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- 03/31/18--07:33: _Obamacare premiums ...
- 04/02/18--12:37: _Trump is raging tha...
- 04/23/18--12:14: _Democrats, health g...
- 05/01/18--09:24: _Trump's former top ...
- 05/07/18--15:02: _Obamacare premiums ...
- 05/08/18--10:18: _Restaurant chains n...
- 05/14/18--14:19: _States want to shie...
- 05/23/18--13:06: _The GOP just dealt ...
- 05/24/18--15:23: _A new report says T...
- 05/31/18--06:15: _Virginia looks pois...
- 06/08/18--07:40: _The Trump administr...
- 07/10/18--14:36: _Everyone is panicki...
- 02/19/18--05:16: _Idaho is making a r...
- 02/20/18--09:56: _The Trump administr...
- 02/21/18--20:59: _Trump administratio...
- 02/24/18--06:03: _Trump's newest plan...
- 03/09/18--06:13: _The Trump administr...
- 03/19/18--11:38: _The government is f...
- 03/20/18--13:00: _HERE WE GO AGAIN: C...
- 03/20/18--14:29: _A last-ditch effort...
- Obamacare premiums increased between 2017 and 2018, according to a new study.
- The average cost of the cheapest silver-tier plan increased 32% across the US. Gold-tier plans saw a 19.1% increase.
- There were a variety of reasons for the increases, from Trump administration changes to marketplace fundamentals.
- Check out the increases for silver and gold plans by state in maps below.
- President Donald Trump renewed his calls for the Senate to kill the legislative filibuster, citing it as a key obstacle to why there is no permanent solution for the Deferred Action for Childhood Arrivals program and funding for a wall along the US-Mexico border.
- A history of major policy failures during Trump's administration stem from factors outside of clearing a 60-vote minimum.
- The Trump administration is moving forward with a new plan to expand the use of short-term health insurance policies.
- Democrats said the new plan would undermine patient protections and drive up prices for sick Americans.
- Many health industry groups such as the AARP, American Heart Association, and America's Health Insurance Plans have come out against the plan.
- The short-term plans are not as generous, which could cause problems for people on the plans who get sick. These plans do not have to adhere to all regulations laid out by the ACA, such as covering the 10 essential health benefits and lifetime limits on benefits. This means that a person who becomes ill while on one of the plans could face high out-of-pocket costs.
- Short-term plans can deny coverage based on pre-existing conditions or charge people more if they have a pre-existing condition. Even after a person gets sick after signing up for a short-term plan, said the Kaiser report, an insurer can investigate to determine if the illness counts as a pre-existing condition and retroactively deny coverage.
- More people leaving for short-term plans could increase costs for people who remain in the ACA marketplace. Young and healthy people help to lower the cost of premiums in the ACA marketplace. So as more of these young, healthy people shift to cheaper short-term plans, those who remain in the marketplace will be sicker, older, and more expensive to cover. In turn, premiums in the marketplace would increase.
- Tom Price, President Donald Trump's former Health and Human Services Secretary, said the GOP's repeal of the Affordable Care Act's individual mandate was a bad thing for insurance markets.
- Price's statement broke from the traditional Republican position and contradicts previous statements Price made during the Obamacare repeal push in 2017.
- Virginia and Maryland posted proposed rates for 2019 Obamacare plans, the first states to do so.
- The proposals showed significant proposed increases in premiums for many of the plans.
- Insurance industry professionals and health policy experts say the market is partly to blame, but President Donald Trump also made the problem worse.
- CareFirst, a member of the Blue Cross Blue Shield Association that focuses on Maryland, requested a 91% increase for its PPO plan in the state and a 19% increase for its HMO plan, according to the Maryland Insurance Administration.
- The other provider in Maryland, the Kaiser Foundation, requested a 37% jump.
- CareFirst requested 64% and 27% increases for its PPO and HMO plans, respectively.
- Kaiser asked for a 32% bump.
- Virginia-based Piedmont requested a 18% increase.
- Cigna asked for a 15% increase.
- And Anthem asked for a 6% jump.
- The only request for a decrease came from Optima, which wants to lower premiums by 2% in the state, though the company's rates are among the priciest in the country.
- Starting this week, chain restaurants are required to post calorie counts on their menus as part of the 2010 Affordable Care Act.
- The measure is designed to help people eat healthier, but it's important to remember where calories come from in the first place — and to know that they're not the end-all, be-all when it comes to nutrition.
- In 1918, a Los Angeles physician played a major role in popularizing the calorie as a way of losing weight.
- It was the first mention of the word in popular culture — and the world's first viral diet book.
- The Trump administration is moving towards allowing states to impose mandatory work requirements on their Medicaid programs.
- Several states including Kentucky, Michigan, and Ohio are proposing waivers that would exempt residents in counties with high unemployment rates from these work requirements.
- While low-income white residents of rural towns would benefit from the waivers, many low-income people of color in urban areas would not qualify.
- Cities with low-income people of color are often surrounded by wealthier suburbs that pull the overall county unemployment rate below the threshold to qualify.
- President Donald Trump and Republicans have so far failed to pass large-scale bills to undo former President Barack Obama's legislative achievements, such as Obamacare.
- But Trump and the GOP have found ways to chip away at Obama's legacy.
- Most recently, that came in the form of the Wall Street deregulation bill passed Tuesday.
- It eliminates some — but not all — of the Dodd-Frank Act's banking rules.
- Trump and Republicans have also used regulatory actions to shape the healthcare system and other federal agencies.
- The Department of Health and Human Services has been aggressive in approving waivers that allow states to make modifications to Medicaid programs and insurance market regulations.
- These waivers are designed to help states bring down costs for consumers, but the waivers granted so far also undermine some of Obamacare's regulations for health plans and possibly reduce the number of poor Americans on Medicaid.
- On the national level, the department is set to roll out an expansion of short-term health plans that could allow insurers to dodge some of the healthcare law's key protections.
- These plans are not subject to the same regulatory scrutiny as long-term plans, making them a cheaper but much less generous option. Healthy policy analysts warn that people on these plans could be subject to higher costs in the event of illness and the expanded use of short-term plans will undermine the main Obamacare market.
- Republicans repealed Obamacare's individual mandate in their tax reform law, which President Donald Trump said was effectively a repeal of Obamacare.
- A new Congressional Budget Office report shows that fewer people will leave the Obamacare market due to the mandate repeal than previously thought.
- Part of the reason, the CBO said, was because people value health coverage more than before Obamacare was passed.
- 05/31/18--06:15: Virginia looks poised to secure a major win for Obamacare's legacy
- The Virginia Senate approved a state budget that includes Medicaid expansion under the Affordable Care Act, or Obamacare.
- A final vote in the House is needed, but the move would make Virginia the 33rd state to approve Medicaid expansion.
- The potential is an example of Obamacare's resiliency despite GOP attempts to repeal the law.
- On Thursday, the US Justice Department proclaimed that the part of the Affordable Care Act requiring people to have health insurance was unconstitutional.
- This also extends to two major provisions of the ACA, also known as Obamacare, including one that protects people with preexisting conditions from being denied coverage.
- A coalition of 20 states led by attorneys from Texas and Wisconsin sued the government in February for the repeal of the Obamacare provisions.
- Attorney General Jeff Sessions said the Justice Department would not defend the preexisting-conditions provision or the provision allowing insurance companies to impose discriminatory pricing.
- President Donald Trump nominated Brett Kavanaugh to replace Justice Anthony Kennedy on the Supreme Court.
- Experts and politicians are questioning how Kavanaugh could rule on cases involving Obamacare.
- Some conservatives say Kavanaugh will not go far enough to dismantle Obamacare, citing a dissent from 2011, while other conservatives believe the judge would rule against the law.
- Democrats and liberals are almost all fearful of Kavanaugh's possible rulings on Obamacare.
- Blue Cross of Idaho has announced health-insurance plans that do not conform with all rules of the Affordable Care Act, or Obamacare.
- The Trump administration could step in and enforce the ACA, preventing the sale of these plans, or decide to allow the sales to go forward.
- The decision will have big consequences for people on the ACA exchanges as well as many other states looking to get around some of Obamacare's rules.
- They would charge sicker people more than healthy people.
- They would have a maximum annual payout to beneficiaries of $1 million.
- The Department of Health and Human Services debuted a new rule expanding the use of short-term health insurance plans.
- The rule would allow people to use short-term plans that do no comply with Obamacare regulations for up to 12 months.
- People are currently only allowed to use such plans for three months.
- Health policy experts say the plan will increase costs for the government and many sick people in the middle class who get their insurance through the Obamacare exchanges.
- President Donald Trump's Council of Economic Advisers released a report Wednesday on the administration's healthcare policies.
- In the report, the CEA noted that the increase in opioid-related deaths exploded around the same time as the implementation of the Affordable Care Act, or Obamacare.
- Republicans have suggested that Obamacare's expansion of Medicaid may have contributed to the opioid crisis, though research disputes the assertion.
- The Trump administration rolled out a new proposal this week that would allow expanded access to short-term health insurance plans.
- While the plans may bring down monthly costs for some healthy consumers, experts say they could cause serious trouble for sicker Americans.
