A Conservative’s Premium Argument Dissected.

An ongoing series addressing the arguments of my conservative relatives.  They’ve drunk of the Tea Party Kool-aid.  I despair for them, but I will at least examine the arguments they make to support their views, which is more than they do for me.

For reference, here is the link to the  actual text of the ACA:
 

The Patient Protection and Affordable Health Care Act
  

From now on, any counter-arguments made about the law must contain references to the law.  No excuses, I’ve given you the link to the act.  I’m digging through it, you can – and should – too.

Of course, in some cases, the actual act doesn’t come into play.  In this case, you must cite a study that contradicts the studies cited here.  I can be wrong, but only facts will sway me, not links to opinion pieces by conservative pundits.

In this installment, we will analyze an article in Forbes that claims they have a study that shows that the ACA will increase insurance premiums as much as 99% for men.  So who authored this study?  The Manhattan Institute, a Libertarian think tank.  Among its patrons are the infamous Koch brothers.

Based on a Manhattan Institute analysis of the HHS numbers, Obamacare will increase underlying insurance rates for younger men by an average of 97 to 99 percent, and for younger women by an average of 55 to 62 percent. Worst off is North Carolina, which will see individual-market rates triple for women, and quadruple for men.

So there’s the claim.  But the article goes on:

“Premiums nationwide will also be around 16 percent lower than originally expected,” HHS cheerfully announces in its press release. But that’s a ruse. HHS compared what the Congressional Budget Office projected rates might look like—in 2016—to its own findings. Neither of those numbers tells you the stat that really matters: how much rates will go up next year, under Obamacare, relative to this year, prior to the law taking effect.

The claim here is that although HHS is saying that premiums are going to be lower than projected, that’s only in comparison to their previous statements on premiums.  In other words, the premiums are only lower than projected ACA premium costs, and not 16% lower than pre-ACA health plans.

Here is something to note, right off the bat:

Earlier this month, I and two colleagues from the Manhattan Institute… published an interactive map that detailed Obamacare’s impact on individually-purchased health insurance premiums in 13 states plus D.C. As the accompanying article described, Obamacare increased premiums in those states by an average of 24 percent.

But those states were largely blue states that had set up their own, state-based insurance exchanges.

I just want to hold on to this: in states that did NOT fully utilize the ACA, premiums are expected to increase an average of 24%.  Remember this.  It implies that this excessive premium inflation only occurs in states that are not fully implementing the ACA.  To me, that indicates that the ACA is having a positive effect, even if it’s less than hoped for.

 

But here’s the more important omission, and the flaw that basically runs a stake through the heart of this study:

So, we conducted two comparisons between pre-ACA data and post-ACA data, as reported by HHS. The first comparison is between the cheapest plan available to 27-year-olds pre- and post-Obamacare. The second is between the cheapeast plan available to the average exchange participant, and to the typical 40-year-old pre-Obamacare.

On the face of it, it looks, fine, right?  Even when you visit the Institute website, we find that indeed, they omitted a key piece of data:

Our pre-ACA dataset consists of the five least expensive plans (by monthly premium) for the most populous zip code in every county. To cover a significant age range we collected rates for 27, 40, and 64-year old male and female non-smokers. We adjusted these rates to take into account those who are denied health insurance coverage as well as those who receive a surcharge. Using the "denial rate" and "surcharge rate" from the federal government's repository, we assumed that those who are surcharged pay 75 percent more and those who are denied, find insurance elsewhere at three times the original rate. We used this to develop a weighted average of the five least expensive insurance plans for every zip code we identified. To develop a state-wide average, we took the state-wide average for every age-gender combination.

Here’s the fatal flaw of this study: while the study does compare the lowest priced available pre-ACA insurance plan against the costs of the lowest-priced post-ACA plan, the study doesn’t actually compare the coverage or benefits of the plans.  Nowhere does the study indicate that the plans being compared offered a similar scope of coverage and benefits.
 

The Kaiser Institute makes this point:

…plans offered in the exchanges –along with coverage sold to individual and small businesses outside the exchanges–must meet several new regulatory requirements. For example,insurers must cover a minimum set of services called essential health benefits…

The Manhattan Institute study didn’t compare premiums on similar plans, they simply compared the lowest priced plans without regard to the difference in coverage.  If the pre-ACA plans do not offer the same scope of coverage, no valid comparison actually exists.

It’s like comparing the costs of raisins against apples.   A single apple costs many times what a single raisin does.     But when you factor in the fact that we eat raisins by the handful, your perception of costs must shift.  A serving of raisins costs the same as a serving of apple.

 

Comparing health insurance plans by premium costs alone without regard for the benefits covered will not yield valid results.

