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Critical Condition

NRO’s health-care blog.

Supreme Court Health-Care Decision: It Is Not Over



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The recent Supreme Court decision may be a disappointment. Many thought the justices would strike the law in its entirety and end this bad dream for the country now. Unfortunately that did not happen. But there is more to come.

The law remains unworkable, unaffordable, and bad health-care policy. It straps the American people with higher taxes and higher premiums and more spending and more deficits. It also breaks the many promises made by President Obama, including keeping the coverage you like, not adding to the deficit, protecting Medicare, and not increasing taxes or premiums on middle-class families.

The House of Representatives has scheduled another vote on full repeal of the health-care law, putting the decision in the hands of the Democrat-controlled Senate.

In addition, there are the 23 lawsuits representing more than 50 organizations relating to the highly polarizing HHS mandate requiring religious employers to provide coverage of abortion-inducing drugs, contraception, and sterilization, regardless of religious or moral objections. These suits challenge the constitutionality of the law relating to religious freedom. This benefit mandate is just the first of many more controversial decisions likely to come out of the administration relating to the essential-benefit package.

Furthermore, as 2013 nears, there are the existing Obamacare taxes that will take effect. Notably, there will be the $210 billion raised by increasing the Medicare payroll tax from 2.9 percent to 3.8 percent and expanding the tax to investment income. While on the surface this tax appears to only impact those individuals with incomes above $200,000 and above $250,000 for couples, that threshold is not indexed to inflation. So, like the AMT, more people will face this tax in the years to come. 

Finally, the election. The American people have been consistent in their opposition to the health care. The Court’s decision will likely not impact American’s long-settled views that health reform based on the premise on more government, more regulations, and more mandates is the wrong way to solve the country’s health-care problems.

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

A ‘Tax on Pro-Life Conscience’



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That’s what Bioethics Defense Fund attorneys Nikolas T. Nikas and Dorinda C. Bordlee are calling the impact of today’s Supreme Court ruling on Americans who happen to oppose abortion. They answered some questions about just what they mean over e-mail this afternoon:

What does today’s health-care decision mean for the dignity of human life?

The dignity of human life is now under tremendous threat. Because Obamacare contains conscience-violating mandates concerning abortion and abortion-inducing drugs, this decision effectively imposes a tax on pro-life conscience. This is because the U.S. Supreme Court majority upheld the Obamacare law in its entirety under the unexpected reasoning that the “penalty” imposed on citizens who do not buy approved insurance is a “tax,” and thus legitimate under the federal government’s taxing power. The dissent characterized the majority’s ruling as illegitimate “judicial tax-writing.”

How and why is abortion even a part of the president’s health-care law?

As we explain in our amicus brief to the Supreme Court, Obamacare contains an unconstitutional “abortion-premium mandate” that could put millions of Americans into conscience-violating situations where they will be required to pay out of their own pockets a separate premium that must be placed by their insurer into an allocation account designated solely to fund other people’s elective abortions. The Act explicitly says that no enrollees in plans that cover abortion can decline the coverage for reasons of age, sex or marital status. While the Amish are allowed to opt-out of Obamacare’s individual mandate, pro-life citizens are not able to opt out for reasons of moral objection to abortion. We argue that this is a classic violation of the Free Exercise Clause. So the Obamacare lawsuits on religious-liberty grounds are just beginning. This is far from over.

Why should we believe you? The president said differently. 

We read the law, and laid it all out in our Supreme Court amicus brief on behalf of seven medical organizations. We summarized our exposé and the president’s word games here

Do you dismiss the care of people once they are alive? 

Actually, as advocates for the dignity of human life, we understand that unborn children are human beings who are indeed “alive” and entitled to special protection as the most vulnerable members of the human family. Authentic health-care reform must be promoted and enacted in a way that the unborn, the elderly, and the disabled are given the full protection of the law, rather than being treated as disposable at the government’s whim — whether by a politically appointed panel in Washington, D.C., or the bureaucracy of the HHS department.

As lawyers, what do you make of “judicial tax-writing” as you call it? 

We are baffled. But since we are not tax attorneys, we will simply let Justices Scalia, Kennedy, Thomas, and Alito speak for themselves in this quote from their dissenting opinion:

For all these reasons, to say that the Individual Mandate merely imposes a tax is not to interpret the statute but to rewrite it. Judicial tax-writing is particularly troubling. Taxes have never been popular, see, e.g., Stamp Act of 1765, and in part for that reason, the Constitution requires tax increases to originate in the House of Representatives. See Art. I, §7, cl. 1. That is to say, they must originate in the legislative body most accountable to the people, where legislators must weigh the need for the tax against the terrible price they might pay at their next election, which is never more than two years off. The Federalist No. 58 “defend[ed] the decision to give the origination power to the House on the ground that the Chamber that is more accountable to the people should have the primary role in raising revenue.”United States v. Munoz-Flores, 495 U. S. 385, 395 (1990). We have no doubt that Congress knew precisely what it was doing when it rejected an earlier version of this legislation that imposed a tax instead of a requirement-with-penalty. See Affordable Health Care for America Act, H. R. 3962, 111th Cong., 1st Sess., §501 (2009); America’s Healthy Future Act of 2009, S. 1796, 111th Cong., 1st Sess., §1301. Imposing a tax through judicial legislation inverts the constitutional scheme, and places the power to tax in the branch of government least accountable to the citizenry.

What’s your takeaway message to Catholics during the Fortnight of Freedom and all Americans as we approach Independence Day and, yes, a presidential election?

The takeaway message is that this is the beginning of the battle, not the end. The religious-liberty suits against Obamacare’s HHS mandate are now more important than ever, and readers may want to review BDF’s short comment letter to HHS pointing out how the alleged “accommodation” still requires material cooperation with evil, and also covering the science behind the required drugs that are capable of terminating the lives of human beings at the embryonic stage of development. Readers may recall that after issuing the HHS regulation mandating employers to pay for abortion-inducing drugs and surgical sterilizations, Secretary of Health Kathleen Sebelius gave a speech at a fundraiser for NARAL Pro-Choice America. She told the assembled crowd that “we are in a war.” Indeed.

We would encourage Catholics and all citizens of good will to take this ruling as a challenge and an opportunity to stand up at this pivotal moment in our nation’s history to defend the human right to life and the conscience rights at the heart of religious liberty. We must not lose heart. As the U.S. Conference of Catholic Bishops has requested, we must embrace this fortnight as our moment to demonstrate the depth of our moral and religious convictions — in our families, in our legislative bodies, in our courts, and in the voting booth. Catholics who follow the beautiful writings of Pope Benedict may remember that he said that those who act with love are “hope in action.” It is time for action, and we cannot and will not lose hope.

