When I say “policy analysis is missing” I’m not talking about coursework from the Kennedy School of Government.  I’m talking about the math that says you can’t cut taxes 20 percent across the board and balance the budget.  Trickle-down doesn’t work.  Climate change is a real threat.  Occupying other countries without clear benchmarks and goals is not in our interest.  If we deeply cut federal spending, we can’t invest in public goods including education, economically productive infrastructure, a safety net, pollution abatement, and so on—investments that matter to many of all political stripes.

But again, what bothers me about the Romney campaign and the current moment is not just the policy agenda, it’s their ability to completely deny that agenda and gain ground in the polls.  It’s Romney’s ability to very successfully argue that he doesn’t really have a big tax cut (the first debate), that the tax cut he doesn’t really have can be paid for by magic math, that his foreign policy is the same as the President’s (the last debate), that his plan will add 12 million jobs—the number that forecasters tell us we’re likely to see regardless of who wins.

How did we devolve to a country where someone like this can just assert things with virtually no backup from reality and not only be taken seriously but be allegedly gaining ground on a President with a solid, if not inspiring, record?  A President who can, with building evidence, make the case that we're heading out of the economic woods, who’s got a budget that’s been scored by the CBO to stabilize the debt within the next decade, who plans to implement historic health care legislation that will unquestionably help tens of millions of people?

In trying to understand how we got here, I remembered a great book I read a few months ago, Ed Luce’s "Time to Start Thinking" (which, in a very positive review in the NYT, the reviewer suggested might be retitled “Time to Start Drinking”).  Ed fleshes out the details in ways worth reading for yourself, but here’s my summary:

–Our politics has lost the pragmatism that no less than de Tocqueville recognized as being integral to our progress; it has been replaced by an ideology that is impenetrable to facts;

–Economists and policy analysts have themselves too often become undependable guides as, from their positions in bought-and-paid-for think tanks and endowed chairs, they have written off the challenges posed by globalization, technological change, and inequality, as essentially consistent with creative destruction and efficient markets.

–Both of the above have led to underinvestment in public goods, particularly in education but relatedly in R&D and innovation;

–Money in politics reinforces all of the above, creating a vicious circle that boosts ideology over information, investment, innovation, and thus blocks both accurate diagnosis and problem-solving prescription.

As can be seen with crystal clarity in this election cycle, as these forces have evolved and gained strength, we are doing an increasingly bad job of maintaining our democracy.  And it’s not just the election—it’s also governing: Consider the fiscal cliff debate today and the debt ceiling debacle last year.

Yes, it’s time to start thinking again, but more pointedly, it’s time to realize what a potentially wonderful country we have here in America and to once again embrace the responsibility for its stewardship.  Right now, that means making the effort to see through shape-shifting flim-flammers whose platform reduces to “tell me what you want and I’ll tell you that I can give to you at absolutely no cost.”   I’ll be happy to keep explaining the details, but I suspect at this point you don’t really need them.

We have a but a few days left to wake up.  I hope this missive serves as an alarm clock.

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Here’s why each map matters.

Map 1: Where Will We Buy Insurance?

The health care act requires all Americans who aren’t already insured to buy coverage. But where? That’s where insurance exchanges come in.

States have to decide whether to set up these online marketplaces, where individuals can choose among different insurance plans. Setting up an exchange allows states to customize the offerings to the needs of their residents.

States can also partner with the federal government on exchanges. But if they elect not to, the federal government will take over with its one-size-fits all exchange. States are supposed to decide which course to take by Nov. 16.

Along the West coast, legislatures have already voted to set up exchanges. Other states, including Texas, Maine and Alaska, have decided to punt.

But many states in the Midwest and South haven’t committed either way. Some governors, such as New Jersey’s Gov. Chris Christie, have held off setting up a state insurance exchange until after the election.

A health care consultant group predicted yesterday that 20 states will elect to operate exchanges.

Map 2: Will States Cover More Poor People?

Obamacare hopes to expand coverage to 30 million of the country’s 48 million uninsured residents. A big part of that would come though Medicaid.

States must also decide whether to expand Medicaid to all residents under 133 percent of the federal poverty line (about $14,893 for an individual and $30,657 for a family of four).  Medicaid currently covers poor children, pregnant women, seniors and some disabled adults. The federal government will pay the full cost for the expanded coverage for three years, and then gradually reduce its contribution to 90 percent over the next three years.

As passed in 2010, the Affordable Care Act required states to expand Medicaid or risk losing all federal matching funds for the program. But the U.S. Supreme Court ruled in June that it was coercive to force states to expand their program just to keep money they were already getting.

