Now that Obamacare has survived at the Supreme Court and the ballot box, proponents and opponents of the law agree it’s here to stay. But Republicans remain committed to botching its implementation, which — along with inherent complexities in implementing parts of the law — leaves in place significant obstacles to achieving its key goals.

Although the GOP’s efforts to repeal, invalidate and defund the law have not succeeded, here are the four biggest obstacles the law faces in meeting its key goals:

1) Ongoing Disapproval Of The Law

Two leading health policy experts argue that the overarching threat to Obamacare is the fact that many Americans continue to disapprove of it.

“I would rank the number one obstacle to be ‘social acceptance,’” said Jonathan Gruber, a professor at MIT who helped craft the Affordable Care Act and the Massachusetts health care law that inspired it. “When we put in the mandate in Massachusetts we were worried that it would cause protests. None came. This was partly because we did a terrific job of advertising and promoting reform. The same is unlikely to be true in all other states. If folks are protesting, it undercuts the whole reform — if folks don’t sign up, then prices are higher, which leads to more protests, and so on.”

If the public doesn’t come around (supporters of the law are convinced it will), that could also encourage congressional Republicans to keep threatening to withhold funds for implementation, as they have been wont to do in recent years. In the future, with a Republican president or GOP-controlled Senate, they may seek to deny appropriating money for the ACA’s essential functions.

“I think that the biggest obstacle to ACA implementation is the relentless negativity and opposition of the Republicans and their media outlets,” said Tim Jost, a law professor at Washington and Lee University and an expert on health care law. “Every step the administration takes toward implementation is resisted by the Republicans in Congress and in the state houses and sympathetic media.”

2) States Declining To Expand Medicaid

Seventeen million Americans were projected to obtain coverage through the Medicaid expansion in the Affordable Care Act — until the Supreme Court made it optional for states. Even then, proponents believed the generous federal funding — 100 percent for the first few years and 90 percent after 2020 — would make the deal too good to pass up.

They miscalculated. Democratic governors are on board, but just six Republicans have said they’ll participate. Under pressure from the right, thirteen Republican governors have rejected the expansion, including blue staters like Scott Walker of Wisconsin and Tom Corbett of Pennsylvania. Ten GOP governors have yet to announce a decision.

The problem: Even though some Republican governors say they’ll look for other ways to expand coverage, it’s an open question how — or whether — Americans below 133 percent of the poverty line will obtain insurance in the states that do not participate.

3) States Refusing To Build Insurance Marketplaces

The law encourages states to set up and run their own one-stop marketplaces to connect sellers and buyers of health insurance — the central mechanism through which its subsidies and coverage guarantees are actualized. Although states had the ability to opt out, it seemed like a no-brainer because if they decline to set one up, the federal government is required to craft and operate one for them. Building and operating the exchanges in according with the complex regulations in the statute was never going to be easy, but this unanticipated political hurdle adds a new dimension of problems.

Conservatives are working to portray any governor who sets up an exchange as pro-Obamacare, despite the irony that refusing to do so would relinquish power over their health care to Washington. As a result, most Republican governors have refused to build a state-run exchange under the law. Others are looking for a way around some of the rules.

The problem: The ACA lacks a funding mechanism for Department of Health and Human Services to set up exchanges for states that decline to do so themselves — and congressional Republicans are unlikely to appropriate additional money for that. HHS, already stretched thin with the law’s implementation, must find the money within its budget.

4) Nullification Of The Medicare Cost-Cutting Board

The centerpiece of President Obama’s plan to save Medicare from bankruptcy in the long-haul is already law under the Affordable Care Act. Set to take effect in 2015, the Independent Payment Advisory Board will be tasked with cutting Medicare reimbursements to providers if per-beneficiary spending rises above per-capita GDP plus 1 percent. It cannot cut seniors’ benefits. IPAB will be composed of 15 Senate-confirmed experts.

The problem: Senate Republicans can — and have signaled their intention to — filibuster nominees to the board unless it’s altered. They’ve already demonstrated their willingness to use the blocking tactic to nullify or reform agencies they dislike. They’d have motive to do the same with IPAB: not only is it a key element of Obama’s agenda, the health industry despises it, and even some House Democrats have voted to repeal it.

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Center-left Washington is arguing with ever-greater ferocity that center-right Washington is mistakenly obsessed with deficit reduction. Part of the argument is familiar:

1. Low Treasury interest rates show markets unconcerned about the $16 trillion national debt.

2. As the economy continues to heal, annual deficits will shrink substantially.

3. To the extent budget shortfalls are a problem, they are a long-term one driven by health care spending.

Now a new wrinkle is being added to that last point: A persistent slowdown in the growth of health care costs might mean scary Congressional Budget Office forecasts are overstating America’s long-term debt problem. The New York Times points out today that new data show overall health care spending growth continuing at the lowest rate in decades for a fourth consecutive year. As it is, the cost slowdown has led CBO to cut $200 billion from its 2020 spending forecast for Medicare and Medicaid. Maybe more downward revisions are on the way. As former White House economic adviser Jared Bernstein tells the Times:

We’re not going from unsustainable to sustainable. Even if the recent changes persist, we’re not done in terms of achieving sustainability in health care cost growth, but we have more time to figure out what’s working without hacking away at social insurance.

Bernstein, shorter: Let Obama’s Affordable Care Act work its magic, no need for major restructuring — and certainly no need for the GOP’s Medicare premium support idea.

Now, I agree that the decline in health care inflation hasn’t just been a cyclical one due to the economic slowdown. The rate of health care spending has been falling since 2002. AEI’s J.D. Kleinke points to some factors which are likely responsible: a) lots of breakthrough drugs from the 1980s and 1990s became widely available in generic form in the 2000s; b) health insurance plans became more diverse, giving consumers more choice, such as health savings accounts; c) the IT and networking revolution has improved disease management.

To sum up: Innovation — both in technology and products and processes — has slowed the rise in health care costs. Is the ACA and its expanded government intrusion into the sector likely to sustain and accelerate innovation or retard it?

Take the treatment of HSAs, for instance. As one analysis from International Society of Certified Employee Benefit Specialists warns:

 The health care reform law contains only two direct changes to health savings accounts (HSAs): eliminating the ability to use the HSA for over-the-counter drugs and increasing the early withdrawal penalty from 10% to 20%. The indirect changes, however, could drastically curtail the growth of HSAs or even result in the end of HSAs.

Or would it be better to transform the ACA into a system that intentionally brings more choice and competition — two things that typically drive innovation — to health care?

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Florida governor Rick Scott, one of the sharpest critics of President Obama's healthcare law, announced late Wednesday that he wanted the state to participate in an optional portion of the law after all.

Florida should accept federal funds to expand Medicaid coverage in the state, Scott said at a news conference, in a stunning reversal.

"While the federal government is committed to paying 100% of the cost of new people in Medicaid, I cannot, in good conscience, deny the uninsured access to care,"Scott said. The Republican-led legislature must approve the measure for it to take effect.

Conservative opponents of "Obamacare" reacted with disappointment and anger.

"I am terribly disappointed in [Scott's] decision to expand Medicaid in Florida," Erick Erickson of the conservative blog Red State wrote. "As one of the chief opponents of Obamacare and, before it, Hillarycare, governor Scott knows this is not the right thing to do. I would like to blame the staff around him, but the ultimate decision was his to make and he made it."