 

McClatchy News Services took a look at several studies on the effects of premiums by the ACA:

“Our analysis found no widespread trend toward sharply higher prices in the individual market,” said a statement by Christine Eibner, a senior economist at RAND, a non-profit research organization based in Santa Monica, Calif.

 “We know what the cost of employer-based insurance is, and these rates are what you’d expect to see for similar benefits,” said Gary Claxton, vice president of the Kaiser Family Foundation. “These rates don’t look to be so high that we should have the sort of widespread sticker shock.”

In a study of 12 states, Avalere found that minimum premiums for a 40-year-old non-smoker averaged $261 for a Silver plan. Maryland had the lowest-cost Silver plan at $197 per month, while Vermont’s lowest-priced Silver plan cost the most at $383.

But McClatchy did include the Manhattan Institute study in their research:

New research by the conservative Manhattan Institute appears to be an outlier. Its report found nine states will see premiums increase, on average, under Obamacare next year, while five others will see average rate declines.

In other words, the Mahattan Institute’s study varies widely from the results of all the other studies.

 

The New Republic believes that all the studies may be accurate.  But it starts by making the point that the premium costs only apply to individual plans, not the group health plans that most of us are part of.

Remember, everything you are about to read is about the “non-group” market only—i.e., it describes changes for people who buy coverage on their own, directly from insurance carriers or through brokers. That’s a relatively small number of people. The vast majority of Americans get insurance through large employers, Medicare, or Medicaid. That's not going to change anytime soon, so none of the following really applies to them

The article then makes the point I just made:

1. Thanks to Obamacare regulations on insurers, the “sticker price” of coverage will go up. Non-group coverage today is usually pretty cheap. One reason is that it frequently has big gaps in coverage—no benefits for maternity or prescription drugs, for example, or deductibles that reach into five figures…

Under the law, all plans will include a basic, essential set of benefits—and must be sufficiently generous to cover at least 60 percent of the typical person’s medical bills. (That’s the standard for "bronze" plans. "Silver," "gold," and "platinum" insurance options would cover a greater share of expenses.) Insurers must also sell coverage to anybody who wants it, regardless of medical condition, without raising prices or withholding benefits. These and other requirements make insurance more comprehensive and more widely available, which is what reformers promised to do. But the regulations also make it more expensive.

And this is a fair observation, and it is borne out by the studies.  Yes, premiums for individuals is going to go up, but so is what they are getting.  And  the article goes on to point out something else we should keep in mind:

Under the law, subsidies are generally available to anybody with income that is less than four times the poverty line—which is about $46,000 a year for an individual and $94,000 a year for a family of four. Most Americans make less than that. The amount will vary by income, with poorer people getting more assistance. But among those families receiving assistance, the subsidies will be worth an average of $2,600 per year, according to another recent Kaiser Family Foundation study. That's a lot of money. And remember the subsidies act as discounts: If you are eligible for a subsidy, you don’t have to wait until you file your tax return to get your money back. Instead, the government will calculate your subsidy when you apply for insurance,

Conservatives note that subsidies aren’t free: They cost money, which the law generates through a combination of taxes (mostly on wealthy people) and reduced spending (mostly through Medicare paying less for goods and services).

This means that where the Manhattan Institute study may be correct in some instances about how much higher premiums will be, the study did not account for income or the attendant tax credits for individuals in the lower income brackets.

And The New Republic reaches the same conclusion I do:

…the lack of good data on what people pay today makes it almost impossible to be certain how premiums will change, and they're not even sure the comparison is valid. If you're paying more for a more comprehensive and stable insurance policy, does that qualify as "rate shock"? But, when pressed by reporters like me, they say the majority of people will probably end up paying less than they do now, as long as you account for subsidies, Medicaid, and the ability of young adults to enroll in special catastrophic plans or stay on their parents' policies.

But even cheap insurance can seem expensive when you're struggling just to pay other bills. How you react to the new prices will depend a lot on how much you value protection from financial shock and access to medical care—and whether you care about paying a modest penalty for having no insurance.

The bottom line is that three out of four surveys indicate that individual health insurance costs will be lower on average than they were prior to the ACA, when you factor in all the coverage benefits in addition to the mere dollar figure of the monthly premium.

A Connservative’s Argument, Dissected (part 3)

This is the third  part of my dissection of my conservative relatives’ arguments against The Patient Protection and Affordable Health Care Act. Part One can be found HERE.  Part Two can be found HERE.
 

