Health Care Bill

[macrockett]

Virginia revving up challenge to federal health bill
March 22, 2010 - 5:31am
Hank Silverberg, wtop.com

RICHMOND, Va. - The health care bill passed by Congress could be facing a legal challenge before the ink is dry -- a challenge from Virginia.

On Wednesday, Governor Bob McDonnell will put his signature on a bill that makes it illegal to penalize anyone who chooses not to participate in the federal health plan.

Delegate Bob Marshall, who wrote the bill, says the lawsuit could be triggered when the federal government goes after someone in Virginia for choosing not to be covered.

"It gives the state of Virginia standing to defend me or anybody else who doesn't want to buy the Obama insurance," Marshall said. "The law requires us to set up a health exchange and that is going to be bitterly fought in this state."

Marshall says a legal challenge could come even faster if the state is asked to administer the federal plan, which includes sanctions for people who don't get coverage.

Virginia is not alone in its opposition. More than two dozen other states may do the same.

(Copyright WTOP. All Rights Reserved.)
Hank Silverberg, wtop.com

[slp]

I hear that there is ONE Dr. who is in favor of this Bill.

His name is Dr. Ben Dover.

Better start making our appts. now!

[macrockett]

lol slp.

I will be watching the 4 points that ryan made, to see if the dems follow through. Personally I don't think this will have a snowball's chance in hell to contain costs.

The fact that some countries have programs that operate within reason doesn't mean a system for 300 + million can duplicate a 30 million program.. Even the state of MA is struggling with only a little over 6 million

[macrockett]

www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/03/23/MN531CJKCG.DTL&type=printable

This is the best timeline I could find so far in implementing the new health care bill.

Key elements of health reform would start soon

Victoria Colliver, Chronicle Staff Writer

Tuesday, March 23, 2010
President Obama and Vice President Joe Biden applaud at t... House Speaker Nancy Pelosi receives applause from Democra... Tanning salons such as San Francisco's Great Tan Union wo...

The health care reforms President Obama is expected to sign into law today would unfold slowly for the most part, with a few provisions kicking in this year, such as extended dependent coverage for young adults up to age 26 and an end to insurers' practice of placing lifetime spending limits on policies.

But the major changes - a mandate that most Americans obtain health insurance, a prohibition against insurers turning down adults for coverage because of pre-existing conditions, and the creation of a marketplace or purchasing pool to make it more affordable for people to buy insurance - won't go into effect until 2014.

In a White House ceremony today, Obama plans to sign the historic, nearly $1 trillion health care overhaul bill passed Sunday by the House of Representatives. Then, as the president heads to Iowa to kick off a campaign to sell the legislation to the American public, the Senate will take up a package of House changes to the Senate bill.

The Senate needs a simple majority of 51 votes to approve the changes, but Republicans in the Senate are preparing to put up stiff opposition, and lawmakers in about 30 states are launching legal challenges to the bill.
First-year changes

Assuming GOP efforts fail, the bulk of the reforms offered in the bill would phase in over the next four years, but a number of noteworthy changes would go into effect in the first year.

Among those, health insurers would not be able to deny coverage for children based on pre-existing conditions, and they will no longer be able to set lifetime limits on the amount of money they are willing to pay out to cover people's health care needs.

Insurers would also be prohibited from canceling policies retroactively unless they can prove that the dropped policyholder engaged in fraud.

Young adults who do not have access to health insurance would be able to stay on their parents' policies as dependents until age 26, and seniors who hit the dreaded "doughnut hole," or the coverage gap in the Medicare prescription drug benefit, would get $250 in rebates to help with their costs. The bill eventually phases out that coverage gap entirely.
Getting immediate help

Several health experts said Monday that Congress was wise to enact aspects of the reform package over the next several months so that people get immediate help.

"They're giving themselves a little bit of time to put the full law into place, but also having some provisions to help people in that interim period," said Sara Collins, vice president at the Commonwealth Fund, a private fund that supports independent health research.

For example, health insurers won't be required to accept all applicants regardless of their health status until 2014. Until that happens, the federal government will kick in funds to help states establish high-risk pools to provide health coverage to people who have pre-existing conditions and have been uninsured for six months.
State's high-risk pool

California already has a state-run, high-risk pool, but it caps annual insurance benefits at $75,000, often has a waiting list, and the coverage can cost more than $1,000 a month.

"The problem with it is we put about $40 million into it back in 1988 when it was created, and then we haven't put in a penny more," said Lucien Wulsin Jr., executive director of Insure the Uninsured Project, referring to the annual funding provided through the state's tobacco tax.

Wulsin's group reports at least 200,000 uninsured Californians say they are in poor health, while the state high-risk pool covers just 7,100 people. He said California could be eligible for about $375 million of the $5 billion in federal funding the bill promises to states for these high-risk pools.
Small employers

A tax credit to small employers with fewer than 25 workers is another change that would go into effect this year. The credit would help pay for health care and a requirement that insurers offer certain preventive services without co-payments or other fees.

One lesser-known provision that would go into effect this summer is the "tan tax," a 10 percent tax increase on indoor tanning services. The tax, considered a way to generate money and discourage potentially unhealthy behaviors, replaced a proposed 5 percent tax on elective cosmetic procedures dubbed the "botax."
Effect on small businesses

John Overstreet, executive director of the Indoor Tanning Association, said the federal government's estimate that the tax would generate $2.7 billion over 10 years is an inflated figure. "That figure is just way, way off," he said. "We're dealing with 18,000 or 19,000 small businesses."

Craig Joyner, owner of three tanning salons in San Francisco, said his industry has already been hit by the recession because of consumers cutting back on discretionary expenses, and believes the tax is unfair.

"The fact that it's in there seems pretty random. There's no logic to segmenting out one type of service industry and not others," said Joyner, who owns Great Tan Castro, Great Tan Geary and Great Tan Union.

Timeline for implementation
2010

-- Sets up a high-risk health insurance pool to provide affordable coverage for uninsured people with medical problems.

-- Starting six months after enactment, requires all health insurance plans to maintain dependent coverage for children until they turn 26; prohibits insurers from denying coverage to children because of pre-existing health problems.

-- Bars insurance companies from putting lifetime dollar limits on coverage and canceling policies except for fraud.

-- Provides tax credits to help small businesses with up to 25 employees get and keep coverage.