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A ‘Tax on Pro-Life Conscience’



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That’s what Bioethics Defense Fund attorneys Nikolas T. Nikas and Dorinda C. Bordlee are calling the impact of today’s Supreme Court ruling on Americans who happen to oppose abortion. They answered some questions about just what they mean over e-mail this afternoon:

What does today’s health-care decision mean for the dignity of human life?

The dignity of human life is now under tremendous threat. Because Obamacare contains conscience-violating mandates concerning abortion and abortion-inducing drugs, this decision effectively imposes a tax on pro-life conscience. This is because the U.S. Supreme Court majority upheld the Obamacare law in its entirety under the unexpected reasoning that the “penalty” imposed on citizens who do not buy approved insurance is a “tax,” and thus legitimate under Congress’ tax and spend power. The dissent characterized the majority’s ruling as illegitimate “judicial tax-writing.”

How and why is abortion even a part of the president’s health-care law?

As we explain in our amicus brief to the Supreme Court, Obamacare contains an unconstitutional “abortion premium mandate” that could put millions of Americans into conscience violating situations where they will be required to pay out of their own pockets a separate premium that must be placed by their insurer into an allocation account designated solely to fund other people’s elective abortion. The Act explicitly says that no enrollees in plans that cover abortion can decline the coverage for reasons of age, sex or marital status. While the Amish are allowed to opt-out of Obamacare’s individual mandate, pro-life citizens are not able to opt out for reasons of moral objection to abortion. We argue that this is a classic violation of the Free Exercise Clause. So the Obamacare lawsuits on religious-liberty grounds are just beginning. This is far from over.

Why should we believe you? The president said differently. 

We read the law, and laid it all out in our Supreme Court amicus brief on behalf of seven medical organizations. We summarized our expose and the president’s word games here

Do you dismiss the care of people once they are alive? 

Actually, as advocates for the dignity of human life, we understand that unborn children are human beings who are indeed “alive” and entitled to special protection as the most vulnerable members of the human family. Authentic health care reform must be promoted and enacted in a way that the unborn, the elderly and the disabled are given the full protection of the law, rather than being treated as disposable at the government’s whim — whether by a politically appointed panel in Washington, D.C. or the bureaucracy of the HHS department.

As lawyers, what do you make of “judicial tax-writing” as you call it? 

We are baffled. But since we are not tax attorneys, we will simply let Justices Scalia, Kennedy, Thomas, and Alito speak for themselves in this quote from their dissenting opinion:

For all these reasons, to say that the Individual Mandate merely imposes a tax is not to interpret the statute but to rewrite it. Judicial tax-writing is particularly troubling. Taxes have never been popular, see, e.g., Stamp Act of 1765, and in part for that reason, the Constitution requires tax increases to originate in the House of Representatives. See Art. I, §7, cl. 1. That is to say, they must originate in the legislative body most accountable to the people, where legislators must weigh the need for the tax against the terrible price they might pay at their next election, which is never more than two years off. The Federalist No. 58 “defend[ed] the decision to give the origination power to the House on the ground that the Chamber that is more accountable to the people should have the primary role in raising revenue.”United States v. Munoz-Flores, 495 U. S. 385, 395 (1990). We have no doubt that Congress knew precisely what it was doing when it rejected an earlier version of this legislation that imposed a tax instead of a requirement-with-penalty. See Affordable Health Care for America Act, H. R. 3962, 111th Cong., 1st Sess., §501 (2009); America’s Healthy Future Act of 2009, S. 1796, 111th Cong., 1st Sess., §1301. Imposing a tax through judicial legislation inverts the constitutional scheme, and places the power to tax in the branch of government least accountable to the citizenry.

What’s your takeaway message to Catholics during the Fortnight of Freedom and all Americans as we approach Independence Day and, yes, a presidential election?

The takeaway message is that this is the beginning of the battle, not the end. The religious liberty suits against Obamacare’s HHS Mandate are now more important than ever, and readers may want to review BDF’s short comment letter to HHS pointing out how the alleged “accommodation” still requires material cooperation with evil, as well as the science behind the required drugs that are capable of terminating the lives of human beings at the embryonic stage of development. Readers may recall that after issuing the HHS regulation mandating employers to pay for abortion-inducing drugs and surgical sterilizations, Secretary of Health Kathleen Sebelius gave a speech at a fundraiser for NARAL Pro-Choice America. She told the assembled crowd that “we are in a war.” Indeed.

We would encourage Catholics and all citizens of good will to take this ruling as a challenge and an opportunity to stand up at this pivotal moment in our nation’s history to defend the human right to life and the conscience rights at the heart of religious liberty. We must not lose heart. As the U.S. Bishops Conference has requested, we must embrace this fortnight as our moment to demonstrate the depth of our moral and religious convictions — in our families, in our legislative bodies, in our courts, and in the voting booth. Catholics who follow the beautiful writings of Pope Benedict may remember that he said that those who act with love are “hope in action.” It is time for action, and we cannot and will not lose hope.

The Top Ten Worst Things in Obamacare



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 “We have to pass the bill so you can find out what is in it.”

Former Speaker Nancy Pelosi, March 2010

Now, all the rest of us are going to find out a lot more about what’s in the 2,700-page health overhaul law.

The president now must spend the next four months defending a law that the majority of Americans dislike, and the more they learn about it, the more they dislike it. Worse, the part of the law that is the least popular — the individual mandate — has now been declared a tax. 

That’s double jeopardy for the president: The unpopular mandate stands, and it is called a tax.  (And this is only one of the 20 new and higher taxes in the law.) Either the president admits it’s a tax as a way of keeping the law on the books, or he says that the Supreme Court is wrong, that it’s not a tax, in which case his law would be invalid.

It’s important to note that the Court did not “uphold Obamacare.” Two specific provisions were being challenged before the Court — the individual mandate and the Medicaid expansion. If either had been struck, then the Court could have decided whether or not to take down the whole law.

Instead, it reached a very narrow decision. The individual mandate is valid as a tax, says the Court. Now, otherwise free citizens will be required to spend our own personal, after-tax money to purchase an expensive private product — $20,000 a year for an average family — or pay a tax.  And the Court said the federal government can tell states to dramatically expand their Medicaid programs but that they can’t be coerced with the threat of losing all of their federal Medicaid money if they refuse.