The Obama healthcare law expands Medicaid eligibility to families with incomes at 133% of the poverty level. That could mean 1.95m more Florida enrollees over five years, when Medicaid and other subsidized programs are included, according to the Florida Agency for Health Care Administration.

Scott's political identity was built on opposition to the Obama healthcare law. He made a fortune – hundreds of millions – by building a network of private hospitals. He has repeatedly told Florida voters that the federal healthcare law would limit patient choice and cost taxpayers tens of billions of dollars.

Scott had said that rejecting the Medicaid expansion was "the right decision for our citizens."

"Florida is not going to implement 'Obamacare'," a Scott spokesman, Lane Wright, told the Associated Press in June. "We are not going to expand Medicaid, and we're not going to implement exchanges."

Erickson tied the decision of Scott, who is up for reelection in 2014, to a desire to remain the governor of Florida.

"Governor Scott is interested in getting re-elected and has terrible poll numbers," Erickson wrote. "No doubt part of this decision has to do with his wanting to get re-elected.

"When politicians do what they feel they must to get re-elected instead of doing what they know is right, they often lose re-election and, even when they do not, lose their way."

Scott's approval rating has never topped 50%, and his governor's seat was considered to be one of the most vulnerable in the country.

"It is a sad day for conservatives," Erickson wrote.

Scott said the move was in line with the country's greatness. "America's greatness is largely because of how we value the weakest among us," he said in his statement.

Florida joined 25 other states in saying no to setting up a state-run health insurance exchange, the second optional prong of the Affordable Care Act.

This article originally appeared on guardian.co.uk

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In a new Time Magazine cover story, reporter Steven Brill writes a rather lengthy piece about the huge problem with health care costs in the United States.

The piece, titled "Bitter Pill: Why Medical Bills Are Killing Us," goes in-depth on the big problems facing hospitals, insurance companies, and the pharmaceutical industry — with patients often bearing the burden.

It's a $2.6 trillion problem, according to 2010 data from The Kaiser Family Foundation — a health expenditure increase ten-times the $256 billion spent in 1980.

There is plenty of blame to go around: Rising prescription drug costs, administrative costs, and changes in the nature of illness. And unlike other industries, new medical technologies have pushed costs up rather than down.

Patient bills can be marked up by as much as 400 percent.

In the opening page, Brill introduces readers to Sean Recchi, who is diagnosed with non-Hodgkins lymphoma. Although Recchi and his wife Stephanie had insurance, it was not comprehensive, forcing them to pay the hospital almost $50,000 before Recchi was ever even seen by a doctor.

But the real problem came when the Recchis found out what the total cost for treatment would be: $83,900. 

Their bill is laden with medical terminology and incomprehensible numerical codes, but some things stick out. A single pill of 325 mg acetaminophen — a generic version of Tylenol — costs $1.50. You can buy 100 of those pills on Amazon.com for $1.49.

For a simple X-ray, Recchi was billed $283; Medicare would only pay just over $20 for the same service. A cancer wonder drug called Rituxan cost $13,702, a 400 percent markup from the average price paid by all hospitals for this dose. 

Source: Time

Routine services cost thousands of dollars.

Then there's "Janice S.," a 64-year-old woman in Stamford, Conn. who started feeling chest pains. One year shy of coverage under Medicare eligibility, she rode an ambulance four miles to the emergency room.

It turned out to be only indigestion, but the good news was tempered with a very large bill:

• $995 for the ambulance ride.
• $3,000 in doctors' fees.
• $17,000 for the hospital.

'Non-profit' hospitals are often a city's most profitable business.

Non-profit hospitals enjoy a tax-exemption that gives them quite an edge over others. Brill writes:

... the American health care market has transformed tax-exempt “nonprofit” hospitals into the towns’ most profitable businesses and largest employers, often presided over by the regions’ most richly-compensated executives. And in our largest cities, the system offers lavish paychecks even to mid-level hospital managers, like the 14 administrators at New York City’s Memorial Sloan-Kettering Cancer Center who are paid over $500,000 a year, including six who make over $1 million.

In a survey looking at 2,900 non-profit hospitals conducted by McKinsey and Bank of America, the results reveal higher operating profit margins for non-profit hospitals than for "the 1,000 for-profit hospitals after the for-profits’ income-tax obligations are deducted. In health care, being nonprofit produces more profit."

Source: Time

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For more than 100 years, the Mayo Clinic's built an enviable reputation and medical practice. People all over the world regard it as one of the best places to treat any illness, and it has routinely come in at the top of hospital rankings.

We've already written about the Clinic's plan to spread that knowledge worldwide, but we also spoke to CEO Dr. John Noseworthy about how the clinic built its reputation, attracts the world's best doctors, and manages to stay at the top. 

Our conversation has been edited for length and clarity:

What's it like leading such a large and well-known institution in the aftermath of the Affordable Care Act? 

Well it's a great privilege to work at the Mayo Clinic, and obviously to be the physician leader of this fine institution is a great privilege. Yes, the law is going to change how we work, but we've been at this for 148 years. For well over 100 years everything we do every day is continually retooling how we work to provide safer care, better care, and more efficient care for our patients.The Affordable Care Act and everything else that's happening in the industry is putting a sharper pencil on that, but to be candid, we're not really reacting to the law. We've been on this journey for a long time to drive out waste, use technology, use our staff to provide better care.

This is just another step in our history. We're the first and largest physician-led group practice of medicine supported by research and education, and we've been a model for a lot of other groups, some of whom you've covered. We've been at this for a long time.

Why has Mayo been so successful? 

I think it all comes down to our core value, which is that the needs of the patient come first. I know that might sound kind of trite in today's world, but our staff is extraordinarily committed. If you spend a day here, and you grab anybody at the Mayo Clinic and ask them what's the purpose of your work, they would say "to meet the needs of our patients."

I've been working here 22 years and I've never had a physician say they're too busy to help me with a patient, day or night. That's probably why Mayo has been the leading brand in medicine for the last 100 years.

What do you guys do to build that brand? 

Sometimes we have to make decisions that don't make a lot of sense from a business standpoint, but they're the right thing for the patient. I mean, we don't want to make stupid decisions that will get us in financial trouble, but whenever anything comes up, there is a singular focus on that.

In my role, what I hear every day from patients and family members is that the minute they step onto a Mayo campus, whether it's in Rochester, New York; Scottsdale, Arizona; Florida; or in our large integrated health system, they immediately sense that there's something different. They feel it right form the first person they speak with and it's the physicians, it's the science, it's the engineers and technologists. It's that patient focus and a relentless focus on quality. This goes all the way from the heart surgeons down to the cleaning staff.

How do you get research to the point where it helps patients?

We have a very strong research effort — we invest 600 million a year in our research, half of that is Mayo dollars [and] a third of it comes from the National Institutes of Health. Our research is very integrated. You've probably seen our logo; it has three shields that intersect. Those represent practice, education, and research. For research, we do the full spectrum of discovery research, translational research, then clinical outcomes research, but what we say is that our discovery research is about creating hope and solutions for patients, a reason to come to Mayo Clinic for diagnosis or new treatment.

Our basic science and physician researchers are completely integrated into the Clinic and they work very closely with the physicians to understand the key questions that are out there, so that their work has real meaning. When I said we sort of have a three-legged stool about how we approach the future, one is driving quality, the second is improving the speed with which research gets right into the patient's room, we call that "knowledge to delivery." The third part of that stool is creating a workforce that will help us do that.

How do you create that workforce?