- Seema Verma, the administrator for HHS' Centers for Medicare & Medicaid Services, blocked a move by the state of Idaho that would have undermined Obamacare.
- Verma said that Idaho's new plan to let insurers sell plans that did not comply with Obamacare ws not legally permissible.
- Health policy experts were closely watching the Idaho situation because it could have opened the door for other states to flaunt the rules of Obamacare.
- The federal government will shut down Friday unless a spending bill is passed.
- The deal should be reached after the budget agreement in February set the spending caps for the government.
- Potential additions, dealing with everything from immigration to Obamacare, could pose complications.
- The government will run out of funding at the end of the day Friday.
- A massive $1.3 trillion spending bill to avoid a shutdown is in the works.
- But Congress is struggling to get its act together, with the House already pushing back the bill's release and a planned vote.
- There are still ongoing debates over immigration, infrastructure, and gun-related provisions in the bill.
- Republican Sens. Susan Collins and Lamar Alexander are pushing to include extra Obamacare funding in this week's must-pass spending bill.
- But, lawmakers from both parties have issues with the plan and it may be dead on arrival.
- It would provide funds for the cost-sharing reduction payments that help offset costs for insurers to cover lower-income patients. These are the payments President Donald Trump ended in October.
- It would create a reinsurance program that would mitigate losses for insurers that cover an overall sicker pool of people.
- It would allow people over the age of 30 to buy "copper" plans with limited benefits and loosen regulation around short-term stopgap plans.
- It would allow governors to obtain waivers to loosen Obamacare regulations in their state without the state legislature's approval.
Affordable Care Act premiums are headed in the same direction as last year: higher.
According to a new study from the Urban Institute and the Robert Wood Johnson Foundation, premiums in the Obamacare exchanges — which provide insurance for people who do not get coverage through work or a government program like Medicaid — jumped 32% nationally for the lowest-cost silver-tier plan, as well as 19.1% for gold-tier plans.
There are a variety of reasons for the increase in premiums from last year, according to the study, ranging from Trump administration actions to unresolved deficiencies in the individual insurance market.
"The premium increases reflect significant policy changes and policy debates specifically affecting insurer decisions for the 2018 plan year as well as more typical annual considerations such as trend and healthcare costs," the researchers wrote.
Of particular interest to the researchers was the difference between the increase for silver-level plans, the middle-tier of Obamacare coverage, and the gold-level plans.
Silver plans generally saw larger increases in premiums because insurers predominately loaded onto those plans the loss of cost-sharing reduction (CSR) payments, which helped offset the cost of covering lower-income patients. President Donald Trump ended the CSR payments in October.
States had the option of loading the lost CSR payments into just the silver tier or spreading them out among all the levels.
"26 states had insurers allocate the CSR costs to silver marketplace premiums alone, eight states had the costs allocated to silver plans on and off the marketplaces, three states had insurers spread the costs across all metal tiers in the marketplace, three had insurers spread the costs across all metal tiers on and off the marketplace, and in three states' approaches varied across insurers," the study found.
Much of the cost increases won't be passed onto consumers, since 70% receive subsidies, which bring their premiums below $75 a month. But it means the program costs the federal government more in the end than if Trump had kept the payments in effect.
Overall, 15 states saw an increase of more than 40% for the lowest cost silver plan while eight saw an increase of 10% or less. Of those, four saw a decrease in premiums.
The largest increase in the lowest-cost gold plan premiums came in Kentucky, a 66.2% pop. Kentucky also shifted from a state-based marketplace to the federally run Healthcare.gov platform for the first time in 2017 and suffered a drop off in enrollment last year.
On the other end of the spectrum was Alaska, which saw gold premiums fall by an average of 27.9% between 2017 and 2018.
President Donald Trump once again took aim at the Senate filibuster, a procedural maneuver that can thwart legislation without at least 60 votes to end debate on the subject.
Trump regularly bashes the filibuster as an obstacle to his agenda. But it rarely factors into why certain things are not able to pass. In many cases, it is because the Republican conference is not unified enough on their own.
Trump declared on Monday morning that the Deferred Action for Childhood Arrivals program (DACA) is "dead" amid frustrations with his inability find a permanent solution to the issue many want to see resolved.
"DACA is dead because the Democrats didn’t care or act, and now everyone wants to get onto the DACA bandwagon... No longer works," Trump wrote on Twitter. "Must build Wall and secure our borders with proper Border legislation. Democrats want No Borders, hence drugs and crime!"
Trump also railed against the filibuster. The president would prefer a simple majority to end debate, like is done with executive nominations.
DACA collapsed in the Senate because of other factors
All the proposals for DACA and border security funding went down in flames in February for various reasons unrelated to the filibuster.
The most popular compromise in the Senate would have given in to the White House's demands, which included $25 billion for construction of the wall along the US-Mexico border and other security measures in addition to providing a pathway to citizenship for DACA recipients. That plan received some Democratic support, but failed 54-45.
Even though that plan failed to surpass the 60-vote threshold, the filibuster was irrelevant in that case as the Trump administration had already rejected the deal.
White House officials called it dead on arrival before a vote was even held, and the Department of Homeland Security called it "an egregious violation of the four compromise pillars laid out by the President's immigration reform framework."
The one plan the White House actually backed could not even muster enough support from the entire Republican conference.
An amendment from Iowa Sen. Chuck Grassley, which included many of the same elements of the other plan but significantly reduced legal immigration levels, only managed to get 39 'yes' votes.
Repealing and replacing Obamacare failed too
In the first year of Trump's presidency, Republicans repeatedly stepped on the proverbial rake in their attempts to repeal and replace President Barack Obama's signature law, the Affordable Care Act.
Almost every month of 2017 was full of setbacks in trying to repeal Obamacare. In July, Senate Majority Leader Mitch McConnell said, "It's time to move on" after their plan could not even get 50 Republican votes.
Months later in September, a revamped plan from Sens. Lindsey Graham and Bill Cassidy once again failed to get at least 50 Republicans willing to support it, leading McConnell to scrap it altogether.
Republicans "nuked" the filibuster for Supreme Court nominees when it became apparent not enough Democrats would support Neil Gorsuch's confirmation. The tax overhaul bill was done through a process called "reconciliation," which is why it did not require 60 votes, but also why it did not go as far as many Republicans had hoped.
The bottom line is that when Trump blames the filibuster as his primary obstacle to achieving more legislative wins, he is often ignoring underlying factors, mainly that in most cases Republicans cannot agree enough to make good on years of promises.
Democrats and healthcare groups are attacking the Trump administration's latest healthcare plan as an attempt to undermine the core protections of Obamacare and increase costs for sicker Americans.
The Trump administration's new plan would expand the use of short-term, limited-duration health insurance plans for people who have a lapse in coverage. Currently, if a person experienced a lapse in coverage, for example after the loss of their job, the individual can get a short-duration insurance plan. These plans last a maximum of three months until the individual can sign up for a longer-term plan through the Affordable Care Act exchanges.
Under the proposed rule, these plans could last as long as 12 months, and the Department of Health and Human Services (HHS) is considering letting people renew these plans at the end of the time limit. This would, in essence, allow someone to remain on the short-term plans in perpetuity.
HHS and the Trump administration argue that these expanded plans would give healthy Americans a lower-cost option for coverage, as compared to the more permanent plans found in the Affordable Care Act (ACA), or Obamacare, exchanges. But according to health policy experts, these plans could also cause trouble.
The problems with short-term plans
According to the Kaiser Family Foundation, a nonpartisan health policy think tank, these new plans could cause substantial changes to the individual insurance market — where people who do not receive coverage from an employer or government program access coverage.
In particular, said Kaiser, these plans have three major problems that could cause issues for both the people who sign up for short-term coverage and those who remain in Obamacare's marketplace:
While many people would get higher government subsides to offset the increased costs, many middle-class Americans who do not qualify for those premium subsidies would see large cost increases.
Democrats, industry groups express concerns
Given these limitations, Democrats expressed concern about the effects of the expanded plans in a letter to HHS Secretary Alex Azar, Labor Secretary Alexander Acosta, and Treasury Secretary Steven Mnuchin.
"Unfortunately, creating a new class of health insurance plans that lack basic patient protections and could lead to higher prices for seniors, those with pre-existing conditions, and any American who wants to purchase a plan ," the letter said.
In addition to worries from Democrats, many health industry groups came out against the idea, including AARP, the American Heart Association, the American Academy of Family Physicians, and others. America's Health Insurance Plans, the largest insurance lobby in the US, also came out against the expansion of the short-term plans.
"We are concerned that this proposed rule will lead to more people being uninsured and under-insured, and to higher costs in the long run," AHIP CEO Matt Eyles said in a statement on Monday. "Short-term plans can provide an important temporary bridge for Americans who are transitioning between plans. But they are not a replacement for comprehensive coverage."
The public comment period on the rule ends Monday and a final rule is expected to be released in the coming months.
Tom Price, the former Health and Human Services Secretary under President Donald Trump, criticized a key Republican change to Obamacare during a speech Tuesday.
Speaking at the World Health Care Congress, Price suggested the Republican Party's repeal of Obamacare's individual mandate — the requirement to buy insurance or face a penalty — was a faulty idea. He said it would drive up costs for people in the individual insurance marketplace.