Here is the first article one of my relatives offered to support their position:

 

15 Reasons Why The Obamacare Decision Is A Mind Blowing Disaster For America

  

Here is the link to the  actual text of the ACA:

  

The Patient Protection and Affordable Health Care Act

   

From now on, any counter-arguments you make about the law must contain references to the law.  No excuses, because, hey, I’ve given you the link to the act.

  

So here are the second group of five reasons out of the fifteen outlined by Michael Snyder for End Of The American Dream:

#11 Obamacare is going to result in a much bigger federal government.  In order to fully implement all of the provisions of Obamacare, hordes of new government bureaucrats will be required.

 We’ll grant this one, but so what?  The Homeland Security Act vastly expanded the size of the federal government.  And I guess Mr. Snyder didn’t notice that we still have millions of Americans looking for work.

 

I find #11 to be essentially correct; the ACA brings the added bonus of creating new jobs for Americans.

#12 Thanks to Obamacare, you are going to have to wait much longer to see a doctor.  Just look at what happened once Romneycare was implemented in Massachusetts….

In fact, we have already seen the start of this process in Massachusetts, where Mitt Romney’s health care reforms were nearly identical to President Obama’s. Romney’s reforms increased the demand for health care but did nothing to expand the supply of physicians. In fact, by cracking down on insurance premiums, Massachusetts pushed insurers to reduce their payments to providers, making it less worthwhile for doctors to expand their practices. As a result, the average wait to get an appointment with a doctor grew from 33 days to over 55 days.

Once again, Mr. Snyder’s citation is a dead end: the link to a New York Post article has expired.  But FactCheck.org has looked into this very topic:

Those who claim the law caused longer waiting times frequently cite annual surveys by the Massachusetts Medical Society. Its 2010 survey did find that the average wait time for internal medicine had gone up by six days since 2005 — to 53 days. But results were mixed — the average wait for family medicine went down by 15 days from the year before to 29 days. Wait times for other specialties were down too, since 2005, including those for cardiology, gastroenterology and orthopedic surgery.
 
Regardless of waiting times, however, access to care and use of care overall have actually gone up, according to the Urban Institute’s Sharon K. Long, a professor at the University of Minnesota’s School of Public Health.

Of course, when you combine the ongoing doctor shortage with the increase in the number of patients trying to see them, it is likely that wait times will increase.  But the solution is to lobby Congress to help medical students settle their student loan debt so more of them will move into medical practice as doctors, instead of opting for more immediately lucrative medical technician positions.

I find that Reason #12 airs a valid concern, but does not support repeal of the ACA.

#13 Obamacare contains all kinds of insidious little provisions that most people don’t even know about.  The following is one example from the Alliance Defense Fund….

“Did you know that with ObamaCare you will have to pay for life-saving drugs, but life-ending drugs are free. One hundred percent free. If this plan were really about health care wouldn’t it be the other way around?”

It sounds like they’re saying that you can kill yourself for free, but you have to pay to live. It’s almost the return of the Death Panels.  I can’t find anything in the ACA about euthanasia benefits.

 

So what are these “life-ending drugs” they speak of?  According to Alliance Defense Fund literature:

ObamaCare and its Mandates Fact Sheet

HHS Mandate

• Provides “free coverage for early-abortion pills, contraceptives, sterilizations, and “education and counseling” about choosing and using those things (Women’s Preventive Services Guidelines and HHS Mandates Pg. 2)
• While these items are “free”, nearly all other medications (heart pills, insulin, etc.) still cost the same.

They are referring to mifepristone, or RU-486.  Labelling it a “life ending drug” requires no small amount of hubris. And in fact, insurance plans are not required to cover drugs to induce abortions.

I find that reason #13 is false, at least given that the single example of “insidious little provisions” turns out to be false.

#14  As if the U.S. government was not facing enough of a crisis with entitlement spending, it is being projected that Obamacare will add 16 million more Americans to the Medicaid rolls.  You and I will be paying for all of this.

Unfortunately, Mr. Snyder’s source is an article behind the paywall of Investor’s Business Daily.  However, the Congressional Budget Office is free.  And the source of the information in the first place.  And it reports: 

According to the current estimates, from 2016 on, between 20 million and 23 million people will receive coverage through the new insurance exchanges, and 16 million to 17 million additional people will be enrolled in Medicaid and CHIP as a result of ACA.  

And do you know who has been paying for these 16 million people prior to the ACA?  You and I.  Only we paid more because people only went to the hospital when they had a health crisis, resulting in higher costs.  And because they weren’t in any sort of plan, the bills were a lot higher than if they’d been enrolled in Medicaid to begin with.

 

But Medicaid is administered by the states, and the states can opt out of expanding Medicaid coverage.  In those states that choose not to expand, the rest of us will cover the costs of indigent care through higher premiums instead of through tax dollars.  Either way, we pay.  And that’s just the facts.