We have five schools in our education system, so we train an awful lot of folks from technologists all the way up through heart and brain surgeons, but we recruit heavily from the outside as well. Whenever we post a nursing position, we usually have over 20 applicants for that single position because people want to work at the Mayo Clinic. You have to assume, well you don't assume it you check it, but first of all is the person qualified to work at Mayo clinic?

If [physicians] come from outside and we don't know them, they basically come for a 2- to 3-day visit where we watch them practice and teach as well as talk about their science to see if they're a good fit for us. Competence and passion and compassion are all necessary, but there has to be a fit.

We're not looking for individuals, we're looking for people who can be part of and lead teams, because teams and systems of care always beat individuals. When they're hired, they're kept on for 3 years before we decide whether they'll stay as full consultants. It's a period of testing them, and then staff votes and says whether this person is or is not someone whom we want to keep on. There's quite a training period. We make a huge effort to articulate our culture, what it means to work at Mayo Clinic. We're very proud that our staff generally come and work at Mayo for their entire career. Our workforce is very, very stable ... our physician workforce ... the turnover rate is about 1-2 percent, which is extraordinary in today's world.

How are you responding to increased cost pressures?

Well as I said, we've been doing this forever; we're good at it, if not perfect. One of our secrets is we've had a very strong tradition of engineering at Mayo Clinic. We have 100s of engineers that are integrated in many departments, and their science is efficiency. We've had a quality academy now for over 8 years that trains our staff on systems thinking and on driving out waste. We've published approximately one scientific or medical research paper a week on outcomes at Mayo Clinic, so well over 350 papers in the last 7 years on the quality initiative, and that's better outcomes, safer care for patients. Better quality at affordable cost, that's really value — we call that the value equation. 

I know many of your readers probably wouldn't anticipate this, but over 50 percent of the patients we see at Mayo Clinic are government-paid patients — Medicare largely, but some Medicaid — and because they are obviously older, they have more complex medical problems. Close to 60 percent of the work we do is with patients who are paid for by Medicare. We, like almost everybody else, struggle to pay for that because the government reimbursement doesn't cover our costs. That said, we don't turn away Medicare patients, but at some point you do reach a tipping point where you say, well how much further can you go? We'll have to see how that plays out, but that does drive us to make certain that we've created an efficient health care system.

What role does data play at Mayo?

Data is absolutely everything. As you can imagine, physicians want data if they're going to change how they practice or perform surgery, they're going to want to know that it's data-driven. We have quite good data in the medical profession on quality outcomes, but that's not always what we're asked to measure.

A lot of it is measuring the process — did you ask this question or do that. But the quality outcomes, readmission rate, infections, falls, retained foreign objects, that sort of thing, that data, everyone is collecting that and using that to drive change. The part of the value equation that's still in evolution is the cost data. You need to drive costs down, and  value really goes up if you get the same outcomes or better outcomes at lower cost.

Perhaps you saw this announcement in The Wall Street Journal, that the Mayo Clinic announced a research strategic alliance with a subsidiary of United Health Group called Optum to put together a data center on health care outcomes and cost. That'll be an open innovation center in Cambridge, Massachusetts called Optum Labs, and this is seen as a huge shift in how we believe health care research will go forward.

What it basically is doing is taking the clinical data which the Mayo Clinic has — how did the patient do, what was their diagnosis, what happened over a couple of decades — for about five million lives. We de-identify, we strip the identifiers from those folks of course, then United Health Group, through Optum, has insurance claims data, all the costs that their patients incurred over time over a couple of decades. That database covers 109 million lives; it's the largest, best database on insurance claims. By linking those two data sets together we — Mayo, Optum and other highly qualified research driven partners from academia, other insurance companies, policymakers, life science companies — are coming together to say let's really look at outcomes and costs. What outcomes do we want in health care for Americans, and how do we drive the costs down? This is the way of moving forward and we're very excited about this relationship. 

SEE ALSO: Mayo Clinic Has A Radical Plan To Expand Its Reach Across The World

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The Federal Reserve's latest Beige Book report, which provides anecdotal data on economic conditions around the United States, paints a mixed picture.

One of the things that came up a few times in the report was the Affordable Care Act.

In the release, the Fed noted: "Many District contacts commented on the expired payroll tax holiday and the Affordable Care Act as having restrained sales growth...Employers in several Districts cited the unknown effects of the Affordable Care Act as reasons for planned layoffs and reluctance to hire more staff."

Below is an excerpt from the Richmond Fed's section of the Beige Book:

Labor market activity was little changed since our last report. Hiring remained flat across most sectors, although there were some exceptions. Employers across the District continued to cite the Affordable Care Act and its unknown impacts as reasons for planned layoffs and reluctance to hire more staff.

Here is another excerpt from the Dallas Fed's section:

Reports from staffing firms were mixed. One contact noted sharp declines in demand for services across the board, while another reported stellar demand that broke direct-hiring records. Outlooks were cautious. Some contacts noted concern that client companies are hiring the absolute minimum to get by due to uncertainty about the Affordable Care Act.

On the other hand, it's good news for some health care businesses, according to the San Francisco Fed's section of the Beige Book:

Demand for most business and consumer services gained. Contacts pointed to solid sales of various technology services and greater demand for financial and accounting services. Food service providers reported strong sales on net. Activity in the District's tourism and travel sector advanced, with solid growth of visitor counts and occupancy rates reported in Hawaii; however, more modest gains were reported in Las Vegas and Southern California. Current demand for health-care services remained relatively weak, but contacts projected rising demand as additional components of the Affordable Care Act are implemented.

Bottom line: the Affordable Care Act does seem to be having an effect on business plans in certain areas around the country. At least, that's what respondents are telling the Fed.

DON'T MISS — Wall Street's Brightest Minds Reveal The Charts That Worry Them Most

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Wisconsin Rep. Paul Ryan previewed the Republican House Budget Committee's budget on "Fox News Sunday" with Chris Wallace today, where he laid out some of the envisioned changes to entitlement programs.

Even as some Republicans urge the party to move on from the fight over the Affordable Care Act, Ryan told Wallace that his budget assumes the repeal of the 3020 law colloquially known as "Obamacare"— something that left the host Wallace dumbfounded.

"Are you saying that as part of your budget you assume the repeal of Obamacare?" Wallace said.

"Yes," Ryan answered.

"Well," Wallace said, pausing. "That's not going to happen."

"Well, we believe it should. That's the point," Ryan said. "This is what budgeting is all about, Chris. It's about making tough choices to fix our country's problems. We believe Obamacare is a program that will not work. We believe Obamacare will actually lead to hospitals and doctors and health care providers turning people away.

The future of Obamacare was one of the central pillars of the 2012 election. As a result of President Barack Obama's win, some Republicans have urged the party to move past their fight on the issue. 

Some Republicans in the Senate, too, are prepared to support an amendment to the Senate's government continuing resolution bill to de-fund Obamacare. It was introduced by Sens. Mike Lee and Ted Cruz, and Minority Leader Mitch McConnell has said he will support it.

Watch video of Ryan below, via the Huffington Post:

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Republican House Budget Chairman Paul Ryan introduced his latest budget plan Tuesday — his third in three years — kicking off another round of debate over the government's spending priorities. 

Although Ryan's 2014 fiscal plan is largely the same as the one he offered last year, one notable difference is that the new proposal would balance the budget in just 10 years. Ryan projects that the federal government will spend $4.6 trillion less over the next decade. 

But in order to get to this balanced budget, Ryan relies on deficit reductions that were pushed through by President Barack Obama over loud protests by Ryan and his House GOP colleagues. 