"There are many, and I’m one of them, who believes that that actually will harm the pool in the exchange market, because you’ll likely have individuals who are younger and healthier not participating in that market, and consequently, that drives up the cost for other folks within that market," Price said, according to the Washington Times.
Price's argument echoes that of many health policy experts. Without a mandate to compel younger, healthier people to sign up for coverage, many are projected drop out of the Obamacare marketplaces. That would leave a pool of older, sicker people in those marketplaces that cost more for insurers to cover. To offset the higher costs, insurers would be forced to increase premiums.
Though most people in the marketplaces would not see their premiums go up due to federal subsidies, those families who don't qualify for subsidies could see costs soar. In turn, many people could drop coverage due to the increased expenses, a report from the Congressional Budget Office has shown.
While Price's analysis on Tuesday is in line with many healthcare experts, it contradicts not only the Republican party's position on mandate repeal, but also Price's own statements from 2017.
"The individual mandate is actually one of those things that is driving up the cost for the American people in terms of coverage," Price said in July 2017, in the midst of the GOP's effort to repeal Obamacare.
Price resigned as HHS secretary in September after extensive reporting on his use of private air travel. According to records, Price cost taxpayers more than $1 million between his use of private planes for domestic travel and military jets for recent trips to Africa, Europe, and Asia.
Price's comments were the second in as many days from Republicans sounding a critical tone on the tax law. Sen. Marc Rubio, a Florida Republican, said in an interview published Monday that there was "no evidence" any of the law's provisions have benefited average workers.
Affordable Care Act premiums look like they will continue to soar in 2019, according to early indications from a handful of states. And President Donald Trump may bear some of the blame.
Virginia and Maryland were the first states to post initial proposals for plans through the Obamacare marketplace, which can be purchased by people who do not receive insurance through work or a government program like Medicaid.
In those rate requests, most insurers asked for double-digit increases from 2018 to 2019 following the upward trend in health insurance costs for the marketplaces:
The average increase requested in Maryland was 30%, according to the insurance administration.
Charles Gaba, who writes for the health policy blog ACASignups, said that based on the number of people signed up for each plan, the average rate hike works out to 13.4% in Virginia.
The reasons for the increases, according to insurance commissioners and experts, is twofold.
On one hand are the long-term problems of the marketplaces. Fewer than expected young people have signed up for Obamacare plans, making the pool of people in the marketplace older and more expensive to cover for insurers.
But CareFirst CEO Chet Burrell told The Washington Post that the Trump administration's actions have made the Obamacare marketplaces "materially worse." He said the company could consider leaving the space altogether.
"Continuing actions on the part of the administration to systematically undermine the market and make it almost impossible to carry out the mission," Burrell said. "If continued efforts at the federal level undermine the marketplaces, I would think the board would have to examine what they would want — that’s very much on their mind."
The Trump administration eliminated the individual mandate — the requirement to buy coverage or face a financial penalty — as part of the GOP tax law.
The Congressional Budget Office has projected that eliminating the mandate will hike premiums by 10% and leave 13 million more people without insurance by 2027.
Larry Levitt, senior vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank, said Trump's repeal of the mandate would force premium hikes much higher in 2019.
"With insurers now mostly profitable in the ACA individual insurance market, I would have expected single-digit premium increases for 2019 reflecting health cost growth," Levitt tweeted Monday. "With repeal of the individual mandate and expansion of short-term plans, double-digit hikes are now likely."
Standing before a room of women in Los Angeles, Lulu Hunt Peters wrote a word on a blackboard that she said held the keys to empowerment. It was a word most of her audience had never heard before. Peters insisted it was just as important as terms like "foot" and "yard," and that if they came to understand and use it, they would be serving their country and themselves.
The word was "calorie."
It was 1917, and although the calorie had been used in chemistry for decades, Peters was responsible for popularizing the idea that all we need to become healthier is knowing how much energy is in our food and cutting back the excess. More than 100 years later, that logic lives on in new US rules that require chain restaurants and stores that sell prepared food to list calorie counts on menus.
Peters' teachings weren’t all academic. She also referred to overweight people as "fireless cookers" and accused them of hoarding the valuable wartime commodity of fat "in their own anatomy." Nevertheless, Peters' weight-loss strategy has become so popular that some experts worry it now eclipses more important aspects of nutrition.
Yet while Peters' concept of calories has managed to stick around for 100 years, few have heard her name. As one of a handful of female physicians in California at the turn of the 20th century, Peters occupied a tenuous role as a health authority. After initially opening up her own private practice, she struggled to feel satisfied with her career.
It was only after America entered the first World War that Peters had the opportunity to find her voice — first as a leader of a local women's club and finally as America's most enduring diet guru.
'Hereafter, you are going to eat calories of food'
Lulu Peters was the picture of 1920s fashion.
She wore her dark hair in the flapper style, bobbed and adorned with glittering headbands, and sported luxurious furs. Her ears were decorated with gleaming pearls. She wasn't rail thin, as the social mores of middle-class white America said she ought to be, but she was 70 pounds leaner than she had been when she'd graduated from medical school — a point she emphasized with pride in a pamphlet she sold for 25 cents and later turned into the world's first best-selling diet book.
When it came to the science of nutrition and weight loss, Peters was in many ways decades ahead of her time. While ads in local newspapers pushed women to try everything from smoking ("Reach for a Lucky instead of a sweet!") to wearing medicated rubber garments to lose weight, Peters was breaking down complex scientific concepts like metabolism into accessible ideas that could be used to slim down.
In 1910, when the average life expectancy was 49 years, most Americans had never heard of things like calories, proteins, or carbohydrates. Even the science of vitamins was a fledgling endeavor characterized by a great deal of pseudoscience. Through her newspaper columns and clubhouse talks, Peters introduced hundreds of people to these ideas, and even began to link unhealthy eating with specific diseases. She went so far as to recommend intermittent fasting for those struggling to lose weight, a topic that is only now beginning to emerge in the scientific literature.
Still, what Peters taught her followers about calories has endured the longest: that all you need to do to lose weight is consume fewer calories than you burn.
"Instead of saying one slice of bread, or a piece of pie, you will say 100 Calories of bread, 350 Calories of pie," she wrote in 1918. "Hereafter, you are going to eat calories of food."
'How dare you hoard fat when our nation needs it?'
In 1909, Peters was one of about 1,000 women across the country to graduate as a doctor of medicine.
War and its demand for medical workers had helped temporarily ease some of the barriers blocking women from entering universities, and in 1910 the percentage of women physicians was at an all-time high at 5%. Shortly after receiving her degree from the University of California, Peters got a job leading the Los Angeles County Hospital's pathology lab. Several years later, even as the percentage of women medical-school graduates receded to below 3%, she secured a role as the chair of the public-health committee for the California women's club federation of Los Angeles, a position that a local newspaper described as having "more power than the entire city health office."
Still, Peters occupied a tenuous position in a society led by men. Even as a leading physician with two medical degrees, most of her roles were unpaid, including a one-year stint with the American Red Cross in 1918 during World War I. Many of the public-health events she attended were derided in local newspapers as nothing more than "supper parties" for "female physicians." And these roles, which were already constrained by gender, were made even more exclusive by the fact that they were volunteer-only. Women who didn't have access to money — many of them women of color — were barred from participating. Those who did attend made a show of their wealth. With her high-society flapper fashion, Peters was no exception.
Whatever signs of excess she displayed when it came to clothing, however, Peters made up for in her approach to eating.
After struggling with her weight for years early in her career, Peters lost 70 pounds by carefully restricting the amount of food she ate. Her diet was a seemingly logical extension of basic chemistry: If you want to "reduce," you need to put less energy into your body than it uses up. To do that, a unit of measure she'd applied frequently as a student of child nutrition at several Los Angeles hospitals was key. Peters and her peers had relied on calculating the caloric content of baby formula to ensure premature babies and other infants under their care were properly nourished. Now, the measure seemed an easy way to calculate the energy needs of adults.
As a leading member of the women's club federation, Peters became a diet guru, frequently sharing bits of her dieting wisdom with fellow members. One day, shortly before leaving for her World War I service with the Red Cross, she delivered a talk about weight loss. In order for her audience to understand how she lost weight, she introduced them to the unit of measure at the foundation of her plan. The calorie, she explained, was a measure of what she called "food values."
"You should know and also use the word calorie as frequently, or more frequently, than you use the words foot, yard, quart, gallon, and so forth, as measures of length and liquids," Peters said.
Losing weight wasn't merely about meeting societal expectations, though, at least in the way Peters presented it.
Being severely overweight was also linked with chronic illnesses such as heart and kidney disease, she wrote. At the time, it was an idea that was just beginning to circulate among scientists. More important, Peters presented calorie counting as a moral, patriotic duty. Hungry troops at the front lines, she explained, needed calories that women like her could do without. What was fat, she said, if not a high-energy resource that should be distributed to the soldiers abroad?
"In war time it is a crime to hoard food, and fines and imprisonment have followed the exposé of such practices," Peters wrote. "Yet there are hundreds of thousands of individuals all over America who are hoarding food, and that one of the most precious of all foods! They have vast amounts of this valuable commodity stored away in their own anatomy."
