Immigration enforcement turned on its head

A New Jersey company decides to re-verify all of its workers’ status after they complain of health and safety violations. A California supermarket decides to voluntarily join the federal E-Verify program just as workers' labor organizing campaigning intensifies. An Alabama restaurant worker is arrested and deported after trying to collect two months of unpaid wages.
Across the country, unscrupulous employers are gaming the enforcement system in order to silence “problem” workers and dodge both immigration and labor laws.
Immigration reform gives us a chance to fix this most perverse failure of our broken immigration system.

The bad actors have gotten good at calling in the immigration police whenever workers stand up for their rights — for example, when workers demand to be paid the full wages they’ve earned. Along the way, an immigration enforcement system originally intended to stop employers from hiring undocumented labor has been completely turned on its head.
A new report from the National Employment Law Project documents 22 examples in which employers used the immigration status of their workers to thwart labor claims. These cases of retaliation come from around the country, in nearly every low-wage sector, from agriculture to construction, to restaurant, retail, landscaping, domestic work, shipping, food service and food processing.
That some employers threaten or actually report workers who challenge labor abuses to immigration authorities is nothing new.  What is new is the extent to which the massive build-up of immigration enforcement resources in recent years has given these employers unprecedented new tools to use against their workers.
Some employers have used the much-touted “E-Verify” work verification system to intimidate workers. Employers have also taken advantage of the fact that local police have become increasingly involved in enforcing immigration laws, purportedly to focus on the deportation of serious criminals. But in practice it works differently. In numerous instances, workers landed in jail — and then deportation proceedings — after employers accused them of crimes just so they could avoid paying the workers their earned wages. Workers still faced deportation, even after being cleared of false criminal charges.
These tactics have allowed unscrupulous employers to subvert both the immigration and labor laws. Silencing a broad swath of workers in an industry means that wages remain low, abuses common, and the right to collectively bargain an elusive dream.
Unsavory and illegal employment practices have taught us valuable lessons for immigration reform. Of course, immigration reform must include and broad and clear path to citizenship for the 11 million aspiring citizens. But we must also ensure that workers can speak up about labor abuses and stand up for better wages and working conditions. That means a strong firewall between labor law enforcement and immigration enforcement. It means that workers actively engaged in defending their labor rights must have whistleblower protections.
If we want to do immigration reform right, we must never again allow bad employers to take advantage of vulnerable workers and evade immigration and labor laws in the process.
Smith coordinates the Immigrant Worker Justice Project for the National Employment Law Project.
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Medicare’s Outdated Structure—and the Urgent Need for Reform

The structure of Medicare determines how it functions. It also entails undesirable consequences, such as requiring Medicare beneficiaries to pay additional premiums and purchase supplemental coverage; employing price controls that often result in underpayment or overpayment for medical goods and services; placing massive regulation on doctors, hospitals, and other medical professionals; generating tens of billions of dollars annually in waste, fraud, and abuse; and using an administrative payment system that, as an arena for special interest lobbying, results in the politicization of decisions over health care financing and delivery for America’s senior and disabled citizens. The best policy for fixing the inherently flawed and outdated Medicare program, while improving it as an insurance program for seniors, is structural Medicare reform based on a defined-contribution (“premium support”) program of financing.

Traditional Medicare, which liberals once envisioned as the foundation for national health insurance for all ages,[1] is a fee-for-service model rooted in the 1960s. Its outdated structure makes the program fundamentally flawed, as the editors of The Washington Post remarked recently: “Medicare as we know it is not sustainable” and the “ultimate solution” is structural reform.[2]

Medicare’s current structure determines the way it functions. It also entails certain undesirable consequences. For example, it requires Medicare beneficiaries to pay additional premiums and purchase supplemental coverage; employs price controls to control costs that often result in underpayment or overpayment for medical goods and services; places massive levels of detailed regulation on doctors, hospitals, and other medical professionals; generates tens of billions of dollars annually in waste, fraud, and abuse; and uses an administrative payment system that, as an arena for special interest lobbying, results in the politicization of decisions over health care financing and delivery for America’s senior and disabled citizens.

While Congress should enact comprehensive reform based on a defined-contribution system, like that which funds the Medicare drug-benefit program, there are several short-term measures that can improve the structure of the existing program: the unification of Parts A, B, and D into a single plan; reform of Medicare cost sharing combined with the addition of a Medicare catastrophic benefit; and a restructuring of the Medicare-Medigap relationship with a view toward limiting first-dollar coverage and the excessive use of medical services that drives up beneficiary premiums and taxpayer costs.

Today’s Medicare program is organized into four parts. Each part is financed on an entirely different basis, with different streams of premium payments, revenue, and taxpayer subsidies, as well as complex cost-sharing arrangements.

Medicare Part A. The Hospitalization Insurance (HI) program pays for hospital and certain home health care services; it is funded by a 2.9 percent Medicare payroll tax, equally divided (1.45 percent each) between employers and employees. These funds are deposited in the Hospital Insurance Trust Fund (often called the “Medicare Trust Fund” in the media) to pay hospital insurance benefits. Part A benefits are thus available “premium free” except for persons who have not worked and paid sufficient Medicare payroll taxes.[3] So, the Medicare hospitalization program is a classic pay-as-you-go system; today’s workers primarily fund today’s retirees—not tomorrow’s. Unlike Social Security, there is no cap on this portion of the federal payroll tax.

Beginning in 2013, under the euphemistically named Patient Protection and Affordable Care Act, the payroll tax for upper-income citizens (defined as individuals with annual incomes of more than $200,000 and couples with more than $250,000) is increased by 0.9 percent, for a total of 3.8 percent. In addition, for upper-income Americans, the “Medicare Payroll Tax” is also extended to “unearned income,” including stocks, bonds, mutual funds, and, in certain cases, proceeds from the sale of a home. This revenue does not, in fact, go into the Medicare Trust Fund, but instead funds the provisions of the Affordable Care Act.[4]

Medicare Part B. The Supplementary Medical Insurance (SMI) program pays doctors, funds outpatient medical services, and covers payments for a certain class of drugs, usually physician-infused chemotherapy or biologics. Part B is financed by a combination of beneficiary premiums and federal taxpayer subsidies; federal taxpayer subsidies from general revenues automatically pay 75 percent of the program’s total costs, while beneficiaries pay only 25 percent of total premium costs. Unlike Medicare Part A, which has a fixed funding stream based on payroll taxes, Part B expenses are covered automatically by general revenues from federal income taxes and business taxes.

Medicare Part C. Medicare Advantage (MA) is a system of competing and regulated private health plans. It enrolls about 27 percent of all Medicare beneficiaries. The program is financed by a combination of Part B premiums and federal payments. Unlike traditional Medicare, the payments to these plans are geographically based on a system of “competitive bidding” to provide Medicare A and B benefits. But the actual payments to these plans are not based on pure market bidding—rather, the government payments are “benchmarked” to Medicare’s existing administrative payments in the geographical area for traditional Medicare benefits.[5]

If a plan’s bid is lower than the government benchmark, it must rebate 75 percent of the savings to the beneficiary in the form of lower premiums or richer benefits; the remaining 25 percent of the savings is retained by the federal government. A majority of MA plans bid below the benchmark; thus, since 2007, between 85 percent and 94 percent of participating seniors have had the option of enrolling in private plans while paying no premium other than the standard Medicare Part B premium.[6]

In addition, because of the rebates, MA plans offer more comprehensive coverage. Most notably, unlike traditional Medicare, MA plans cap out-of-pocket costs, which eliminates the need for beneficiaries to purchase separate supplemental insurance. Further, many plans include prescription drug coverage. In fact, 21 percent of all beneficiaries in 2010 received their drug coverage through a Medicare Advantage prescription drug plan.[7]

Medicare Part D. The Medicare prescription drug program provides stand-alone drug coverage for Medicare beneficiaries through a system of competing private plans. About 90 percent of seniors today have drug coverage, and about 60 percent of them get that coverage through prescription drug plans. Part D is also financed by a combination of beneficiary Part D premiums and state and federal taxpayer subsidies. Federal revenues account for roughly 80 percent of program costs. A crucial difference in Part D, however, is that the payment to plans for providing a standard drug benefit is based solely on a competitive bidding process among competing plans; it is not tied to traditional Medicare’s administrative payment system, but represents the plans’ market bids for the standard drug benefit. The government makes its payment 75 percent to the plan of the beneficiary’s choice. Medicare Part D, in other words, operates on a defined-contribution (“premium support”) basis similar to that of the Federal Employees Health Benefits Program (FEHBP).[8]

Traditional Medicare has certain undesirable consequences. These are inevitable as long as the basic structure of this Great Society program remains as it is today. For example:

The Need for Supplemental Coverage. Medicare still does not protect beneficiaries from catastrophic costs, causing about 90 percent of all beneficiaries enrolled in traditional Medicare (Parts A and B) to enroll in supplemental insurance plans, mostly private plans or Medigap plans. Seniors pay extra premiums and enroll in these private plans to plug the coverage gaps in traditional Medicare and limit out-of-pocket costs.

