ACP American College of Physicians - Internal Medicine - Doctors for Adults

A health reform wish list

Remember as a kid tossing a coin into a fountain, closing your eyes, and silently mouthing your deepest wish (a puppy, a bike, a BB gun?). Didn't work, of course, unless your parents or Santa (coincidentally?) had the same wish for you.

Nowadays, I wish there was a magical Wishing Well that would deliver on my wish for a more civil, more informed, less ideological, more evidence-based, more compassionate, and less polarizing debate over health care reform and the Affordable Care Act. More specifically, I wish:

--That fiscal conservatives who say we can't afford the ACA because it doesn't do enough to control costs would not in the next breath label as "rationing" the programs it creates to reduce costs and even improve patient outcomes. Advance care planning, Accountable Care Organizations, evidence-based benefit packages, medical homes, Comparative Effectiveness Research, regulation of insurance companies' underwriting and administrative expenses, preventive care, and even the beleaguered Independent Payment Advisory Board may save money, or maybe they won't, and maybe there is a better way (let's hear it!), but they won't ration care, period. And while we are at it, how about acknowledging that no society can spend unlimited resources on health care alone, so decisions have to be made on what we can afford, and what we can't? It is just a question of how, and by whom.

--That liberals would not automatically dismiss the concerns of conservatives about the ACA's cost. The law will cost a ton of money—a trillion dollars over the next decade, according to the CBO. Both sides should admit that even though the CBO says that the law (barely) pays for itself, long-term cost estimating is an imprecise business and it could cost more, it might cost less. One can still argue that the ACA is worth it—my view, and ACP's view—for the good it can do in expanding health insurance and eliminating other barriers to care, while still acknowledging that it is legitimate to worry about the cost of a big new entitlement program.

--Speaking of CBO, I wish that all sides (and yes, I have done this myself, mea culpa!) would stop selectively citing the CBO or the Medicare actuary when it helps their case and then dismiss the same when it doesn't. The CBO and actuaries do the best they can, but as far as know they are not soothsayers and can't see the future. And let's face it, their methodologies are rather opaque. So yes, their forecasts should be considered in context, but we should all be a bit more humble about citing them to "prove'' our own biases.

--That conservatives would stop calling the law socialism. Only in America would subsidizing the purchase of private, often for-profit, health insurance be labeled socialism! (We do have socialized medicine in the U.S—it is called the VA and the health care system for men and women in uniform administered by the Department of Defense—but even Tea Party types aren't calling for their repeal!).

--That liberals would acknowledge that the government isn't the source of all good and business and markets the source of all evil. The government does some important and good things, like regulating the safety of food and drugs, funding medical research and providing programs to help people who are falling behind—like the uninsured who will be helped by the ACA. But the government also often does things inefficiently, bureaucratically, indifferently, and expensively, and at its worst, it can stifle innovation and distort markets. And corporations—yes, even drug companies and health insurers, for heaven's sake—can simultaneously contribute to the public good and generate profits for their shareholders, like producing a new cure (drug companies) and helping millions of people afford health care (insurers).

--That conservatives would acknowledge that the government isn't the source of all evil and business and markets the source of all good. An elected government "of the people, by the people, for the people" (as Lincoln called our American democracy in his Gettysburg address) is the way that Americans make decisions together on how to "promote the public welfare" (per the constitution). Government regulation and funding can help keep us safe, find cures to diseases, and provide economic help to people (see above list) when companies and markets are unable or unwilling to. The ACA was created precisely because business and markets alone have not been able to provide tens of millions of Americans with access to affordable health insurance.

--That liberals would listen to the concerns of conservatives about government getting too involved in their health care, the most personal of personal concerns. It is not irrational or unreasonable for people to worry that if the government can define what services will be covered, how and what their physicians would be paid, what insurance companies can cover, and even require people to buy health insurance, the government will over-reach and limit personal choices and freedom.

--That conservatives would acknowledge that lack of health insurance is a matter of life and death, and that liberals would admit that having health insurance doesn't guarantee access to care. It used to be that Republicans and Democrats alike agreed that the government has a role in ensuring that all Americans have access to health insurance, but disagreed on the means, but now many on the right argue that health insurance really isn't all that important, that the uninsured get care anyway. But an Urban Institute update of a groundbreaking Institute of Medicine report from several years back found that tens of thousands of Americans die each year because of lack of health insurance. But the left needs to understand that many of the uninsured get compassionate care from selfless physicians, and that health insurance won't guarantee access if, say, there aren't enough doctors to take care of them.