First, Ryan's budget will keep the $716 billion in Medicare cuts included in Obamacare as a way to balance the budget. So Ryan keeps the savings, but gets rid of the reform part.

As First Read notes, Ryan campaigned vigorously against the Obamacare Medicare savings at the Republican vice presidential candidate last year, and even attacked the cuts in his convention speech. 

Ryan's budget also assumes all of the revenue from the fiscal cliff deal, which raised income tax rates for individuals earning more than $400,000 per year. That measure is estimated to raise about $600 billion over 10 years, according to various estimates. And those too are tax increases that the GOP opposed.

At the very least, this looks like Ryan is trying to have his cake and eat it too — a fact that his critics are likely to harp on as budget wrangling picks up with the unveiling of the Senate Democrats' budget Wednesday. 

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“Who is going to end up making all the money in the end if Obamacare continues to be in place?”

Republican National Committee chairman Reince Priebus growled Monday on Sean Hannity’s Fox News show. “It’s going to be the big corporations, right? And who gets screwed? The middle class.”

The Republican Party makeover is breathtaking. Now, suddenly, instead of accusing Democrats of being “redistributionists,” the GOP is posing as defender of the middle class against corporate America — and it’s doing so by proposing to do away with the most progressive piece of legislation in well over a decade.

Paul Ryan’s new budget purportedly gets about 40 percent of its $4.6 trillion in spending cuts over ten years by repealing Obamacare, but Ryan’s budget document doesn’t mention that such a repeal would also lower taxes on corporations and the wealthy that foot Obamacare’s bill.

According to an analysis by the non-partisan Tax Foundation, Obamacare redistributes income from the wealthy to the middle class. This is mainly because it hikes Medicare taxes on the top 2 percent (singles earning more than $200,000 and couples earning more than $250,000, including their investment income).

This year, for example, families in the top 1 percent will be paying about $52,000 more in Medicare taxes, on average, than they paid in 2012.

And where will the money go? Not to pay for the healthcare of poor families; most of them already receive Medicaid. The rich will be helping middle and lower-middle class Americans.

Obamacare also imposes some taxes and fees on insurance companies, drug makers, and manufacturers of medical devices. Here again, most of this will be borne by affluent Americans, who own most shares of stock (assuming the taxes and fees come out of corporate profits). And, again, beneficiaries are in the middle and lower-middle class.

In other words, Mr. Priebus has it exactly backwards. If Obamacare were repealed, who would end up making all the money? Big corporations and the wealthy. Who would get screwed? The middle class.

The rest of Ryan’s budget plan also runs counter to the new Republican thematic. Not only does it turn Medicare into vouchers (“premium support” in Republican-speak) whose value can’t possibly keep up with rising healthcare costs but it also dramatically reduces spending on education, infrastructure, and much else the middle class depends on.

Meanwhile, it redistributes upward, cutting the top tax rate for individuals down to 25 percent — a bigger tax cut for the top than even Mitt Romney proposed — and the corporate tax rate down to 25 percent, from 35 percent today.

Ryan would pay for these tax cuts by “closing tax loopholes,” but — where did we hear this before? — his budget doesn’t say which loopholes, or even hint at what it would do with rates on capital gains and dividends. Like Romney’s plan, it leaves all the heavy lifting to Congress.

The reality, of course, is that the only possible way Ryan could pay for his proposed tax cuts for the wealthy and corporations would be to raise taxes on the middle class.

Don’t expect the Chairman of the Republican National Committee, or other Republicans reading from the same talking points, to admit any of this.

But if you look at what they’re proposing rather than what they’re saying, the GOP isn’t really interested in balancing the budget at all. It’s out to redistribute income and wealth — to the best-off Americans, from everyone else.

If any party is into redistribution, it’s the Republicans. And Paul Ryan is leading the charge. 

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We were sad to learn that Arijit Guha, the 32-year-old graduate student whose clever online campaign "Poopstrong" helped convince his health insurer to cover $118,000 worth of outstanding medical bills, recently died of colon cancer.

It's a heartbreaking end to a story that still seemed hopeful just a few months ago. Guha fought for nearly a year to convince Aetna to loosen the $300,000 lifetime spending cap on his student health plan policy. In a fit of frustration, he tweeted the company's CEO, Mark T. Bertolini, with a plea for help back in July.

It worked. Bertolini pulled some strings and agreed to cover the rest of his treatment.  Guha's health was on the mend.

Unfortunately, the cancer came back in the fall of 2012.

Guha didn't make it in the end, but consumer activists are pointing toward a long-awaited stipulation under the Affordable Health Care Act that would prevent insurance companies from denying treatment for cases like Guha's. It's set to go into effect in Jan. 2014. 

We spoke with Guha just a few weeks after his victory with Aetna in August. 

"It's unconscionable that we allow the sick to be forced to choose between bankruptcy and treatment," Guha said at the time. "Or that people can be denied insurance coverage simply on the basis of being too expensive." 

Here's the rest of his story, as we reported at the time.

--

Guha was diagnosed with cancer following a trip to India in February 2011. After undergoing an emergency colostomy, he faced a mountain of medical debt that threatened to put him in bankruptcy. 

He realized that his health plan through ASU, the Aetna Student Health plan, came with a major caveat: A lifetime cap of $300,000. In less than a year of treatment, he had maxed it out and Aetna refused to cover the rest of his expenses. 

He went to Aenta and contacted his school administration for help. He briefly considered public assistance, but all three roads led him nowhere.

"I knew I had no choice but to turn to charity and try to spread word about my case as far and wide as possible," Guha said. 

That meant tapping web designer friends to set up a store called PoopStrong.org, where Guha blogged about his current treatment and encouraged people to send in donations. The spoof on Lance Armstrong's site worked, and soon Guha was fielding more T-shirt and baby onesie orders than he could ship. He also raised enough money to cover most of his treatment. 

"In the face of a pretty scary diagnosis, I went into this the only way I knew how—to be slightly irreverent and laugh in the face of adversity," he said. The Web also "helped me pull together and leverage various communities I've been a part of and spread the word much quicker than it would have happened otherwise." 

The real social media coup came when Guha turned to Twitter. Using the handle @Poop_Strong on July 26, he fumed, "@Aetna has now denied $118k in claims (in just 5 mos) since kicking me to the curb. Gotta preserve that $2 billion annual profit somehow." 

Surprisingly, @AetnaHealth replied: "@Poop_Strong We care about our members. We want you to be empowered to be healthy and make informed decisions." 

Now it was on. "That's so sweet you want me to be empowered," said Guha, invoking Aetna CEO Mark. T. Bertolini, "Does @mtbert care to empower me by paying my $118K and counting in bills?"

Turns out he did. Though Bertolini and Guha never spoke outside of Twitter, the two publicly agreed on the platform that the health care system is broken, and the insurer got in touch with Guha's and promised to clear his outstanding debt. 

"When I went to Twitter pointing out the $2 billion profit Aetna made last year alone, I was just trying to highlight the fact that there exists this trade-off between the competing values of profit-maximization and patient care," Guha said.

But he achieved much more than that. Guha brought his story to "media outlets around the globe," gave fellow cancer sufferers a voice and rallied students to his cause. What's more, the funds raised from the PoopStrong campaign will go to Arizona and University of Arizona's Cancer Center's Patient Assistance Fund. 