 

So while #14 is true, it is also not a reason to repeal Obamacare.

#15 The Congressional Budget Office estimates that Obamacare will add more than a trillion dollars to government spending over the next decade.  Considering the fact that the U.S. government is already drowning in debt, how in the world can we afford this?

I must preface this with the fact that there is a difference between spending and debt.  Not all spending contributes to the deficit.  Deficits occur when spending is mandated without a revenue stream in place to fund the spending, or the mandated revenue stream brings in fewer funds than are disbursed.  But if you mandate spending, and install an adequate revenue stream, you do not create a deficit.

Once again, Mr. Snyder cites himself to support this claim.  In his article, he cites a story in USA Today talks about the deficit, but it says nothing about the ACA’s effects on the budget deficit.

But Politifact has examined claims from US Representative Morgan Griffith (R-Va) that the ACA will add $6.2 trillion to long-term deficits.  His claims are based on a January 2013 GAO study.  That study analyzed two scenarios: one in which the ACA remained completely intact, and the other in which the coverage requirements were kept, but all the cost containment measures were phased out.

The GAO reports that if the ACA moves forward, and that all of its cost containment measures remain in place, the act will reduce the primary deficit by 1.5 percent over 75 years.  Yes, that is a very small number, but it’s still a reduction.

In the other scenario, the ACA is stripped of its cost containment measures, it would increase the primary deficit by 0.7 percent over 75 years.

Politifact also examined Grover Norquist’s claim that eliminated the ACA would shave $35 Billion  from the national deficit and found that that was true.  However, they also examined Carol Shea Porter’s claim that repealing the ACA would increase the budget deficit and found that yes, it would, by around  $1,280 billion.  How can that be? Well, the ACA mandates a lot of fee reductions and creates several new revenue sources.  Eliminate the act, you lose both the savings and the extra funds it generates.

Mr. Snyder also does not address the fact that the deficit is currently falling at the fastest rate in 60 years, at least according to research done by Politifact.

I must concluded that #`15 does not provide a reason to repeal or impede the ACA.

Reasons 1-5 * Reasons 6-10 * Reasons 11-15

A Conservative’s argument, dissected (part 2)

This is the second part of my dissection of my conservative relatives’ arguments against The Patient Protection and Affordable Health Care Act. Part One can be found HERE.  Part Three can be found HERE.
 

Here is the first article one of my relatives offered to support their position:

15 Reasons Why The Obamacare Decision Is A Mind Blowing Disaster For America
 

Here is the link to the  actual text of the ACA:

The Patient Protection and Affordable Health Care Act
 

From now on, any counter-arguments you make about the law must contain references to the law.  No excuses, because, hey, I’ve given you the link to the act.
 

So here are the second group of five reasons out of the fifteen outlined by Michael Snyder for End Of The American Dream:

#6 Obamacare is going to impose nightmarish paperwork burdens on doctors, hospitals and the rest of the healthcare system.  This is going to significantly increase our healthcare costs as a nation.

Here’s the thing; I actually worked at a 200 bed hospital’s billing department.  And I can assure, our current network of private insurance companies created nightmarish paperwork burdens many years ago.  Which is why, in 1975, Congress created the National Uniform Billing Committee  (NUBC) to simplify health insurance paperwork.  It’s still in business, and the ACA doesn’t override it in any way.
 

Sadly, the link Mr. Snyder supplied is dead, and so is any possibility of analyzing its evidence in support of reason #6.  But Politifact has looked into similar claims made by Junior Senator Ted Cruz on this subject.

The tracker that Cruz relied upon has unexplained holes, miscalculates some burdens and folds in paperwork associated with non-health-care programs such as student loan changes. Significantly, too, we could not tell how the document’s largest single entry--46 million of the declared hours--was calculated.

We rate this statement, based on a partially unsupported hour count plus unrealistic Mount Rushmore math, as Mostly False.

So much for Reason #6.

#7 Obamacare is going to send health insurance premiums soaring.  This is especially true for younger Americans.

So, the first supporting evidence offered by Mr. Snyder is another article by Mr. Snyder.  This doesn’t bode well, does it? Interestingly, Mr. Snyder notes a WSJ article that pointed out that Americans already pay more for healthcare than anyone else on the planet, with a very low return on the investment.  But then he references another WSJ article entitled “Health Insurers Plan Hikes”.

Aetna Inc., some BlueCross BlueShield plans and other smaller carriers have asked for premium increases of between 1% and 9% to pay for extra benefits required under the law, according to filings with state regulators.