In other words, my wish is that all sides of the health reform debate would be more humble, more willing to consider the other sides' views, more informed about what the law actually does and doesn't do, less inclined to use polarizing and absolutist words to make their points, that is, to be more willing to listen to each other and try to find the right balance on how much the government should be involved in health care. But getting that wish fulfilled is about as likely as the BB gun I wanted as a child and that my (rightly) protective parents would never give me.

Today's question: What do you think of my wish list? Do you have your own?

posted by BDoherty at 4:05 PM   1 Comments

Is family medicine the only “pure” primary care specialty?

posted by BDoherty at 12:19 PM   4 Comments

Walking the Walk

Talking the talk about lowering health care costs is easy, walking the walk—not so much. But today the nation’s largest physician specialty organization—the American College of Physicians—released a plan to achieve big savings in Medicare while also improving outcomes for patients. The plan, released at a press conference held in conjunction with ACP’s annual scientific meeting in New Orleans, proposed major restructuring in Medicare pricing, payments, benefits and delivery systems to achieve better value for patients and taxpayers. ACP hopes to set an example for politicians and other advocacy organizations who talk about controlling costs, but aren’t willing to walk the walk by putting any serious proposals on the table.

How does ACP propose to reduce spending while achieving better outcomes?

Allow Medicare to consider the comparative clinical effectiveness and cost of different treatments and diagnostic tests in deciding what it will pay for.

Give beneficiaries some skin in the game by allowing cost-sharing contributions to vary based on evidence of clinical effectiveness and cost, so that they would pay little or nothing out-of-pocket for services of high value, and more for services of lower value.

Cover and pay for advanced care planning and palliative care.

Allow Medicare to get the best prices for drugs by acting as a prudent buyer, just like the VA does for its programs, but Medicare is prohibited by law from doing.

Begin to pilot test ways to adjust the pricing of physician services based on evidence of clinical effectiveness, so that doctors might be paid more for services that have more value to their patients and less for ones of lesser value.

Reward and strengthen primary care, which studies show is associated with better outcomes at lower cost. Pay for models, like Patient-Centered Medical Homes, where internal medicine specialists and other primary care physicians would work with teams of other health professionals to improve care coordination and achieve better outcomes for their patients—with accountability for achieving the desired results.

In other words, allow Medicare to do what any good business or government purchaser of services would do: purchase care that has been shown to deliver the best bang for the buck.

Common sense, you would think, but ACP’s proposals will invite controversy because much of the health care industry benefits from the status quo. If you are a physician who is doing just fine because Medicare pays you more than its services might be worth to the patient, you won’t want change. If you are medical device manufacturer that is doing just fine because you can get Medicare to cover the fanciest and newest diagnostic test without having to show that it offers any real value over existing and less costly alternatives, you won’t want change. If you are a drug manufacturer that is doing just fine by charging the federal government and patients a lot more than you would get if you had to competitively bid for Medicare’s business, you won’t want change.

But for internal medicine specialists and their patients, change is needed because the status quo is not working. You are not being paid commensurate with your value. You are not paid for things that can improve outcomes and save money, like advanced care planning and care coordination of high-risk, high-cost patients. You and your patients are not benefiting when hundreds of billions of dollars are wasted each year on things that have little or no clinical value or are overpriced, money that could be used to shore up support for primary care internal medicine and cut the deficit.

Some controversial ideas to save Medicare money have not earned ACP’s support, because they would shift more costs onto the backs of seniors who can’t afford to pay more. So in the position paper released this morning, ACP reaffirmed its opposition to a Medicare premium support model, unless and until well-designed pilot tests are done to determine the impact of premium support on patients’ access and out-of-pocket costs, adverse selection, and other factors.

Making seniors wait until age 67 instead of 65 to qualify for Medicare also didn’t make ACP’s cut, because this will just lead to more uninsured seniors—although some of them would end up on underfunded Medicaid programs—unless they are provided other affordable coverage options during the two more years they would have to wait for Medicare. For instance, ACP suggested that advancing the age of Medicare eligibility could be accompanied by allowing anyone over the age of 55 to buy into Medicare, with subsidies for lower-income persons, bringing more younger and lower-risk, lower-spending persons into the program while providing a coverage bridge until they reach age 67.