There is still more to be done, but Guha is hopeful the system can be fixed with a market-based approach like Obamacare, or a single-payer plan that's similar to Medicare. Both options, he says, "could deliver services more efficiently and cheaply"—and remove private companies' incentive to put profits before people. 

"It's unconscionable that we allow the sick to be forced to choose between bankruptcy and treatment," Guha said, "or that people can be denied insurance coverage simply on the basis of being too expensive." 

His message should be heard loud and clear. 

–– Jill Krasny contributed to this report.

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WASHINGTON (AP) — A new study finds that insurance companies will have to pay out an average of 32 percent more for medical claims under President Barack Obama's health care overhaul.

What does that mean for you?

It could increase premiums for at least some Americans.

If you are uninsured, or you buy your policy directly from an insurance company, you should pay attention.

But if you have an employer plan, like most workers and their families, odds are you don't have much to worry about.

The estimates from the Society of Actuaries could turn into a political headache for the Obama administration at a time when much of the country remains skeptical of the Affordable Care Act.

The administration is questioning the study, saying it doesn't give a full picture — and costs will go down.

Actuaries are financial risk professionals who conduct long-range cost estimates for pension plans, insurance companies and government programs.

The study says claims costs will go up largely because sicker people will join the insurance pool. That's because the law forbids insurers from turning down those with pre-existing medical problems, effective Jan. 1. Everyone gets sick sooner or later, but sicker people also use more health care services.

"Claims cost is the most important driver of health care premiums," said Kristi Bohn, an actuary who worked on the study. Spending on sicker people and other high-cost groups will overwhelm an influx of younger, healthier people into the program, said the report.

The Obama administration challenged the design of the study, saying it focused only on one piece of the puzzle and ignored cost relief strategies in the law, such as tax credits to help people afford premiums and special payments to insurers who attract an outsize share of the sick.

The study also doesn't take into account the potential price-cutting effect of competition in new state insurance markets that will go live Oct. 1, administration officials said.

At a White House briefing Tuesday, Health and Human Services Secretary Kathleen Sebelius said some of what passes for health insurance today is so skimpy it can't be compared to the comprehensive coverage available under the law. "Some of these folks have very high catastrophic plans that don't pay for anything unless you get hit by a bus," she said. "They're really mortgage protection, not health insurance."

Sebelius said the picture on premiums won't start coming into focus until insurers submit their bids. Those results may not be publicly known until late summer.

Another striking finding of the report was a wide disparity in cost impact among the states.

While some states will see medical claims costs per person decline, the report concluded that the overwhelming majority will see double-digit increases in their individual health insurance markets, where people purchase coverage directly from insurers.

The differences are big. By 2017, the estimated increase would be 62 percent for California, about 80 percent for Ohio, more than 20 percent for Florida and 67 percent for Maryland. Much of the reason for the higher claims costs is that sicker people are expected to join the pool, the report said.

Part of the reason for the wide disparities is that states have different populations and insurance rules. In the relatively small number of states where insurers were already restricted from charging higher rates to older, sicker people, the cost impact is less.

The report did not make similar estimates for employer plans that most workers and families rely on. That's because the primary impact of Obama's law is on people who don't have coverage through their jobs.

A prominent national expert, recently retired Medicare chief actuary Rick Foster, said the report does "a credible job" of estimating potential enrollment and costs under the law, "without trying to tilt the answers in any particular direction."

"Having said that," Foster added, "actuaries tend to be financially conservative, so the various assumptions might be more inclined to consider what might go wrong than to anticipate that everything will work beautifully." Actuaries use statistics and economic theory to make long-range cost projections for insurance and pension programs sponsored by businesses and government. The society is headquartered near Chicago.

Bohn, the actuary who worked on the study, acknowledged it did not attempt to estimate the effect of subsidies, insurer competition and other factors that could offset cost increases. She said the goal was to look at the underlying cost of medical care.

"We don't see ourselves as a political organization," Bohn added. "We are trying to figure out what the situation at hand is."

On the plus side, the report found the law will cover more than 32 million currently uninsured Americans when fully phased in. And some states — including New York and Massachusetts — will see double-digit declines in costs for claims in the individual market.

Uncertainty over costs has been a major issue since the law passed three years ago, and remains so just months before a big push to cover the uninsured gets rolling Oct. 1. Middle-class households will be able to purchase subsidized private insurance in new marketplaces, while low-income people will be steered to Medicaid and other safety net programs. States are free to accept or reject a Medicaid expansion also offered under the law.

___

AP White House Correspondent Julie Pace contributed to this report.

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Humana CEO Bruce Broussard runs the fourth-largest health insurance group in America. He has spent more time engaging with the provisions of President Obama's health care reform than just about anybody else. And even he isn't sure what the law's going to look like or what its impact will be over the next 7 years.

Broussard told Knowledge@Wharton:

"We have not seen all the details around health care reform. The implementation is going to be at the end of the year. In fact, people will probably start buying [insurance] in the fourth quarter or so. We are asking for some more detail. The second aspect is that it is such a complicated bill. There are so many interrelated details that I don't think anyone knows all the different parts. Our concern is about what we don't know."

Broussard expects prices to to go up, particularly for the young healthy population. That's a fact that hasn't totally sunk in for the public and businesses, which worries the Humana CEO.

"I don't think it's been talked about enough in public. I think the communication of the reform has been around the expansion of the coverage. But I do not see a real, large conversation around what the impact is on the public."

He calls pricing the biggest issue, and says that we can expect a "bumpy road" until the details get hashed out. And there are lots of details. 

There's also uncertainty about what health care exchanges — a set of regulated and standardized health care plans which can be federally subsidized — will look like. Some will be run by states, some in partnership with the government, meaning there could be wide variety of different rules.

They're supposed to be up and running by January 1st, 2014, but Broussard says there's still a tremendous amount of detail to be worked out, which could cause delays.

The hospital industry has already massively consolidated ahead of health care changes.

Other businesses, however, are unprepared. After all, there has been little discussion of the impact since the Supreme Court upheld the law.

In the long run, Broussard expects that the law and technology will work to reduce cost long term. But for now, we can expect "troubled times." 

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Much of Obamacare’s success hinges on whether a pair of new taxes can compel more Americans to have health insurance.

For all the carrots in the 2010 law such as tax credits and subsidies, there are two big sticks of the big sticks meant to change the behavior of a projected 58 million uninsured. There are other taxes on medical devices and gold-plated insurance plans that all told will raise $1 trillion over the next decade.

The two big ones are taxes that will hit employers and consumers directly—a critical element of a law that remains a political hot button. House Republicans are banking on its unpopularity, putting forward a budget that strips away all of the spending attached to Obamacare while some GOP lawmakers demand it be defunded as a condition for raising the government’s borrowing authority in May.

The most recent Congressional Budget Office projections estimate that 14 million Americans will opt to become insured next year rather than pay a penalty that for individuals starts as low as $95. Companies that decline to provide coverage would pay a $40,000 fee.

By the time the penalties are fully ramped up in 2017, 27 million uninsured Americans would receive health coverage, but 29 million would still go without. The combined  taxes, designed to raise $202 billion through 2023, were designed to cover the cost of insuring 90 percent of the U.S. nonelderly population. But that intention may be undermined by what could be a growing swarm of insurance dropouts.

The CBO has all but acknowledged that the economic impact of the law is a crapshoot. The nonpartisan agency adjusted its forecast this year, under the assumption that state-run exchanges providing subsidized health coverage will be slow to get off the ground, meaning that more Americans will initially have to rely on private insurers.