Peters even went so far as to describe the discomfort of dieting as a physical reminder of American loyalty and an easier way to deal with rationing. If the food they didn't eat didn't go directly to the troops abroad, their leftovers could be used to feed their children: "That for every pang of hunger we feel we can have a double joy, that of knowing we are saving worse pangs in ... little children, and that of knowing that for every pang we feel we lose a pound."
It may have sounded like a noble goal at first, but Peters had taken the idea of calorie counting too far.
An imperfect science
In a world dominated by celebrity fad diets that range from the absurd, like Reese Witherspoon's alleged "baby-food diet," to the absurdly unaffordable, such as Gwyneth Paltrow's $200 "moon dust"-infused breakfast smoothie, calories can seem like the most scientific option for improving your health. But there is more guesswork involved in calorie calculations than you might think.
The current system of calorie counting on which our nutrition labels are based "provides only an estimate of the energy content of foods,"Malden C. Nesheim, a professor of nutrition at Cornell University, said at a 2013 meeting of the nonprofit Institute for Food Technologists.
Traditionally, scientists calculated the energy content of foods using a large piece of machinery called a bomb calorimeter. The process involved placing a sample of food into the device, burning it, and measuring how much the water in a surrounding container heated up. Since a calorie raises the temperature of a liter of water by 1 degree Celsius, the calorie count would be found by calculating the change in the water's temperature multiplied by the water's volume. Today, we use a shortcut called the Atwater system, named after agricultural chemist Wilbur Olin Atwater.
Atwater — who wanted to use his work in the 1890s to help poor people get the most calories for their money— determined the average number of calories in four main energy sources: carbs, fats, protein, and alcohol. Fats, he found, were the most energy-dense with about 9 calories per gram, while proteins and carbs were roughly equal at about 4 calories per gram. Alcohol was worth about 7 calories per gram.
The Atwater system is how the calorie counts on nutrition labels have been determined by the US Department of Agriculture since 1988. Before that, they were done by hand. Using this method, you'd be able to determine that a slice of wheat bread with 3 grams of protein, 9 grams of carbs, and 1 gram of fat had roughly 60 calories.
Here's the problem: Not all of us process all foods the same way.
"It's definitely not just 'calories in and calories out' because two people could be [burning] more and consuming less and one person gains and one doesn't," Cara Anselmo, a nutritionist at New York's Memorial Sloan-Kettering Cancer Center, told Business Insider. "There are metabolic differences person to person."
These variations mean that each of us needs a different amount of energy from our food, and it can vary substantially by the day. One issue that the Atwater system will never account for, Anselmo says, is the delicate balance of hormones that guide everything from appetite to digestion. These hormones can be influenced a great deal by our previous history of weight loss or weight gain.
"We find that with people who lose a significant amount of weight, hormones play an important role, too. So someone who's always been at 150 pounds can actually get away with eating more calories than someone who was at 250 pounds and lost 100 pounds. Your body is producing fewer of the hormones that make you feel full and more of the hormones that make you hungry," Anselmo said.
This means that Peters, who lost a substantial amount of weight before writing her best-selling diet book, might have had to limit her diet more than someone who had always weighed what she did.
Other factors that scientists are just beginning to understand also influence the number of calories we get from food. In a large review of studies published in the Journal of Nutrition, Purdue University scientists found that whole tree nuts and peanuts have roughly 15% fewer calories than the figure calculated using the Atwater method. Although nuts are high in fat, the researchers found, a significant portion of those oils end up being secreted when we eat them. Another study published in the British Journal of Nutrition in 2012 came to a similar conclusion about pistachios, finding that they had about 5% fewer calories than originally assumed.
When calories aren't king
Let's say that at lunchtime you're given two options with the same number of calories. You can either have a ham sandwich, potato chips, and a can of soda or a salad and a whole-grain roll. Which would you choose?
You might be tempted to pick the sandwich and soda if they stack up the same in terms of calories, right?
According to Peters and many modern diets that she influenced, the answer is yes. But it's not that simple. While counting calories can be a useful part of a bigger toolkit for weight loss, it is not a perfect solution for healthy eating, especially when used in isolation.
Nichola Whitehead, a registered dietitian with a private practice in the UK, summarized the problem this way: "While calories are important when it comes to losing, maintaining, or gaining weight, they are not the sole thing we should be focusing on when it comes to improving our health."
Take the following two daily meal plans, for example, both of which are about 2,000 calories:
While they tally up to the same number of calories, the two plans are far from equal.
"Both of these would give you the same number of calories, but only one of them will leave you feeling satiated and satisfied and give you the energy you need," Whitehead said.
That's because the meal on the right doesn't provide what Whitehead refers to as "balance"— essentially the right mix of proteins, complex carbohydrates, fruits, and vegetables that your body needs to be properly fueled in the long term. Instead, that meal plan is based around refined carbohydrates, which the body breaks down quickly. Those carbs will give you a short burst of energy and make you feel full for a few hours, but probably leave you hungry before your next meal.
"Empty calories only give a temporary fix," Whitehead said.
To keep energy levels up and keep you full and healthy for the long term, your diet needs to feed more than your stomach. It has to satiate your muscles, which crave protein, your digestive system, which runs at its best with fiber, and your tissues and bones, which work optimally when they're getting vitamins from food.
How we got to now, from grapefruit diets to Weight Watchers
It wasn't until 1990 that calories made an appearance on the food we buy, and they weren't required by law until four years later.
Before that, there was simply no way to know for sure what was in the food you bought. Several years after Peters gave her calorie talk, Spam debuted as one of the first processed convenience foods. When World War II broke out, the easy-to-eat, no-spoil food was a hit among soldiers.
"In the universe of processed food," Anastacia Marx de Salcedo writes in "Combat-Ready Kitchen,""World War II was the Big Bang." The 1960s saw the invention of two more processed-food milestones: The first chicken nugget and high-fructose corn syrup.
Perhaps in response to these unhealthy eating trends, severe diet fads emerged in each decade from Peters' day to the present. In the 1930s, about a decade after Polish biochemist Casimir Funk first recommended people get enough of micronutrients called "vitamines" (later found in abundance in citrus fruits and veggies), the first grapefruit diet emerged. That was followed by a banana-and-skim-milk diet promoted by United Fruit, the planet's leading banana importer. Several decades later, Weight Watchers surged in popularity, and in the 1970s, women were encouraged to take sleeping pills whenever they felt hungry. Just last summer, singer Katy Perry claimed the "M Diet," otherwise known as eating only raw mushrooms for one meal a day for two weeks, helped her lose fat in select areas of her body.
Throughout history, most of these diets were heavily marketed to women, and that's still true today. Nevertheless, in Peters' day, she claimed to see weight loss as a tool that she and other women could use to liberate themselves, or, in her words, to become more "efficient."
Today, neither the mantra "calorie is king" nor the allure of fad diets appears to have won out in the global battle for our waistlines. Instead, there may be a move toward eating a more well-rounded diet based — and dietitians and public-health experts say they're encouraged by that trend.
Several recent studies suggest that whether you're looking for weight loss or to improve your health, the best eating plans are based around vegetables, whole grains, and lean proteins. These diets generally also include a variety of healthy fats, like those from nuts, fish, avocados, and olive oil. In its most report on the best eating plans, US News and World Report described vegetable-based ("plant-based") diets as "good for the environment, your heart, your weight, and your overall health."
This means that while we can certainly use calories as a tool to guide our eating choices, we shouldn't live like Lulu Peters, focusing solely on one number.
"Calories should be a tool for information, rather than a way to live your life," Whitehead said.
As the Trump administration moves aggressively to allow more states to impose mandatory work requirements on their Medicaid programs, several states have come under fire for crafting policies that would in practice shield many rural, white residents from the impact of the new rules.
In the GOP-controlled states of Kentucky, Michigan, and Ohio, waiver proposals would subject hundreds of thousands of Medicaid enrollees to work requirements, threatening to cut off their health insurance if they can't meet an hours-per-week threshold.
Those waivers include exemptions for the counties with the highest unemployment, which tend to be majority-white, GOP-leaning, and rural. But many low-income people of color who live in high-unemployment urban centers would not qualify, because the wealthier suburbs surrounding those cities pull the overall county unemployment rate below the threshold.
"This is sort of a version of racial redlining where they're identifying communities where the work requirements will be in full effect and others where they will be left out," George Washington University health law professor Sara Rosenbaum told TPM. "When that starts to result in racially identifiable areas, that's where the concern increases."
Rosenbaum and other health law experts say the waivers — already approved for Kentucky, pending for Ohio, and advancing in Michigan's legislature — may run afoul of Title 6 of Civil Rights Act of 1964, which prohibits race-based discrimination in federal assistance programs. Under that statute, even policies that are racially neutral on their face but have a disparate impact on a particular group could be illegal.
The waiver in Kentucky, the first state to win federal approval for a Medicaid work requirement, will have the effect of exempting eight southeastern counties where the percentage of white residents is over 90 percent. The work requirements will be imposed first in Northern Kentucky, which includes Jefferson, the county with the highest concentration of black residents in the state. The rules are set be enforced first in that area this July, but a federal court challenge in June could decide the fate of the program.