Funny, he skipped this statement:

…the increases apply mostly to the new policies insurers write after Oct. 1, consumers could be subject to the higher rates if they modify their existing plans and cause them to lose grandfathered status.

In other words, if you currently have insurance with theses companies, you probably will not see any increase in your rates or premiums.
 

Now, for new policy holders, or people changing their current policies, yes, your rates could go up between 1% and 9%.

But the WSJ article does go on and on about the rate increases, giving the impression that everyone’s rates are going to skyrocket, even though they don’t offer any actual evidence of it in the article.  The actual rate increases mentioned are actually quite low:

Aetna, one of the nation's largest health insurers, said the extra benefits forced it to seek rate increases for new individual plans of 5.4% to 7.4% in California and 5.5% to 6.8% in Nevada…

…Regence BlueCross BlueShield of Oregon said the cost of providing additional benefits under the health law will account on average for 3.4 percentage points of a 17.1% premium rise for a small-employer health plan…

…Celtic Insurance Co. says half of the 18% increase it is seeking comes from complying with health-law mandates.

The WSJ gives the appearance of higher rates by including the NON related increases.  The BC/BS of Oregon’s increase is only 3.4%.  Celtic’s increase is really 9%, the highest increase in the article.

“Soaring?”  Really?
 

The second source is an opinion piece written back in 2009 by Prateik Dalmia, an international studies major at Johns Hopkins University.

Young people are  least likely to need health insurance because we tend to be healthier than the remaining population. With good reason, we often choose to go uninsured…   we are the poorest segment of the population. We have not had time to build up capital, many of us have accrued student loans and after graduation we face a crippled economy due to no fault of our own…

Mr. Dalmia is absolutely correct that the young are least likely.  But he’s dead wrong that that means they don’t need or shouldn’t have health insurance coverage.
 

Senator Angus King  (I-Maine) was a young man once, and talks about his first experience of having health insurance with Salon:

Forty years ago, when King was 29 years old, he was provided health insurance as a staffer for then-Sen. Bill Hathaway, D-Maine, and for the first time in a decade went to a clinic for a checkup.

“I had a health policy that included in it a free annual physical as a part of the policy and they had evening clinic hours. And I wouldn’t have taken the day off — and if that hadn’t been covered under the insurance there’s no doubt in my mind that I wouldn’t have gone to have the checkup,” King said.

“It was a routine checkup and the doctor found this mole, and I went in a week later to have the stitches out. The doctor told me I’d better sit down and that I had melanoma…. A month later I found myself having every cancer test you could imagine. Ultimately I had a fairly major surgery. The point of the story is that without the surgery I would have died.”

The ACA works several ways to help; first off, refer to page 14:

‘‘SEC. 2714. EXTENSION OF DEPENDENT COVERAGE.
‘‘(a) INGENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage that provides dependent coverage of children shall continue to make such coverage available for an adult child (who is not married) until the child turns 26 years of age.

That will cover most young adults for a few years after college, and through the period where a young person is trying to find a full-time job.  And even then, there are tax credits and other assistance to help someone at a low income level acquire coverage.
 

So we have to dismiss reason #7; its citations fail to support claims of “soaring premiums.”

#8 Many small businesses are going to be absolutely crushed by the provisions in Obamacare that require them to provide expensive health insurance coverage for their employees.  This is going to make them even less competitive with companies in other countries where businesses are not required to provide healthcare for their workers.  This is also going to make it even less attractive for businesses to hire new employees.

I want to highlight something that jumped out at me:

This is going to make them even less competitive with companies in other countries where businesses are not required to provide healthcare for their workers.

Which countries is Mr. Snyder referring to?  Japan?  Germany?  Both are highly industrial nations with strong, first-world economies.  And employers are not required to pay for healthcare because their governments already do so.  If Mr. Snyder is calling on Congress to completely dismantle our polyglot network of numerous health insurance and healthcare providers in order to replace them with a nationalized healthcare system, I am duly impressed.  Certainly, going that route would remove a tremendous burden from every level of business nationwide.  In fact, it would also eliminate the paperwork burden, as well as the income problem.
  

But the article he cites does not call for nationalized healthcare; it’s a press release from the National Retailers’ Foundation saying they are “dismayed” that the SCOTUS upheld the ACA.
  

But neither Snyder nor the NRF refer to Title 1, Part V, Subtitle E, Part II, SMALL BUSINESS TAX CREDIT, SEC. 1421. CREDIT FOR EMPLOYEE HEALTH INSURANCE EXPENSES OF SMALL BUSINESSES.   It starts at the bottom of page 119.  They can get a credit for up to half of what they spend.
  

We can also take a look at the model system: “Romneycare.”  A 2008 survey found that “a majority of firms” had a positive experience meeting the Massachussetts mandate.
  