-- Begins narrowing the Medicare prescription coverage gap by providing a $250 rebate to seniors in the gap, which starts this year once they have spent $2,830. It would be fully closed by 2020.

-- Reduces projected Medicare payments to hospitals, home health agencies, nursing homes, hospices and other providers.

-- Imposes 10 percent sales tax on indoor tanning.
2011

-- Creates a voluntary long-term care insurance program to provide a modest cash benefit helping disabled people stay in their homes, or cover nursing home costs. Benefits can begin five years after people start paying a fee for the coverage.

-- Imposes a $2.3 billion annual fee on drugmakers, increasing over time.

-- Requires employers to report the value of health care benefits on employees' W-2 tax statements.

-- Provides Medicare recipients in the prescription coverage gap with a 50 percent discount on brand-name drugs; begins phasing in additional drug discounts to close the gap by 2020.

-- Provides 10 percent Medicare bonus to primary care doctors and general surgeons practicing in underserved areas, such as inner cities and rural communities.

-- Freezes payments to Medicare Advantage plans, the first step in reducing payments to the private insurers who serve about one-fourth of seniors. The reductions would be phased in over three to seven years.
2012

-- Sets up a program to create nonprofit insurance co-ops that would compete with commercial insurers.

-- Penalizes hospitals with high rates of preventable readmissions by reducing Medicare payments.

-- Initiates Medicare payment reforms by encouraging hospitals and doctors to band together in "accountable care organizations" along the lines of the Mayo Clinic. Sets up a pilot program to test more efficient ways of paying hospitals, doctors, nursing homes and other providers who care for Medicare patients from admission through discharge. Successful experiments would be widely adopted.
2013

-- Standardizes insurance company paperwork, first in a series of steps to reduce administrative costs.

-- Limits medical expense contributions to tax-sheltered flexible spending accounts (FSAs) to $2,500 a year, indexed for inflation. Raises threshold for claiming itemized tax deduction for medical expenses from 7.5 percent of income to 10 percent. People over 65 can still deduct medical expenses above 7.5 percent of income through 2016.

-- Imposes a 2.3 percent sales tax on medical devices. Eyeglasses, contact lenses, hearing aids and many everyday items bought at the drug store are exempt.

-- Increases Medicare payroll tax on couples making more than $250,000 and individuals making more than $200,000. The tax rate on wages above those thresholds would rise to 2.35 percent from the current 1.45 percent. Also adds a new tax of 3.8 percent on income from investments.
2014

-- Prohibits insurers from denying coverage to people with medical problems or refusing to renew their policy. Health plans cannot limit coverage based on pre-existing conditions or charge higher rates to those in poor health. Premiums can only vary by age, place of residence, family size and tobacco use.

-- Coverage expansion goes into high gear as states create new health insurance exchanges - supermarkets for individuals and small businesses to buy coverage. People who already have employer coverage won't see any changes.

-- Medicaid expanded to cover low- income people up to 133 percent of the federal poverty line, about $28,300 for a family of four. Low-income childless adults covered for the first time.

-- Requires citizens and legal residents to have health insurance, except in cases of financial hardship, or pay a fine to the IRS. Penalty starts at $95 per person in 2014, rising to $695 in 2016. Family penalty capped at $2,250. Penalties indexed for inflation after 2016.

-- Penalizes employers with more than 50 workers if any of their workers get coverage through the exchange and receive a tax credit. The penalty is $2,000 times the total number of workers employed at the company. However, employers get to deduct the first 30 workers.

-- Provides income-based tax credits for most consumers in the exchanges, substantially reducing costs for many. Sliding-scale credits phase out completely for households above four times the federal poverty level, about $88,000 for a family of four.

2018

-- Imposes a tax on employer-sponsored health insurance worth more than $10,200 for individual coverage, $27,500 for a family plan. The tax is 40 percent of the value of the plan above the thresholds, indexed for inflation.
2020

-- Coverage gap in Medicare prescription benefit is phased out. Seniors continue to pay the standard 25 percent of their drug costs until they reach the threshold for Medicare catastrophic coverage, when their co-payments drop to 5 percent.

Source: Associated Press
What happens today

-- At the White House, President Obama will sign the Senate health care legislation approved by the House on Sunday.

-- The Senate then will begin considering a package of House changes to the Senate measure known as "reconciliation." Senate Republicans will try to derail it with parliamentary challenges and amendments, but Democrats are confident they will prevail and complete the overhaul of the health care system. Obama would then sign the reconciliation bill.

E-mail Victoria Colliver at [e-mail].

sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/03/23/MN531CJKCG.DTL

This article appeared on page A - 1 of the San Francisco Chronicle

[macrockett]

www.washingtonpost.com/wp-dyn/content/article/2010/03/19/AR2010031901470_pf.html

Is health-care reform constitutional?

By Randy E. Barnett
Sunday, March 21, 2010; B02

With the House set to vote on health-care legislation, the congressional debate on the issue seems to be nearing its conclusion. But if the bill does become law, the battle over federal control of health care will inevitably shift to the courts. Virginia's attorney general, Ken Cuccinelli II, has said he will file a legal challenge to the bill, arguing in a column this month that reform legislation "violate the plain text of both the Ninth and Tenth Amendments." On Friday, South Carolina Attorney General Henry McMaster and Florida Attorney General Bill McCollum announced that they will file a federal lawsuit if health-care reform legislation passes.

Will these cases get anywhere? Here is a guide to the possible legal challenges to a comprehensive health-care bill.

The individual mandate.

Can Congress really require that every person purchase health insurance from a private company or face a penalty? The answer lies in the commerce clause of the Constitution, which grants Congress the power "to regulate commerce . . . among the several states." Historically, insurance contracts were not considered commerce, which referred to trade and carriage of merchandise. That's why insurance has traditionally been regulated by states. But the Supreme Court has long allowed Congress to regulate and prohibit all sorts of "economic" activities that are not, strictly speaking, commerce. The key is that those activities substantially affect interstate commerce, and that's how the court would probably view the regulation of health insurance.

But the individual mandate extends the commerce clause's power beyond economic activity, to economic inactivity. That is unprecedented. While Congress has used its taxing power to fund Social Security and Medicare, never before has it used its commerce power to mandate that an individual person engage in an economic transaction with a private company. Regulating the auto industry or paying "cash for clunkers" is one thing; making everyone buy a Chevy is quite another. Even during World War II, the federal government did not mandate that individual citizens purchase war bonds.