So let’s get ready for the debate. About seven in ten Americans had told pollsters they wanted the Supreme Court to strike down all or part of the health overhaul law. Since it didn’t do that, we all must be armed with the facts as the battles continue at least into November so the voters can issue the final verdict.

Here’s a quick checklist of the ten worst things in the law — in addition to the individual and Medicaid mandates:

1. Employer mandate. Most companies will have to provide and pay for expensive government-determined health insurance for their employees or face federal fines. 

2. Anti-conscience mandate. Religious organizations will be required to provide free sterilization, contraceptives, and abortion-inducing drugs to their employees, even if it violates their religious beliefs.

3. New and higher taxes.The law contains at least 20 new taxes totaling $500 billion that will hit medical innovators, health insurance, and even the sale of your home.

4. The Independent Payment Advisory Board. IPAB will still stand, with its rationing power over Medicare.

5. State exchanges. States will be compelled to set up vast new bureaucracies to check into our finances and families so they can hand out generous taxpayer subsidies for health insurance to families earning up to $90,000 a year.

6. Medicare payment cuts. $575 billion in payment reductions to Medicare providers and Medicare Advantage plans will cause more and more physicians to stop seeing Medicare patients, exacerbating access problems.

7. Higher health-care costs. The Kaiser Family Foundation says the average price of a family policy has risen by $2,200 during the Obama administration. The president promised premiums would be $2,500 lower by this year. Hospitals, doctors, businesses, and consumers all expect their taxes and health costs to rise under Obamacare.

8. Government control over doctor decisions.Value-based payments, quality reporting requirements, and government comparative-effectiveness boards will dictate how doctors practice medicine. Nearly half of all physicians are seriously considering leaving practice, leading to a severe doctor shortage.

9. Huge deficits. The CBO has raised its cost estimate for the law to $1.76 trillion over ten years, but that is only the opening bid as more and more people lose their job-based coverage and flood into taxpayer-subsidized insurance. At this rate, the cost will be $2 trillion, not the less than $1 trillion the president promised.

10. 159 new boards, agencies, and programs: The Obama administration will work quickly to set up as many of the law’s new bureaucracies as fast as it can so they can take root before the election.

The November elections are the last hope — we must elect a Congress and a president committed to repealing Obamacare. They, and all of us, will need to be armed with the facts to explain to the American people exactly what is in this monstrous law.

The Battle Isn’t Over



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The U.S. Supreme Court’s 5–4 decision with Chief Justice John Roberts siding with the liberal wing of the court upholds the individual mandate as a tax — not under the Commerce Clause which grants Congress the power to regulate commerce. As of this morning, the Patient Protection and Affordable Care Act is now upheld as constitutional. 

However, there was one small victory in that the Court at least ruled that by restricting the limits of the Commerce Clause, the federal government does not have the authority to create activity for the purpose of regulating it. The good news is the government will not be able to force me to eat broccoli or purchase a Prius against my will. But by maintaining the mandate as a tax, it means that this regressive tax will have the most impact on the middle class. This is something that the president wanted to avoid as he had promised the American people there would be no tax increases on the middle class.

The high court may have deemed Obamacare constitutional, but politicians in both parties realize that this ruling won’t bring about affordable, accessible, quality care for all Americans. Health-care spending already accounts for 17.9 percent of GDP or one-sixth of our economy. According to a study published in Health Affairs, it will reach 20 percent of GDP by 2020 unless changes are made. And for many people, coverage will remain unaffordable.

The president had two main goals for the law: universal coverage and bending the cost curve down. Under Obamacare neither will be accomplished. There will still be 23 million Americans uninsured in 2019 and the cost will be about $2.7 trillion over the decade 2014 to 2024. Already costs are out of control. The Congressional Budget Office projected that between 2010 and 2020, the law would cost $940 billion. However, the cost from this year till 2022 has now been revised to $1.76 trillion. While the Court ruled the law constitutional, it doesn’t mean it is good policy.  

The polls have consistently shown that the American people do not support the law. Prior to the decision today, 54 percent of Americans wanted the law repealed. That number held steady following the ruling. And, according to a new Reuters poll, 61 percent of voters want the individual mandate repealed. 

While the decision may be a short-term victory for the president, fortunately, Americans have the chance this fall to put in place a Congress and a president who will dismantle this law as it was created — through the legislative process — and replace it with reforms that actually lower health-care costs and improve the quality of Americans’ care. Chief among these ideas are allowing a health insurance market to develop with high-deductible plans coupled with Health Savings Accounts; allowing consumers to purchase insurance across state lines; changing the federal tax code; state-based medical malpractice reform; Medicare reform that focuses on vouchers/premium support, means-testing, raising the eligibility age; block grants to the states for Medicaid, and focusing on innovation in the medical-device and drug industries so that we all have access to the latest treatments and procedures.

The battle over health-care reform will continue well into the future. Our main goal is to achieve affordable, accessible, quality care for all by empowering doctors and patients, not the federal government.

 Sally C. Pipes is President, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her latest book is The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare (Regnery 2012).

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The Price Is Right



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Dr. Tom Price, chairman of the House Republican Policy Committee Chairman responds to the Supreme Court ruling today:

“Today’s ruling by the Supreme Court has set a dangerous precedent by allowing this administration to continue pursuing its unbridled effort to erode personal freedom and undo the principles upon which this country was founded,” said Chairman Price. “President Obama’s health care law trumps personal health care choices in exchange for a more powerful Washington. It will force American citizens to endure diminished quality of care, increased insurance costs, health care rationing and excessive taxation brought on by an overzealous Washington bureaucracy. We have no choice but to exercise every possible legislative option to repeal this disastrous law, and the American people should know that House Republicans will continue to advocate on their behalf to restore personal control over health care decisions.”

“Since the beginning of this debate, Republicans have developed and promoted positive solutions that empower individuals and families to choose the health care coverage they want. We have done so because it is obvious the status quo in America’s health care system is broken and in need of reform. Our solutions would preserve the sacred doctor-patient relationship and keep unelected bureaucrats from denying access to care. Most importantly, these measures would expand access, address costs, assure quality and encourage innovation all without putting the government in control or imposing mandates.”

The orthopaedic surgeon takes the opportunity to pitch his own reform plan.