Now, states that don’t opt in will keep their current funding, but residents who might have qualified under an expansion will likely remain uninsured. There isn't a deadline for the expansion, but the federal government says states will receive less federal help if they decide to expand later, according to The New York Times.

As with exchanges, the states are divided.

So far, a handful – including California, Washington and Illinois – have already embraced the expansion. Florida, South Carolina, Mississippi and Louisiana have opted out.

(The states marked with scales participated in litigation against the Act that culminated in June’s U.S. Supreme Court decision.)

Too Murky to Map  

Not everything is left to states. Other issues remain murky about the law, perhaps because the deadlines are further in the future.

The requirement for individuals to either buy insurance or pay a fee to the IRS begins Jan. 14, 2014. But the federal government has not made clear how vigorously it plans to pursue those who don’t comply.

Here’s a flow chart showing who has to pay and who doesn’t.

Also unclear is the impact on employers, who will be required to provide health insurance to full-time workers beginning in 2014. Some, according to The Wall Street Journal, are responding by moving employees to part-time positions.

Finally, the Act's opponents in Congress and on the grassroots level will likely do what they can to delay or dilute these requirements, which are among its most unpopular.

If you’re interested in comparing the politics further, here’s a link to the final presidential election results by state.

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On The Daily Show last night, Jon Stewart ranted about CEOs and attempted secessionists for making up "Whine Country" after President Barack Obama won re-election last week.

Stewart slammed CEOs who have complained Obama’s Affordable Care Act and its effect on their businesses. In particular, he targeted Papa John's CEO John Schnatter, who said he will have to raise prices and cut back worker hours to compensate for insuring them. Stewart offered a solution for Papa John's: Stop giving away free pizzas.

"Maybe next time," Stewart said, "take all the millions you donated for partisan political purposes and pump it back into the type of health care advances that may ultimately increase business productivity."

Watch the clips below:

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House Republicans are publicly infighting about what to do about Obamacare in the wake of President Barack Obama’s re-election last week.

House Speaker John Boehner has now backed off his promises to repeal the president’s health care reform law – at least until a Republican is elected president.

“Well, I think the election changes that,” Boehner told ABC News’ Diane Sawyer when asked if he would still pursue repealing the law.

“It’s pretty clear that the president was reelected, Obamacare is the law of the land. I think there are parts of the healthcare law that are going to be very difficult to implement and very expensive.”

On Fox News this weekend, however, Georgia Republican Rep. Tom Price, who chairs the House Republican policy committee, said he didn’t agree with Boehner’s assessment.

“I can tell you, as a physician, we’re not opposed to the president’s health care law because of this election, we’re opposed because it’s bad policy, and it’s bad for patients all across this land,” said Price.

When asked if the more conservative Republican Study Committee, chaired by Ohio Republican Rep. Jim Jordan, thinks the fight against Obamacare should continue, spokesman Brian Straessle told The Daily Caller that “the answer to your question is yes.”

“There is still a lot we can and should do,” Straessle said. “More and more workers are going to see their take-home pay fall and their hours cut back because of this law. People will be forced to pay more for less access to care because of this law. Conservatives have no intention of just sitting around and watching that happen.”

Boehner has already taken criticism from more conservative members of the House for backing down on immigration and taxes after Obama was re-elected.

For instance, Louisiana Republican Rep. John Fleming hammered the Speaker publicly last week for some of the things he said in that interview with Sawyer. However, Fleming appears to mostly support Boehner’s position on Obamacare.

“I don’t see anything happening to Obamacare but implementation,” Fleming said in a phone interview with TheDC. “All of that is out of our hands now. HHS [Health and Human Services] and CMS [Centers for Medicare & Medicaid Services] have full control of that. And, despite the fact that there will probably be a number of bills that we try to pass, that we maybe get a vote on or possibly get through the House, I don’t see Harry Reid or the president doing anything on that. So, we’ll have to have a whole new administration with a Republican president before we can reform it or again repeal it.”

Conservative House Republicans are planning to get their message synced more closely together in the coming days – especially on Obamacare. On Wednesday, some conservative members plan to meet with press to discuss their agenda post-election. It’s expected a major issue that will come up is what to do about Obamacare.

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Nine Wisconsin state legislators have vowed to support a bill to arrest any federal officials caught implementing Obamacare in the state.

Wisconsin, a crucial swing state in this year's election that ultimately went to President Barack Obama, has been plagued by political controversy ever since its recall election.

But state legislators seem to be kicking it up a notch with their most recent pledge.