While supplemental coverage fills benefit gaps, it also covers cost sharing and thus encourages first-dollar coverage, especially in Medigap plans, which leads to excessive use of medical services. The cost estimates vary, but point to much higher total costs for the Medicare program. As Daniel P. Kessler, professor at the graduate school of business at Stanford University, says,

These policies have an adverse effect on Medicare’s finances, because they effectively eliminate cost sharing as a motivator to keep health care consumption in check. After all, if seniors have supplemental insurance, they basically have free health care—which means they pay no price for seeking more and more care. Several studies have shown that this leads to significantly greater spending, and only marginal medical benefit.[9]

Outpatient elective procedures, says Kessler, is where one finds the greatest utilization, and the Medicare Payment Advisory Commission, the panel that advises Congress on Medicare reimbursement, has estimated that today’s supplemental coverage arrangements have resulted in 33 percent more Medicare spending.[10] Summarizing earlier literature on the subject, Walton Francis, a prominent Washington-based health care economist, estimates that this structural feature adds between 15 percent and 25 percent to program costs.[11]

The Distortions of Flawed Price Controls. Medicare’s rigid price controls and massive regulatory regime reflect its structural design. The complexity of the varying processes and payment rates results in a patently nonsensical detachment from the real conditions of supply and demand for medical care.

Price controls and payment restrictions placed on health plans, doctors, hospitals, home health agencies, nursing homes, and other medical professionals directly affect the beneficiaries who depend on their services.

For doctors, traditional Medicare provides fee-for-service medical care in name only, because all fees are capped by price controls. Since 1989, fees for physicians have been governed by a complex set of administrative payments. Medicare’s physician fee for any given medical procedure or service is based on a formula called the resource-based relative value scale (RBRVS). This payment formula used to calculate the time, energy, effort, and practice costs—that is, the resources—that constitute the provision of a medical service. It is a social science exercise, removed from the dynamic conditions of the supply and demand for medical services that would otherwise exist in a real market. Physicians are thus paid for thousands of medical services on the basis of this fee schedule, but the payments, as noted, are also capped. The physician payment is also annually updated on the basis of another formula, the sustainable growth rate (SGR). The SGR ties physician payments to the growth of the economy, even though there is also no necessary relationship between the macro-conditions of the general economy and the micro-conditions of supply and demand for medical services.[12] The SGR is so unrealistic that Congress has routinely blocked its implementation since 2003.

In 2011, Medicare paid hospitals only about 69 percent of what private insurers paid, for which Medicare also uses a fixed-payment system.[13] The determination of Medicare payment rates and how they are calculated varies by setting (such as inpatient acute-care hospitals, hospital outpatient departments, physician offices, home health agencies, or skilled nursing facilities). For example, the payment formula for the operating costs of acute-care hospital inpatient stays under Medicare Part A is based on prospectively set rates, called the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into one of the 751 Medicare severity diagnosis-related groups (MS-DRGs), which are updated annually.[14] Each has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that MS-DRG. The base payment rate is divided into a labor-related and non-labor share. The labor-related share is adjusted by the wage index applicable to the area where the hospital is located. The wage-adjusted base payment rate is then multiplied by the DRG relative weight to determine the payment for the case.

There is evidence that, as Congress tries to rein in Medicare costs by arbitrarily slashing hospital reimbursements, the hospitals try to make up the difference by shifting costs to the private sector. Hospitals, in particular, make up their losses and maintain their profit margins by charging privately insured patients more than patients who have government-funded insurance. As Dennis Cortese, MD, a professor of health policy at Arizona State University, and his colleagues, observe, “In essence, individuals in the employer-sponsored insurance category are paying an undeclared tax to fund the low reimbursement rates from government programs.”[15] Before the enactment of the Affordable Care Act in 2010, perhaps the largest Medicare payment reductions were embodied in the Balanced Budget Act (BBA) of 1997. Research shows that “[a]t hospitals where Medicare is a small payer relative to private insurers, up to 37 percent of BBA cuts was transferred to private payers through higher payments. In contrast, hospitals with greater reliance on Medicare were more financially distressed, as these hospitals saw large BBA cuts but were limited in their abilities to cost shift.”[16]

Not all medical professionals are equally capable of shifting the burden of Medicare reimbursement cuts. But the lower Medicare payment rates incentivize more and more doctors to favor private patients over Medicare patients, which is why seniors sometimes experience difficulty finding a doctor or accessing care.

The Costs of Regulatory Overkill. Enactment of major amendments to the Medicare law (legislation such as the Balanced Budget Act of 1997, the Medicare Modernization Act of 2003, and the Affordable Care Act of 2010) has added tens of thousands of pages of Medicare rules that are tying up doctors, hospitals, and other medical professionals in fat reams of red tape, reporting requirements, and paperwork.[17] For example, an estimated 80 percent of Medicare doctors are projected to incur financial penalties in 2015 under the Affordable Care Act for not complying with Medicare’s quality reporting standards, at least based on current trends.[18] Compliance with these and other rules imposes a transactional cost on medical practice that affects patient care. Douglas Perednia, MD, formerly a principal investigator of computer imaging for the National Cancer Institute, observes,

A wide range of state and federal rules suck up enormous amounts of provider time and overhead. As time is the only inventory clinicians have, more time spent on administration means that less time will be spent on providing services to patients. Less time with patients yields fewer services and lower total bills. The de facto result is a rationing of care.[19]

Medicare is pumping out thousands of pages of new rules, regulations, and guidelines. New rules, published in 2011 and 2012 governing Medicare physicians and hospitals—including updates to the prospective payment system, hospital-based value purchasing, hospital outpatient services, and updates to the physician fee schedule—totaled 4,643 pages in the Federal Register.[20] While seniors are spared the direct impact of the regulatory regime, they are not immune to its consequences, such as difficulty finding a doctor, lost quality time with a physician, or reduced access to care.

More Costly Waste, Fraud, and Abuse. In contrast to consumer-driven insurance systems like the FEHBP, and private insurance in general, traditional Medicare generates enormous costs to the taxpayer from waste, fraud, and abuse. Medicare administrators merely process taxpayers’ dollars, rather than operate under intense market pressures to root out questionable practices that undercut private insurers’ competitive position.

Largely due to the program’s size and complexity, Medicare is at a high risk for waste, fraud, and abuse that leads to improper payments, both overpayments and underpayments. Once again, there is a range of estimates. In 2008, Senator Charles Grassley (R–IA) charged that Medicare was losing approximately $60 billion a year to waste, fraud, and abuse.[21] On the discrete issue of “improper payments,” the Centers for Medicare and Medicaid Services determined in 2011 that Medicare fee-for-service for Parts A and B had an improper payment rate of 8.6 percent, representing $28.8 billion in improper payments.[22] In trying to reduce this cost to taxpayers, the federal government allocated over $608 million in 2011 in an effort to combat health care fraud and abuse.[23]

Honest doctors struggle to cope with the administrative costs imposed on them by this vast regulatory regime, properly fearful of audits, investigations, and fines and penalties. This vast and impenetrable array of rules and restrictions also inhibits innovation in the delivery of care. Not surprisingly, the very complexity of this regime creates exactly the kind of cluttered and confusing environment where dishonest providers can navigate undetected at taxpayers’ expense.[24]

The Continued Politicization of Health Care. Medicare’s coverage and payment decisions are subject to detailed congressional micromanagement. Instead of routine business and medical decisions, Medicare financing and delivery is a great arena for special-interest politics and provider income redistribution, the playground of the “Medicare Industrial Complex.”[25] Rent-seeking lawyers, lobbyists, and consultants, acting on behalf of powerful medical interests and organizations, feverishly engage in an annual fight to secure higher federal payments for themselves and lower federal payments for others. As Heritage Foundation Distinguished Fellow Stuart Butler has observed,

Providers included in the [benefits] package fight diligently—and usually effectively—to block serious attempts to scale back outdated coverage for their specialties. Meanwhile, talk of upgrading the Medicare benefits package unleashes an intense lobbying battle among other specialties that seek to be included in the Medicare benefits package. Invariably, the result depends as much (if not more) on shrewd lobbying than on good medical practice.[26]

The centralized structure of traditional Medicare guarantees this politicization and directly contributes to the program’s notorious waste. In a seminal article for Health Affairs in 1999, former Medicare administrator Bruce Vladeck observed,

There are plenty of $400 toilet seats in the Medicare program, because Medicare cannot deliver services to its beneficiaries without providers and because providers are major sources of employment, political activity and campaign contributions in every congressional district in the nation.[27]

The voluminous Patient Protection and Affordable Care Act of 2010 contains an estimated 165 provisions that affect Medicare. So, the law will indeed make major changes in Medicare “as we know it.” But these changes do not alter the basic structure of the traditional Medicare program. Foremost among these are the enactment of record-breaking payment reductions, a hard cap on the growth of future spending to be enforced by a newly created Independent Payment Advisory Board, and the enactment of new provisions designed to improve the conditions and outcomes of medical practice.