Court Upholds What Congress Disavowed



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The Supreme Court ruled that Obamacare’s individual mandate is not constitutional under the Commerce Clause, which was how Congress framed the mandate to avoid a political backlash from calling it a tax. Congress and the president swore up and down that the mandate was not a tax. Yet the Court upheld the mandate as a valid use of that disavowed taxing power. 

Where does that leave us? What Congress said the individual mandate is, the Court said is not constitutional. What Congress said the mandate is not, the Court ruled is constitutional. Everybody got that? And the Supreme Court just told Congress it is okay to lie to the people to avoid political accountability.

The key provision of the Court’s ruling on Obamacare’s Medicaid mandate is this: “Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that States accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.” This makes no sense. New Medicaid conditions can only come with new Medicaid money? Congress cannot reform Medicaid unless it spends more?

The silver lining to this ruling is that states have the power to block all of Obamacare’s new Medicaid funding, in addition to the employer mandate (tax!) and subsidies for private health-insurance companies.

Obamacare Supreme Court Decision Live Blog



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On Thursday, June 28, at 10 a.m. ET, the Supreme Court will issue its decisions in the several related issues in the Obamacare legal challenge, Florida v. HHS. Starting at 9:30, we will be here to digest the opinions, provide our own commentary, and answer questions from readers.

As a reminder, the Court in March heard oral argument on four separate questions, over three days, related to the Affordable Care Act: (1) is the individual mandate a penalty, or a tax, for purposes of the Anti-Injunction Act; (2) is the individual mandate constitutional; (3) is the mandate severable from the rest of the law; and (4) is the law’s Medicaid expansion excessively coercive upon the states. (The hyperlinks in this paragraph link to the transcripts of our previous live blogs.)

We’ll be joined by Ilya Shapiro, a constitutional scholar at the Cato Institute, who will be reporting live from the Supreme Court. In addition, we’ll have expert health policy commentary from Ben Domenech of the Heartland Institute and Nicole Fisher of the University of North Carolina. Please join us, and bring your comments and questions!

After Obamacare, Congress Needs to Confront the Control Freaks



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The United States Supreme Court will soon render a historic decision on the constitutionality of the Affordable Care Act (“Obamacare”). However the Court rules on the specific legal issues – those affecting the reach of congressional power over the lives of individuals and states — a much more basic question remains: How we are to govern ourselves?  

It’s an unavoidable question. The massive edifice of Obamacare is the greatest triumph of Progressive governance in the last hundred years: It establishes the intrusive rule of appointed and tenured “experts” — operating though a multiplicity of boards, panels and commissions — who enforce their notions of what is good for us through detailed rules and regulations. This is rule by administrators — another stage in the evolution of the “fourth branch” of government, America’s expanding administrative state.

Obamacare is also just the latest expansion of a bureaucratic empire of many kingdoms. Step by statutory step, Congress has been transferring lawmaking powers to federal agencies. Their power to make rules having the force of law has been rooted in broad and often intentionally vague statutory language, and nourished by malign neglect. Congress has persistently failed to stop, re-examine, and roll back bureaucratic excesses.

When the Environmental Protection Agency (EPA) became operational in 1970, legislative delegation had locked in its regulatory power, which judicial rulings confirmed. The aggressive agency’s own initiatives, including the granting and withholding of waivers, became commonplace. When EPA decided in 2009 to classify carbon dioxide — a natural substance that sustains plant life — as a dangerous pollutant, Congress played a tertiary role as a mere stagehand in a national drama with vast economic consequences. The agency has thus emerged as one of the most powerful players in the American economy,

Meanwhile, Obamacare has fattened the Feds’ official rule book by over 12,000 pages. The edicts range from the kind of health insurance, plans, and benefits we must have to a weird requirement that we must fund federally certified abortifacients. If the law stands, it is only the beginning. As we have already seen with exemptions for the officially favored — ranging from union health plans to chic San Francisco restaurants — some Americans will be treated differently from others. Invariably, the rule of regulators is arbitrary.  

One can, of course, complain. But tenured civil servants are not accountable to voters. Their rule-making is an often murky process, whose results are known but to those poor souls who take The Federal Register with their morning coffee.    

However the Supreme Court disposes of Obamacare, Congress must never again repeat such a gigantic statutory mistake. If Congress can make the administrative state, Congress can unmake it. Lawmakers must write clear and intelligible statutes, undertake serious regulatory reform, and demand greater agency accountability in federal rule-making. They must first control themselves, and then the control freaks.  

Robert Moffit is a Senior Fellow at the Heritage Foundation’s Center for Policy Innovation.

Don’t Be Reckless with New Drug Law



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Congress is on the verge of completing work on legislation to renew the Prescription Drug User Fee Act, which establishes the rules under which private companies pay fees to support the Food and Drug Administration’s process for reviewing their drug applications. 

Under the legislation, pharmaceutical, medical-device, and biotech companies would agree to pay at least $6 billion in user fees over the next five years to help fund the FDA’s work on reviewing submissions for safety and efficacy. The fees provide more than half of the FDA’s budget, and without them, getting new drugs and devices to patients likely would be significantly delayed.

Both houses of Congress have passed user-fee bills out of committee with strong bipartisan agreement but with some difference between the two versions. They hope to complete work in ironing out differences by the end of June. 

But the rush to complete work always opens the gate to mischief.  This time is no different.

Tucked into Section 1131 of the Senate bill is a provision that would require the creators of some new biopharmaceuticals to provide supplies of their drugs to generic competitors, but without the patient safeguards required of the brand-name companies.

This misguided policy relates to an obscure provision called the Risk Evaluation and Mitigation Strategies (REMS) guidelines. The FDA may determine that REMS information is necessary to ensure that the benefits of a drug or biological product outweigh its risks. Products with REMS requirements mean the developer must provide information to doctors, pharmacists, and patients to help manage a known or potential serious risk associated with the drug or biologic. A REMS may warn, for example, that a biologic be avoided by women who are pregnant to protect against possible birth defects.

The current PDUFA legislation would require biopharmaceutical developers to supply REMS drugs to generic manufacturers when the FDA deems it necessary. Failure to do so could expose the developer to fines and potential criminal penalties. But patients could be at risk because generic manufacturers may not comply with the same requirements for REMS notifications as do the brand-name companies developing the drug or biologic.

This provision also faces a potential constitutional challenge.  Such FDA intrusion into the marketplace would be unprecedented because the government would be compelling a commercial transaction between companies that does not involve a willing seller and willing buyer.