"Just because Obama was re-elected does not mean he's above the constitution," Rep. Chris Kapenga, who has vowed to support the controversial legislation in the upcoming session, told the Milwaukee Journal Sentinel earlier this week.

He's joined by eight other Republican state lawmakers supporting the measure.

"I'm certainly not for Obamacare, and if there's any way we could stop that in the state of Wisconsin, I'd be up for that," Tom Larson, another legislator supporting the measure, told the Sentinel.

But Larson said he doesn't really think it's possible to actually arrest federal officials.

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Now that Barack Obama has been reelected, Obamacare will become reality.

This means that a lot more people in the United States will have health insurance.

If the program works as it is supposed to, it also means that the growth of healthcare spending overall will eventually slow.

Both of those are good.

But, in the near term, Obamacare also means a lot of people will be paying more taxes and higher insurance premiums.

(You didn't think Obamacare was free, did you?)

Here are some of the new taxes you're going to have to pay to pay for Obamacare:

• A 3.8% surtax on "investment income" when your adjusted gross income is more than $200,000 ($250,000 for joint-filers). What is "investment income?" Dividends, interest, rent, capital gains, annuities, house sales, partnerships, etc. Thanks to the expiration of the Bush tax cuts, taxes on dividends will rise rise from 15% to a shocking 43.8% on January 1st, unless Congress cuts a deal with respect to the fiscal cliff. (WSJ)
• A 0.9% surtax on Medicare taxes for those making $200,000 or more ($250,000 joint). You already pay Medicare tax of 1.45%, and your employer pays another 1.45% for you (unless you're self-employed, in which case you pay the whole 2.9% yourself). Next year, your Medicare bill will be 2.35%. (WSJ)
• Flexible Spending Account contributions will be capped at $2,500. Currently, there is no tax-related limit on how much you can set aside pre-tax to pay for medical expenses. Next year, there will be. If you have been socking away, say, $10,000 in your FSA to pay medical bills, you'll have to cut that to $2,500. (ATR.org)
• The itemized-deduction hurdle for medical expenses is going up to 10% of adjusted gross income. Right now, any medical expenses over 7.5% of AGI are deductible. Next year, that hurdle will be 10%. (ATR.org)
• The penalty on non-medical withdrawals from Healthcare Savings Accounts is now 20% instead of 10%.  That's twice the penalty that applies to annuities, IRAs, and other tax-free vehicles. (ATR.org)
• A tax of 10% on indoor tanning services. This has been in place for two years, since the summer of 2010. (ATR.org)
• A 40% tax on "Cadillac Health Care Plans" starting in 2018.Those whose employers pay for all or most of comprehensive healthcare plans (costing $10,200 for an individual or $27,500 for families) will have to pay a 40% tax on the amount their employer pays. The 2018 start date is said to have been a gift to unions, which often have comprehensive plans. (ATR.org)
• A"Medicine Cabinet Tax" that eliminates the ability to pay for over-the-counter medicines from a pre-tax Flexible Spending Account. This started in January 2011. (ATR.org)
• A "penalty" tax for those who don't buy health insurance. This will phase in from 2014-2016. It will range from $695 per person to about $4,700 per person, depending on your income. (More details here.)
• A tax on medical devices costing more than $100.  Starting in 2013, medical device manufacturers will have to pay a 2.3% excise tax on medical equipment. This is expected to raise the cost of medical procedures. (Breitbart.com)

So those are some of the new taxes you'll be paying that will help pay for Obamacare.

Any big ones I've missed?

Note that these taxes are both "progressive" (aimed at rich people) and "regressive" (aimed at the middle class and poor people). The big ones--the 3.8% investment income hike and the Medicare tax increase--only hit you if you're making more than $200,000 a year. The rest hit you no matter how much you're making.

SEE ALSO:
Here's How Much The Obamacare Penalty Tax Will Cost You...
Here's Who Doesn't Have To Buy Health Insurance Or Pay Penalties Under Obamacare

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Unless Congress intervenes, taxes are set to rise significantly on January 1st, when we hit the "fiscal cliff."

Most of the focus of this tax increase has been on income taxes.

Income taxes for incomes over ~$388,351, for example, are set to revert back to the Clinton-era 39.6% from the current 35%.

That's a relatively modest increase, and a 39.6% tax for the top bracket is still historically low.

Capital gains taxes are also set to rise, from 15% to 20%. That's a bigger percentage increase, but the resulting capital-gains rate will still be historically low.

Screams about how these top-bracket income tax and capital-gains tax increases will ruin the economy by hammering spending and eliminating the incentive to work can be seen for what they are: The whining of people who don't want their taxes to go up.

The change in one tax rate on January 1, however, will be startlingly large: The change in dividend taxes.