The new law also creates various agencies and programs to accomplish its payment and quality improvement objectives. These include the creation of Accountable Care Organizations (ACOs),[28] which are designed to bring together doctors and hospitals to coordinate care for Medicare patients, apply the government’s quality standards, and allow providers to share savings from compliance with those standards; the Patient-Centered Outcomes Research Institute (PCORI) that will conduct comparative effectiveness research;[29] the Physician Feedback Program, which reports on resources that physicians use in patient care; the creation of a “quality of care” modifier to be factored into the Medicare physician payment system; the extension of the Physician Quality Reporting Initiative, which ties physician bonus payments to reporting data to the Department of Health and Human Services in compliance with government quality standards; and the Center for Medicare and Medicaid Innovation, which is charged with developing new payment and delivery reforms.

Delivery Reforms. A key objective of the new law is to secure lower Medicare costs through the provision of better quality of care. Various provisions are designed to accomplish this goal, including the Hospital Value-based Purchasing Program, which will adjust Medicare payments to reflect hospital compliance with government quality standards, and the Hospital Readmission Reduction Program, which would impose Medicare payment penalties for hospitals with high readmission rates.

Medicare bonus payments and penalties for underperformance are at the heart of the Administration’s delivery reform initiative. Thus far, the best that can be said about this strategy is that the jury is still out. As yet, there is no solid evidence to support the contention that “value-based purchasing” for hospitals or “pay for performance” for physicians will yield serious Medicare cost savings. When the Congressional Budget Office (CBO) initially scored the Affordable Care Act on March 20, 2010, the agency concluded that most of the new law’s delivery reforms would have little if any effect on health care spending. For example, the CBO’s 10-year savings estimate for hospital-based value purchasing, required by Section 3001 of the statute, was zero dollars.[30] The following year, the Medicare Trustees observed, “The ability of new delivery and payment methods to significantly lower cost growth rates is very uncertain at this time, since specific changes have not yet been designed, tested or evaluated.”[31]

In 2012, the CBO released a more comprehensive report on demonstrations of delivery reforms, and concluded:

Results from demonstrations of value-based payment systems were mixed. In one of four demonstrations examined, Medicare made bundled payments that covered all hospital and physician services for heart bypass surgeries; Medicare’s spending for those services was reduced by about 10 percent under the demonstration. Other demonstrations of value-based payment appear to have produced little or no savings for Medicare.[32]

The success of the Administration’s “carrots and sticks” cost-reduction strategy depends on complex interactions among physicians, hospitals, and government authorities, as well as on the ability and willingness of physicians and hospital administrators to continue to comply with the government’s rules and standards for care delivery and reimbursement. But pursuing that strategy may prove to be a serious challenge.[33] There is a clear decline in the morale of the medical profession, and based on a recent survey conducted on behalf of the Physicians Foundation, 59.3 percent of physicians report that they are less positive about the direction of health care because of the enactment of the Affordable Care Act.[34] That survey also shows that, as a result of “ongoing problems” with Medicare payment, 22.9 percent are going to place new or additional limits on their Medicare practice, and 12.6 percent will not accept new Medicare patients.[35]

There is nothing inherently rational about traditional Medicare’s current structure. As a health insurance program, it is clearly deficient.[36] Today’s different parts, with diverse funding streams, are not so much a product of sound policy as they are the vicissitudes of congressional politics.[37] Compatible with comprehensive structural reform, Congress should take these initial steps.[38]

Unify Medicare Parts A, B, and D into a single plan and streamline Medicare’s cost sharing with one premium, one deductible, and a unified trust fund. Turn Medicare into a true insurance plan by adding a catastrophic benefit. Reduce costs and utilization by limiting first-dollar coverage by Medigap plans.

Variations of such an approach have long attracted broad, bipartisan support—such as from the Bipartisan Policy Center, the National Commission on Fiscal Responsibility and Reform, and The Heritage Foundation. As Henry Aaron of the Brookings Institution and Robert Reischauer of the Urban Institute argued in 1995: “Whatever rationale may once have existed for the distinction between services in Parts A and B, medical technology, the development of new forms of service delivery, and new payment structures have rendered it obsolete.”[39] Their argument is even more compelling today.

As Kessler has argued, “Medicare’s out-of-control spending is the natural result of its centralized, politicized structure.”[40] The best policy for fixing the inherently flawed and outdated Medicare program, while improving it as an insurance program for seniors, is structural Medicare reform based on a defined-contribution (“premium support”) program of financing. The Heritage Foundation has developed the components of such a reform in detail.[41]

Under premium support, which would build on the experience of Medicare Part D and the success of the popular Federal Employees Health Benefits Program, government payment to competing health plans (including traditional Medicare) would be calculated on market-based bids to provide Medicare benefits, and beneficiaries would choose the plan that best meets their personal needs. Intense market competition among plans and providers, driven by personal choice, will not only secure better value for Medicare dollars but also slow the growth in Medicare spending.

—Robert E. Moffit, PhD, is Senior Fellow in the Center for Policy Innovation at The Heritage Foundation. Alyene Senger is a Research Assistant in the Center for Health Policy Studies at The Heritage Foundation.

[1] “The original hope was that Medicare would grow into a universal health insurance, not coverage only for the elderly, the disabled and those suffering from renal failure.” Theodore Marmor, Spencer Martin, and Jonathan Oberlander, “Medicare and Political Analysis: Omissions, Understandings and Misunderstandings,” Washington and Lee Law Review, Vol. 60, No. 4 (Fall 2003), p. 1151. On the Left, this old hope is very much alive, as evidenced by periodic proposals calling for “Medicare for All.”

[2] “Repairs to Medicare,” The Washington Post, January 6, 2013, http://www.washingtonpost.com/opinions/repairing-medicare/2013/01/06/1646366c-56a3-11e2-a613-ec8d394535c6_story.html (accessed March 6, 2013).

[3] A person must have worked for at least 10 years to qualify for Part A benefits without paying a monthly premium.

[4] As Medicare Trustee Charles Blahous explains, “Though termed an ‘Unearned Income Medicare Contribution’ (UIMC) under the law, this revenue would not come from Medicare’s traditional contribution base and it would not be allocated to a Medicare Trust Fund. The $200,000 and $250,000 income thresholds for triggering this tax would not be indexed and would thus capture (if the law remains unchanged) an increasing number of taxpayers over time.” Charles Blahous, “The Fiscal Consequences of the Affordable Care Act,” Mercatus Center at George Mason University, April 10, 2012, p. 49, http://mercatus.org/sites/default/files/publication/The-Fiscal-Consequences-of-the-Affordable-Care-Act_1.pdf (accessed March 6, 2013).

[5] For further explanation of Medicare Advantage’s financing, see Jeet S. Guram and Robert E. Moffit, “The Medicare Advantage Success Story—Looking beyond the Cost Difference,” The New England Journal of Medicine, March 29, 2012, pp. 1177–1179, http://www.nejm.org/doi/full/10.1056/NEJMp1114019 (accessed March 6, 2013).

[6] Medicare Payment Advisory Commission, A Data Book: Health Care Spending and the Medicare Program, June 2012, p. 159, http://www.medpac.gov/documents/Jun12DataBookEntireReport.pdf(accessed March 6, 2013).

[7] Ibid.

[8] For more information on the FEHBP and its defined-contribution financing, see Stuart Butler and Robert Moffit, “The FEHBP as a Model for a New Medicare Program,” Health Affairs, Vol. 14, No. 4 (1995), pp. 47–61, http://content.healthaffairs.org/content/14/4/47.full.pdf (accessed March 6, 2013).