If you choose to drive a car, then maybe you can be made to buy insurance against the possibility of inflicting harm on others. But making you buy insurance merely because you are alive is a claim of power from which many Americans instinctively shrink. Senate Republicans made this objection, and it was defeated on a party-line vote, but it will return.

The Cornhusker Kickback, the Louisiana Purchase, Gator Aid and other deals.

Some states are threatening lawsuits to block the special deals brokered by individual senators in exchange for their votes. Unless the reconciliation bill passes the Senate, such deals could remain in place. Article I of the Constitution allows Congress to tax and spend to "provide for the common defense and general welfare of the United States." Normally, this is no barrier to legislation benefiting a particular state or city. Congress can always argue that, say, an Air Force base in Nebraska benefits the United States as a whole. But the deals in the Senate bill are different. It is really hard to identify a benefit to all the states from exempting one state from an increase in Medicare costs or allowing only the citizens of Florida to get Medicare Advantage.

The Slaughter House rule.

A far graver threat to the bill would have been to declare it unconstitutional because it was never formally voted on by the House and therefore never became law. Article I requires that every bill "shall have passed the House of Representatives and the Senate" to become law, and that "the votes of both houses shall be determined by yeas and nays, and the names of the persons voting for and against the bill shall be entered in the journal of each House respectively."

The whole purpose of the "deem and pass" procedure -- which was advocated by Rules Committee Chairman Louise Slaughter -- was to avoid a separate vote on the Senate bill, which many House members find objectionable, and instead vote on the reconciliation bill and simultaneously "deem" the Senate measure passed. Although Democrats cited prior examples of deem and pass, "the Republicans did it" is not a recognized constitutional argument -- especially if the public and the justices have never heard of such a thing. This constitutional objection seems to have succeeded, as House leaders decided on Saturday to take a separate vote on the Senate version, rather than "deeming" it passed.

State sovereignty provisions.

Several states are considering measures attempting to exempt their residents from an individual health insurance mandate. While such provisions may have a political impact, none is likely to have any effect on the legislation's constitutionality. Under the 10th Amendment, if Congress enacts a law pursuant to one of the "powers . . . delegated to the United States by the Constitution," then that law is supreme, and nothing a state can do changes this. Any state power to "nullify" unconstitutional federal laws has long been rejected.

Constitutional amendments.

Of course, there is one additional way for states to win a fight about the constitutionality of health-care legislation: Make it unconstitutional. Article V of the Constitution gives state legislatures the power to require Congress to convene a convention to propose an amendment to the Constitution. If two-thirds of state legislatures demand an amendment barring the federal regulation of health insurance or an individual mandate, Congress would be constitutionally bound to hold a convention. Something like this happened in 1933 when Congress proposed and two-thirds of the states ratified the 21st Amendment, removing from the Constitution the federal power to prohibit the manufacture, sale and transportation of alcohol. But the very threat of an amendment convention would probably induce Congress to repeal the bill.

Ultimately, there are three ways to think about whether a law is constitutional: Does it conflict with what the Constitution says? Does it conflict with what the Supreme Court has said? Will five justices accept a particular argument? Although the first three of the potential constitutional challenges to health-care reform have a sound basis in the text of the Constitution, and no Supreme Court precedents clearly bar their success, the smart money says there won't be five votes to thwart the popular will to enact comprehensive health insurance reform.

But what if five justices think the legislation was carried bleeding across the finish line on a party-line vote over widespread bipartisan opposition? What if control of one or both houses of Congress flips parties while lawsuits are pending? Then there might just be five votes against regulating inactivity by compelling citizens to enter into a contract with a private company. This legislation won't go into effect tomorrow. In the interim, it is far more vulnerable than if some citizens had already started to rely upon its benefits.

If this sounds far-fetched, consider another recent case in which the smart money doubted there were five votes to intervene in a politicized controversy involving technical procedures. A case in which five justices may have perceived that long-established rules were being gamed for purely partisan advantage.

You might have heard of it: Bush v. Gore.

Randy E. Barnett teaches constitutional law at Georgetown University. He is the author of "Restoring the Lost Constitution: The Presumption of Liberty." He will be online to chat with readers at 11 a.m. on Monday, March 22. Submit your questions and comments before or during the discussion.

[asmodeus]

It is amazing to me that such an enormous, far-reaching piece of legislation could be passed solely because a handful of pro-life Democrats switched from no to yes at the last minute.

[doctorwho]

Mar 24, 2010 6:59:47 GMT -6 asmodeus said:

It is amazing to me that such an enormous, far-reaching piece of legislation could be passed solely because a handful of pro-life Democrats switched from no to yes at the last minute.

And won't they look like geniuses when the wording is switched back in the not too distant future by the Pelosi mob -- as one the so called 'fixes'

[macrockett]

www2.timesdispatch.com/rtd/news/state_regional/state_regional_govtpolitics/article/CUCC241_20100323-232802/332545/

Virginia, 13 other states sue over health-care law

BOB BROWN/TIMES-DISPATCH

Virginia Attorney General Ken Cuccinelli filed suit to challenge the new health care legislation immediately after President Barack Obama signed it.

By Jim Nolan
Published: March 24, 2010
Updated: March 24, 2010
» 11 Comments | Post a Comment

Minutes after health-care legislation was signed into law by President Barack Obama yesterday, Virginia made good on its promise to sue the federal government over it, joining at least 13 other states that are legally challenging the health-system overhaul.

State Solicitor General E. Duncan Getchell Jr. and Deputy Attorney General Wesley G. Russell Jr. filed Virginia's complaint in U.S. District Court in Richmond on behalf of Attorney General Ken Cuccinelli.

Virginia is challenging the constitutionality of the new law, primarily based on the argument that the "commerce clause" of the U.S. Constitution cannot be used by Congress to mandate that individuals purchase health insurance as part of the Patient Protection and Affordable Care Act.

"It has never been held that the 'commerce clause,' even when aided by the 'necessary and proper clause,' can be used to require citizens to buy goods and services," Cuccinelli asserts in the seven-page complaint.

The federal law is unconstitutional because "the individual mandate exceeds the enumerated powers conferred upon Congress," the complaint states. "Because the individual mandate is an essential, nonseverable provision, the entire act is likewise invalid."

The complaint asserts that Virginia's own recently enacted law -- which prohibits residents from being required to purchase insurance or from being subject to fines for failure to do so -- is valid over federal law. Idaho recently enacted a similar law, called the Idaho Healthcare Freedom Act, to prevent its residents from being compelled to purchase health insurance.