People who live in counties with unemployment rates above 8.5 percent would be exempt, and those counties are overwhelmingly white, rural, and vote Republican. But low-income residents of color in Detroit and Flint, where the joblessness and poverty are extremely high, would not receive an exemption.
A Washington Post analysis found that while African Americans make up about 23 percent of Medicaid enrollees in Michigan, they would make up just 1.2 percent of the people eligible for an exemption. Meanwhile, 57 percent of Michigan Medicaid enrollees are white, but white residents would make up 85 percent of the population eligible for an exemption.
Ohio's Medicaid work requirement proposal — recently submitted for federal approval — is of a similar design, and would have the same disparities between urban residents of color in Cleveland and Columbus and rural white residents in the rest of the state.
John Corlett, Ohio's former Medicaid director and the president of Cleveland's Center for Community Solutions, studied the 26 counties that qualify for an exemption from the proposed Medicaid work requirements and found they are, on average, 94 percent white. Meanwhile, his research found, "most of these non-exempted Ohio communities have either majority or significant African-American populations."
"The communities most at risk under this scenario are African American, and those communities already have significantly higher rates of infant mortality, lower life expectancy, and a number of other serious health disparities," he told TPM.
Additionally, Corlett noted, the racial divides within and among counties across the US are a product of decades of racist policies, and designing the exemptions on a county-by-county basis only serves to lock in those divides.
"Our housing patterns in Ohio are influenced by a past history of institutionalized segregation, and the Medicaid waiver reinforces that instead of mitigating it," he said. "Ohio could help mitigate the racially discriminatory impact of the waiver by exempting smaller units of government — like municipalities."
Ohio submitted its waiver to HHS the first week of May, and the policy is now under active consideration. Michigan's still needs approval from the governor, but the GOP legislature is pressuring him to sign it, even threatening to cut state officials' salaries if he fails to do so.
Leonardo Cuello with the National Health Law Program, one of the groups bringing the federal lawsuit on behalf of Kentucky residents, told TPM that while the exemptions in these states are aimed at addressing a genuine problem — the lack of work opportunities in many areas — they are impossible to extricate from the racialized national conversation about federal assistance and work.
"We're talking about a policy based on stereotypes about Medicaid enrollees," Cuello added, pointing to research that most non-elderly, non-disabled Medicaid recipients already work. "There is a constant dog whistle in the background here about making lazy people get off their couches and go to work, and playing into stereotypes about African Americans. It's almost impossible to argue that the policy is not racial."
Complicating the arguments playing out in several states over carve-outs for certain Medicaid recipients is the Trump administration's ongoing internal battle over exemptions Native Americans.
As some HHS continue to insist that exempting tribal citizens from the work requirements would be an illegal racial preference, legal experts and members of Congress warn that imposing the requirements on tribal communities violates their sovereignty.
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Congress' passage Tuesday of the first major rollback of Wall Street regulations enacted after the financial crisis are set to not only reshape the financial system, but also serve as the latest Republican blow in a bid to unwind former President Barack Obama's legacy.
The bill, which President Donald Trump says he will sign, does not undo the post-crisis banking regulation Dodd-Frank Act completely. But it is set to roll back many of the rules and regulations that came to define Obama's relationship to Wall Street.
Sen. Mitch McConnell, the majority leader, said the legislation would give "smaller community lenders relief from Obama-era overregulation."
"I frequently discuss how our Democratic colleagues' top-down policy agenda worked well for a select few urban areas but left much of the rest of the nation behind. This issue is a perfect illustration of that," he said.
But at the margins, the Trump administration and GOP lawmakers have managed to chip away at some of the former president's signature accomplishments.
Trump attacks Obama's agenda on all fronts
Trump has undertaken extensive reversal to his predecessor's legacy through executive order. Most significantly, he has done so by pulling the the US out of the Iran nuclear deal, the Paris climate agreement, the Trans-Pacific Partnership, three major, multilateral deals.
But Congress and the administration have also used other parliamentary and regulatory tactics to slowly but surely hack away at the former president's policy achievements.
Republicans also slipped a monumental Obamacare change into their recently implemented tax bill. Starting next year, individuals will no longer face the law's individual mandate— the rule that requires all American get health coverage or face a fine.
While the mandate will allow some people to avoid paying the penalty, the Congressional Budget Office estimated the repeal will result in 13 million more Americans going uninsured by 2027 compared to the current system.
The Trump administration has also worked to reshape healthcare rules on the state and national level:
Other agencies, such as the Environmental Protection Agency, Department of the Interior, and Department of Housing and Urban Development are making similar rule changes to reverse Obama-era practices.
Congress uses an unusual route to chip away
In Congress, Republicans have also made use of the Congressional Review Act, which allows lawmakers to rescind regulations put in place by executive agencies. Recently, Republicans also tried an unused wrinkle to the CRA, which could allow Congress to rescind regulations dating back to the CRA's passage in 1996.
Previously, the CRA was thought to only apply to regulations that were created within the past 60 days. But, the GOP pointed a small provision that says the CRA can be used for up to 60 days after a regulation is submitted to Congress. Since many regulations were not submitted, Republicans have argued they have even more leeway to continue to undo Obama's executive actions and regulations with very little effort.
Republicans were able to block a 2013 rule from the Consumer Financial Protection Bureau that attempted to prevent racial discrimination in auto lending. More could be on the way.
"By setting this terrible precedent of repealing regulatory guidance, the majority is opening up a Pandora’s Box that could have deeply harmful consequences for the public and badly impede the important work of regulators not just of the financial services industry, but of all industries," Rep. Maxine Waters, the top Democrat on the House Financial Services Committee, said at the time.
Even after sustaining a major blow from Republicans, Americans may not ditch Obamacare as quickly as previously thought.
The new GOP tax reform law contained a provision that virtually eliminated Obamacare's individual mandate, which requires all Americans to purchase health coverage or face a penalty. After Congress passed the tax law, Trump claimed that getting rid of the mandate amounted to a "repeal" of the landmark healthcare law.
Trump's language was a bit strong — the mandate is only one element of Obamacare — but the Congressional Budget Office estimated in November that 13 million more Americans would end up uninsured by 2027 than under the current baseline.
Six months later, a CBO update found that the mandate repeal would only cause about 5 million more people to go uninsured in that timeframe. There are several reasons for the adjustment, including insurance market changes and methodology tweaks.
While those changes were more technical in nature, the CBO also mentioned an interesting shift that helped cause the drop: people like having health insurance.
"The mandate has been in place for an additional year (five years in total), and people’s expectations about whether one should have coverage are more established and, in CBO’s current judgment, less sensitive to repealing the legal mandate," the report said.
Put another way, Obamacare prompted millions of American to get health coverage for the first time — and a good portion don't want to give up what they've bought.
Recent polling also appears to confirm that many Americans plan to stick with their coverage despite the mandate repeal.
The Kaiser Family Foundation, a nonpartisan health policy think tank, found in a March poll that 90% of people currently enrolled in a plan purchased on the Obamacare marketplace planned to keep their coverage even when the penalty disappears in 2019. Just 7% of people who had these plans told Kaiser they planned to drop the coverage.
The Kaiser also poll found that most people didn't consider the mandate to be a big reason for their insurance purchase. Just 34% of those surveyed said the law's requirement to buy coverage was a "major reason" they decided to sign up.
This could, of course, change over time based on factors like the cost of coverage.
In the report, the CBO also estimated that premiums on the Obamacare individual insurance market would increase by 15% in 2019 and 7% each year afterward through 2027.
Virginia's state Senate voted Wednesday in favor of a plan that would expand the state's Medicaid program under the Affordable Care Act, or Obamacare, in a move that shows the resiliency of the landmark healthcare law.
The Virginia Senate voted 23 to 17 to pass a budget that included Medicaid expansion, which could extend healthcare coverage to roughly 400,000 low-income Virginians.
The House must re-ote on the Senate package, but a similar measure already made it through that chamber and the second vote is expected to follow suit.
The move would make Virginia the 33rd state to approve Medicaid expansion. Washington, DC, also expanded the program, and while Maine citizens voted for expansion in 2017, GOP Gov. Paul LePage has refused to implement it.
The move is the culmination of five years of back-and-forth on Medicaid expansion in the state.
GOP Gov. Bob McDonnell turned down the expansion in 2013. Former Democratic Gov. Terry McAuliffe, who was elected in 2014, attempted multiple times but was ultimately unable to convince the GOP-controlled legislature to approve a expansion measure.
But after devastating electoral losses in 2017 that substantially reduced the Republican majorities in both the House and Senate, a handful of Virginia Republicans came around on the issue. Newly elected Democratic Gov. Ralph Northam added extra pressure when he told legislators that he would not sign a state budget that did not include Medicaid expansion.
While Democrats secured a large victory, the final bill does include a caveat. The bill also institutes a work requirement for the Medicaid program, which compels recipients to work or volunteer for at least 20 hours a month to get benefits. The minimum number of hours a month would steadily increase while the person was on Medicaid before topping out at 80 hours a month after a year.
The Senate-approved plan would also require people making above the federal poverty limit to pay more for out-of-pocket care, another Republican request.