Politifact found that 87% of small businesses employing 25 to 49 people already offer health benefits.  94% of companies with 50 to 199 employees already offer coverage.  And those with less than 25 employees may already qualify for the tax credits mentioned above.
  

I conclude that #8 doesn’t offer any evidence that businesses will be “absolutely crushed.”

#9 Obamacare is going to make the emerging doctor shortage in America a lot worse.  Surveys have found that we could potentially see hundreds of thousands of doctors leave the medical profession because of Obamacare.

In this case, Mr. Snyder turns to… himself.  He wrote an article for The Economic Collapse Blog about “The Coming Doctor Shortage.” To prove his case there, he references an opinion piece in The New York Post. The only citation offered there is a discredited poll.  But Mr. Snyder backs himself up by referring to another article he wrote himself.  And in that article, he refers to the same NY Post opinion piece, as well as the discredited poll used in the Post column.
  

So far, we’ve got one survey that he’s referenced several times.  And it was a survey that even Fox “News” admitted had no scientific merit.
  

But back in 2011, the Association of American Medical Colleges looked at the doctor shortage:

A physician shortage was already expected before ACA was signed into law in March 2010, and now that gap could worsen. According to projections released last fall by the AAMC Center for Workforce Studies, there will be a shortage of about 63,000 doctors by 2015, with greater shortages on the horizon…

So in fact, there was already a doctor shortage, even before the ACA.  That is “the emerging doctor shortage.”
  

But then we learn this little tidbit:

Several factors are contributing to the growing demand. On top of the 32 million Americans who will get insurance cards if the ACA is fully implemented, 15 million more will become eligible for Medicare in the coming years. Meanwhile, physician supply is projected to drop because of baby boomer retirement and other factors.

In other words, while we we are losing doctors because they are reaching retirement age, most of the shortage is due to millions of Americans receiving health insurance that will for the first time make a doctor visit affordable.  But what are the “other factors?”  Are they ACA related?  This article doesn’t say, but it does report that the ACA does have provisions to ease the crisis:

The ACA did take steps to address the shortage. For example, the reform law will redistribute some unused residency slots and increase funding for the National Health Service Corps..

But the AAMC report concludes that the biggest hurdle to training new doctors is funding for training, and regulations that require residencies in hospitals in order to earn their doctorates. Residencies limited by recent budget cuts at both the state and federal level.
  

AARP reports that simply enrolling more medical students isn’t the issue; the matter of student debt is the true culprit:

While students may enter medical school wanting to practice primary care medicine, they graduate saddled with heavy debt — $250,000 is not unusual — which prompts them to switch to a more lucrative specialty. The starting salary for a primary care physician is $150,000 to $170,000; a radiologist or gastroenterologist can make two to three times that.

Only one in five graduating internal medicine residents plans to go into primary care medicine, the Journal of the American Medical Association reports.

But what about doctors retiring?  Fortunately, MedPage Today links to a Deloitte Study for Health Solutions took a survey that has some answers.
  

Deloitte summarizes the study:

Most U.S. physicians are concerned that the future of the medical profession may be in jeopardy and consider many changes in the market to be a threat. They believe that the performance of the U.S. health care system is suboptimal, but the Affordable Care Act is a good start to addressing issues of access and cost.

Most also believe that…

• Medicaid and Medicare reimbursements may be problematic, prompting many physicians to limit or close their practices to these enrollees.
• Physician-hospital integration is expected to increase.
• Clinical decision support information technologies that reduce unnecessary services and increase clinician adherence to evidence-based practices are of interest to physicians

So while there is indeed a shortage of doctors, and the Affordable Care Act will create many new patients who will increase demand for a shrinking pool of doctors, the ACA is seen primarily as a tool to help address the problem.
  

So I’ll have to pass on #9 being a valid reason to dump the ACA.

#10 Obamacare has already forced the cancellation of dozens of doctor-owned hospitals.

This time, Michael Snyder’s reference is a blog post at Survival Blog written by someone identified only as… Michael.  I don’t think that’s a coincidence, I think this is yet another occasion where Mr. Snyder is referencing himself.  In the Survival article, the first reference leads us to a comment in a forum at God Like Productions which in turn links to an article at something called CNS News. It is a spinoff of the Media Research Center, a conservative propaganda service.
  

Already, this one has a bad smell to it.
  

But it is the first story to actually reference the  ACA!  Specifically, Title VI, Section 6001 of the Patient Protection and Affordable Care Act.
  

CNS News summarizes the affects thus:

Physician-owned hospitals are advertised as less bureaucratic and more focused on doctor-patient decision making. However, larger corporate hospitals say doctor-owned facilities discriminate in favor of high-income patients and refer business to themselves.