Organizations such as the International Franchise Association—which represents the owners of hotel, fast food, and moving company chains among others—also see the affects of the taxes as somewhat unpredictable. Too high a penalty creates a new financial burden, while one that’s too low likely preserves the status quo.

“No one really knows how an employer or employee is going to react until the law gets implemented,” said Judith Thorman, senior vice president for government relations and public policy at the International Franchise Association.

So, how would these taxes work?

For individuals without health insurance, the penalty would start next year at $95 a person, $285 for a family of three or more, or 1 percent of their income—whichever is largest. The size of the penalties would increase through 2016 to $695 a person, $2,085 for a family, or 2.5 percent of income. The tax would raise $52 billion through 2023, the CBO forecasted.

The U.S. Supreme Court ruled last year that this individual mandate made Obamacare constitutional. President Obama reacted to the ruling in a speech where he said the tax would hold down the costs of medical treatment.

“First, when uninsured people who can afford coverage get sick, and show up at the emergency room for care, the rest of us end up paying for their care in the form of higher premiums,” Obama said. “And second, if you ask insurance companies to cover people with preexisting conditions, but don’t require people who can afford it to buy their own insurance, some folks might wait until they’re sick to buy the care they need -- which would also drive up everybody else’s premiums.”

But the concern among insurers is that the penalty fee might be too low for the first two years.

Their perspective is that younger Americans with fewer medical problems will decline to enroll, because a $95 or even a $300 fee is likely a fraction of what they would otherwise pay for coverage.  And there may be a reason for that decision.  In the past, a healthy twenty-something could buy “catastrophic insurance” for a very low monthly fee.  Under the new law, they would have to buy a more expensive policy, which helps pay for the new class of insured, including those with chronic diseases.

New payments from healthy individuals who don’t need medical services would in theory enable insurance to be cheaper for everyone. So it’s not just about how many people enroll in health insurance, but who they are.

“These first couple of years are going to be critical,” explained Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the association representing the industry. “If only older people buy coverage in the first couple of years, then the cost of coverage becomes less affordable.”

If the program does not control costs, then the benefits promoted by Obama won’t happen.

On the corporate side, it can be confusing just which companies would be hit with a penalty. Only companies with more than 50 full-time employees would be required to provide health insurance, or pay a $2,000 per person penalty fee.

The penalty would not apply to the first 30 employees, so this would mean the fee would start being assessed on the next 20 workers and be at least $40,000. For many, that could be a drop in the bucket.  The average cost to insure a family of four for a year is 20,000. Based on CBO projections, the tax would generate $5 billion next year and a total of $150 billion in the decade to follow.

The Hudson Institute, a conservative think tank, calculated in 2011 how many International Franchise Association members would face a penalty. Almost 60 percent would not, since the vast majority of their members own one or two locations. But the penalties would likely start for a franchise business that controls more than three—for example—McDonald’s.

For 63 franchisers who own more than 250 stores each, their bills could exceed $8.5 million and in total would account for $2.5 billion in fees.

But the wildcard is who counts as a full-time employee. Obamacare defines it as anyone with a 30-hour workweek—and employers are using this year as a look back to determine how many of their workers count as full-time over the course of six months to a year, since shifts can vary during busy seasons.

This could mean that more workers find themselves stuck with fewer hours.

“The intent was to cover a lot of people under the law by making the definition 30 hours,” said Thorson at the International Franchise Association. “The unintended consequence is a shift in employment—not just with our members—toward part-time. Businesses that have to manage their costs are going to have to look at that option.”

More from The Fiscal Times:

• What Middle Class? Politicians Pander to an Illusion
• Chained CPI Could Raise Taxes on Lower Middle Class
• The Incredible Perks of Credit Cards for the Rich
  

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Much of Obamacare’s success hinges on whether a pair of new taxes can compel more Americans to have health insurance.

For all the carrots in the 2010 law such as tax credits and subsidies, there are two big sticks of the big sticks meant to change the behavior of a projected 58 million uninsured.

There are other taxes on medical devices and gold-plated insurance plans that all told will raise $1 trillion over the next decade.

The two big ones are taxes that will hit employers and consumers directly—a critical element of a law that remains a political hot button. House Republicans are banking on its unpopularity, putting forward a budget that strips away all of the spending attached to Obamacare while some GOP lawmakers demand it be defunded as a condition for raising the government’s borrowing authority in May.

The most recent Congressional Budget Office projections estimate that 14 million Americans will opt to become insured next year rather than pay a penalty that for individuals starts as low as $95. Companies that decline to provide coverage would pay a $40,000 fee.

By the time the penalties are fully ramped up in 2017, 27 million uninsured Americans would receive health coverage, but 29 million would still go without. The combined  taxes, designed to raise $202 billion through 2023, were designed to cover the cost of insuring 90 percent of the U.S.  nonelderly population.  But that intention may be undermined by what could be a growing swarm of insurance dropouts.

The CBO has all but acknowledged that the economic impact of the law is a crapshoot. The nonpartisan agency adjusted its forecast this year, under the assumption that state-run exchanges providing subsidized health coverage will be slow to get off the ground, meaning that more Americans will initially have to rely on private insurers.

 
Organizations such as the International Franchise Association—which represents the owners of hotel, fast food, and moving company chains among others—also see the affects of the taxes as somewhat unpredictable. Too high a penalty creates a new financial burden, while one that’s too low likely preserves the status quo.

“No one really knows how an employer or employee is going to react until the law gets implemented,” said Judith Thorman, senior vice president for government relations and public policy at the International Franchise Association.

So, how would these taxes work?

For individuals without health insurance, the penalty would start next year at $95 a person, $285 for a family of three or more, or 1 percent of their income—whichever is largest. The size of the penalties would increase through 2016 to $695 a person, $2,085 for a family, or 2.5 percent of income. The tax would raise $52 billion through 2023, the CBO forecasted.

The U.S. Supreme Court ruled last year that this individual mandate made Obamacare constitutional. President Obama reacted to the ruling in a speech where he said the tax would hold down the costs of medical treatment.

“First, when uninsured people who can afford coverage get sick, and show up at the emergency room for care, the rest of us end up paying for their care in the form of higher premiums,” Obama said. “And second, if you ask insurance companies to cover people with preexisting conditions, but don’t require people who can afford it to buy their own insurance, some folks might wait until they’re sick to buy the care they need -- which would also drive up everybody else’s premiums.”

But the concern among insurers is that the penalty fee might be too low for the first two years.

Their perspective is that younger Americans with fewer medical problems will decline to enroll, because a $95 or even a $300 fee is likely a fraction of what they would otherwise pay for coverage.  And there may be a reason for that decision.  In the past, a healthy twenty-something could buy “catastrophic insurance” for a very low monthly fee.  Under the new law, they would have to buy a more expensive policy, which helps pay for the new class of insured, including those with chronic diseases.

New payments from healthy individuals who don’t need medical services would in theory enable insurance to be cheaper for everyone. So it’s not just about how many people enroll in health insurance, but who they are.

“These first couple of years are going to be critical,” explained Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the association representing the industry. “If only older people buy coverage in the first couple of years, then the cost of coverage becomes less affordable.”

If the program does not control costs, then the benefits promoted by Obama won’t happen.

On the corporate side, it can be confusing just which companies would be hit with a penalty. Only companies with more than 50 full-time employees would be required to provide health insurance, or pay a $2,000 per person penalty fee.