Also yesterday, another legal challenge to the federal health-care bill was filed in Florida, asserting the rights of states outlined in the 10th Amendment.

Joining Florida Attorney General Bill McCollum's litigation were attorneys general from Alabama, Colorado, Idaho, Louisiana, Michigan, Nebraska, Pennsylvania, South Carolina, South Dakota, Texas, Utah and Washington -- all Republicans with the exception of Louisiana Attorney General James D. "Buddy" Caldwell, a Democrat.

Virginia Gov. Bob McDonnell on Monday endorsed Cuccinelli's pursuit of the litigation, saying the health overhaul represents "an unprecedented expansion of federal power."

McDonnell said the new laws would have "a significant and unavoidable impact on the bottom line of our state budget by adding 400,000 people to Medicaid rolls and costing a total of $1.1 billion by 2022.

"The issues raised by Attorney General Cuccinelli require a full and prompt review by the judicial branch," McDonnell said.

Cuccinelli's legal action had critics, who were buoyed yesterday by a survey showing increased public support for the health-care overhaul.

A Gallup Poll released yesterday showed that nationwide, 49 percent of Americans said the restructuring of the nation's health-care system is a "good thing," compared with 40 percent who classified it as a "bad thing." Eleven percent of respondents said they were undecided.

Social activists also weighed in. "We are concerned that the political actions of Attorney General Ken Cuccinelli may simply allow health-insurance industry abuse of small business, seniors and children to continue," said a statement issued by the Virginia Interfaith Center for Public Policy.

"Virginians of faith embrace the health-reform provisions and are glad that about 1 million of our brothers and sisters who are uninsured in Virginia will finally get access to quality, affordable health care," said the statement, by health policy analyst Ali Faruk.

David Mills, executive director of the Virginia Democratic Party, said the attorney general's office was being used as a "piggy bank for Ken Cuccinelli's political agenda."

Cuccinelli's office said the litigation will not cost taxpayers extra money but would come from the attorney general's budget. Yesterday, the office paid the required $350 fee to file the suit.

In a ceremony today, McDonnell will sign the Virginia Health Care Freedom Act. The legislation passed the Republican-controlled House with bipartisan support 91-2; it passed the Democrat-controlled Senate, with the governor's amendments, 26-14.

Four of Virginia's 11 members of the U.S. House -- all Democrats -- supported the president's health-care bill, which narrowly passed the House on a 219-212 vote. The remaining seven, including two Democrats, voted against the measure.

[macrockett]

Shortly, interview with Texas AG on CNBC discussing lawsuit over healthcare bill.

www.cnbc.com/id/15840232?video=1449820312&play=1

[macrockett]

As Jack Welch, former GE head, said in the interview with CNBC yesterday, and I believe as well, the cost of health care will mushroom to a couple of trillion dollars in 4-5 years.

[macrockett]

www.chicagotribune.com/health/ct-met-health-reform-illinois-20100323,0,4596796.story
chicagotribune.com
Health care reform in Illinois: what to expect
State Insurance Director Michael McRaith discusses the impact of health care reform on Illinois

By Judith Graham, Tribune reporter

5:42 PM CDT, March 23, 2010

New health care reform legislation is national in scope, but the task of implementing it will fall heavily on the states.

In Illinois, Michael McRaith, director of the state's Department of Insurance, will be at the center of activity, overseeing broad changes in the health insurance market.

The Tribune asked McRaith about the new law, signed Tuesday by President Barack Obama. He promised to challenge insurers that charge sky-high rates and vigorously enforce new consumer protections. An edited version of the conversation follows.

Q: What are the first changes Illinoisans will see?

A: Effective immediately, the secretary of (the U.S. Department of) Health and Human Services, in conjunction with the states, has authority to review and challenge unreasonable health insurance rate increases.

Right now, insurance companies report premium increases in the individual market, but we (in Illinois) do not have the authority to approve or deny rate changes. In the small-employer market, we don't even get informed of rate increases or premiums charged.

We will establish a protocol (for reporting data) as soon as possible. … It is absolutely certain that if there is an unreasonable rate increase, we will examine that and we will challenge that.

Q: What about people with pre-existing conditions who haven't been able to get insurance?

A: Another big challenge for our state is the expansion of high-risk pools, or what we in Illinois know as ICHIP (Illinois Comprehensive Health Insurance Program).

(These pools provide coverage to people with chronic illnesses or disabilities who can't get insurance elsewhere.)

Right now, ICHIP is prohibitively expensive, with premiums of $12,000 to $16,000 annually. It's funded two-thirds by premiums and one-third by general revenue funds. The federal law shifts that burden so enrollees pay no more than 35 percent of the cost of the program. That's about a 30 percent reduction in costs.

Our expectation is that we'll get clear guidance from Washington (about who can get insurance through the pools) within 90 days. We expect an implementation time of 15 to 45 days following that.

Since individuals in Illinois can be denied health insurance for any reason other than race, religion, color or national origin, we expect a large number of people will sign up.

Q: What about people who don't have pre-existing medical conditions but who don't have insurance?

A: On Jan. 1, 2014, health insurance exchanges will be established in all states, including Illinois. (These exchanges will offer a menu of standardized insurance plans to the uninsured and small businesses. No one will be turned away because of a medical condition.)

(Until then) we are concerned that some of the less responsible companies may try to increase premiums and eliminate people who need health care from their lists. … They might say, "Because we have to accept everyone starting in 2014, let's try to start 2014 only with healthy people who are profitable."

We're going to be there to help consumers every step of the way. If people have concerns, they should contact us.

Q: What about rescissions of insurance coverage?

A: Six months from the law's enactment, rescissions will only be allowed in cases of fraud.

Regrettably, Illinois has more rescissions than any other state, including California and Texas. Rescissions can occur up to two years after a policy is first issued. The company looks into the medical history of the patient and if it sees any reason that would have justified the denial of the application or a pre-existing condition exclusion or that would have justified charging the patient more, the policy can be rescinded.

The change in the rescission law is a significant improvement for Illinois families.

Q: Will the federal government take over regulation of insurance?

A: There are people throwing around statements about this being a government takeover of health insurance. The truth is, it's far from it.

Now we'll have national standards, but the health insurance market will continue to be regulated at the state level.

Q: What kinds of standards?