On January 1, dividend taxes for those in the top tax bracket will jump from the current 15% back to the Clinton-era 39.6%. And then a new 3.8% surcharge to pay for Obamacare will be added on top, for a total top tax rate on dividends of 43.4%.

In short, unless Congress compromises, the top bracket for federal dividend taxes will nearly triple on January 1, from 15% to 43.4%.

(Lower dividend tax brackets will rise, too--back to ordinary income tax rates--but these brackets seem likely to be given a tax cut. And dividend taxes may be included in that cut).

What this means is that well-off Americans who are collecting, say, $100,000 a year in gross dividend income will keep about $57,000 next year versus $85,000 this year, a drop of 33%.

Unlike the change in income taxes and capital-gains taxes, that change is big enough to create a strong incentive for changes in behavior.

For the highest earning Americans, receiving taxable dividend income will become strikingly less attractive than it is now. As a result, they will likely try to shelter this income in non-taxable accounts or shift  dividend-paying investments to investments designed to produce long-term capital gains (which will still be taxed at a far lower rate than ordinary income).

Companies, meanwhile, may come under pressure from shareholders to stop raising dividends and, instead, use excess cash to buy back their own stocks.

None of this is necessarily "bad." It's also certainly reasonable to tax dividends at ordinary income rates, unless you're trying to encourage people to invest in dividend paying investments. And, unlike some of the other tax increases that are scheduled to hit on January 1, a top-bracket dividend tax increase will land squarely on the highest earning Americans, folks who arguably have more flexibility with which to be able to afford it.

But a jump from 15% to 43.4% is a big tax increase. And, as yet, Congress hasn't paid much lip-service to changing that.

SEE ALSO: No Worries! Higher Taxes On Rich People Won't Hurt Economic Growth

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After two years of political battles and a Supreme Court case, many if not most states are expected to tell the federal government Friday if they’re willing carry out a key part of President Barack Obama’s health care overhaul.

At issue is the creation of new health insurance markets, where millions of middle-class households and small businesses will shop for private coverage. The so-called exchanges will open for business Jan. 1, 2014, and most of their customers will be eligible for government subsidies to help pay premiums. The exchanges will also steer low-income people into expanded Medicaid programs, if states choose to broaden their safety net coverage.

Thursday evening, the Obama administration responded to a request for more time from Republican governors by granting states a month’s extension, until Dec. 14.

Ahead of the original deadline, a check by The Associated Press found that 21 states plus the District of Columbia, have already indicated they want to become involved, either by building and running their own exchanges or partnering with Washington. The 16 that want to build their own exchanges, plus the District of Columbia, face a Jan. 1 deadline for the federal government to approve their plans.

Photo Credit: AP

This group of 16 includes mainly Democratic-led states such as California and New York, but also some Republican-led ones such as Mississippi and New Mexico.

Five other states have signaled they want to partner with the federal government. Those states would handle consumer issues and oversight of health plans in the exchanges, while the feds do the heavy lifting by enrolling individuals for coverage and determining who’s eligible for government assistance. Among these states are Arkansas and North Carolina.

The number of partnership states could grow significantly, since the Obama administration has given states until next February to decide on that option. As of Thursday, 16 states indicated that they were weighing their options and have not made a final decision.

Among those, Ohio and Tennessee were considering the partnership route. And in Florida, Republican Gov. Rick Scott is now saying he wants to find a way to work with the federal government after years of steadfastly opposing Obama’s overhaul.

Finally, 13 states have indicated they will default to the federal government, allowing Washington to set up and run their exchanges. The health care law provided that the feds would run exchanges in states that were not ready or willing to do so. In this group are states whose Republican governors have staunchly opposed the law, including Texas, Louisiana and South Carolina.

Obama’s election victory guaranteed the survival of his health care law, which is eventually expected to provide coverage to more than 30 million people through the exchanges and expanded Medicaid programs. It was the final hurdle, after the Supreme Court upheld a legal challenge from 26 states. In the aftermath of the election, some Republican state leaders say it’s time to accept the law.

“I don’t like it; I would not vote for it; I think it needs to be repealed. But it is the law,” said Mississippi Insurance Commissioner Mike Chaney, after announcing that his state wants to set up its own exchange. “If you default to the federal government, you forever give the keys to the state’s health insurance market to the federal government.”

Traditionally, states have regulated the private health insurance market.

But other Republican-led states say they don’t have enough information to make a decision at this point and are clamoring for the Obama administration to release major regulations that have been bottled up for months.