The penalty would not apply to the first 30 employees, so this would mean the fee would starting being assessed on the next 20 workers and be at least $40,000. For many, that could be a drop in the bucket.  The average cost to insure a family of four for a year is 20,000. Based on CBO projections, the tax would generate $5 billion next year and a total of $150 billion in the decade to follow.

The Hudson Institute, a conservative think tank, calculated in 2011 how many International Franchise Association members would face a penalty. Almost 60 percent would not, since the vast majority of their members own one or two locations. But the penalties would likely start for a franchise business that controls more than three—for example—McDonald’s.

For 63 franchisers who own more than 250 stores each, their bills could exceed $8.5 million and in total would account for $2.5 billion in fees.

But the wildcard is who counts as a full-time employee. Obamacare defines it as anyone with a 30-hour workweek—and employers are using this year as a look back to determine how many of their workers count as full-time over the course of six months to a year, since shifts can vary during busy seasons.

This could mean that more workers find themselves stuck with fewer hours.

“The intent was to cover a lot of people under the law by making the definition 30 hours,” said Thorson at the International Franchise Association. “The unintended consequence is a shift in employment—not just with our members—toward part-time. Businesses that have to manage their costs are going to have to look at that option.”

Read more from The Fiscal Times:

Small businesses could dodge Obamacare mandates >

How startups are profiting from aging boomers >

Puzzling rise in food stamp use as economy improves >

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We all want to keep as much of our own money as possible, right?

Of course. And that's especially true when it comes to investments.

Starting this year, many investors likely will see tax hikes because of the new taxes imposed as a result of health care reform.

Because the only certainties in life are death and taxes, you likely will pay higher taxes no matter what you do. But you can soften the blow if you plan your tax strategy now.

But first, a little background on what you face, starting this year.

In 2010, Congress passed the Patient Protection and Affordable Care Act, sometimes called Obamacare. As many expected, this law included higher taxes on individuals who have what lawmakers consider high net worth.

Any couple making $250,000 a year or a single tax filer making more than $200,000 sees an extra 0.9% tax on income starting intax year 2013. On top of that, if you fall into those income categories, you face a 3.8% Medicare tax on your unearned (read: investment) income.

If you want to reduce your tax liability and keep more of your money, do these six things throughout the year.

1. Reduce Your MAGI

The income thresholds layed out by Obamacare are based on Modified Adjusted Gross Income, so it's important you manage this income. This works best if you are reasonably close to the threshold. If you plan it right, and with a tax planner's help, you can avoid the Medicare surtax altogether.

However, some won't be able to finagle their finances that far. So the following strategies focus more on how you can invest your assets to avoid the label "unearned" income.

2. Municipal Bonds

The federal government doesn't tax you on munis, so the Obamacare tax doesn't apply to this income. It's an investment loophole you can use if you don't mind moving some of your money into tax-exempt bonds.

3. Tax-Deferred Investments

If you aren't too attached to your investment income right now, you can take a long-term view andput more assets into tax-deferred accounts. If you qualify for a retirement account or HSA -- and have room for more contributions -- you can move your income-producing assets into these accounts. Later, you can withdraw the money during retirement when you have a lower income and may not reach the threshold.

Other investors like tax-deferred annuities, but that's an individual choice you can make with afinancial planner's help.

4. Put Some Of Your Investments In Your Child's Name

Give some of your income assets to your children. The results might be subject to kiddie tax rules, but it will avoid the previously mentioned 3.8% tax. The main drawback is that once your child comes of age, he or she will control the investment.

5. Switch Your Rental Income From Passive To Professional

When you invest in rental property, it's common to decide to stay out of it as much as possible and just enjoy the income. Unfortunately, there are many cases in which rental income is considered "passive" -- and subject to the 3.8% Medicare surtax that comes with Obamacare.

To get around that, take a more active role in managing your rental assets so you can be considered a "real estate professional." With this designation, your rental income avoids the surtax.

6. Boost Your Business Participation

Business owners might reduce their participation in their business, retain interest in the company and enjoy the income it provides. If you have interest in a business, but don't "materially participate," your income is unearned and it will be taxed under Obamacare. Avoid this fate and become a material participant again. Meet the minimum for participation in a year, and the income suddenly becomes earned.

The Investing Answer: Taxes like the 3.8% Medicare surtax need to be planned for all year. Approach your situation in a way that legally reduces your tax liability under the new Obamacare rules.

You'll need to employ long-term tax planning to reduce your liability in subsequent years, so stay on top of your tax situation.

SEE ALSO: Teens reveal the craziest things they've done to make money >

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Experts are predicting a shortage of primary care doctors in the next few decades, just when Boomers will need them the most — with skyrocketing medical debt to blame.

Bloomberg's Janet Lorin reports that the median student loan debt for 2012 medical student grads has reached an astronomical $170,000. That number includes additional debt from undergrad, but does not include accrued interest. Tuition for all four years is typically more than $200,000 and can reach as high as $300,000 at some elite institutions.

All told, 2012 medical school graduates faced $1.7 billion in combined debt.

Federal Reserve Chairman Ben Bernanke even testified to Congress last year that his son, a student at Cornell's medical school, is facing $400,000 in loans.

When looking at this kind of debt, it's likely med school students will increasingly choose higher-paying specialties, leaving a shortage of primary care doctors. The Association of American Medical Colleges estimates by 2020 there wil be 45,000 too few primary care physicians. The AAMC also predicts a shortage of 46,000 surgeons and medical specialists.

Demand for primary care is actually increasing. The Affordable Care Act places a big emphasis on primary and preventative care, because it helps catch problems early, rather than waiting until they become chronic conditions or require a trip to the emergency rooms. That helps reduce health care costs.

The law makes preventative care services free to Medicare and Medicaid enrollees, and provides incentives to doctors that treat them. It total, around 40 million Medicaid enrollees and 50 million Medicare seniors now have free access.

Some of those services can come from nurse practitioners and other sources, but it's still going to put strain on the system. 

"I don't there's a question that there aren't going to be enough docs," Cleveland Clinic CEO Dr. Toby Cosgrove told Business Insider in an interview.  

The swelling costs of medical school haven't turned all students away. Enrollment grew at medical school by 1.5 percent in the last year, reports Bloomberg. But the increasing costs could be deterring more students from getting on the medical school track and helping solve the looming doctor shortage ahead. The high potential for debt is likely turning away low-income students and minorities as well.

Matthew Moy, a third-year medical student told Bloomberg's Lorin that he's racked up about $190,000 in debt. "When I think about it, it will keep me up at night," he said. "I’m dreading the exit interview when I will find out exactly how much I’ll have to pay back."

Eighty-six percent of medical school students have at least some debt, according to data from the association. The data also showed that grants and scholarships "rarely" are enough to cover all medical student tuition bills. 

In addition, the amount of residency training positions — required after medical school in order to become certified doctors — aren't keeping up with growing enrollments, despite the amount of money students are pumping into their education. Medicare provides support for many residency positions, but its funding for the training programs has been frozen for 15 years. 

The AAMC issued a statement in March saying it was dismayed by the number of graduating medical students unmatched with residency training this year, calling it cause for "significant concern."

SEE ALSO: This stunning upstate NY wedding cost less than $9,000 >

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President Barack Obama held a press conference at the White House on Tuesday, answering questions on a broad array of items on his legislative agenda that have struggled to gain any momentum in Congress. 

Obama was asked about the recent failure of gun-control legislation to pass through the Senate, as well as the fact that sequestration is still in place. ABC reporter Jonathan Karl asked Obama if he was, essentially, a "lame duck" at this early stage of his second term.