A: For instance, a requirement that insurers (pay 100 percent) for certain preventive treatments, such as childhood inoculations, … a requirement that insurers spend a certain amount of revenues on medical care (80 percent for individual and small group policyholders, 85 percent for members of large groups), and a standard benefit package to be developed by state regulators in collaboration with Health and Human Services.

[e-mail]

Copyright © 2010, Chicago Tribune

Hello! Don't you think an important question would be the cost? What happens between now and the effective date of some of these changes?

[twhl]

Looks like a double whammy. Increased insurance premiums and the cost of consumer goods. Expected but not really hit hard enough during the debate - from the AP News on the discussion of discontinuing prescription benefits for retirees. And generally when rates or consumer prices increase it takes an awful lot for them to come down:

"That financial hit will be a one-time cost as companies report a new cost estimate for the benefits over the life spans of all retirees.
Deere and Caterpillar were among a group of 10 companies that sent a letter to congressional leaders in December warning of the cost increases. The others were Boeing Co., Con-Way Inc., Exelon Corp., Navistar Inc., Verizon, Xerox Corp., Public Service Enterprise Group Inc. and MetLife Inc.

Most of the other companies that signed the letter said Thursday that it was too soon to estimate their costs. A number of other major U.S. companies also said they did not know how much the tax change would cost them. Some companies might wait until they release their earnings reports next quarter to address the costs so they have time to review the entire law.
The companies that signed the December letter warned that changing the way retiree drug benefits are subsidized would have a broad impact on the economy, and there are already indications that the effects will trickle down to individuals.
Consumers Energy, a Michigan gas and electric company with 2.9 million customers, said it will not take a big first-quarter charge because, like most utility companies, it can try to recover the added costs from its customers through rate hikes."

[macrockett]

www.nytimes.com/2010/03/27/health/policy/27massgov.html?ref=us&pagewanted=print

March 26, 2010
Deciding Who Will Lead a Health Care Leader
By KEVIN SACK

BOSTON — Here in the cradle of health reform, where universal coverage was pioneered, this year’s tightening race for governor is focused on the question that now confronts the nation: how to keep spiraling costs from bankrupting the experiment.

Four years ago, when Massachusetts enacted a health insurance plan that became a national template, state leaders deferred any serious discussion about controlling health care costs, with predictable results. While the law succeeded in insuring nearly all residents, the state had to raise taxes and trim benefits to preserve its essential contours.

As with the new federal plan, leaders of both parties here agree that expanded coverage cannot be sustained without arresting the growth of spending. But in what may be another preview for Washington, the campaign for governor has stirred a debate over how best to do that.

Three years into his first term, Gov. Deval Patrick, a Democrat, has jolted the health care industry by proposing an aggressive, albeit temporary, solution.

Using untapped authority, he has directed his insurance commissioner to deny proposed health insurance premiums that are deemed “unreasonable or excessive,” starting April 1. Mr. Patrick, who took office just in time to implement the health care overhaul here, also has submitted a bill to allow state regulation of the fees that hospitals and doctors command from insurers. That is seen as an audacious move in a state where prestigious academic medical centers hold heavy sway over pricing.

Mr. Patrick’s assertiveness is widely interpreted as a shot over the bow of his chief rival, Charles D. Baker Jr., a Republican who, as it happens, spent the last 10 years as chief executive of one of the state’s largest insurers, Harvard Pilgrim Health Care.

Emboldened by the January victory here of another Republican, Senator Scott Brown, Mr. Baker has been raising record sums, much of it from the health care industry, and has drawn nearly even with Mr. Patrick in recent polling.

As Mr. Baker gains standing, the governor has worked to remind voters of his opponent’s role in an industry roundly vilified by the Obama administration. He asserted in an interview in his office that Mr. Baker had done little to control escalating premiums during his tenure at Harvard Pilgrim.

“It is actually somewhat dismaying the number of people who stand on the sidelines and root for failure, who could lift a finger, but don’t, to help,” Mr. Patrick said of Mr. Baker. “You have to make powerful interests mad if you want to change the status quo. And I have never, ever seen any evidence from Charlie of a willingness to do that.”

Mr. Patrick said his emergency measures would bring quick relief to individuals and small businesses as the state tries to spur its recovery. He said the price controls would be a bridge until the legislature could consider a second phase of restructuring.

Mr. Baker, who has long called for more transparency in health care pricing, questioned why Mr. Patrick waited until his re-election year to tackle the problem.

“He’s really late to the game,” said Mr. Baker, formerly a top aide to two Republican governors. “That’s a long time to sit on your hands.”

The Massachusetts race has taken shape in the shadow of the national debate, which produced a law that Mr. Patrick supports but Mr. Baker derides as “a bad deal.”

The contest has been complicated by the candidacy of the state treasurer, Timothy P. Cahill, who left the Democratic Party to run as an independent.

Appealing to Mr. Brown’s voters, Mr. Cahill charged this month that the Massachusetts health plan had “blown a hole” in the budget and warned that the federal changes would “bankrupt this country within four years.”

In 2006, Mr. Patrick’s Republican predecessor, Mitt Romney, joined with Democratic lawmakers to enact legislation that required most residents to have insurance, offered subsidized coverage to those with low incomes, and set up an insurance exchange to encourage comparison shopping. But to preserve a fragile coalition of powerful stakeholders, state leaders put off the painful work of cutting costs, and the slumping economy made the problem worse.

This year’s state budget is out of balance by $295 million, partly because of rising health costs, meaning more cuts may lie ahead. Insurance premiums continue to grow far faster than inflation. State regulators are thinking about exempting more people from the insurance mandate because they cannot afford to buy policies.

Despite Mr. Patrick’s threat to deny unreasonable premiums, health insurers are seeking approval of increases from 7 percent to 34 percent. Mr. Patrick said he would use a medical inflation rate of 3.2 percent as a rough benchmark. “It’s a soft cap,” he said. “We’re not going to be jerks about it.”

Any relief would give the governor and legislature time to design and enact a “global payment” system that would reward doctors and hospitals for keeping patients healthy, rather than reimbursing for each office visit, test and procedure. That plan, recommended by a state commission, is designed to remove incentives for needless treatment, and would take five years to implement.

Health insurers and providers predict market chaos if Mr. Patrick follows through and rejects rates. They warn that existing contracts with doctors and hospitals will be broken, leading to lawsuits.