The REMS provision is expected to save the government at least $100 million over ten years (for reasons that are unclear even to careful observers). The risks to innovation and patient safety are incalculably larger. 

It would be reckless for Congress to even consider this provision without a complete congressional examination of the many potential adverse consequences for innovation and drug safety.

The House would be wise to reject the Senate REMS provision in the final bill to avoid this assault on patient safety and the principles of competition. 

 

Three ‘What-if’ Scenarios for Obamacare



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The health sector is in a state of semi-paralysis over the fate of Obamacare.

While the Supreme Court’s decision is likely a month away, the American people already have made up their minds: Opinion polls show support for the law is at its lowest level since it passed more than two years ago, and two-thirds of Americans say they either want the whole law or the individual mandate overturned, according to a recent Washington Post/ABC News poll.

Meanwhile, Congress, state governments, and businesses across the country are puzzling over “what if” alternatives to try to be ready when the decision is issued. Here are the three most likely options:

1) If the Court upholds the whole law, then the battles would move to the ballot box while implementation of the sweeping health overhaul charges forward. Repealing Obamacare would instantly move to the top of the agenda for the presidential contest as opponents of the law work to elect a new president and majorities in both houses of Congress who are pledged to repeal. Their arguments would be compelling since the Court’s validation of the compulsory purchase of private insurance would mean the government would have authority for the first time to direct how citizens spend their private, after-tax money.

A parade of new lawsuits would march through the courts to challenge other provisions in the law, such as the contraceptive/abortifacient/sterilization mandate that 43 Catholic institutions are challenging as a violation of religious liberty, and the Independent Payment Advisory Board — the Medicare rationing board which the Goldwater Institute in Arizona is challenging as unconstitutional.

Meanwhile, the health sector and overall economy will be forced to start answering to the 159 new agencies, programs, and bureaucracies authorized under Obamacare and complying with the 12,000 pages — and counting — of new regulations. The burden of costly mandates on businesses will kill any hopes of job recovery. And the law’s perverse incentives for employers to drop insurance will likely toss tens of millions more people into taxpayer-subsidized coverage, destroying any chances of getting the federal budget deficit under control. The legislative and legal battles over the unpopular law will go on and on.

2) If the Court strikes part of law — the individual mandate and related insurance provisions — the battle over “fixes” will be instantly engaged. The House would quickly take another repeal vote — which would likely die in the Senate — while the president and the law’s supporters would mobilize to rescue the law. Expect them to propose alternatives to the individual mandate, such as limiting enrollment in federally subsidized insurance to a fixed period each year and imposing premium penalties for people who sign up later. Another alternative: automatically enroll people in health plans but permit them to opt out.

Neither will get any traction from conservatives. They will argue that the Court has removed the center pole in the Obamacare tent, and the rest of the law therefore must be struck to avoid doing even more damage.

Full repeal will rise to the top of the political agenda for November, while the administration works overtime to put as much of the law in place as fast as possible.

The business community and health sector will have no choice but to continue their plans to implement the law, even as they operate under a continuing cloud of uncertainty awaiting the election outcome.

3) If the Court strikes the whole law, activist groups that have been the strongest supporters of Obamacare will instantly take to the airwaves and possibly the streets. To calm the protests, a new and very different conversation must begin right away about viable short- and long-term solutions.

Congress will be pressured to act quickly to rescue some of the early Obamacare provisions that already are in place, such as allowing 26-year-old “children” on their parents’ health insurance policies and insurance pools for people with pre-existing conditions.

Congress must move very cautiously with any legislative backstop. Private health insurers likely could be convinced to keep the policies in place that allow 26-year-olds to stay on their parents’ policies since the policies already have been priced and written.

There also will be pressure to continue funding for the 50,000 people receiving insurance through the law’s pre-existing condition insurance pools so they don’t get thrown off the rolls. A short-term patch may be necessary. But over the longer term, legislators should focus on helping states fund their own pre-existing condition pools, or create them, but in ways that fit their needs and resources.

Any temporary solutions should not block the path for Congress to work in the next term on real patient-centered, market-based health reform that gives people control and choice over their health care and health-coverage arrangements. After Obamacare, any new comprehensive 2,800-page health-reform bill will be toxic. Incremental steps will be essential.

Presumptive nominee Mitt Romney is expected to release details of his long-term health-policy agenda this summer, which will set the terms for the general-election conversation. In recent speeches and articles, he has emphasized his support for “a free market, federalist approach” that spurs competition, flexibility, and consumer choice. That’s a hopeful sign.

Most people know only about the few early provisions of Obamacare, and few have seen major changes to their coverage. But it is a freight train that is gaining steam every day and is headed straight at our health sector and economy in 2014.

If the Court upholds the whole law, it will quickly become clear that the law simply can’t work. The American people will resist its intrusion into their lives, the states will find new ways to fight back, lawsuits will proliferate, and Congress will be forced to protect taxpayers from its budget-busting entitlements.  

If the Court strikes it down, the nation will breathe a collective sigh of relief that we now can get on with the business of real reform that is consistent with our Constitution, our liberty, and our market economy.

— Grace-Marie Turner is president of the Galen Institute and a co-author of Why ObamaCare Is Wrong for America (Broadside/HarperCollins, 2011).

HHS, Department of Ed ‘Reach Out’ to Young Voters



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In their “Letter to University Presidents and Student Associations Regarding Health Insurance for Young Adults,” issued May 18, Department of Education secretary Arne Duncan and Health and Human Services secretary Kathleen Sibelius encouraged campus leaders to remind graduating seniors about the options now available under the Patient Protection and Affordable Care Act.  But they are doing more than simply raising awareness:

Before the new health care law, the Affordable Care Act, was passed in 2010, graduation day was the day when millions of young adults lost their health insurance, making them one of the most vulnerable groups of Americans. Many young adults were forced to go without coverage, making them just one accident or serious medical illness away from unmanageable medical bills that could make them go broke trying to pay for the care they needed….

Millions of young adults do not have to worry about this anymore.  The new health care law makes it possible for young adults under age 26 to remain on their parents’ health care plan if the policy covers dependent children.  This is true whether they are unemployed, looking for a job, married, in school, living at home, or even if they are employed but their employer does not offer coverage…. Now, graduating students are free to make career choices based on what they want to do, not where they can get health insurance.

The letter also includes a variety of ways to participate in the campaign: downloadable website “badges” by which schools can link directly to Obamacare information; a series of flyers and brochures to hand out, with a distinct brochure for each minority group; and a link to the “Young Adult Coverage” Facebook page, which features feel-good stories about youngsters already benefiting from the PPACA.