By walking the walk on proposing ways to lower Medicare costs while improving outcomes, ACP will get its share of abuse. I have no doubt that someone will try to pin the "rationing" label on us, even though there is a huge difference between spending money rationally by taking into account value to the patient—ACP’s approach—and denying access to services that actually have been shown to have value because the government doesn’t want to pay for them, the true definition of rationing.

But someone had to take the issue of unsustainable Medicare spending head on, and I am glad it is an organization of internal medicine specialists, because doctors more than anyone else have the credibility with the public, and the understanding of where our health care dollars are going, to make a real contribution to enlightening the debate on health care costs.

Today’s question: What do you think of ACP’s proposals to reform Medicare in an age of deficit reduction?

posted by BDoherty at 3:55 PM   2 Comments

"You say you want a revolution, well you know, we’d all like to see the plan"

Many skeptical doctors react to the mantra about revolutionizing health care delivery the same way John Lennon did when he wrote these lyrics for the 1968 Beatles anthem. Well you know, they’d all like to see the plan.

Well, you know, this week Medicare released two critical pieces of its plan to revolutionize health care delivery, naming the 27 medical organizations/groups selected for Medicare’s Shared Savings (Accountable Care Organization) program, and the geographic sites chosen for the Comprehensive Primary Care Initiative. (As I blogged in September, the Comprehensive Primary Care Initiative could be a game-changer for primary care, because it will provide sustained financial support and revenue opportunities from Medicare and private payers for participating practices.)

The Innovation Center’s announcements this week effectively counter two pernicious myths about the Affordable Care Act and physicians:

Myth # 1: That the government is trying to put independent physician practices out of business.

Myth # 2: That the government wants to put hospitals in control of physicians.

Actually, a majority of the organizations selected for the Shared Savings Program are "physician-led," as the AMA noted in praising the CMS announcement. But you don’t have to take the AMA’s (or my) word for it: just look at the descriptions from CMS and the physicians themselves of several of the 27 organizations who voluntarily agreed to join the Shared Savings Program:

The Atlantic Integrated Health Network "is one of the oldest self-sustaining physician-led networks in North Carolina."

The Coalition of Athens Area Physicians "represents 300 independent physicians from Athens, Georgia and surrounding counties."

Mississippi Coast Physicians "was founded by community physicians to offer accessible, cost effective and high quality healthcare services to employers and healthcare consumers along the Mississippi Gulf Coast."

North Country Physicians Organization "is a physician organization of 160 physicians" in upstate New York.

The Independent Physicians Network is "a Physician managed and controlled medical delivery network established in 1984" in the Milwaukee, WI community.

Accountable Care Coalition of Texas, Inc. is "an ACO created through a partnership between an affiliation of Independent Physician Associations, medical groups and health systems in the Houston/Beaumont area of Texas and Collaborative Health Systems."

"Owned and managed by physicians, AppleCare Medical ACO partners with more than 800 physicians in the region, as well as major hospitals and medical centers across Southern California to provide access to a full spectrum of facilities for receiving whatever care a patient may require."

"Located in Buffalo, NY, Catholic Medical Partners is a network of more than 900 independent practicing physicians."

"Coastal Carolina Health Care, the ACO’s sole participant, is a physician-owned and operated medical practice with over 50 providers."

There’s many more physician organizations in the 27 ACOs selected by CMS, but I think you get the point: physicians are the ones who will be leading the ACO revolution, through physician-controlled and owned organizations, ranging from tightly integrated group practices to looser coalitions and networks of independent smaller practices. The Comprehensive Primary Care Initiative will soon provide an opportunity for another 500 or so physician practices to lead the transition to the Patient-Centered Medical Home model, supported but not controlled by Medicare and other payers.

Well, you know, this is the way it should be: ACP has long argued that physicians are uniquely qualified to achieve the triple aim of better individual patient health outcomes, better population health, and lower per capita costs—not the government, not the hospitals, and not insurance companies. It is good to see this is Medicare’s plan as well.

Today’s question: What do you think CMS’s announcements say about its view of the role of independent, physician-owned organizations in revolutionizing health care delivery?

posted by BDoherty at 12:22 PM   6 Comments

Overturn the ACA, and chaos will follow

Imagine you’re a physician, and you have a full schedule of patients to see the day after the Supreme Court has thrown out the entire Affordable Care Act. Imagine you never liked “Obamacare” in the first place, so you are feeling pretty good about the Supreme Court decision.