[9] Daniel P. Kessler, “Real Medicare Reform,” National Affairs (Fall 2012), p. 90, http://www.nationalaffairs.com/publications/detail/real-medicare-reform (accessed March 11, 2013).

[10] Ibid.

[11] Walton J. Francis, Putting Medicare Consumers in Charge: Lessons from the FEHBP (Washington, DC: AEI Press, 2009), p. 27.

[12] Under the SGR formula, in any given year, if physician payment is higher than the growth in GDP, it is automatically reduced the following year. In 2013, Medicare doctors faced a 27 percent payment cut, which, of course, was blocked once again by congressional intervention.

[13] American Hospital Association, Chartbook: Trends Affecting Hospitals and Health Systems, “Chapter 4: Trends in Hospital Financing,” Table 4.4, February 26, 2013, http://www.aha.org/research/reports/tw/chartbook/ch4.shtml (accessed March 6, 2013).

[14] For a list of DRGs in fiscal year 2013, see the Centers for Medicare and Medicaid Services, “Acute Inpatient PPS, Details for Title: FY 2013 Final Rule Tables,” http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/FY-2013-IPPS-Final-Rule-Home-Page-Items/FY2013-Final-Rule-Tables.html (accessed March 6, 2013).

[15] Dennis Cortese, Natalie Landman, and Robert K. Smoldt, “A Roadmap to Medicare Sustainability,” a paper prepared by analysts from Arizona State University and the Healthcare Transformation Institute, February 2013, p. 66.

[16] Vivian Y. Wu, “Hospital Cost Shifting Revisited: New Evidence from the Balanced Budget Act of 1997,” International Journal of Health Care Finance and Economics, Vol. 10, No. 1 (March 2010), pp. 61–83, http://link.springer.com/article/10.1007%2Fs10754-009-9071-5?LI=true (accessed March 6, 2013).

[17] Regulatory excess has been a periodic theme in Medicare reform efforts. Fifteen years ago, the Mayo Foundation for Medical Education and Research presented its findings on Medicare paperwork to the National Bipartisan Commission on the Future of Medicare, and then estimated Medicare’s paperwork burden at 110,758 pages, with the total volume of federal health care regulation, including Medicaid rules, amounting to 132,720 pages. With the Affordable Care Act, another massive expansion of Medicare regulation is well underway.

[18] Elise Viebeck, “Study: Most Medicare Docs Set to Face Performance Penalties,” The Hill, January 8, 2013, http://thehill.com/blogs/healthwatch/medicare/275987-study-most-medicare-docs-set-to-pay-performance-penalties?wpisrc=nl_wonk#ixzz2HULSNo6x (accessed March 6, 2013).

[19] Douglas A. Perednia, Overhauling America’s Healthcare Machine (Upper Saddle River, New Jersey: FT Press, 2011), p. 93.

[20] Cortese et al. “A Roadmap to Medicare Sustainability,” p. 58.

[21] Rita Numeroff and Michael Abrams, Healthcare at a Turning Point: A Roadmap for Change (Boca Raton: CRC Press, 2013), p. 107.

[22] Centers for Medicare and Medicaid Services, “Medicare Fee-for-Service 2011 Improper Payments Report,” http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/CERT/Downloads/MedicareFFS2011CERTReport.pdf (accessed March 6, 2013).

[23] The Department of Health and Human Services and the Department of Justice, Health Care Fraud and Abuse Control Program, “Annual Report for Fiscal Year 2011,” February 2012, p. 7, https://oig.hhs.gov/publications/docs/hcfac/hcfacreport2011.pdf (accessed March 6, 2012).

[24] For an account of federal efforts to combat Medicare fraud and abuse, see Cliff Binder, “Medicare Program Integrity: Activities to Protect Medicare from Payment Errors, Fraud, and Abuse,” Congressional Research Service, June 23, 2011. Senators Tom Coburn (R–OK) and Thomas Carper (D–DE) have co-sponsored remedial legislation: The Medicare and Medicaid Fighting Fraud and Abuse to Save Taxpayer Dollars Act (S. 1251).

[25] Bruce C. Vladeck, “The Political Economy of Medicare,” Health Affairs, Vol. 18, No. 1 (January/February 1999), pp. 22–36. This essay is the best account yet of the political dynamics of the program.

[26] Stuart M. Butler, “Principles for a Bipartisan Reform of Medicare,” Heritage Foundation Backgrounder No. 1247, January 29, 1999, www.heritage.org/Research/Reports/1999/01/Principles-for-a-Bipartisan-Reform-of-Medicare.

[27] Vladeck, “The Political Economy of Medicare,” pp. 30–31.

[28] For a further discussion on Accountable Care Organizations, see John S. Hoff, “Accountable Care Organizations: Obamacare’s Magic Bullet Misfires,” Heritage Foundation Backgrounder No. 2592, August 10, 2011, www.heritage.org/research/reports/2011/08/accountable-care-organizations-obamacares-magic-bullet-misfires.

[29] For an excellent explanation of comparative effectiveness research and its potential impact, see Kathryn Nix, “Comparative Effectiveness Research Under Obamacare: A Slippery Slope to Health Care Rationing,” Heritage Foundation Backgrounder No. 2679, April 12, 2012, www.heritage.org/research/reports/2012/04/comparative-effectiveness-research-under-obamacare-a-slippery-slope-to-health-care-rationing.

[30] Congressional Budget Office, Douglas Elmendorf, letter to Speaker Nancy Pelosi, March 20, 2010, Table 5, http://www.cbo.gov/sites/default/files/cbofiles/ftpdocs/113xx/doc11379/amendreconprop.pdf (accessed March 6, 2013).

[31] Centers for Medicare and Medicaid Services, 2011 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplemental Medical Insurance Trust Funds, April 23, 2012, p. 41, http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/downloads/tr2011.pdf (accessed March 7, 2013).

[32] Congressional Budget Office, “Lessons from Medicare’s Demonstration Projects on Disease Management, Care Coordination, and Value-Based Payment,” January 18, 2012, http://www.cbo.gov/publication/42860 (accessed March 7, 2013).

[33] Nix, “Comparative Effectiveness Research Under Obamacare.”

[34] The Physicians Foundation, “A Survey of America’s Physicians: Practice Patterns and Perspectives,” September 2012, p. 29.

[35] Ibid., p. 41.

[36] “Medicare fails to perform its insurance function.” Katherine Baicker and Helen Levy, “The Insurance Value of Medicare,” The New England Journal of Medicine, October 31, 2012, http://www.nejm.org/doi/full/10.1056/NEJMp1210789?viewType=Print&viewClass=Print (accessed March 7, 2013).

[37] Marilyn Moon, “Modernizing Medicare’s Benefit Structure,” Washington and Lee University Law Journal, Vol. 60, No. 4 (Fall 2003), p. 1207.

[38] For a further discussion of initial Medicare reform steps, see Robert E. Moffit, “The First Stage of Medicare Reform: Fixing the Current Program,” Heritage Foundation Backgrounder No. 2611, October 17, 2011, www.heritage.org/research/reports/2011/10/the-first-stage-of-medicare-reform-fixing-the-current-program.

[39] Henry J. Aaron and Robert D. Reischauer, “The Medicare Reform Debate: What is The Next Step?” Health Affairs, Vol. 14, No. 4 (1995), p. 14.

[40] Kessler, “Real Medicare Reform,” p. 94.

[41] Robert E. Moffit, “The Second Stage of Medicare Reform: Moving to a Premium Support Program,” Heritage Foundation Backgrounder No. 2626, November 28, 2011, www.heritage.org/research/reports/2011/11/the-second-stage-of-medicare-reform-moving-to-a-premium-support-program.

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Back To 1948: Ryan’s Fantasy Budget Cuts Spending To Its Lowest Level In 65 Years

Over at Investors.com, Jed Graham ran the numbers on Rep. Paul Ryan’s (R-WI) new budget for the House GOP, and found that by 2023, it would drive all government spending that isn’t either Social Security or interest on the debt to its lowest level since 1948. On every other occasion in the last 60 years that this category of spending dipped that low, unemployment was never over 4.5 percent — it’s currently at 7.7 percent.