But this message is not just for collegians.  An HHS press release issued Monday, May 21, states that the secretaries “are reaching out to campus leaders to remind graduating high school, college and university seniors about their new health insurance options…” (emphasis added)  Ben Shapiro, at Breitbart.com, explains why the administration is also targeting the pre-college crowd:

This is obvious propagandizing; under the old health care law, most insurance programs allowed dependent care coverage for people under the age of 21.  So why would Sebelius and company be reaching out to high schoolers?  The answer: those high schoolers are turning 18, and can therefore vote.

Obamacare Hurts Seniors



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The Verdict’s Already In



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For those willing to look, “the Court” has ruled on Obamacare. The court of public opinion, that is. A look at recent polling only reinforces the electorate’s negative perception of the administration’s health-care overhaul. Most troubling for the White House is that the verdict — and its political consequences — could actually get worse.

Two polls released last week do not simply confirm the public’s dissatisfaction with Obamacare, they show how dangerously deep it is.

On March 26, CNN/ORC International released a poll (1,014 adults, margin of error +/- 3.1 percent) showing that only 43 percent favored the law. Worse, a combined 73 percent favored overturning some provisions (43 percent) or overturning all the provisions (30 percent). Only 23 percent wanted the law to be kept as is.

There was even more detail and even worse news for the administration in a CBS News/New York Times survey (986 adults, M.O.E. +/-3.1 percent ) released on March 26. This poll found only 36 percent of Americans approved of the law and just 26 percent wanted to retain the law without change.

The reason for these respondents’ negativity became clear from their verdict of its effect on them. Only 19 percent thought it would help them personally. Only 15 percent thought it would decrease their health costs — 52 percent thought it would increase them. By 2 to 1, they thought it would reduce (33 percent), rather than increase (17 percent), the quality of health care they received.

This serious negativity has serious implications.

The administration’s health-care law was not popular before. That’s no surprise — not to Americans and not to the White House. There’s a reason why health care was not mentioned at all in this year’s State of the Union speech and why its two-year anniversary was virtually ignored by the White House.

The Supreme Court’s case only serves to raise the profile of something that the White House would apparently like to ignore. That profile will remain raised over the next three months as we wait and speculate on the Court’s decision. But that is nothing compared to what will happen when the Court finally rules.

There are many ways that the Court could rule; however, there are very limited options as to how the public will react.

If the Court upholds the law, does anyone believe that this will reverse the negative opiniond that Americans still hold after two years’ time? It is likely to only stoke the opposition’s negative opinion.

If the Court strikes it down entirely, some have said this could help the administration by eliminating the complaints of those who oppose it and raising the fervor of those who had supported it. In what other public issues have supporters been moved to quiescence by a favorable Court ruling? As for stoking the fervor of those who had supported it, those who should be the most disappointed are those who supported the law without changes — and both polls found that group only comprises about 1 in 4.

The only good political outcome for the administration would seem to be for the Court to overturn part of the law — say, the individual mandate — and hope this creates a composite coalition of those supporting some or all of the law. Pulling against your own signature accomplishment is hardly a pleasant place for the White House to be.

The administration appears to be stuck between a rock and a hard place. Actually, it is stuck between the Court of Public Opinion and the Supreme Court. It has already lost in the first and perhaps its best outcome would be to lose, at least in part, in the second as well. Failing that, the alternative might mean losing in November.

— J. T. Young served in the Treasury Department and the Office of Management and Budget from 2001 to 2004 and as a congressional staff member from 1987 to 2000.

Swinging for the Fences on Severability



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Tuesday’s Supreme Court arguments on the individual mandate were certainly the main event from the constitutional-law perspective. But from the health-policy perspective, Wednesday’s arguments over severability were the top draw.

Even with the individual mandate in place, Obamacare is an unstable and unworkable mess. Should the Court strike only the mandate, the practical result would be to merely accelerate Obamacare’s inevitable, functional collapse.

Thus, from the perspective of health policy the more interesting question before the Court is that of severability — or, how the Court deals with the rest of Obamacare if it strikes the mandate as unconstitutional.

As Robert Alt and I noted recently, the Court has three options on severability — none of which is attractive from the Justices’ perspective:

1) Strike only the mandate, and leave the rest of the statute. That would be the equivalent of pulling the pin before tossing the hand grenade back to Congress.

2) Map the complex interrelationships between the mandate and numerous other provisions, and then try to divine a rationale for discarding (along with the mandate) some provisions, but not others.

3) Conclude that the first option is irresponsible and that the second is impossible, and therefore follow their own stated legal standard to strike the whole law — despite that being an uncomfortable practical position for most judges.

Thus, Wednesday’s oral argument on severability was essentially an exercise in the Justices trying to determine which option, from their perspective, was “least ugly.”

As the questioning unfolded it seemed that the Justices (including the Court’s liberals) grasped that discarding only the mandate and hoping for the best would be irresponsible. At least the more conservative ones also seemed to struggle with how they might find some number of other provisions to be non-severable (including even the few offered by the government) without severability devolving into an illogical and impossible exercise.

Indeed, in the questioning it became apparent that even adopting the government’s limited position of striking only a few provisions as “non-severable” from the mandate was internally inconsistent and no more logical than any other potential rationale for partial severability — points that Robert and I made in our paper. That conclusion also seemed to be reinforced (albeit, unintentionally) in the questioning of the Court-Appointed Amicus Curiae tasked with advocating for striking only the mandate — which was the decision of the Eleventh Circuit, but a position that neither the plaintiffs nor the government supported.

My overall impression was that the Justices appeared to be gravitating, reluctantly but inexorably, toward the solution that they were initially least inclined to embrace — that of striking down the whole law.

Given that context, what particularly intrigued me was that the plaintiffs’ attorney, Paul Clement, was clearly “swinging for the fences” on severability. Prior to oral arguments, there was an assumption, even among conservatives, that the plaintiffs’ argument for striking the whole law was a kind of “ask for the whole loaf to increase your chances of getting half a loaf” strategy. But Clement’s references to Buckley v. Valeo — not once, but three times, including making it the final point in his rebuttal argument — showed that he really was going for the home run.