Democrats nearly universally opposed the idea, but it was a requirement for many Republican members to get on board with expansion. In theory, such a provision could be repealed if Democrats gains a firm advantage in the legislature.
The Virginia vote comes at a crucial vote for Medicaid expansion and the broader ACA in general.
In addition to the Commonwealth state, proponents in three other states are attempting to pass measures to expand the program. A ballot measure in Utah will allow voters to decide on the issue, while activists in Idaho and Nebraska are collecting signatures for similar ballot measures in those states. Reclaim Idaho, the group pushing for expansion in that state, said the group received enough signatures to secure a ballot measure.
For the broader ACA, the popularity of the Medicaid expansion underscores the continued resiliency of the law despite the GOP's attempts to repeal the legislation. In addition, a Kaiser Family Foundation poll in April 2018 found that 49% of American held a favorable view of Obamacare while 43% viewed the law unfavorably.
WASHINGTON — The US Justice Department on Thursday said the part of Affordable Care Act requiring people to have health insurance is unconstitutional, an unusual move that could lead to stripping away some of the most significant and popular parts of the law, better known as Obamacare.
In a brief filed in a federal court in Texas, the department said a tax law signed last year by President Donald Trump that eliminated penalties for not having health insurance rendered the so-called individual mandate under Obamacare unconstitutional.
The Justice Department said that also nullified two other major provisions of Obamacare linked to the individual mandate, including one barring insurance companies from denying coverage to people with preexisting conditions.
Attorney General Jeff Sessions, in a letter to House Speaker Paul Ryan, said he had determined the individual mandate would be unconstitutional when the tax law takes effective in 2019.
The mandate in Obamacare was meant to ensure a viable health-insurance market by forcing younger, healthier Americans to buy coverage.
The Justice Department rarely declines to argue in favor of existing law in court, and this decision will put pressure on the Affordable Care Act, which was President Barack Obama's signature domestic achievement.
A coalition of 20 US states sued the federal government in February, claiming the law was no longer constitutional after last year's repeal of the penalty that individuals had to pay for not having insurance.
Led by Texas Attorney General Ken Paxton and Wisconsin Attorney General Brad Schimel, the lawsuit said that without the individual mandate, Obamacare in its entirety was unlawful.
Sessions said in his letter that the Justice Department was not arguing that the entire law did not pass constitutional muster. He said the department refused to defend only the preexisting-conditions provision as well as one forbidding insurers from charging people in the same community different rates based on gender, age, health status, or other factors.
Trump and fellow Republicans in Congress have sought to dismantle Obamacare, which sought to expand insurance coverage to more Americans.
(Reporting by Eric Beech and Lisa Lambert; Editing by Leslie Adler)
President Donald Trump's nomination of Brett Kavanaugh to replace Justice Anthony Kennedy on the Supreme Court has legal scholars and politicians carefully parsing the judge's previous decisions for clues about the future of US policy.
One of the biggest issues on which Kavanaugh is expected to have a say is the future of the Affordable Care Act, or Obamacare. The landmark healthcare law has been the subject of a series of intense legal battles, and many observers expect more decisions on the ACA's future to make it to the Supreme Court during Kavanaugh's tenure.
Given Kavanaugh's conservative bent, many Democrats are up in arms about the future of Obamacare should the judge be confirmed. But conservatives are also concerned about the future of the law under Kavanaugh.
The crux of the conservative disagreement over Kavanaugh's Obamacare record comes from a single decision in 2011.
When ruling on Seven-Sky v. Holder, Kavanaugh dissented from the majority opinion that the law's individual mandate — which compelled every American to have health insurance or face a fine — was constitutional.
"Even as he avoided a definitive ruling on the merits of the case, Kavanaugh revealed himself as favorably disposed to the mandate," Jacobs wrote at The Federalist. "Worst of all, in so doing, he cultivated a theory that ultimately led Chief Justice John Roberts to uphold the mandate."
In essence, Kavanaugh argued that he could not rule on the case because the Anti-Injunction Act of 1867 did not allow judges to rule on the legality of a tax before it was imposed. Since the mandate did not kick in until 2014, he wrote, the court could not render an opinion.
Jacobs wrote that Kavanaugh's use of the century-and-a-half-old law validated the Obama administration's argument before the Supreme Court that the mandate was legal since it was a tax.
Combined with other sections of the dissent, Jacobs said Kavanaugh gave the "road map" for the Obama administration's legality argument and Roberts's decision.
But other conservatives reject Jacobs's suggestion that Kavanaugh's dissent presented a legal basis to uphold the ACA by pointing to other sections of his argument.
In the dissent, Kavanaugh said the mandate was "a law that is unprecedented on the federal level in American history" and called the penalty for people not buying insurance "jarring."
Justin Walker, a law professor at Louisville University and a former clerk for both Kavanaugh and Kennedy, wrote that the dissent was ultimately more an argument against the mandate than in favor.
"Kavanaugh’s thorough and principled takedown of the mandate was indeed a roadmap for the Supreme Court — the Supreme Court dissenters, justices Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito, who explained that the mandate violated the Constitution," Walker said.
Liberals worry Kavanaugh puts 'healthcare protections in jeopardy'
While conservatives debated the semantics of Kavanaugh's decision, Democrats and liberal activists were overwhelmingly alarmed by the nomination.
"Judge Kavanaugh should not be allowed anywhere near our nation’s highest bench," a post on the Democratic Party's official blog said. "Let’s be clear: a vote for Kavanaugh would be a vote to rip health care from American families and deny women their constitutional right to make their own health care decisions."
Democrats and pro-ACA activists are worried Kavanaugh could weaken key tenants of the ACA, given new legal challenges to the underlying thesis of the law.
While experts are dubious the new challenges have standing, in no small part because Chief Justice John Roberts sided with the liberal members of the court in 2012 to uphold the law, Democratic senators have hinted healthcare will be a core piece of their opposition to Kavanaugh's nomination.
"He’s demonstrated a hostility to the Affordable Care Act that the Trump administration is continually working to undermine," Democratic Sen. Booker said in a statement following the nomination announcement.
Senate Minority Leader Chuck Schumer said during a press conference on the steps of the Supreme Court on Tuesday that Kavanaugh's selection would put healthcare protections in the ACA, such as protections for people with preexisting conditions, "at grave, grave risk" and said people should demand a justice to "protect our healthcare, not strike it down."
The state of Idaho is making a huge play to undermine Obamacare. But whether it succeeds depends on whether the Trump administration plays along.
Last week, Blue Cross of Idaho announced that it would begin to offer health-insurance plans that did not abide by the regulations set out in the Affordable Care Act, or Obamacare.
The Freedom Blue plans would violate the ACA's regulations in a few key ways:
Matthew Fiedler, a fellow at the Brookings Institution's Center for Health Policy, said Idaho would clearly be in violation of the law if the Freedom Blue plans went forward.
"Idaho's proposal transparently violates federal law," Fiedler told Business Insider. "Few things are as clear cut."
Nicholas Bagley, a law professor focusing on health policy, agreed. He called the plans "crazy-pants illegal."
And Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health-policy think tank, held a similar view.
"There's just no question that what Idaho is allowing is on the face of it not permitted under the ACA," Levitt said. "Probably most egregious is that these new plans charge sick people more than healthy people, and that's clearly prohibited by the ACA."
Experts say, however, that the big question is what President Donald Trump's administration will do about it.
A looming choice
If a state does not enforce the ACA's regulations, the Department of Health and Human Services is obligated to intervene and uphold the law. In fact, the department is already doing just that in four states.
"HHS has a responsibility to step in and enforce the law," Fiedler said. "Whether they will or not, I do not know."
HHS Secretary Alex Azar, newly confirmed on January 24, told lawmakers in hearings on Tuesday and Wednesday that the department was keeping an eye on Idaho's moves.
"We'll be looking at that very carefully and measure it up against the standards of the law," Azar said during a Senate Finance Committee hearing on Thursday.
Bagley said Blue Cross' move represented a gamble that the Trump administration would not enforce the law.
"States are vested with primary responsibility for enforcing the ACA, with HHS stepping in only if the states fail to substantially enforce the law," he said. "Blue Cross is betting that HHS won't step in and that the courts won't interfere. Neither is a safe bet."
Blue Cross says it will begin to sell the plans in early March, with coverage starting in April.
What it means for consumers
The Idaho plans would change the face of the individual health-insurance exchanges in states where they are offered.
While the unregulated plans would be cheaper for healthy people, they would steer healthier people away from the ACA marketplace. That could lead sicker people to see their costs go up.
The federal government's subsidies could counteract such increases for individuals making below $50,000, but sicker Americans making more than that could be hit with serious cost increases.
"The main result here is that middle-class people who are healthy will be able to get cheaper coverage, while middle-class people who have preexisting conditions and are ineligible for premium subsidies will pay more," Levitt said.
Fiedler noted that the plans healthy people would get could have far less generous benefits.
"Among enrollees with incomes too high to qualify for subsidies, however, healthier people will tend to leave the ACA-compliant market, while those with significant healthcare needs will remain," he said. "As a result, middle-income people with significant health needs will pay more for their coverage. Healthy middle-income people will pay less, although the coverage they obtain will often be much less robust."