Graham found, “the entirety of federal spending outside of Social Security and interest on the debt (16.4 percent of GDP in 2012) would shrink to 11.2 percent of GDP” by 2023, “a level not seen since 1948.” In fact, the situation is even worse, since in 1948 this spending did not yet include “ObamaCare, Medicare, Medicaid, NASA, the interstate highway system” or a host of other needed programs now in operation:

In fact, if Medicare is discounted as well as Social Security and interest payments, spending shrinks to 7.9 percent in 2023, the lowest levels for that slice since 1938.

This is tiresome and grossly irresponsible, but hardly surprising. Ryan’s previous budget would’ve shoved non-defense discretionary spending — which includes most of the government’s investments in economic growth, veterans’ health care, food safety, drug safety, consumer product safety, federal law enforcement, and more — to 2.1 percent of GDP. Since 1962, the first year for which we have comprehensive data, non-defense discretionary spending has never dropped below 3.2 percent of spending.

Nonetheless, Ryan’s latest budget once again aims for the 2.1 percent mark by 2023, leading Michael Linden at the Center for American Progress to dismiss it as fantasy. “[I]t’s is far easier to ‘cut’ the nebulous category called ‘nondefense discretionary’ than it is to cut actual programs, benefits, and protections that the public knows and likes,” Linden writes. “But in fact, for these kinds of cuts to actually come to pass, Congress — now and in the future — will have to get specific. And if they decide that they can’t, in reality, reduce these things to levels unheard of in generations, then Rep. Ryan’s claim to a balanced budget falls apart.”

Sure enough, American voters only support cutting spending when it’s vaguely referred to as “spending.” Name specific programs, and public support for cutting them utterly collapses.

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User:Roof0cost

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The ‘Veronica Mars’ Movie Kickstarter And Why Fans Need To Start Thinking Of Themselves As Investors

The news yesterday that Warner Brothers had given Rob Thomas, the television writer who created Veronica Mars (he’s also an extremely strong young adult novelist whose work is well worth a look), permission to crowdfund a movie continuation of the show, was met with some disgruntlement that viewers were being asked to be the investors in a corporate product from which they’d recognize no profits, and, at the point of this writing $2.761 million in donations, more than enough to get the movie made. Willa Paskin is obviously correct that consumers’ ticket dollars already fund the production of movies. But in between her argument and the view of critics of the project lies an important point: if consumers are going to get asked like investors by mainstream media companies, they should think about what they want out of the bargain other than the simple creation fo the product.

The idea that investors deserve something more than the existence of whatever product or movie or show they’re funded is embedded in Kickstarter’s rewards system. If you give at different levels, you might get a t-shirt, tickets to a premiere party, or even an opportunity to name a character or appear in a film or game. Those rewards tend to be set by the people who are proposing the project, based on what they think they can manageably offer (though a considerable portion of crowd-funded projects ship their core products late, and some developers are running into problems when demand or unexpected costs for rewards means higher burdens for delivery than they expected). Where consumer choice enters into the process is the selection of the reward level, rather than the offerings themselves.

One thing that’s striking about the Veronica Mars Kickstarter is that you have to give at least $35, more than four times the cost of the average American movie ticket in 2012, to get a digital download of the movie. You have to give $750 to get a ticket to the premiere of the film in Los Angeles. If the Kickstarter was really inverting the process by which ticket sales fund the production of movies, going from taking the profits from one project and plowing them into the creation of another, to letting people put that ticket money up in advance, then the campaign would have to get tickets or downloads to all of its donors. It would be a method that would be fair to fans, who after all, want to see the thing they’re funding, and it might make a lot of sense for both the studios and for third-party retailers like Fandango. Nothing sells tickets like advance buzz, and getting people to commit to see the movie in advance is probably a good way to get them to bring their friends along as well. And while tickets and downloads require initial coordination with Fandango or iTunes, they’re less costly and work-intensive than say, printing and mailing t-shirts.

That’s a small example of the sorts of material things that fans could and should express that they want out of projects like this. But there are a lot of other ways to think about these kinds of investment opportunities. I might have been more excited, for example, to invest in buying back the rights to create new work in the Veronica Mars universe for Rob Thomas, if Warner Brothers could have been persuaded to sell it. I’d love to see a block of fan investors who prioritize projects that commit to work with union crews and pay actors union wages.

And I’ve written about this before, but I’d frankly love to see fans move beyond investing in single projects. Given all the discussion we have about the whiteness of movies and television, and, as Ta-Nehisi Coates and I have written, the lack of black investors who are willing and able to lose money financing projects, I’d be excited to see a crowd-funded film investment fund that only backs projects by creators of color or featuring non-white actors, perhaps that’s structured as a non-profit*. Ditto for an investment fund that could back projects by women. There’s nothing wrong with passionate attachment to single franchises, or single creators, but those aren’t the only ways that fans think about popular culture. And limiting our demonstrations of investment power to single artists or single projects ultimately limits our reach, and our ability to affect the culture. I don’t think fans are ever going to put together Megan Ellison money, for example. But I think ordinary viewers, over time, and perhaps through subscription, could put together enough to fund a series of projects that would be good enough to attract notice at places like Sundance and SXSW.

All of these approaches mean thinking through an awful lot of logistics and organizational questions. But those are all much less difficult to do than that getting fans to think of themselves not as supplicants but as an economic force. It’s easy to feel disempowered in the face of show cancellations and fired showrunners and huge delays in movie adaptations. But at a moment of extraordinary chaos in the television industry, and of new and emerging distribution models in both movies and television, this is the perfect moment for viewers with money to spend to assert ourselves, and not just to buy a speaking part in a Veronica Mars movie.

*

I should note have no objection to the idea of fans making money off such funds. I just think that a non-profit structure might help alleviate expectations for first-time investors, given the number of film and television projects that end up generating losses.

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Spectrum licenses Ligand multiple myeloma drug

NEW YORK -- Spectrum Pharmaceuticals Inc. said Thursday it licensed a potential treatment for multiple myeloma from Ligand Pharmaceuticals Inc.

Ligand's drug candidate is a form of melphalan, which is already used to treat multiple myeloma. The new form of the drug is designed to be given before the patient receives a round of autologous stem cell treatment, and the companies say it could allow for longer, safer, and stronger treatment because it could have fewer side effects.

The experimental formulation of melphalan eliminates ingredients that are reported to cause kidney and heart side effects. Those side effects force physicians to use smaller doses of the drug.

Multiple myeloma is a cancer of the blood that mainly affects older adults. Spectrum, based in Henderson, Nev., said about 20,000 cases are diagnosed each year.

The Food and Drug Administration has designated the treatment an orphan drug, which means similar products will be barred from the market for up to 7 years if it is approved. Spectrum is now responsible for clinical testing of the drug and expects to file for marketing approval in the first half of 2014.

Ligand said it will get an upfront license payment of $3 million and could receive more than $50 million in milestone payments. The San Diego company will also get royalties on sales of the drug if it is approved.

Ligand raised its financial guidance, saying it now expects to report net income of 47 to 51 cents per share in 2013 on $43 million to $46 million in revenue. It had forecast income of 35 to 39 cents per share on $41 million to $44 million in revenue.

Analysts expect net income of 41 cents per share and $43.1 million in revenue, according to FactSet.

For the first quarter, the San Diego company said its net income will be between 10 and 13 cents per share in the first quarter, and revenue will be between $10 million and $11 million. Analysts are forecasting a profit of 2 cents per share with $8.5 million in revenue on average.

Shares of Ligand rose 55 cents, or 2.5 percent, to $22.41 in afternoon trading, and Spectrum shares picked up 7 cents to $7.86.

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Why the Obamacare Medicaid Expansion Is Bad for Taxpayers and Patients

Medicaid needs reform, not expansion. This federal–state health care program provides health care to over 60 million Americans and consumes a growing portion of state and federal budgets. Research shows a long history of Medicaid enrollees having worse access and outcomes than privately insured individuals.[1] Due in part to low reimbursement, one in three doctors refuses to accept new Medicaid patients.[2] Despite access issues, Medicaid spending continues to grow. In 2010, total federal and state spending on Medicaid exceeded $400 billion.[3]

Instead of reforming Medicaid, the Patient Protection and Affordable Care Act (Obamacare) expands eligibility to all individuals earning less than 138 percent of the federal poverty level (FPL).[4] The Medicaid program is already struggling to provide care to its core obligations—a diverse group of low-income children, disabled, pregnant women, and seniors. Adding more people further exacerbates Medicaid’s underlying problems.