The new health care rules single out such hospitals, making new physician-owned projects ineligible to receive payments for Medicare and Medicaid patients.

And what does the act say?  It’s pages of updates to Section 1877 of the Social Security Act (42 U.S.C. 1395nn) . Fortunately, the Centers for Medicare and Medicaid Services sums it up nicely:

Section 6001 of the Affordable Care Act of 2010 amended section 1877 of the Social Security Act to impose additional requirements for physician-owned hospitals to qualify for the whole hospital and rural provider exceptions. A physician-owned hospital is now generally prohibited from expanding facility capacity. However, a physician-owned hospital that qualifies as an applicable hospital or high Medicaid facility may request an exception to the prohibition from the Secretary.

So the ACA does limit expansion of doctor-owned hospitals, and we have to admit that building a new hospital would certainly count as expansion.  But what about payments for Medicare and Medicaid patients?

Section 1877 of the Social Security Act (42 U.S.C. 1395nn) prohibits physicians from referring Medicare patients for certain designated health services (DHS) to an entity with which the physician or a member of the physician's immediate family has a financial relationship unless an exception applies. It also prohibits an entity from presenting or causing to be presented a bill or claim to anyone for DHS furnished as a result of a prohibited referral.

So in fact, the limits on payments for doctors referring patients to facilities owned by said doctor were already in place before the ACA.  But it does not flat-out deny claims for Medicare and Medicaid completely.
  

Bloomberg Law explains the origin of this limit on Medicare and Medicaid payments for referrals, The Stark Law:

The Stark law essentially prohibits a physician from referring Medicare, Medicaid, and other federally covered patients to a provider that provides designated health services (DHS).1 The first DHS was clinical laboratories owned by physicians. The federal government determined that physicians may be over utilizing lab services and billing for those services where the physician owns the lab. Later, the government expanded DHS to include inpatient and outpatient hospital services.2 Again, the concept underlying the prohibition was that if physicians had any financial relationship with entities providing DHS, the physicians would overutilize those services because they would be financially compensated.

Whether or not such abuse is commonplace is a subject of much debate.  The Stark Law went on to include Whole Hospital Exception:

The federal government recognized the ramifications of the Stark law and adopted a number of different exceptions to it, including the Whole Hospital Exception, which allowed physicians to own a hospital or part of a hospital as long as the investment interest is in the entire hospital.3 The exception included hospitals in existence at the time the law was adopted and those that were developed after the law was adopted.

So, to bring you up to speed, the government made it illegal for doctors to refer patients for additional services from laboratories and other facilities owned by said doctor so that said doctor would be tempted to pad his bill by ordering extra services or diagnostics.  However, as long as a physician’s investment was in the ENTIRE hospital, as opposed to just the lab, or just an operating room, he could refer Medicare and Medicaid patients to the hospital for treatment.
  

The ACA removed the Whole Hospital Exception, as well as limiting the expansion of hospitals.

But how has that affected these facilities ability to operate profitably – or at all?  The Wall Street Journal reports:

The Affordable Care Act aimed to end a boom in doctor-owned hospitals, a highly profitable niche known for its luxury facilities. Instead, many of the hospitals are wiggling around the federal health-care law's growth caps and even thriving.

Meanwhile, to grow without running afoul of the rules, some of the country's roughly 275 doctor-owned hospitals are expanding their operating hours, increasing procedures in ways not restricted by the law and rejecting patients on Medicare, the federal insurance program for the elderly and disabled.

 In 2011, the first year of the law's restrictions, more than half of the 30 largest doctor-owned hospitals showed operating margins that either matched or surpassed their 2010 figures, and some had operating margins of more than 40%. Only a handful showed drops of more than a few percentage points that year, according to American Hospital Directory data.

So it may be premature to weep for the doctors who own hospitals. Kaiser Health News goes so far as to categorize physician-owned hospitals as “the biggest winners under two programs in the health law.”
  

And as for construction of new physician-owned hospitals? 

Physician-owned hospital breaks ground in Austin

Other than the press release from Physician Hospitals of America (PHA), we can’t find documentary evidence of “60 hospitals canceled due to Obamacare.”  It certainly is possible that 60 planned hospitals have been canceled, but the ACA is helping the existing facilities make money hand-over-fist, and it hasn’t stopped at least one new hospital from being built.
  

So I must rate Reason # 10 as possible, but irrelevant.  Thousands of projects get canceled every day for a variety of reasons, and since new facilities can still be built, citing the ACA can only be an excuse, not a reason.
  