If the HHS does not step in, experts say, other states could rush to try the same maneuver.
"If the Trump administration allows Idaho to go forward with this and doesn't step in to enforce the ACA's insurance rules, it sends a clear signal to other conservative states that they can also just flout federal law," Levitt told Business Insider.
Dean Cameron, the director of the Idaho Department of Insurance, told reporters that "dozens" of other states expressed interest in following along.
But even if other states go through with the change, insurers would take on a huge risk, Fiedler said.
"In some cases, enrollees may be able to sue their insurer for selling them a plan that lacks legally required protections," Fiedler said. "In addition, a future administration could decide to enforce the law, which exposes insurers offering these plans to substantial fines. Blue Cross Blue Shield of Idaho's decision to take on these risks strikes me as reckless."
The Trump administration on Tuesday debuted a new rule that would allow Americans more access to short-term health insurance plans, in a move that some experts warn could have serious consequences for the Affordable Care Act, or Obamacare.
The new rule would permit people with individual health insurance to purchase short-term coverage for up to one year.
Currently, these short-term plans — which are designed to fill gaps in coverages in case someone loses their job or experiences a major life change — can't be used for more than three months.
The Trump administration says the expanded use of short-term health plans will allow people greater flexibility and lower prices for healthy people.
"The status quo is failing too many Americans who face skyrocketing costs and fewer and fewer choices," Alex Azar, the secretary of the Department of Health and Human Services, said in a statement announcing the move. "The Trump Administration is taking action so individuals and families have access to quality, affordable healthcare that works for them."
These short-term plans offer skinnier sets of benefits and do not have to abide by all regulations under the Obama-era health law. For instance, the plans can charge people more based on their health history, cap the amount of benefits a person can receive, and do not have to cover what are known as essential health benefits— 10 baseline types of care.
Given the "skinny" nature of the plans, they typically cost less up front and can save healthier people money.
But many health policy experts warn that shifting more healthy people from Obamacare markets to these short-term plans could drive up costs for sicker people who remain in the individual ACA marketplaces.
According to the administration's memo on the new rule, between 100,000 and 200,000 people are expected to take advantage of the new plans and shift out of the Obamacare marketplaces.
Larry Levitt, a senior vice president at the Kaiser Family Foundation, a health policy think tank, said lower-income people in the ACA marketplace will be protected since they receive subsidies to offset the cost of insurance. But he predicted middle-class people would get hit hard.
"Short-term insurance plans will cherry pick healthy people, leaving ACA-compliant plans to cover a sicker pool with higher premiums," Levitt tweeted. "With the expansion in short-term insurance plans, low-income people will be protected from higher premiums by subsidies. Middle-class people with pre-existing conditions will feel the full brunt of higher premiums."
He said the expansion would force the federal government to offset cost increases for some people by hiking tax credits they get on their premiums. The administration's memo said the need for increased premium assistance would cost the federal government between $96 million and $168 million per year.
"Keep in mind that HHS projects this change will cost the government $96-$168 million more every year," Rachel Sachs, an associate professor of law at Washington University in St. Louis, tweeted after the rule's release. "So the government will spend millions more to provide fewer people with comprehensive insurance."
Loren Adler, associate director at the University of Southern California and Brookings Institutions' Schaeffer Initiative for Health Policy, similarly pointed to the large cost.
"This is a VERY expensive rule for taxpayers," Adler tweeted.
The new rule is another in a series of major changes to the nation's healthcare system from the Trump administration over the past year, including allowing new work requirement for Medicaid recipients and the repeal of the ACA's individual mandate.
President Donald Trump's Council of Economic Advisers released a report Wednesday detailing the administration's work to roll back the Affordable Care Act, and at one point in the report noted that the law's passage came around the same time as the opioid crisis worsened.
The post criticized the law known as Obamacare for its focus on bringing down the number of uninsured Americans, which the CEA said did not necessarily translate to a healthier population.
"Determinants of health other than insurance and medical care — such as drug abuse, diet and physical activity leading to obesity, and smoking — have a tremendous impact and have exacerbated recent declines in life expectancy, despite the ACA’s increased coverage," the post said.
As part of the post, the CEA authors also discussed the growing number of overdose deaths from opioids.
"This Administration is focused on reversing the harm caused by the ACA by fostering competition, choice, and innovation while also addressing the many factors beyond insurance that influence health," the post reads. "The Administration is particularly concerned about the opioid crisis that exploded during the ACA expansion."
While the CEA did not directly tie the ACA to the growing opioid crisis, other Republicans have recently been more explicit about a possible link between the law's implementation and the opioid crisis.
Sen. Ron Johnson, chair of the Homeland Security and Governmental Affairs Committee, released a report in January linking Medicaid generally and the law's expansion of Medicaid specifically to the increase in overdose deaths.
"This report is not meant to suggest that Medicaid, or any other federal program, is the only factor contributing to the opioid epidemic," Johnson's report said. "But if Medicaid is helping to drive the epidemic, it stands to reason that expanding the program — particularly to people most susceptible to abuse — could worsen the problem. The epidemic has indeed spiraled into a national crisis since the Obamacare Medicaid expansion took effect in 2014."
DJ Norquist, chief of staff for the CEA, told Business Insider that Johnson's report resembles their offices thinking on the issue.
"We agree with Senator Johnson that government policies are an overlooked part of the problem," Norquist said in an email.
In a 2017 study in Health Affairs, health policy researchers Andrew Goodman-Bacon and Emma Sandoe found that the evidence linking the ACA's Medicaid expansion and the opioid crisis was tenuous at best.
"While we do not reject the possibility that public policy has played a role in our current prescription abuse crisis, on balance we find little evidence to support the idea that Medicaid caused or worsened the epidemic," the study said.
The Department of Health and Human Services this week announced a new proposal that would expand the use of short-term health insurance plans, opening the door for more people to use the "skinny" coverage products while taking another swipe at the law known as Obamacare.
Under the proposed rule, people could enroll in low-cost plans with skimpier benefits for up to 12 months, an increase from the current three-month limit imposed by the Affordable Care Act, or Obamacare. The rule would also attempt to make it easier for people to reenroll in the short-term plans, which are generally designed for people between jobs or close to retirement.
The change, the Trump administration says, is meant to give more low-cost options to healthy people who do not get their coverage from an employer or government program. But many experts say the new plans could also open the door to problems that could result in sicker people paying much more.
Dania Palanker, Kevin Lucia, and Emily Curran, health policy researchers at Georgetown University, pointed to a series of potential trouble spots that could arise under the plans.
One potential problem they identified would come if an individual falls sick during the short-term plan period. For instance, if an individual enrolls in a 12-month short-term health plan in March and discovers a health problem in July, an insurer could determine the issue predated the person's enrollment. The insurer could then treat the sickness as a preexisting condition and deny some coverage — even if the person had no knowledge of the illness before enrolling.
"Even if they are offered coverage, people with preexisting health conditions may never have claims paid under short-term coverage," said a report from the trio. "Insurers may comb through members’ medical histories to determine if a service was for a preexisting condition in order to deny a claim."
The Trump administration recognized this possible pitfall in a report on the proposed rule.
"Depending on plan design, consumers who purchase short-term, limited-duration insurance policies and then develop chronic conditions could face financial hardship as a result, until they are able to enroll in PPACA-compliant plans that would provide coverage for such conditions," the administration's report said.
A questionable history
Additionally, many of the short-term plans have a pattern of past misuse. Bloomberg's Erik Larson and Zach Tracer laid out how some short-term plan providers have a history of overcharging consumers and not delivering on promised care.
Issues have also arisen when a person is even able to sign up for the plans in the first place. May short-term insurers use rigorous questionnaires to determine whether a person had a pre-existing condition.
For instance, some short-term plans ask if someone weighs more than a certain amount, has ever been pregnant, or experienced symptoms related to a slew of health problems over the five previous years. An answer of "yes" to any of those questions could make a price's plan increase dramatically.
The Georgetown researchers noted that currently offered short-term plans have out-of-pocket payment maximums well above the current limits under Obamacare. That could lead to people signing up for the short-term plans because of cheap monthly premiums and paying much higher amounts when they need care.
Obamacare, and the restrictions on short-term plans, were designed to prevent these sorts of problems for people with preexisting conditions. But it came at a cost, said Larry Levitt, a vice president at the Kaiser Family Foundation, a nonpartisan health policy think tank.
"The ACA provided protections for people with pre-existing conditions, but raised premiums for middle-class healthy people who don't qualify for subsidies," he tweeted. "An expansion in short-term insurance plans rolls that back some."
The Department of Health and Human Services announced it will block a new health care initiative by the state of Idaho, preventing the state from circumventing key Obamacare rules.
Seema Verma, the administrator for HHS' Centers for Medicare & Medicaid Services, said in a release Thursday that the governor of Idaho was informed of the decision.
Idaho's new process would have allowed insurers to sell plans that did not comply with regulations that are part of Obamacare, which is formally named the Affordable Care Act (ACA), as long as the company also sold ACA-compliant plans.
Blue Cross of Idaho announced soon afterwards that the insurer would offer these skinny plans which would have charged sick people more than healthy people.
Verma said that while Idaho's desire to bring down costs — the stated reason for the policy — was admirable, it was also illegal.