Your first patient, an elderly retiree named Mrs. Jones, comes in for her annual Medicare wellness visit—one of the new Medicare preventive benefits offered at no cost to the patient. But this new preventive service benefit was created by the ACA, so presumably with the ACA overturned, Medicare no longer is allowed to pay for wellness visits. Do you tell Mrs. Jones that Medicare might not cover the visit? Provide the visit anyway, hoping that somehow Medicare will find a way around the Supreme Court ruling and pay for it? Offer it at no charge, or try to collect the 20% you would collect for a normal (non-preventive) office visit? 

Your second patient, Mr. Jones, another senior, comes in for a follow-up visit for an ongoing chronic condition. You decide to renew his expensive brand-name prescription drug, knowing that he is eligible for a 50% discount because he has fallen into the Medicare Part D “doughnut hole.” Oh wait ... the Medicare Part D drug discount was part of the now-defunct ACA. So does that mean he now has to pay full price? Do you prescribe the drug anyway, knowing he can’t afford to pay the regular retail price? Prescribe a lower cost no-name brand drug that he doesn’t tolerate as well?

Your billing person prepares to submit the claim for Mr. Jones’ office visit. It ordinarily would have been eligible for the 10% bonus that Medicare pays for all office visits, nursing home and custodial care visits provided by primary care physicians. But that was before the Supreme Court overturned the ACA, and with it, wiped out the primary care bonus created by the law. With the bonus gone, your practice will lose about $4,000 over the next six months. Does the bonus disappear immediately—with this visit? What happens to bonus payments that were already paid out? Who knows?

Next up is Ms. Wilkins, a single mother of three who is seeing you for her diabetes and congestive heart failure. She is fortunate enough to be among the 50,000 Americans enrolled in the low-cost Pre-existing Condition Insurance Plan created by the Affordable Care Act and administered by the state. Oh wait, that was until the Supreme Court decision. With the ACA gone, the authority and funding for the Pre-existing Condition Insurance Plan disappears. Will she still be covered for this visit and any tests or medications she needs? And if so, for how long before the program is forced to shut down? Where else will she find affordable insurance? Will she go without it? Who knows?

A text message comes into you from your 22 year old son, a recent college graduate who hasn’t found a job. He has a doctor’s appointment for the knee he hurt playing rugby, and wants to know if he still will be covered by your health insurance plan. But the requirement that young adults up to age 26 be covered by their parents’ plans was part of the ACA, so presumably, your health plan no longer is obligated to keep him. Will it drop him? If it keeps him on, for how long, and for what extra premium? 

You start thinking about your oldest daughter, a fourth year medical student who plans to apply for a loan repayment program from the National Health Services Corps in exchange for providing primary care in an underserved community. But the funding for NHSC in 2012 comes entirely from dollars mandated by the ACA. Will the NHSC now have to cut back on its award amounts and recipients? When, and by how much? Will she no longer be able to get a NHSC slot?

Your practice has joined with other primary care physicians in the community to become an accountable care organization (ACO) under the Medicare Shared Savings Program. It has spent tens of thousands of dollars and countless hours to do the planning and set up the infrastructure to qualify. But the federal money to pay for the Shared Savings Program comes from funds obligated by the ACA, so with the ACA gone, the ACO program may be suspended as well. Does that mean your practice wasted all of that money preparing to become an ACO?

Your local medical school has applied for Title VII primary care grants for faculty and scholarships for low-income students—the only federal program specifically designated to support primary care training. But the Title VII grant program was part of the ACA. Does that mean that the grants will be suspended? Who knows?

Your hospital expanded its internal medicine residency program because of a provision in the ACA that redistributes unused residency slots in other specialties to primary care. Who will pay for them if Medicare can’t? Will the slots have to be eliminated?

I could write pages and pages more of programs created by the ACA that would be invalidated if the Supreme Court overturns the whole law. What I can’t tell you—what no one can tell you—is how the federal government will deal with the absolute chaos that will follow.

Rules will have to be withdrawn and re-written, contracts suspended, agencies closed down or downsized, agreements renegotiated, delivery reform pilots terminated or scaled back, and mandated insurance protections suspended—with little guidance from the Supreme Court or Congress on what to do next. And there’s almost no chance that Congress will step in to repair the wreckage.

In the meantime, physicians and patients will be left reeling by the resulting chaos and confusion created by the court’s decision.