“Our concern,” said Jay McQuaide, vice president at Blue Cross Blue Shield of Massachusetts, “is that this be an actuarial review of the rates, not a political review of the rates.”

Two of the state’s four largest insurers lost money in 2009, and the others, including Harvard Pilgrim, posted only modest profits. Premium increases at Harvard Pilgrim generally have tracked the Massachusetts market during Mr. Baker’s tenure, typically hovering around 10 percent a year. Mr. Baker, who made $1.7 million in his last full year, is widely credited with pulling the company back from the precipice of financial ruin.

As secretary of health and human services under Gov. William F. Weld, a Republican, Mr. Baker oversaw deregulation of the health care industry in 1991, ending the state’s last experiment with price-setting. Like other health insurance executives, he argues that Mr. Patrick’s singling out of health insurers, a strategy plucked from the White House playbook, is misdirected.

He points to a recent investigation by Attorney General Martha Coakley that identified doctor and hospital prices as the main drivers of health care inflation. Ms. Coakley concluded that wide variations in prices paid by insurers to hospitals and physicians were related to providers’ market leverage, but not to quality.

Mr. Baker said he would demand that hospitals and doctors disclose their prices, and would generate savings by converting the state’s Medicaid program to managed care.

With Mr. Baker faulting Mr. Patrick for inattention to the cost problem, the governor has set out to convey a sense of action. The doomsday talk from the industry is unfounded, he said.

“I think people are exaggerating to protect the status quo,” he said. “It’s about time they got off their duffs and came in here and tried to solve this with a sense of urgency.”
-------------------------------------------------

This drama is going on in a state with 6.6 million people. Can you imagine 300 + million. You don't have to look far to get a sense of what is to come. Just look at medicare with approximate 45 million participants.

The most common figure I have seen that quantifies the current unfunded liability of medicare is approximately $35 trillion.

If you look at this CBO summary of current and projected health care spending, you begin to see the magnitude of this problem.

www.cbo.gov/ftpdocs/102xx/doc10297/Chapter2.5.1.shtml#1092607

Short of rationing and cost controls I personally don't see how the cost of health care can ever be contained (as an example, many areas of health care didn't even exist 20 years ago).

Relative to our GDP, it is just a juggernaut that will not stop.

[macrockett]

Recent CBS Poll on the New HC Bill:

www.cbsnews.com/htdocs/pdf/poll_health_care_032410_7am.pdf?tag=contentMain;contentBody


www.cbsnews.com/8301-503544_162-20001117-503544.html

opinionator.blogs.nytimes.com/2010/03/26/can-no-revive-the-republicans/?pagemode=print

March 26, 2010, 6:46 pm
Can ‘No’ Revive the Republicans?
By TOBIN HARSHAW

David Frum, democrats, health care reform, republicans, Tea Party

Well, Karl Rove isn’t one to let a downpour dampen his parade. “Democrats are celebrating victory,” the Republican strategist wrote in The Wall Street Journal after President Obama signed the health care reform package. “The public outcry against what they’ve done doesn’t seem to bother them. They take it as validation that they are succeeding at transforming America. But we’ve seen this movie before and it won’t end happily for Democrats.”

Rove’s version of “hope and change”? “Republicans have a powerful rallying cry in ‘repeal, replace and reform.’ ” Well, I can’t say that it sings, but there may be more public support than you’d expect:

“The latest Rasmussen Reports national telephone survey, conducted on the first two nights after the president signed the bill, shows that 55% favor repealing the legislation. Forty-two percent (42%) oppose repeal. Those figures include 46% who Strongly Favor repeal and 35% who Strongly Oppose it.” Yes, I know that many liberals think Scott Rasmussen as a G.O.P. shill, but they may want to look at this CBS News survey that found “nearly two in three Americans want Republicans in Congress to continue to challenge parts of the health care reform bill.”

Some conservatives think intransigence is a political winner. One who disagreed, David Frum, got fired.

Rove’s got a bevy of supporters on the right side of the blogosphere. “Republicans aren’t going to get 67 votes needed to override an Obama veto that would greet repeal attempts, but it’s no longer inconceivable that the Senate could flip, leaving the remaining Democrats (especially those up for re-election in 2012) quaking,” writes Jennifer Rubin at Commentary. “Certainly there will be other issues — repeal of the Bush tax cuts in 2011, unemployment, and national security. But if you have a large base of active support on one key issue – which the other side obsessively emphasizes — it’s hard to resist making that issue the central focus of the campaign.”

And it looks like plenty of Republican officials like the playbook. Here’s John McCain, the man many on the right considered an insufficiently conservative presidential candidate, in a radio interview on Monday: “There will be no cooperation for the rest of the year. They have poisoned the well in what they’ve done and how they’ve done it.”

And let’s hear from his party’s leader in the chamber, Mitch McConnell: “Senate Republicans will now do everything in our power to replace the massive tax hikes, Medicare cuts and mandates with the reforms our constituents have been calling for throughout this debate.”

Strong words, but not strong enough for Erick Erickson of RedState (and now CNN)” “What word is missing?” he asks of McConnell’s statement. “How about the word ‘repeal.’ So fearful of being labeled the ‘Party of No,’ the Senate Republicans cannot bring themselves to give a full throated defense of the proposition that this monstrosity should be repealed. They will instead go with nibbling at the edges.”

All this raises a question that goes well beyond the health care debate: can the Republicans make any progress, in Congress or at the polls in November, with that ‘Party of No’ label?

Darrell Delamaide of MarketWatch is skeptical:

The excessive rhetoric of House Minority Leader John Boehner, who called the bill “Armageddon,” will leave Republicans looking silly as the law’s various provisions are quietly implemented, and affordable health care becomes as natural to people as Social Security and Medicare have become.

The midterm elections will not be a referendum on health-care reform. That was the election in 2008, when the majority voted in favor of reform and finally got what it sought through our tortured legislative process. But midterm elections will be a referendum on Obama’s performance, and the outcome depends on how skillfully the administration and the congressional majority now use the game-changing momentum of the health-care vote over the weekend.

John Quiggin at Crooked Timber thinks this debate marked an epochal change for the G.O.P.:

The Republicans have become the Party of No in another sense. Having been the party of initiative since the election of Ronald Reagan in 1980, they are back to their more accustomed role as the party of reaction. The change can probably be dated back to the 2004 election, when Bush failed to privatize Social Security or maybe even in 2003 when electoral pressure pushed him into introducing the Prescription Drug Subsidy (a pork laden monster as you’d expect from Bush, but still an expansion of the welfare state).