The expansion of Medicaid fuels a larger trend under Obamacare: government coverage supplanting private coverage. By 2021, 46 percent of all Americans will be dependent on the government for their health care. Of this group, 86.9 million will be on Medicaid/Children’s Health Insurance Program (CHIP), followed by 64.3 million on Medicare and 23.4 million enrolled in government exchanges.[5] This will push U.S. health care closer to a government model.

The Temptation of Medicaid Expansion

Obamacare provides additional federal funding to the states for this new expansion population. Starting in 2014, the federal government would pick up 100 percent of the benefit costs for the newly eligible population for three years. Thereafter, this enhanced federal funding would gradually decline to 90 percent in 2020.

Obamacare also directed states to expand eligibility or risk forgoing all of their federal Medicaid dollars. The Supreme Court, however, ruled on behalf of 26 state plaintiffs that this “all-or-nothing” proposition was coercive. To rectify this, the Court essentially made the expansion optional, meaning that a state could reject the expansion but not lose its existing Medicaid funding.

Today, governors and state legislators are weighing this option as they develop their budgets for the coming year. Proponents use a variety of unrealistic arguments in support of the Medicaid expansion:

It provides states with an influx of new, generous federal revenue. This will cause states to spend money that they otherwise would not have spent. Moreover, due to the structure of Obamacare, states will likely have to absorb many currently eligible but not enrolled individuals as well as those who lose their existing employer coverage. These effects would add to the cost.[6]It will result in savings as the cost of uncompensated care declines with expanded coverage. Heritage data analysis shows that in the first few years, when federal funding is at its peak, states may see some savings. Over time, however, in the majority of states, Medicaid spending will accelerate and dwarf any projected uncompensated care savings.[7] These savings are also contingent on states enacting legislation to further reduce uncompensated care funds (Disproportionate Share Hospital [DSH] payments) on top of the $18 billion of federal cuts enacted under Obamacare. Heritage analyst Ed Haislmaier predicts that “governors and state legislators should expect their state’s hospitals and clinics to lobby them for more—not less—state funding to replace cuts in federal DSH payments.”[8]
Finally, contrary to the theory that expanding Medicaid would cause the number of uninsured to decline and reduce the need for uncompensated care, a similar expansion in Maine found the opposite effect. In Maine, uncompensated care increased, and the number of uninsured in the targeted population (those below 100 percent of FPL) saw limited change.[9]Rejecting the expansion will mean that other states get more. The federal share of Medicaid is based on a formula calculation and actual expenditures. Rejected funds do not go into a general fund for redistribution to other states. The fewer states that expand, the less the federal government spends. States that draw down on these new federal funds fuel the fiscal crisis in our country.

The Trade-Off Dilemma

Committing to an expansion creates a dilemma for the states. To control Medicaid spending, states typically fall back on predictable techniques to manage costs, such as limiting reimbursements to health care providers and limiting services, which ultimately limits access to care. These Medicaid cost controls, however, go only so far. Today, Medicaid consumes over 23 percent of state budgets, surpassing education as the largest state budget item.[10] As Medicaid spending continues to rise, other important state priorities such as education, emergency services, transportation, and criminal justice are squeezed.

Finally, if states resist balancing among spending programs, the alternative is generating more revenues with tax increases. But higher taxes come with a steep price: They reduce economic growth. With most states still experiencing anemic growth, tax increases on top of already higher taxes at the federal level are not an appealing option.[11]

Fueling the Country’s Fiscal Crisis

Any positive assumptions about Medicaid expansion also assume that federal funding remains unchanged. With deficits running over $1 trillion a year, the country’s fiscal future is in need of reform. Federal spending on health care entitlements, including Medicare and Medicaid, is the largest driver.[12]

Even this Administration recognizes that such entitlement spending, including Medicaid, is unsustainable. The President’s fiscal year (FY) 2011 budget outlined several Medicaid reform policies, including setting an across-the-board blend rate for federal reimbursement and limiting the states’ ability to leverage provider taxes for the state share of matching funds. Although the Administration attempts to distance itself from its own proposal, any serious efforts toward entitlement reform must include Medicaid.

In spite of this fact, several Democrat and Republican governors that support Medicaid expansion condition their support on federal funding remaining untouched. In essence, pro-expansion governors are telling Washington, “don’t touch entitlement spending.” This reliance on federal revenues exacerbates the country’s fiscal challenges and could also affect states’ own fiscal health. Recently, Moody’s cited Missouri’s reliance on the federal government, including Medicaid funding, as adversely affecting its credit rating outlook.[13]

Setting Good Policy

There are several recommendations that the states and Congress could adopt to help mitigate the crisis that Obamacare has exacerbated:

Reject the Medicaid expansion. Greater dependence on federal dollars tangles the states in bad fiscal policy and bad health care policy. States that reject the expansion avoid relying on unsound federal revenues, stretching an already thin program beyond its means and adding millions to a failing program.  Scale back existing eligibility where possible. Some states have allowed Medicaid to grow beyond its original intent by moving middle-class families into a welfare program. To restore Medicaid as a safety-net program, states should review eligibility levels, scale back eligibility where possible, and restore the program’s focus on its core Medicaid functions.Advance a separate, state alternative. Instead of using a flawed Obamacare model, states should put in place an alternative. States should develop a state solution tailored to the specific needs of this new population rather than placing them in a one-size-fits-all Medicaid option.[14] A non-Medicaid, state-based approach, especially for this targeted population, would give states the control to design policies best suited to addressing the needs of their citizens without onerous Medicaid constraints. Congress should eliminate the federal enhanced Medicaid match. To avoid the argument that states rejecting Medicaid are leaving federal dollars on the table, Congress should level the playing field by removing the new, enhanced federal dollars. This would remove/minimize the temptation of excessive and unsustainable federal funding and restore fiscal constraint at the federal level. States would still be able to expand eligibility but would have to do so with the traditional (non-enhanced) federal matching rate. If Congress ignores this opportunity to restrain federal spending, it could “block grant” the enhanced federal dollars to the states to develop their own state-specific approaches, including alternatives outside of Medicaid.

Alternate Solution Needed

Medicaid is already spread too thin. Adding a new and complex population to this program does not solve its challenges; it only makes them worse. States should resist, and Congress should remove, this temptation. Both should begin to lay out a better and more sustainable alternative than a failing government health program to care for the less fortunate.

—Nina Owcharenko is Director of the Center for Health Policy Studies and Preston A. Wells, Jr., Fellow at The Heritage Foundation.

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Hospitals, states face challenges under new health regime-Moody's

March 14 (Reuters) - Cuts in federal funds for hospitals serving low-income patients, which are set to begin later this year under the new U.S. healthcare law, will create budget challenges for both hospitals and states, Moody's Investors Service said on Thursday.

The ratings agency said it expects the cuts to federal disproportionate share hospital (DSH) payments to rise to $17 billion annually by 2019 after scheduled reductions begin on Oct. 1.

DSH adjustment payments provide additional help to hospitals that serve large numbers of low-income patients.

The DSH payments will be reduced as part of an expansion of the Medicaid health insurance program for the poor under the Patient Protection and Affordable Care Act, more commonly known as "Obamacare." As the program expands, those payments will be reduced by half.

States that choose to opt out of Medicaid expansion but have a high number of uninsured residents will feel the greatest budget impact, Moody's said, as they could face both political and economic pressure to make up for the federal funds.

The rating agency also said "large, urban safety net hospitals that typically treat large populations of Medicaid and uninsured patients are most at risk from the DSH phase-out."

Among the states with the highest uninsured rates and who are undecided, but leaning towards opting out of the Medicare expansion are Texas, Georgia, Idaho, Louisiana, North and South Carolina and Wyoming.

The law calls for DSH payments to be restored in 2022, but Moody's said that current Congressional budget battles put in doubt any return to full funding.

(Reporting by Caryn Trokie and Ed Krudy; Editing by Chizu Nomiyama)

((Caryn.Trokie@thomsonreuters.com)(+1-646-223-6318)(Reuters

Messaging: caryn.trokie.reuters.com@reuters.net))

Keywords: MUNICIPALS/HEALTHCARE

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Conservapedia: Over 450 million Views & 1,000,000+ Edits. Free courses are here. Or join our discussion of the Origination Clause.

Andrew Schlafly of the Association of American Physicians & Surgeons on ObamaCare

A recent study of Y-chromosomes in Jewish and Arab men strongly supports the biblical account that they all descended from one man.[1]

101 evidences for a young earth

Comprehensive resource to refute the claims of evolutionists

Question evolution! campaign - worldwide anti-evolution campaign featuring 15 questions that evolutionists cannot satisfactorily answer]

The Question evolution! campaign is a worldwide anti-evolution campaign and is primarily being conducted in the United States, the United Kingdom, Canada, Europe, Australia, New Zealand, Singapore and South Africa.[2] The focus of the campaign is on 15 Questions that evolutionists cannot satisfactorily answer. The 15 questions can be found HERE.