"CMS is committed to working with states to give them as much flexibility as permissible under the law to provide their citizens the best possible access to healthcare," Verma said. "However, the Affordable Care Act remains the law, and based on our review of Idaho Bulletin No. 18-01, CMS has reason to believe that Idaho would be failing to substantially enforce the provisions in Part A of title XXVII of the Public Health Service Act (the Part A market requirements) as amended by the ACA."
Experts raised concerns about both the legality of the move and the changes to the insurance market in Idaho as a result. For sick people who needed the coverage of a more generous ACA-compliant plan removing healthy people from the market would have likely driven up prices.
In the event that a state does not enforce the ACA, the HHS is technically obligated to step in and enforce the law. Health policy experts were curious to see whether the Trump administration came in given its history of undermining the ACA over the past year.
If Idaho was allowed to move ahead it could have opened the door for other conservative states to flout the law but, for now, that opening appears to have been shut.
For the third time in as many months, the federal government is facing a fast-approaching government shutdown and racing to complete the deal to avoid a lapse in funds.
The possibility of a government shutdown appears less likely than the last two times Congress has gone through this process, but aides and analysts say nothing is guaranteed. The deadline to pass a spending bill and avoid a shutdown is the end of the day Friday.
Congress is likely to avert a shutdown because of the February deal reached by the two parties' leaderships, which increased the federal budget caps. The agreement set the levels of how much the government can spend over the next two years — the current discussions revolve around how exactly that $1.3 trillion will be divided up.
Chris Krueger, strategist at Cowen Washington Research Group, said the broad deal reached in February will help smooth out the process this time around.
"There could be another Rand Paul-type shutdown of a few hours, but this ship sailed once the gigantic sequester relief bill passed last month," Kreuger said in a note to clients Monday. "The pie has been baked, they are just quibbling over the scraps."
But there could be some bumps along the way. As part of the shutdown negotiations, both sides are attempting to add various policy goals — on everything from the tax code to healthcare.
Riders could trip up the bill
One of the biggest sticking points appears to be efforts to attach provisions that would shore up the marketplaces of the Affordable Care Act, or Obamacare. The changes, which have the support of many Democrats and some Senate Republicans, would allocate funds to mitigate losses for insurers in the market in hopes of keeping down premium costs.
Conservatives, on the other hand, believe the move would be a bailout for insurance companies. Many Republicans also want to include language in the budget deal that would prevent these funds from going to groups that provide abortion services, like Planned Parenthood, which would risk losing the support of Democrats.
Also, Politico reported that the White House and Democrats have attempted to work toward an immigration agreement that would trade funding for the president's proposed wall along the Mexican border for a codification of the Deferred Action for Childhood Arrivals immigration program that protects from deportation nearly 700,000 unauthorized immigrants that came to the US as minors.
The talks about the proposal broke down as the two sides remain at an impasse on a pathway to citizenship for the DACA recipients, according to the report.
The add-ons have also split parties amongst themselves.
For instance, GOP Rep. Mark Meadows — the head of the hardline conservative House Freedom Caucus — called for the spending bill to strip funding from sanctuary cities that do not cooperate with federal immigration enforcement laws.
Other Republicans were quick to dismiss the idea, since it would cause a major political fight with Democrats that could risk the danger of a shutdown.
"I think that that’s — I don’t think that’s gonna happen in the Senate," GOP Sen. John Boozman told Business Insider. "I mean that’s — Congressman Meadows might feel like that’s a good idea but practically speaking, that would be very difficult to actually get done."
Sen. Roy Blunt, the vice chair of the Republican conference, told Business Insider last week that the decisions were being made by leaders.
"Everybody kind of has everything they like attached to it," Blunt said. "That’s gonna be decided in a room that I’m not in."
At the same time, Blunt did not expect too many additions to the spending bill.
"Nothing’s done until it’s done, but I think we’ll not have very many riders on this bill," he said.
Despite the fast-approaching deadlines and various policy arguments, the bill is expected to make it through both chambers before the deadline at the end of the week.
"Given the considerable work done to date, and the scheduled recess at the end of the week, we believe the odds of a government shutdown are only 25%," Isaac Boltansky, a policy analysts at Compass Point Research and Trading, wrote in a note to clients on Monday.
The giant bill is expected be released late Monday with a vote coming from the House on Wednesday and the Senate soon after.
With the clock ticking on the next government shutdown deadline, Congress is rushing to get a massive $1.3 trillion spending bill passed in time to avoid a third lapse in funding this calendar year.
Despite the stated desire from leaders of both parties to avoid overstepping the Friday night deadline, they have not yet released a huge omnibus spending bill. And the timeline for a vote is already slipping.
After initially planning to release the bill on Monday to secure a Wednesday vote, House Speaker Paul Ryan told Republicans in a conference meeting Wednesday that they would instead release the bill Tuesday for a planned Thursday vote.
That would give the Senate just 24 hours to pass the bill with no changes and prevent a shutdown.
"There are some unresolved issues, we’re working through them while we speak," Ryan told reporters at a weekly press conference. "We’re hoping to close it today."
Sen. John Cornyn, the second-highest ranking Republican senator, told reporters on Tuesday that the Senate could push the process into the weekend due to procedural delays.
"It’s going to extend our week into the weekend perhaps, it just means we are going to be here into the weekend perhaps," Cornyn said.
The Texas Republican also suggested that a short-term funding bill to "keep the lights on" may be passed to ensure no interruption in funding. This would also help avoid another scenario similar to February, when Sen. Rand Paul held up a vote on the spending agreement and single-handedly forced a shutdown that lasted a few hours.
Outside of procedural concerns, Cornyn also took aim at the way the negotiations on the bill were being conducted.
"This is really a terrible way to have to do business," Cornyn said. "To deal with a $1.3 trillion spending bill as one big, where the final decisions are left to four people is not the way the founders intended the legislative branch to work under our constitution."
Conservatives are mad
Lawmakers from both parties are quibbling with the bill's provisions, saying it leaves off key policy goals or includes too much new spending.
Among the issues being discussed as potential additions to the legislation are funding for a tunnel between New Jersey and New York City (which President Donald Trump has threatened to block) and an immigration deal that would trade funding for a border wall for an extension of the Deferred Action for Childhood Arrivals, or DACA, program.
"It sounds like the Democrats in the Senate are getting all kinds of wins in terms of riders," Rep. Mark Meadows, chair of the hardline conservative House Freedom Caucus, told Business Insider.
Meadows said outside of the bill fully funding military requests, conservatives would get little items of
"There may be some nuggets in there that are real encouragements and would be conservative wins," he said. "But I’m not real optimistic."
A GOP aide told Business Insider that Meadow's assertion that the bill contained no wins for conservatives was "ridiculous" and a short-term deal to extend the deadline through the weekend was unlikely.
Senate Minority Leader Chuck Schumer said during a speech on the Senate floor on Tuesday that the bill would have issues that either side would dislike but were necessary to reach a compromise.
"It has some things no one likes and it has some things not everybody likes, but most people like," Schumer said. "It was a fair compromise, the basic structure of it and hopefully we can get to an agreement."
Other items that appear to also be on the cutting-room floor are an Obamacare stabilization package — seemingly derailed over language regarding abortion funding — and a provision to strengthen gun background checks to the spending package.
Two Republicans' last-ditch effort trying to shore up the Affordable Care Act looks like it's falling apart.
The measure, from by Republican Sens. Susan Collins and Lamar Alexander, would increase funding for key programs to attempt to reduce premiums in Obamacare's individual insurance markets while also deregulating some of the insurance plans in the same markets.
The authors and other lawmakers claim the move would bring down premiums for people obtaining coverage through the exchanges.
"It is the right thing to do," Collins said Monday. "It would result in rate decreases that would provide substantial relief."
But an attempt to include the provisions in this week's spending bill appear to have hit a wall.
The measure received pushback over the past few days from members of both parties. Republicans felt that allocating more money to the Obamacare marketplaces would be a tacit admission that the law was here to stay, while Democrats were unhappy with some of the technical aspects of the bill.
What's in the plan
The authors believed that by combining the more Democratic-friendly funding options with GOP-friendly easing of regulations, they could strike a compromise. Instead, it's left lawmakers on both sides of the aisle unhappy.
Everyone has a problem with it
For Republicans, it's a no-go because it works within the existing frame of Obamacare.
"The idea you’re going to vote for billions of dollars to stabilize a system you never supported in the first place?" GOP Rep. Tom Cole said Tuesday. "Pretty hard to choke down."
Democrats, meanwhile, pushed back on language that would ban using the new funds at providers that also provide abortion services.
"I am disappointed that Republicans are pushing a partisan bill that includes an unacceptable last-minute attack on women's health on what should be bipartisan work to lower healthcare costs," Sen. Patty Murray, an author of the earlier Alexander-Murray stabilization bill, told reporters Monday.
Given the pushback, it is reportedly no longer being included in the massive spending bill set to be released this week.
Attaching the Obamacare provisions to the spending bill, which needs to pass to avoid a government shutdown on Friday, is the last hope for the bill. When asked by reporters of the bill's chances of coming back without being a part of the shutdown negotiations, Alexander simply said: "Zero."