The shift is certainly evident when you compare Obama’s first year in office with Clinton’s. Clinton was introducing policies demanded by the Republicans and their response (the Contract with America) was that he wasn’t doing nearly enough. Now, the Republicans have nothing of their own to offer, except more tax cuts (and, I guess, more torture).

The most surprising critic of this approach, however, was the former George W. Bush speechwriter David Frum. “It’s hard to exaggerate the magnitude of the disaster,” he lamented at his site FrumForum. “Conservatives may cheer themselves that they’ll compensate for today’s expected vote with a big win in the November 2010 elections. But: (1) It’s a good bet that conservatives are over-optimistic about November — by then the economy will have improved and the immediate goodies in the healthcare bill will be reaching key voting blocs. (2) So what? Legislative majorities come and go. This healthcare bill is forever. A win in November is very poor compensation for this debacle now.”

In this pessimism, Frum was part of a sizeable minority of conservatives. But in the rest of the column, he crossed a Rubicon of sorts. “At the beginning of this process we made a strategic decision: unlike, say, Democrats in 2001 when President Bush proposed his first tax cut, we would make no deal with the administration,” Frum explains. “No negotiations, no compromise, nothing. We were going for all the marbles. This would be Obama’s Waterloo — just as healthcare was Clinton’s in 1994.”

The result of this blind ambition?

We followed the most radical voices in the party and the movement, and they led us to abject and irreversible defeat.

There were leaders who knew better, who would have liked to deal. But they were trapped. Conservative talkers on Fox and talk radio had whipped the Republican voting base into such a frenzy that deal-making was rendered impossible. How do you negotiate with somebody who wants to murder your grandmother? Or — more exactly — with somebody whom your voters have been persuaded to believe wants to murder their grandmother? I’ve been on a soapbox for months now about the harm that our overheated talk is doing to us. Yes it mobilizes supporters — but by mobilizing them with hysterical accusations and pseudo-information, overheated talk has made it impossible for representatives to represent and elected leaders to lead …

So today’s defeat for free-market economics and Republican values is a huge win for the conservative entertainment industry. Their listeners and viewers will now be even more enraged, even more frustrated, even more disappointed in everybody except the responsibility-free talkers on television and radio. For them, it’s mission accomplished. For the cause they purport to represent, it’s Waterloo all right: ours.

Frum’s cri de coeur got rave reviews, albeit not from the intended audience.

Here’s Bill Barol at Huffington Post: “Last night was more than a legislative moment. It was also, and the implications of this will be deeper and broader than any legislation, a political one. (God help me, this is a part of the argument David Frum made yesterday.) Had the administration been turned back on health care it would have been crippled, probably irreversibly, in its ability to do big things in the areas that still need big things done: Energy, jobs and immigration, to pick just three.”

“Frum seemed to be picking up on exactly what I, and others, have been arguing: the midterm elections in 2010 are likely above all else to be a function of the state of the economy, which, as Frum notes, may actually be looking better by November,” adds
Joshua Tucker at Salon. “They will also … be a function of President Obama’s approval ratings, which have held relatively steady at around 50 percent for months, despite all the supposed angst in the country since then over health care reform.”

Jonathan Chait at the New Republic thinks Frum is spot on: “The Republican strategy of total opposition instead forced the Democrats into an all-or-nothing choice of passing a comprehensive bill or collapsing into catastrophic defeat. (Republicans tried desperately to convince them that letting the bill die was their best political strategy, but Democrats wisely rejected this awful advice.) Let me be clear: I’m glad they did it. I’m willing to accept higher Democratic losses in exchange for a health care bill that really solves the pathologies of the health care market. The Republican strategy was an audacious gamble, and it could have worked, but it came up empty. Thank goodness.”

Joe Gandelman at the Moderate Voice thinks Frum shows a good grasp of Republican history: “Political parties have kept power by only appealing to true believers, but coalition building which requires some consensus and compromise has proven to be the enduring and politically endearing course, (go back and read how Ronald Reagan upset many conservatives: Reagan is categorized as a ‘moderate’ by one historian due to his willingness to work with the opposition and compromise to achieve his broader goals).”

“Folks, if you want to know why bipartisanship failed, don’t look to Democrats,” writes Justin Gardner at Donklephant, naming the names that Frum left out. “Look to Boehner. Look to Palin. Look to Rush. Look to Hannity. Look to McConnell. Look to Beck. Look to Fox News. Look to the Tea Party.” He continues:

Democrats came to the table ready to deal. What they weren’t ready to do is develop a health care bill that was based almost solely on Republican economic philosophies. Still, they askewd a public option, even when their base was crying foul and demanding it. But Republicans made the political calculation that defeating the legislation was more important.

Fair enough, but Frum thinks that this bill represents the biggest legislative defeat for Republicans since the 60s. Because, even with all of this talk of repeal, it’s unlikely they’ll be able to sell the idea of jacking prices back up on prescription drugs, reinstituting the pre-existing conditions clause and a whole host of other things that this current legislation addresses.

As for the response from conservatives, well, let’s let Frum’s wife, the writer Danielle Crittenden, give us a window into their lives (via Huffington Post):

For days I’ve been sitting here in the bunker beside him (and our three dogs), watching the whizzbangs land all around. What is distressing is not the predictable hate mail he has been receiving — and thanks to the internet, he’s been receiving it in hundredfold; we’ve both seen that before. What is distressing (to me, anyway) are the dishonest slurs on his character and integrity by people who know him, and in some cases have known him for many years — truly ugly suggestions that David is motivated by cynicism or sycophancy, or both …

We have both been part of the conservative movement for, as mentioned, the better part of half of our lives. And I can categorically state I’ve never seen such a hostile environment towards free thought and debate — once the hallmarks of Reaganism, the politics with which we grew up — prevail in our movement as it does today. The thuggish demagoguery of the Limbaughs and Becks is a trait we once derided in the old socialist Left. Well boys, take a look in the mirror. It is us now.

Frum’s own update was rather more terse: “I have been a resident fellow at the American Enterprise Institute since 2003. At lunch today, AEI President Arthur Brooks and I came to a termination of that relationship.”