10 reasons why 2013 will be a BAD year for Darwinism

5 strategies to collapse Darwinism

Can social unrest in Europe lead to a change of their religious landscape? Are creationists poised and in a position to take advantage of this unrest to further grow biblical creation belief in Europe? [3][4]

Essays on atheism and evolution

Good person test

"I do not seek. I find."

Pablo Picasso

If you want the present to be different from the past, study the past.

Baruch Spinoza

Kind words do not cost much. Yet they accomplish much.

Blaise Pascal

Christian apologetics is the defense of the Christian faith through logical arguments. The term comes from the Greek word apologia, which means "defense".

"To everything there is a season, A time for every purpose under heaven." - Ecclesiastes 3:1 (NKJ)

“when the wicked perish, there is song,’’ but later warns, “If your enemy falls, do not rejoice.” - The Book of Proverbs.

"The wicked flee when no one is pursuing, But the righteous are bold as a lion." - Proverbs 28:1 (NASB)

Though translation of the New Testament is complete, improvements and ideas are always welcome, and much work remains in the Old Testament.

Find your favorite verses and join the Best of the Public in translating a few!

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Top Anti-Gay Attorney Insults Chief Justice Roberts And Justice Thomas’ Decisions To Adopt Children

The "second-best option" for the Roberts children

When President Bush announced his decision to nominate future-Chief Justice John Roberts to the Supreme Court, his wife Jane stood nearby holding the hands of two beautiful children — Jack and Josie Roberts. Both of these children were born in Ireland, and later adopted by the future Chief Justice and his wife. Justice Clarence Thomas also has an adopted son, his grandnephew Mark Martin, Jr., who Thomas adopted when Martin was six.

So it is a bit hard to understand why a top anti-gay advocate decided to insult adoptive parents in general — and Chief Justice Roberts in particular — as the justices are preparing to hear two cases that will decide whether same-sex couples will enjoy the same right to marry as all other Americans. According to John Eastman, a law professor and chair of the anti-gay National Organization for Marriage, Roberts and Thomas’ adopted children are only growing up in the “second-best” environment:

The justices also are not immune to considering how they might be affected by the course one side or the other is advocating in a dispute before them. . . . [Johns Hopkins Sociology Professor Andrew] Cherlin, who does not follow the high court especially closely, wondered whether the gay marriage cases might take on a similar dynamic. “If justices consider their own family lives in these cases, it may change the way they rule,” he said.

Gay marriage opponents said they are not worried about the votes of Roberts and Thomas.

“You’re looking at what is the best course society wide to get you the optimal result in the widest variety of cases. That often is not open to people in individual cases. Certainly adoption in families headed, like Chief Roberts’ family is, by a heterosexual couple, is by far the second-best option,” said John Eastman, chairman of the National Organization for Marriage. Eastman also teaches law at Chapman University law school in Orange, Calif.

There is nothing “second-best” about the family environment Roberts and Thomas have provided to their adopted children. While many critical things can be said about Justice Thomas — and we have said a lot of them — his decision to adopt his grandnephew is admirable and speaks well of Thomas’ capacity for personal sacrifice:

Neither Thomas nor his wife nor several Savannah sources contacted for this story would discuss the circumstances behind Thomas’ taking custody of Mark. But others say that the situation, while not dire, called for a responsible person to step in quickly. Mark Sr., Thomas’ nephew, had been in prison on cocaine trafficking charges. And Mark Jr.’s mother, Susan, was struggling with her own problems, raising four children, including young Mark Jr., on her own. Thomas believed that the boy would face lifelong trouble if he were not removed from his environment soon, and the parents agreed. “He was paying back his own grandfather by taking care of Mark,” says one friend.

The Roberts’ adoption story is rooted less in family tragedy and more in their devout faith. John and Jane Roberts married late in life — Jane was 42. The Chief Justice and his wife chose not to seek medical treatment that would have enhanced Jane’s ability to conceive because “Catholic doctrine prohibits most forms of fertility treatment,” and instead chose to adopt two children. As with Thomas, there are many critical things that can be said about the Chief Justice, but he is by all accounts very kind in his personal interactions and he and his wife provided their adopted son and daughter with a household where they could thrive. Roberts deserves praise for adopting children, and he certainly does not deserve the aspersions cast upon adopted parents by Professor Eastman.

Eastman is also not the first attorney involved in the marriage cases to suggest adoptive parents are somehow a second-best opinion for children. In his brief on behalf of the House Republicans defending the Defense of Marriage Act, conservative superlawyer Paul Clement claimed that “[b]iological parents have a genetic stake in the success of their children that no one else does.”

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UPDATE 2-FDA studies possible pre-cancerous link with diabetes drugs

* Studying unconfirmed findings from researchers

* Says has asked for samples of pancreatic tissue

* Says agency has not reached new conclusions on drugs

* Suggests patients remain on therapies

(Adds details on Victoza, drug class, diabetes, updates share prices)

By Ransdell Pierson

March 14 (Reuters) - The U.S. Food and Drug Administration is studying unconfirmed reports that a widely used class of diabetes drugs, which includes Merck & Co's

Januvia, may cause inflammation of the pancreas and pre-cancerous changes to the pancreas.

The agency, in a notice on its website on Thursday, said this is the first time it has communicated potential pre-cancerous links to the medicines, known as incretin mimetics.

The drugs for type 2 diabetes also include Victoza from Danish drugmaker Novo Nordisk

and Onglyza from Bristol-Myers Squibb Co and AstraZeneca Plc .

Patients should continue taking their medicines as directed until speaking with healthcare professionals, the agency said. The FDA said it is investigating findings from academic researchers that highlighted the potential risk.

"These findings were based on examination of a small number of pancreatic tissue specimens taken from patients after they died from unspecified causes," the agency said.

The FDA has asked the researchers to explain how they collected and studied the specimens and to provide tissue samples so the agency can further assess any possible risks.

In the meantime, the FDA said it has not reached any new conclusions about safety risks of the class of drugs.

The agency noted it has previously warned the public about acute pancreatitis, including fatal and nonfatal cases, seen with the medicines. Package insert labels for the class of drugs already warn about risk of the potentially dangerous inflammation.

"It's too early to tell, but we'll keep an eye on it," Edward Jones analyst Judson Clark said, when asked about the significance of the potential safety issues in Thursday's FDA advisory.

But Clark said he did not expect any immediate changes in prescribing habits for the drugs because the pancreatitis risk is already noted on the drug labels.

The class of medicines, which mimic a natural hormone called incretin, prompt the pancreas to release insulin when blood sugar is rising. They are approved to treat type 2 diabetes, the most common form of diabetes which usually develops in adulthood and is closely linked to obesity.

Merck's Januvia and its related drug, Janumet, had combined sales last year of almost $6 billion, making them by far the company's biggest product franchise. Onglyza and a related drug called Kombiglyze had sales last year of $709 million.

Shares of Merck were down 1.1 percent at $44.08, while Bristol-Myers shares were down 0.8 percent at $38.18 on Thursday afternoon on the New York Stock Exchange. Shares of AstraZeneca were up 1 percent at $46.31, also on the NYSE. Novo Nordisk shares closed down 1 percent in Copenhagen.

(Reporting by Ransdell Pierson in New York; Editing by Sofina Mirza-Reid and Matthew Lewis)

((ransdell.pierson@thomsonreuters.com)(646 223 6030)(Reuters Messaging: ransdell.pierson.thomsonreuters.com@reuters.net))

Keywords: DIABETES PANCREAS/FDA

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Obamacare Costs Spark Voter Cynicism

Ask any pollster. Distrust of the government in Washington stands at unprecedentedly high levels. Between three-quarters (Pew) and four-fifths (Gallup) of Americans now instinctively question the veracity of promises from politicians and government agencies. Their frustration with all things governmental, in fact, has reached the boiling point. According to one recent poll by the Pew Research Center, “For the first time, a majority of the public [53 percent] says that the federal government threatens their personal rights and freedoms.”