I haven’t even mentioned the 32 million Americans who would have gotten coverage in 2014 if the law was sustained—but will lose the most if the court overturns it. 

Henry Aaron, a renowned health care expert at the Brookings Institution, also predicts chaos if the Supreme Court overrules the law:

“And what if the Supreme Court throws out the whole bill?

That would leave America, including the nearly 50 million uninsured, even worse off than we were four years ago: with higher costs, more uninsured and a political atmosphere poisoned by the failure of an all-out effort to reform a health care system everyone knows is flawed.

Health insurance costs, driven by the steady march of new technology and population aging, will claim ever larger shares of our income. Those higher costs will make health insurance unaffordable for more and more people.

It would be hard to imagine any President or Congress returning for a generation to touch the endless political grief of basic health care reform with a ten-foot pole.

Is that the future we want?”

Today’s questions: What are you going to do to prepare for the chaos that will happen if the Supreme Court overturns the entire Affordable Care Act? Is that the future we want?

posted by BDoherty at 2:32 PM   9 Comments

Don’t Ask, Don’t Tell

Don’t Ask, Don’t Tell is making a comeback—directed now at doctors, not the military, but this version has nothing to do with sexual orientation and everything to do with the doctor-patient relationship.

Lawmakers across the country are involved in a feeding frenzy to see who can pass the most obnoxious, offensive and intrusive laws to prohibit physicians from asking or telling patients about clinical information that is relevant to their health. They also are going at the physician-patient relationship from the opposite direction, mandating what physicians must ask or tell patients about their medical care—and even what tests and procedures they have to impose on them. Without regard to a physician’s clinical judgment, patient preferences, informed consent, clinical effectiveness, medical necessity, or cost!

To illustrate how ridiculous this has gotten, last June I posted a satirical description of a new Florida law to prohibit doctors from discussing alcohol consumption with their patients.  Actually, the real Florida law prohibits doctors from asking or telling patients about firearms safety—but to make my point, I substituted references to alcohol whenever firearms were referenced in the actual statute, such as:

“An act relating to the privacy of consumers of alcoholic beverages; providing that a licensed medical care practitioner or health care facility may not record information regarding ownership or consumption of alcoholic beverages in a patient's medical record . . .”

I asked “If Florida’s ban [on doctors asking patients about firearms] stands up in court, is it really out of the question that manufacturers and sellers of whiskey, or red meat, or even marijuana, might want to do the same?”

Well, I didn’t think to include fracking (high-pressure chemicals, sand, and water that is blasted into rock to tap into natural gas). Pennsylvania has passed a law so that doctors can get information from mining companies about a patient’s potential exposure to hazardous chemicals related to fracking, but they can’t disclose the information to anyone, including the patient they are treating! Here is the offending section of the PA law:

“If a health professional determines that a medical emergency exists and the specific identity and amount of any chemicals claimed to be a trade secret or confidential proprietary information are necessary for emergency treatment, the vendor, service provider or operator shall immediately disclose the information to the health professional upon a verbal acknowledgment by the health professional that the information may not be used for purposes other than the health needs asserted and that the health professional shall maintain the information as confidential. The vendor, service provider or operator may request, and the health professional shall provide upon request, a written statement of need and a confidentiality agreement from the health professional as soon as circumstances permit, in conformance with regulations promulgated under this chapter.”

Excuse me, but doesn’t this seem fracking ridiculous to you? If I were a patient, and my doctor found out that I had been exposed to specific chemicals that might have harmed my health, shouldn’t I have the right to know about them—and shouldn’t my doctor be obligated to tell me?

To be clear, the American College of Physicians has no policies on fracking. We don’t have policies on access to abortion services, or the right to bear arms (although we do support gun safety screening as part of a preventive risk assessment). On a few occasions, we or our state chapters have taken positions on state laws based on broad policies on the doctor-patient relationship and informed consent. With the national ACP’s support, our Florida chapter has objected to and joined in a lawsuit to successfully block the Florida gun safety gag rule. And ACP’s Virginia chapter recently wrote to its legislature to urge opposition to Virginia’s ultrasound before abortion bill, on the basis that “this legislation represents a dangerous and unprecedented intrusion by the Commonwealth of Virginia into patient privacy and that it encroaches on the doctor-patient relationship . . .” The chapter pointed out that it has no position, individually or collectively, on abortion itself. (An amended version of the bill passed and was signed into law by the governor.)