"If you put it that way — maybe I should just pack up and go home! As Mark Twain said, rumors of my demise might be a bit exaggerated at this point," Obama said.

Obama also answered questions about the conflict in Syria and the Boston bombings. And he praised NBA player Jason Collins, who on Monday became the first player in a major American sports league to publicly reveal that he is gay.

Check out a full recap of the press conference, question-by-question, below:

Question 1: Obama gets a question on his "red line" on Syria and on survivors of the Sept. 11 terrorist attack in Benghazi, Libya. 

"What we've been seeing is a slowly unfolding disaster for the Syrian people," Obama said, repeating that the use of chemical weapons is a "game-changer."

He suggested that the administration needs more evidence on Syria's chemical weapon use in order to decide what type of action to take. 

"When I said the use of chemical weapons would be a game-changer, that wasn't a position unique to the United States," Obama said.

When asked a follow-up on whether that would include military action, Obama said that the U.S. would have to "look at the range of options that are available to us."

On Benghazi survivors, Obama said he is "not familiar with this notion that anyone has been blocked from testifying."

Question 2: Obama is asked about the Boston bombings by CNN— and if it means, as some like Sen. Lindsey Graham has suggested, that the U.S. has taken a "step back" on national security.

"No, Mr. Graham is not right, though I'm sure it generated some headlines," he said.

"Based on what I've seen so far, the FBI performed its duties," Obama added. "But this is hard stuff."

He said that one of the challenges the U.S. now faces is the threat of "self-radicalized" individuals like the Tsarnaev brothers.

Obama said that Russia and its leaders have been "very cooperative" with the U.S. since the Boston bombings.

Question 3: Obama gets a question from ABC's Jon Karl, who asks if he "still has the juice to get the rest of your agenda through Congress."

"If you put it that way, Jon," he quipped, "maybe I should just pack up and go home. Golly."

"Rumors of my demise have been a little exaggerated," he said, paraphrasing Mark Twain.

Obama blamed what he called "dysfunction" on Capitol Hill — lamenting, for example, that "even the most modest piece of legislation" needs 60 votes to pass through the Senate. 

Obama said that the sequester is harming the economy, and that he has been proven right on the sequester by people who called him "chicken little" because of the recent passage of a bill to fix the mounting flight delays at U.S. airports.

"You seem to suggest that these folks over there have no responsibility, and my job is to get them to behave. That’s their job," he said of Congress.

Question 4: Obama is asked about the growing hunger strike in Guantanamo Bay. He said that it is "not a surprise" that the U.S. has problems at the facility.

"Guantanamo is not necessary to keep America safe," he said, casting it as expensive, inefficient, and a recruitment tool for terrorist groups.

"We've got to close Guantanamo," he said.

"The idea that we would still maintain forever a group of individuals that have not been tried — that needs to stop."

He pointed to the individuals who planned to bomb Times Square and the so-called "underwear bomber" as examples of "how we prosecute terrorists."

"We can handle this," he said.

Question 5: NBC's Chuck Todd asks about Sen. Max Baucus (D-Mont.) recently calling the implementation of the President's signature health care law a "trainwreck."

"All the implementation issues coming up are implementation issues related to" a narrow group, Obama said. Many people are already experiencing benefits from the law, "even if they don't know it."

He added: "Even if we do everything perfectly, there will still be glitches and bumps."

Question 6: Obama is asked about immigration reform. He said he has been "impressed" by the work of the bipartisan "Gang of 8" in the Senate, though it is not the ideal bill he would have written.

After answering the question, Obama stepped back to the podium to remark on Jason Collins, and said he "couldn't be prouder" of him after Monday's announcement.

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The Department of Health and Human Services has released a new, three-page application form for health insurance under the Affordable Care Act, responding to mounting criticism over what was originally a 21-page application.

The new, five-step process is clear, concise, and simple to follow. Though applying for health insurance can be a convoluted process, I filled out the application in 5 minutes and 20 seconds. 

Granted, as a young, single person with a solitary source of income and no dependents, I'm not the most complicated potential applicant.

But the form requires only basic information, even for more complicated situations. The most involved question entailed the amount of annual student loan interest, which was still easy to access from my taxes. 

Families, however, will have to fill out an 11-page application, which is still much slimmer than the original draft. 

The earlier form required applicants to list deductions, relationship status, voluminous information about employers and other details. 

Most of the effort in the new forms will be completed on the back-end by the exchange. All applicants have to do is provide basic information and a Social Security number, indicate which federal health care programs they're involved with, and list estimations of annual income.

Early reviews of the 21-page draft had called it "tedious" and "daunting," and Sen. Max Baucus (D-Mont.) said it looked like rollout of the law would be a "trainwreck." Shedding some of those labels might make it easier for the estimated 4.3 million Americans who will apply for assistance in the first year. 

If implementation proceeds as planned, applicants can submit forms beginning on Oct. 1 and will start receiving benefits on Jan. 1, 2014. 

Here's the main page of the form:

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Obamacare has survived a Supreme Court challenge, but Americans are still confused about what Obamacare means for them, according to a Kaiser Family Foundation poll.

The poll found that a shocking 42% of Americans are confused about whether the three-year-old health care reform is still law.

Of that 42% who were confused, 12% believe it's been repealed by Congress, 7% think it's been overturned by the Supreme Court, and 23% weren't sure whether it had been repealed or refused to answer.

Over half of those surveyed think that the law's opponents should continue trying to weaken or repeal it, so it has "less impact on taxpayers, employers, and health care providers."

SEE ALSO: Here's All The New Obamacare Lingo Consumers Need To Know

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Expansion of health insurance to everyone has been a primary liberal goal for decades.

And with Obamacare on the verge of implementation (things really got going last year) that outcome is closer than ever.

So in that context here are two interesting tweets from liberal NYT columnist Nick Kristoff:

I hate to admit it, but @douthatnyt may be right that we liberals oversold benefits of health insurance nyti.ms/16FDzF3

— Nicholas Kristof (@NickKristof) May 5, 2013

There clearly are benefits, e.g. on bankruptcy & mental health, but Oregon data doesn't show health improvements we anticipated

— Nicholas Kristof (@NickKristof) May 5, 2013

The "Oregon Study" he's referring to is a landmark study that came out just this week (published in the New England Journal of Medicine) which found that expanded Medicaid may help the financial well being of those who get coverage, but that there aren't very big physical health results.

This isn't a big surprise to people who have followed the debate closely for a long time.

As Ross Douthat points out in the NYT, there have been studies showing this exact phenomenon before:

IN one of the most famous studies of health insurance, conducted across the 1970s, thousands of participants were divided into five groups, with each receiving a different amount of insurance coverage. The study, run by the RAND Corporation, tracked the medical care each group sought out, and not surprisingly found that people with more comprehensive coverage tended to make use of it, visiting the doctor and checking into the hospital more often than people with less generous insurance.

But the study also tracked the health outcomes of each group, and there the results were more surprising: With a few modest exceptions, the level of insurance had no significant effect on the participants’ actual wellness.

That health care coverage does not necessarily equate to better health does not undermine the importance of health care. Paul Krugman snarked this week that fire insurance must be worthless, since it doesn't prevent fires.

Still, the latest study has revived the notion that perhaps health care should be more focused around preventing catastrophic financial outcomes, rather than providing a means for people to see the doctor more on someone else's tab. Alas, with Obamacare about to be implemented, that debate might be irrelevant.

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