Nowhere is this frustration and distrust more apparent than in the realm of health policy. Three years after the enactment of Obamacare, the level of skepticism about it remains high. Pollster Scott Rasmussen has found that, despite repeated assurances from the president and other Democrats, Americans remain convinced that Obamacare will make things worse. Voters believe the quality of their health care will deteriorate even as their costs continue to skyrocket. Federal budget deficits, moreover, will worsen. Revealingly, the level of their cynicism goes hand in hand with how much experience they have had with government promises — i.e., older voters are by far the most cynical.

The voters’ cynicism, however, is most rampant in their overwhelming sense that “the health care reform law will cost more than the official estimates.” Fully 73 percent of respondents overall, Rasmussen found, trust their own instincts over the official projections of government bean-counters, with three-quarters or more of men, seniors, whites, independents, and voters with annual incomes over $20,000 doubting the government. Even 58 percent of Democrats and 59 percent of liberals concur. The caucus of true believers in government is a small one.

The voters’ distrust is well founded. Nearly half a century ago, Congress established the two programs that lie at the heart of today’s fiscal crunch: Medicare and Medicaid. The bean-counters assured lawmakers that these brand new entitlements were affordable. By 1990, they predicted, Medicare’s hospital benefits would cost taxpayers “only” $9 billion. The actual cost was a cool $67 billion.

The most egregiously wrong prediction came two decades after the programs were launched. It had to do with the portion of the Medicaid program that sends cash to hospitals that treat large numbers of low-income and uninsured patients. In 1987, congressional budget experts assured lawmakers that the cost of this health-care entitlement five years hence would be less than $1 billion. The actual cost, thanks to accounting shenanigans by hospitals and complicit state governments, was an astounding $17 billion.

Sadly, underestimating the real costs of government-run health-care programs is the norm. This has been true for Medicare costs relating to kidney dialysis, coverage for catastrophic illness, home health care, the State Children’s Health Insurance Program, and, more recently, the subsidy for nursing-home costs included in Obamacare (known as the CLASS Act). Obama administration officials quickly shelved this latest entitlement upon learning that costs would so exceed projections as to be unsustainable, and it was recently repealed. The exceptions to the rule that costs of government-run health care will always outrun predictions are programs where the patients control the dollars spent on their care, such as the federal-employee health-insurance system, Medicare Part D (prescription-drug coverage), and consumer-directed and flexible spending accounts.

Where will the next huge cost overruns arise? From Obamacare’s expansion of Medicaid, which is scheduled to add 17 million Americans to the 70 million currently enrolled in this beleaguered program. Governors and state lawmakers are now assessing whether they should succumb to the siren song of  federal subsidies. 

But this would be a foolish decision. Today’s Medicaid patient already encounters enormous obstacles just getting in to see a physician, with worse health outcomes as a result. One 2009 survey of more than 1,100 physician practice groups nationwide found that over two-thirds of Medicaid patients seeking physical exams or in need of routine cardiology or gynecological care were turned away in cities such as Philadelphia, San Diego, Miami, New York, and Dallas. Fewer than one in ten of the physician practices surveyed in Philadelphia and Dallas, for example, would accept Medicaid patients looking for a heart checkup.

These findings are nothing new. As far back as 1993, peer-reviewed studies documented that Medicaid patients incurred worse health outcomes in areas as diverse as childhood asthma; breast, cervix, colon, and lung cancers; myocardial infarctions; strokes; and pneumonia than do comparable patients with private insurance. Asked to explain why they refuse to see Medicaid patients, physicians pointed to the impenetrable government paperwork and bureaucratic obstacles they encounter as well as to Medicaid’s notoriously low reimbursement rates.

Medicaid’s crisis, moreover, has spread to the entire health sector. A 2012 national survey of nearly 14,000 physicians identified a “silent exodus of physicians from the workforce” driven by “significant changes to the medical practice environment,” including physicians’ frustration with the recent round of health reforms. “Physicians,” the researchers found, “are working fewer hours, seeing fewer patients and limiting access to their practices.” Within four years, the equivalent of over 44,000 physicians will leave the workforce, and more than half will “cut back on patients seen, work part-time, switch to concierge medicine, retire, or take other steps likely to reduce patient access.”

Governors and state lawmakers beware: This “silent exodus” of physicians comes at precisely the time when Obamacare will be asking states to add fuel to Medicaid’s raging fire. And the temptation to embark on this fiscally foolhardy path will be great. Obamacare’s architects are offering a generous — but temporary — 100 percent federal payment to cover the cost of the expansion, as well as federal coverage of a temporary increase in the fees primary-care doctors receive for seeing Medicaid patients. But, like the cherry blossoms that ring the Tidal Basin, these payments will quickly wither away, leaving it to the states — suffering from the fiscal straitjacket Medicaid already puts on their budgets — to assume the burgeoning costs of Obamacare’s Medicaid expansion.

Far better to embrace Medicaid reforms that put patients first.

— Michael G. Franc is vice president of government studies for the Heritage Foundation.

First appeared in National Review Online.

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White House Launches Initiative To Keep Guns Out Of The Hands Of Domestic Abusers

Vice President Joe Biden and Attorney General Eric Holder announced a new gun violence prevention initiative on Wednesday aimed at addressing issues of intimate partner violence. By helping local government officials better identify high-risk offenders and their potential victims, the new Domestic Violence Homicide Prevention Demonstration Initiative hopes to prevent gun-related domestic homicides:

The program will help law enforcement and social service officials identify vulnerable women who may be in potentially fatal abusive relationships and connect them with law enforcement, prosecutors, court personnel and other service providers. As part of the initiative, the Justice Department will distribute a total of $2.3 million in one-year grants to 12 counties and municipalities. [...]

The vice president noted that from 2009 to 2012, 40 percent of mass shootings — those with four or more victims killed — started with the shooter targeting his girlfriend, wife or ex-wife, according to the White House. And Biden repeated a factoid — often noted by advocates for tighter gun control such as the Mayors Against Illegal Guns — that in states that require a background check for private handgun sales, 38 percent fewer women are shot to death by their intimate partners.

“The issue of domestic violence and reducing gun violence are connected,” Biden said. “That’s why the president and I believe that every person who buys a gun — every person — should have a criminal background check.”

The announcement comes the same week that legislation to expand background checks to almost all gun purchases is beginning to advance in Congress.

A similar initiative to make sure domestic abusers can’t easily access firearms is making its way through the Colorado legislature. Local law enforcement often mishandle sexual assault cases, but more training — through local VAWA grants as well as through these new initiatives — could help start to change that.

In recent months, gun issues and domestic violence issues have become particularly intertwined — but not in the same way that Biden and Holder are approaching them. On the other side of the issue, gun advocates have attempted to construe increased access to firearms, particularly concealed carry laws on college campuses, as a “women’s issue” because they claim guns are necessary to help protect women against sexual assault. But hidden guns won’t actually do anything to help address rape culture. In fact, as Biden pointed out, those weapons typically end up being used against victims of domestic abuse themselves. Abusers who have access to a gun are more than seven times more likely to kill their partners.

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NYPD Poised To Make Its 5 Millionth Stop-And-Frisk Today

The New York Police Department is on track to make its 5 millionth stop-and-frisk today, according to the New York Civil Liberties Union. The controversial program, which directs police to stop suspicious-looking people on the street and frisk them for weapons or drugs, has come under fire for disproportionately targeting minorities, while showing little discernible impact on crime.

Since Mayor Michael Bloomberg took office in 2002, NYPD officers have stopped 4.4 million innocent people, the vast majority of whom were black or Latino:

About 4.4 million of the stop-and-frisk encounters, or 88 percent, were of innocent people as they did not result in an arrest or summons. More than 86 percent of people stopped were black or Latino.

At 5 million, the NYPD has stopped more than the combined populations of Baltimore, Boston, Denver, Detroit, Pittsburgh, San Francisco, Seattle, and Washington DC. The racial bias is glaringly obvious; in 2011, the police stopped young black men more times than the total number of young black men in New York City.

The NYPD’s relationship with minority communities has become especially strained by the program’s overzealous targeting of young black and Latino men, culminating in the death of a 16-year-old boy, Kimani Gray, last weekend. Gray. Police stopped Gray for suspiciously adjusting his belt. Gray then allegedly pulled a gun on the officers, forcing them to shoot him multiple times. However, the autopsy found several bullets hit Gray from behind, and eyewitnesses claim Gray was unarmed.

Stop-and-frisk is not only harming New Yorkers’ trust in the police — it’s also using their money. Stop-and-frisk cost New York City taxpayers $22 million in civil rights lawsuits last year.

On Monday, a federal district judge will hear the broadest legal challenge to stop-and-frisk yet, and could decide to do away with the program entirely.

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