State lawmakers will offer all kinds of reasons for intruding into the doctor-patient relationship, from protecting business interests, to their ideology, to constitutional rights, to seemingly sincere and principled views on the morality and need for different medical interventions.  But to me, the issue comes down to one thing: the government not telling my doctor what he can say or do or the decisions we make together about my health. 

You would think that at least some of the people who are parading with their “Keep government out of health care” signs today outside the Supreme Court today would be even more concerned about their own states’ efforts to insert government, in the most fundamental and intrusive ways possible, into the relationship between doctors and their patients. They may discover that the real government takeover of medicine is happening in their own state capitols, not Washington. 

Today’s questions:  What do you think of state laws to tell doctors what they can and can’t ask or tell patients or what tests they must perform on them? And why do you think that there is not more of an outcry about such laws from the public, and from many physicians?

posted by BDoherty at 2:57 PM   4 Comments

What now for health reform?

Today, the American College of Physicians, the nation's second largest physician membership organization and largest specialty society, reminded the public why it is essential that the country not turn its back on reforms to provide all Americans with access to affordable health coverage. The statement, issued the day that the Supreme Court will begin to hear oral arguments about the Affordable Care Act's constitutionality and three days after the second anniversary of it being signed into law, points to the millions of Americans who already have been helped by the law. These include: young adults who are now on their parents' plans, children who can't be turned down because they have a pre-existing condition, seniors who have access to no-cost preventive services and reduced prices on prescription drugs, and fourth year medical students who are getting loan forgiveness or scholarships to practice primary care in underserved areas.

But the biggest changes are yet to come: affordable health insurance for nearly all Americans and 32 million fewer uninsured, to be achieved by offering sliding scale subsidies to help people with incomes up to 400 percent of the poverty level buy competitive private insurance offered through state-run exchanges, expanding Medicaid to pay for the poorest families (paid for almost entirely by the federal government—100 percent in 2014, going down to 90 percent of the cost by 2020—so that it isn't an unfunded mandate on the states), and a ban on insurance companies turning down or overcharging anyone who has a pre-existing condition. Oh, and the requirement that people pay a small (but unenforceable) penalty—the law doesn't allow the government to file charges or liens against people who refuse to pay—if they can afford health insurance but refuse to buy it.

These changes are hardly radical, and they are not "socialized medicine." (Only in the weird world of American partisan politics could subsidizing someone to buy for-profit private insurance be called socialism.)

And they used to have bipartisan support. ACP first proposed a similar set of policies in 2002 with no objections from our more conservative members—in fact, the only objections I recall came from liberal doctors who favored a single payer system! ACP's ideas were then incorporated into a bipartisan bill, the HealthCARE Act, introduced in two consecutive Congresses. Conservative think tanks including the Heritage Foundation until recently advocated a similar set of policies, including the individual insurance requirement that it now says is unconstitutional. 

It was only when these policies became the Affordable Care Act, or "Obamacare," that bipartisan consensus broke down. 

Now, the question is: will the Supreme Court, and the U.S. political process, allow these reforms to remain, or will we go back to the days when the country tolerated 50 million or more uninsured persons and allowed insurance companies to cherry-pick who they choose to insure? 

I don't know what the Supreme Court will rule, and ACP's statement stayed away from the constitutional arguments because the organization's expertise is in evidence-based development of health policy, not constitutional law. But based on its assessment of the most effective ways to expand access to health care, ACP concluded that the key reforms created by the ACA—subsidies, exchanges, Medicaid expansion, and the individual insurance requirement—should be maintained.  

I see no other viable political pathway to achieve ACP's decades-long vision that every American, no matter where they live or work or how rich or poor they are, should have access to affordable coverage for essential health benefits. If the ACA goes, there will not be a "replacement" plan offered by the law's opponents that will come anywhere close to providing coverage to nearly all Americans. (The GOP plans offered to date—health savings accounts, buying insurance across state lines, and medical liability reforms—would not materially reduce the percentage of uninsured Americans, according to the Congressional Budget Office.)

People will disagree on whether universal health insurance coverage is a right, but there didn't use to be much disagreement that it is the right thing to do. As we hear arguments over the next few days about the Commerce Clause, states’ rights, the anti-injunction act, broccoli, and rationing, I hope we don't forget the millions who have been helped by the ACA, and the millions more who will be if it is allowed to stand.

posted by BDoherty at 11:56 AM   4 Comments

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