Put in unvarnished terms, Clement was essentially saying to the Justices: “In Buckley v. Valeo, the Court struck some provisions but left standing others (including some constitutionally dubious ones), out of deference to Congress. Look at what that got you. Forty years of an unworkable statute and yet more constitutional challenges to it brought before you. The latest of those, Citizens United v. FEC, resulted in an unprecedented (and both institutionally and personally insulting) attack on you, to your face, by the president in his State of the Union Speech. That is the thanks you got for trying to be deferential to the political branches while legitimately exercising your duty to defend the First Amendment. Do yourselves, and everybody else, a big favor by not repeating that mistake in this case. Strike the whole law, and send the Congress and the president a message that they should think carefully about the Constitution before legislating. Sure, some of them are going to scream. But if you strike the whole thing, they only get to scream once.”

Of course, Clement didn’t need to spell it out quite so crassly. He knew that the Justices would read those unspoken inferences into his concluding statement — which, by the way, was also the last word in the entire argument over severability:

And that takes me to my last point, which is simply this court in Buckley created a halfway house and it took Congress 40 years to try to deal with the situation, when contrary to any time of their intent, they had to try to figure out what are we going to do when we are stuck with this ban on contributions, but we can’t get at expenditures because the Court told us we couldn’t? And for 40 years they worked in that halfway house. Why make them do that in health care? The choice is to give Congress the task of fixing this statute, the residuum of this statute after some of it is struck down, or giving them the task of simply fixing the problem on a clean slate. I don’t think that is a close choice. If the individual mandate is unconstitutional, the rest of the Act should fall.

I came away from the severability arguments thinking, for the first time, that the Court might actually strike down the entire law.

Of course that would be an excellent outcome for both the Constitution and the health system, but it would still not be the end of the matter. The Left would immediately begin bleating about the loss of Obamcare’s supposed “benefits” and attack the right for not having solutions to health-care problems. 

We on the right must be prepared to vigorously counter both lines of attack. Conservative health-policy experts at Heritage and elsewhere are already fact-checking the Left’s claimed “benefits” of Obamacare. Conservatives have also long advocated an alternative vision of a patient-driven, market-based health system, most recently summarized in Heritage’s Saving the American Dream proposal. While awaiting the Supreme Court’s decision, my colleagues and I will continue to advance in detail the benefits of conservative health reforms while also continuing to critique the flaws and failings of Obamacare.

— Ed Haislmaier is senior research fellow in health-policy studies at the Heritage Foundation.

Post-Court Report: Sally Pipes on the Future of Health-Care Reform in America



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Sally C. Pipes is president of the Pacific Research Institute and author of The Pipes Plan: The Top Ten Ways to Dismantle Obamacare. She reviews this week’s Supreme Court oral arguments and the state of health care in America, politics and all.  

KATHRYN JEAN LOPEZ: What’s your greatest hope and greatest fear about the Supreme Court and this individual-mandate case?

SALLY C. PIPES: On the Supreme Court hearings and the individual mandate, my greatest hope is that a majority of the justices decide that the mandate is unconstitutional. My greatest fear is that they decide it is constitutional and then the power of the federal government to force us to purchase things in the private market will have no bounds — health insurance first and then Prius cars, burial insurance, a ban on red meat.


LOPEZ
: Could we live with an individual mandate? 

PIPES: I believe it would be very bad for us if the individual mandate remains part of Obamacare. The cost of insurance will increase and it will not reduce the number of uninsured. In our amicus brief to the court, we were able to show that the cost shift from the uninsured to the insured for uncompensated care will increase by $3–$5 billion because of the individual mandate. This is diametrically opposite to the administration’s claim.


LOPEZ
: Could Republicans ironically lose a clarifying issue in the election this fall if the Court strikes down the mandate? 

PIPES: Should the Court strike down the individual mandate, I think it will be a positive development for Republicans seeking office. Two years after signing the law, 56 percent of Americans support repeal of the Affordable Care Act. On the individual mandate, 72 percent favor repeal. In the 2010 congressional elections, one of the main reasons Republicans took back the House and made gains in the Senate was because of their disdain over government’s takeover of the health-care system. #more#


LOPEZ
: Does anyone really know what the implications for the entire law would be if they did strike it down? 

PIPES: If the entire law is struck down by the Court, I think it will be very positive for Congress to prepare a health-care bill that will lead to affordable, accessible, quality care for all Americans. Obamacare will not lead to universal coverage and will not bend the cost curve down. The CBO recently estimated that the cost of Obamacare will almost be $1.76 trillion from 2012 to 2022. It is a far cry from the president’s desire for a plan that cost $900 billion over ten years. The real cost will probably exceed $2.6 trillion over the decade 2014 to 2024.


LOPEZ
: Is Romneycare ultimately a help or a hindrance to Mitt Romney as a general-election candidate? As a prospective conservative problem-solving president?

PIPES: I think that the president will try to use Romneycare as a tool against Mitt Romney should he be the Republican candidate. Romney will have to emphasize over and over again that if elected president his first order of business would be to get Congress to repeal Obamacare and that he would sign the bill. Such a move would help him with conservative voters who are skeptical of Romneycare and who see the similarities between Romneycare and Obamacare.


LOPEZ: Has anything surprised you this week? 

PIPES: Prior to the three days of Supreme Court hearings, I was very nervous about how the justices would deal with the Anti-Injunction Act and whether the mandate is a tax or a penalty. On the constitutionality of the individual mandate, I was worried about the positions of Justices Kennedy and Scalia. Following the hearings, I felt encouraged. However, it is not possible to predict the votes and we will have to wait for their decisions on the mandate, and if it is struck down, whether the law can survive and whether the federal government has the power to coerce the states to expand their Medicaid programs for low-income Americans.


LOPEZ: How is Obamacare already harming innovation? 

PIPES: Obamacare is harmful to innovation in the pharmaceutical and medical-device industries. Investment in research and development is already down because of Obamacare. Excise taxes on drug-company sales are already in effect. In 2013, there will be a new 2.3 percent excise tax on medical-device companies. We have already seen firms such as Stryker announce they are going to cut their workforce. These industries are job creators and will no longer be unless the Affordable Care Act is repealed and replaced.


LOPEZ: What do you make of the Department of Health and Human Services contraception/abortion/sterilization mandate debate? 

PIPES: On the HHS mandate that would force insurance companies to provide free pills for contraception, etc., I feel it is wrong and an invasion of people’s personal liberty. On a broader level, it is part of the president and the administration’s goal to increase the mandates on insurance companies, which increase costs of coverage.


LOPEZ: You write that “if the Supremes let the law stand, then the federal government’s power will effectively know no bounds.” Isn’t that just a right-wing talking point? A wee bit of an exaggeration?