Politico’s Mike Allen was able to get Frum’s fuller account:

David Frum told us last night that he believes his axing from his $100,000-a-year “resident scholar” gig at the conservative American Enterprise Institute was related to DONOR PRESSURE following his viral blog post arguing Republicans had suffered a devastating, generational “Waterloo” in their loss to President Obama on health reform. “There’s a lot about the story I don’t really understand,” Frum said from his iPhone. “But the core of the story is the kind of economic pressure that intellectual conservatives are under. AEI represents the best of the conservative world. [AEI President] Arthur Brooks is a brilliant man, and his books are fantastic. But the elite isn’t leading anymore. It’s trapped. Partly because of the desperate economic situation in the country, what were once the leading institutions of conservatism are constrained. I think Arthur took no pleasure in this. I think he was embarrassed. I think he would have avoided it if he possibly could, but he couldn’t.

“The idea that AEI donors sit down to talk with AEI’s president about who should and shouldn’t be on the staff, or what the staff should write, is fantasy,” insists Charles Murray, a scholar at the institution, writing at the Corner. “David has never seen the slightest sign of anything like that at AEI. He can’t have. He made it up. AEI has a culture, the scholars are fiercely proud of that culture, and at its heart is total intellectual freedom. As for the reality of that intellectual freedom, I think it’s fair to say I know what I’m talking about. I’ve pushed it to the limit.”

Others, however, feel that Frum’s comments have the ring of truth to them. “I was fired by a right wing think tank called the National Center for Policy Analysis in 2005 for writing a book critical of George W. Bush’s policies, especially his support for Medicare Part D,” writes the former Reagan White House adviser Bruce Bartlett, at Capital Gains and Games. “In the years since, I have lost a great many friends and been shunned by conservative society in Washington, DC. Now the same thing has happened to David Frum, who has been fired by the American Enterprise Institute … Since, he is no longer affiliated with AEI, I feel free to say publicly something he told me in private a few months ago. He asked if I had noticed any comments by AEI ’scholars’ on the subject of health care reform. I said no and he said that was because they had been ordered not to speak to the media because they agreed with too much of what Obama was trying to do.”

Bartlett thinks this story is much bigger than the careers of two Republican free-thinkers:

I have always hoped that my experience was unique. But now I see that I was just the first to suffer from a closing of the conservative mind. Rigid conformity is being enforced, no dissent is allowed, and the conservative brain will slowly shrivel into dementia if it hasn’t already.

Sadly, there is no place for David and me to go. The donor community is only interested in financing organizations that parrot the party line, such as the one recently established by McCain economic adviser Doug Holtz-Eakin … this is a black day for what passes for a conservative movement, scholarship, and the once-respected AEI.

If Bartlett is right, it gives a whole new meaning to Frum’s admonition that “a win in November is very poor compensation for this debacle now.”

(Note: Frum had more comments on Bartlett’s and Murray’s posts Friday evening.)

[macrockett]

March 26, 2010
Op-Ed Contributor
Fix Health Reform, Then Repeal It
By PAUL RYAN

Washington

ON Thursday night, Congress sent to President Obama the reconciliation package to remove some of the embarrassing provisions in his signature legislative achievement, health care reform. But a serious fix for what ails health care in America will entail far more than merely tweaking the new law of the land; we will need to repeal the entire faulty architecture of the government behemoth and replace it with real reform.

To be clear: it is not sufficient for those of us in the opposition to await a reversal of political fortune months or years from now before we advance action on health care reform. Costs will continue their ascent as the debt burden squeezes life out of our economy. We are unapologetic advocates for the repeal of this costly misstep. But Republicans must also make the case for a reform agenda to take its place, and get to work on that effort now.

So what can we do?

Health care experts across the political spectrum acknowledge that a fundamental driver of health inflation is the regressive tax preference for employer-based health insurance. This discriminatory tax treatment lavishes the greatest benefit on the most expensive plans while providing no support for the unemployed, the self-employed or those who don’t get coverage from their employer.

Reform-minded leaders like Senator Ron Wyden, Democrat of Oregon, and Senator Tom Coburn, Republican of Oklahoma, pushed legislative proposals that would directly address this issue. I helped write a plan that would replace the bias in the tax code with universal tax credits so that all Americans have the resources to purchase portable, affordable coverage that best suits their needs, with additional support provided for those with lower incomes. All these ideas, though, were dismissed early on, as they didn’t fit with the government-driven plan favored by the majority. But going forward it’s important that we reconsider this regressive tax issue.

Then, when helping Americans with pre-existing conditions obtain coverage, we should focus on innovative state-based solutions, including robust high-risk pools, reinsurance markets and risk-adjustment mechanisms. I intend to continue advancing true patient-centered reforms like attaching tax benefits to the individual rather than the job, breaking down barriers to interstate competition, and promoting transparency and consumer-friendly coverage options.

We should ensure that health care decisions are made by patients and their doctors, not by bureaucrats, whether at an insurance company or a government agency. By inviting market forces into health care, we can encourage a system where doctors, insurers and hospitals compete against one another for the business of informed consumers.

We must also immediately begin dealing with our crushing debt burdens, which this legislation will worsen. The Democrats’ fiscal arguments never did add up: they claim that their program will reduce the deficit even though the federal government will pick up the tab for more than 30 million uninsured Americans and subsidize millions more. Even after accounting for the $569 billion in tax increases and $523 billion in Medicare cuts, the true costs of this legislation — concealed by timing gimmicks, hidden spending and double-counting — will make the deficit explode, plunging us deeper into debt.

Washington already has no idea on how to pay for its current entitlement programs, as we find ourselves $76 trillion in the hole. Our country cannot afford to avoid a serious conversation on entitlement reform. By taking action now, we can make certain that our entitlement programs are kept whole for those in and near retirement, while devising sustainable health and retirement security for future generations.

The case for attempting health care reform was not difficult to make. Skyrocketing health care costs are driving more and more families and businesses to the brink of bankruptcy, leaving affordable coverage out of reach for millions of Americans and accelerating our path to fiscal ruin. The challenge was how to deal with the seemingly inexorable increase in health care costs.

Yet the Congressional majority went at this goal backward: with the force of the federal government, cover all Americans — then figure out which screws to twist to contain costs. Democrats opted for this approach because their concern was never about costs. It was about expanding coverage through an expansion of government.

As the dust settles from this historic and fiscally calamitous week, we have to try to steer this country back in the right direction. The opposition must always speak with vigor and candor on the need for wholesale repeal and for real reform to fix what’s broken in health care.

Paul Ryan, a Republican, is a representative from Wisconsin.