“States are struggling with many unanswered questions and are not able to make comprehensive far-reaching decisions prudently,” Govs. Bob McDonnell of Virginia and Bobby Jindal of Louisiana wrote Obama earlier this week. They asked for a meeting with the president, as well as a postponement of the original Nov. 16 deadline.

Some of their main concerns are hidden costs of operating the exchanges and the sheer bureaucratic complexity of the new system. The Obama administration has steadfastly maintained it will not postpone the Jan. 1, 2014, launch date for the law’s coverage expansion. Open enrollment for exchange plans will begin even sooner, Oct. 1, 2013.

Policy experts in Washington are noticing the shift.

“I think it’s a very practical decision for states now,” said Alan Weil, executive director of the nonpartisan National Academy for State Health Policy. “We are going to have a significant number of states running their own exchanges, a significant number where the federal government is running the exchange and a significant number of partnerships. The bottom line is, we are going to have to figure out how to make all three models work.”

Although the public remains divided about the health care law, the idea of states running the new insurance markets is popular, especially with Republicans and political independents. A recent AP poll found that 63 percent of Americans would prefer states to run the exchanges, with 32 percent favoring federal control.

The breakdown among Republicans was 81 percent to 17 percent in favor of state control, while independents lined up 65-28 for states taking the lead. Democrats were almost evenly divided, with a slim majority favoring state control. Below, find a list of states, their current decision for managing the health care system and the number of people who are uninsured within each:

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Late last week more than a dozen Republican governors declared that they will not build the insurance market exchanges called for by the Affordable Care Act, including prominent names like Bobby Jindal of Louisiana, John Kasich of Ohio, Scott Walker of Wisconsin and Rick Perry of Texas.

On Monday, Mary Fallin of Oklahoma joined them, declaring in a statement that it “does not benefit Oklahoma taxpayers to actively support and fund a new government program that will ultimately be under the control of the federal government.”

The original deadline for states to notify the Department of Health and Human Services on whether they intend to build their own exchange was last Friday, but the administration extended it to Dec. 14.

About a dozen Republican governors are weighing their options, including Chris Christie of New Jersey, Rick Scott of Florida and Terry Branstad of Iowa.

The decisions carry important implications for the long-term arc of Obamacare, which supporters and opponents alike agree is here to stay now that President Obama has been re-elected.

The Obama administration wants states to build the exchanges so they have an incentive to make the law work. If the federal government takes over, state-level Republicans have a scapegoat in case things go wrong.

The more states stonewall the exchanges, the more it complicates the task of the federal government. One challenge is that the law lacks an automatic funding mechanism for HHS to set up state exchanges. Enrollment is slated to begin next October, and the exchanges are scheduled to start functioning by January 2014.

The Affordable Care Act encourages each state to build and operate its own exchange — a regulated, subsidized marketplace where consumers and small businesses can shop for insurance plans. If a state declines, the federal government has the power under the health care reform law to build one for it.

“This is a federally-mandated exchange with rules dictated by Washington,” Perry wrote in a letter to the Obama administration last Thursday. “It would not be fiscally responsible to put hard-working Texans on the financial hook for an unknown amount of money to operate a system under rules that have not even been written.”

Twenty-three states, mostly Democratic, and Washington, D.C. have said they’ll move forward with the exchanges, either on their own or in partnership with the feds.

Propelling the GOP governors’ stance is a desire to protect themselves politically from accusations of abetting a law that conservatives fervently oppose. Some governors argue that the regulations are too stifling and provide little flexibility for them to construct the marketplaces in accordance with their states’ needs.

“At this point, based on the information we have, states do not have the flexibility to build and manage exchanges in ways that respond to unique needs of their citizens or markets,” Kasich wrote in his Friday letter. “Regardless of who runs the exchange, the end product is the same.”

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Esquire has released its "Americans of the Year" list. And several of the folks who represent the spirt of the United States were also at the center of 2012's hottest legal stories.

• One of the Americans featured, Trayvon Martin, was "just a normal teenager" before he became another painful symbol of persisting racial tension in the nation, Esquire reported.
• Another of the featured Americans, Louis Freeh, once headed up the FBI and gained notoriety again this summer when he exposed a huge alleged cover-up of Jerry Sandusky's sex crimes.
• Colorado Governor John Hickenlooper made the list in part because of his strength and composure after last summer's shooting rampage in an Aurora, Colo. movie theater.
• The only Supreme Court justice who made the list had a lot of resolve, too. Justice John Roberts"made the court his"when he defied other conservatives by passing Obamacare, Esquire says.

Head over to Esquire for the full list >

SEE ALSO: Forensic Psychologist Reveals Why Eye Witnesses Get It Totally Wrong >

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