PIPES: If the Supremes let the law stand, it is absolutely true that the federal government’s power will know no bounds. This was definitely evident in the hearing on Tuesday which focused on the constitutionality of the individual mandate. As Justice Kennedy, the likely swing vote on the Court, said “the ACA would change the relationship between the individual and the federal government.” He also asked Solicitor General Donald Verrilli “what constitutional power the government has to force all Americans to buy health insurance?”


LOPEZ
: Where do you stand on calling it Obamacare?

PIPES: I have written two books with Obamacare in the title: The Truth About Obamacare (Regnery 2010) and The Pipes Plan: The Top Ten Ways to Dismantle Obamacare (Regnery 2012). It was the president’s goal to be the first president in 75 years to achieve health-care reform. Hence, he owns it and the American people don’t endorse it.


LOPEZ: What happens if the individual mandate stands in court and Barack Obama is reelected? If it goes down and Barack Obama is reelected?

PIPES: If President Barack Obama is reelected and the mandate stands, it will be very difficult to repeal and replace Obamacare because he will veto any repeal bill. I think because the main cost drivers come into effect in 2014 — Medicaid expansion, employer and individual mandates, federal subsidies, ending of caps on insurance companies, and no price differential on policies for those with preexisting conditions —  it will be difficult in 2016 under a new president to reverse the law.

If the mandate is struck down and the president is reelected, I think Obama and the administration will try to move forward with the parts mentioned above, with the exception of the guaranteed-issue and community-rating provisions.


LOPEZ: “Our congressional leaders can repeal Obamacare and replace it with market based reforms that actually expand access to coverage, provide quality care, and reduce the cost of health care.” Is repeal really for real? And why are you so confident that something — never mind something market-based” would really come after it?

PIPES: The American people fear that if the legislation is not repealed, private insurers will be crowded out and we will all be left in a Canadian-style “Medicare for All” system with long waits for treatment and rationed care.

Strong leaders in Congress and a GOP president with backbone can repeal of Obamacare and introduce a new bill with market-based reforms that empower doctors and patients.


LOPEZ: Do you like anything you’re hearing from any elected official or anyone who wants to be one? 

PIPES: I think several elected officials are on board with repeal and replace, and more are joining the movement. They include Dr. Tom Price (R., Ga.), Senator Tom Coburn (R., Okla.), and Paul Ryan (R., Wisc.) to name a few.


LOPEZ: What’s so special about “The Pipes Plan”? 

PIPES: The Pipes Plan was written in an easy-to-read format so that politicians and candidates can articulate a ten-point plan to really bring about health-care reform that empowers doctors and patients. Understanding health-care reform is similar to unraveling an onion — many layers and many tearful moments. I wanted to make a reform agenda that works for all.

 

If the Mandate Falls, Would Romney Be Committed to Repealing the Rest?



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No one knows how the Supreme Court will rule on Obamacare. But let’s assume that the Court does end up striking down the individual mandate when it releases its opinion this summer, and perhaps along with it Obamacare’s “guaranteed issue” and “community rating” provisions (which together say that insurers can’t avoid offering policies to those with expensive preexisting conditions and cannot charge them any more for those conditions). And let’s assume that the Court leaves the rest of the 2,700-page monstrosity intact. This is certainly a realistic scenario.

In that event, Obamacare would still increase federal spending by about as much as (and quite possibly much more than) it would now. According to the Congressional Budget Office, Obamacare’s “coverage provisions” alone, mostly in the form of its taxpayer-subsidized “exchanges” and its massive and underreported expansion of Medicaid, would cost a colossal $2 trillion (and change) in Obamacare’s real first decade — 2014 to 2023 ($1.753 trillion from 2014 to 2022, plus more than $265 billion in 2023). These coverage provisions wouldn’t get much cheaper, and could get a lot more expensive, without the individual mandate.

Given that Mitt Romney’s own health-care overhaul in Massachusetts also offers huge taxpayer-funded exchange subsidies and also expanded Medicaid coverage in the Bay State, if Romney is then the Republican nominee, would he be committed to repealing such provisions in Obamacare? Romney said just last week that we need “to abolish” Obamacare, “root and branch.” But if the Court snips away the most visible part of Obamacare and removes it from public view, would Romney still be determined to pull out the rest, and would he make it a centerpiece of his general-election campaign?

Since Romney has said very little about Obamacare’s massive exchange subsidies and Medicaid expansion, and not a ton about Obamacare generally, these would seem to be fair questions for GOP voters to ask.

It’s More than Broccoli



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Obamacare Supreme Court Live Blog - Day Three



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Today, the Supreme Court will hear two sets of oral arguments: At 10 a.m. EST, they’ll discuss whether the individual mandate is “severable” from the rest of the Affordable Care Act, and whether the rest of the law — or part of it — should go down alongside. At 1 p.m. EST, the Court will hear arguments on whether Obamacare’s dramatic expansion of Medicaid is excessively coercive to the states, given that states are forced to go along or lose all of their Medicaid funding.

We had nearly 6,000 readers for Tuesday’s live blog on the individual mandate, so we’ll be back again, starting at 10:00 a.m., and going on until the end of the day. (The transcript of Monday’s live blog is here.) We’ll be joined, as usual, by leading conservative health-care journalists and policy experts. Please join us, and bring your comments and questions!

Avik Roy is a senior fellow at the Manhattan Institute and the author of The Apothecary, the Forbes blog on health-care and entitlement reform. You can follow him on Twitter at @aviksaroy.

Pictures from Obamacare Hearings, Day Two



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“Tea Party Patriots” try to speak as pro-Obamacare forces chant loudly that they love the law.


A woman in wheel chair opposes Obamacare because she fears her care will be rationed.

Tea Party Patriots chant “We Love Liberty.” Marchers chant “We Love ObamaCare.”

“Hey-Hey, Ho-Ho! ObamaCare has got to go!”

Obamacare is not working.

“Tell me what the Constitution looks like?” “THIS is what the Constitution looks like!”

As SCOTUS arguments end, cameras prepare for news conference with pro-Obama supporters.

An anti-Obamacare patriot!

The arguments are over and lawyers are leaving.

“Strike it down!” the crowd cheers.

This person marching with the Left seems not to have gotten the memo.

Bad community-organizing decision: The other side sent their marchers to lunch!

Tea Party supporters are having a big rally just down the street from SCOTUS.

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