This ends the second part of the dissection; we’ll handle “Reasons 11-15” next.

Reasons 1-5 * Reasons 6-10 * Reasons 11-15

A Conservative’s argument, dissected (part 1)

I’m afraid I have to admit that I have some conservative family members.  And I don’t mean simply deep-rooted Republicans, they are rabid Tea Party lunatics.
 

I actually started dissecting the arguments they’ve been making last week, but Blogger hiccupped, and four hours of composition was completely lost.  So now I’m using an off-line blog editor, and I’m breaking it down into smaller pieces.
 

My relative offered up an article to defend his views on The Affordable Care Act:
 

15 Reasons Why The Obamacare Decision Is A Mind Blowing Disaster For America
  

It’s an article on a right-wing propaganda site called End Of The American Dream.  And of course, they can’t bring themselves to call the Patient Protection and Affordable Health Care Act by its proper name, referring to it simply as “Obamacare.”  the fact that they can’t use proper nomenclature should set alarm bells ringing, followed by klaxons when you find that at no time do they ever cite any actual portion of the ACA to support their arguments.  But the thing about being a rabid Tea Party conservative is that intellectual processes are considered a hindrance.
 

So first, I’ll supply a link to the ACA, and I will reference it as it applies.
 

The Patient Protection and Affordable Health Care Act
   

From now on, any counter-arguments you make about the law must contain references to the law.  No excuses, because, hey, I’ve given you the link to the act.
  

So here are the first five reasons outlined by Michael Snyder for End Of The American Dream:

#1 According to the U.S. Supreme Court, the federal government has the power to force you to buy private goods and services.  Now that this door has been opened, what else will we be forced to buy in the future?

“This door has been opened” back in 1790. The New England Journal of Medicine reports that in that year, Congress mandated all ship owners to provide medical insurance for seamen in their employ. Eight years later, they required all seamen to buy hospital insurance for themselves.
  

And what have we been mandated to buy?  Well, car insurance, for one.  Sure, this is at the state level rather than the federal level, but it’s still a mandate from a governing body that applies to all people governed by that body.  Strange that I haven’t seen Tea Party conservatives holding signs demanding we repeal the car insurance mandate.
  

For what it’s worth, the link is dead.  Which gives it as much life as the argument it was supposed to support.
  

So reason #1 must be dismissed for lack of merit.

#2 Obamacare is another step away from individual liberty and another step toward a “nanny state” where the government dominates our lives from the cradle to the grave.

Interesting leap of logic: by requiring every individual in this country to take responsibility for providing their own health insurance coverage, the United States will become a “nanny state.”

Let me look up this term; perhaps I’m not clear on what a “nanny state” actually is:

nanny state  n, (Government, Politics & Diplomacy) a government that makes decisions for people that they might otherwise make for themselves, esp those relating to private and personal behaviour

OK, that’s what I thought it meant.  Of course, the ACA isn’t making any decisions about “private and personal behaviour.”  It’s tasking us with lifting up our share of the burden of health insurance costs.  And of course, this is a ludicrous argument coming from a group that regularly attempts to legislate what a woman can and can’t do with her very body.  If becoming a nanny state is a legitimate conservative concern, they’d be denouncing every conservative that introduces legislation related to the human reproduction system.  Can being told to have health insurance coverage really be less invasive than forcing a woman to have an internal sonogram before she can have an abortion?

We should note that the individual is still free to choose any provider they like, with several different layers of coverage.  This falls under Title 1, Subtitle F Part 1, Section 1501, which is on page 124 of the ACA.
 

Reason #2 makes claims, but does little to support it the claim beyond offering a dead link.

#3 The IRS is now going to be given the task of hunting down and penalizing millions of Americans that do not have any health insurance.  In fact, the Obama administration has given the IRS 500 million extra dollars “outside the normal appropriations process” to help them enforce the provisions of Obamacare that they are in charge of overseeing.

This one is simply a whopping lie with two parts.  Part 1; there is nothing in the bill anywhere that authorizes the IRS to hunt down and penalize anyone for failing to have healthcare.  I’ve given you the link; check it out.  If you can find such an order in the document, please leave the exact citation in the comments section.
 

The second part is even worse; it links to another blog, where one Sam Baker states that the IRS was given funding “to impliment healthcare law.”  The problem?  The article offers absolutely no evidence.  Nothing. Nada.  It doesn’t offer a single document.  Not one recording.  Not even names or dates.

My verdict on #3: it’s a whopping lie. 

#4 Obamacare imposes more than 20 new taxes on the American people.  You can find a comprehensive list of Obamacare taxes right here.  If you love paying higher taxes, then you are going to absolutely love Obamacare once it is fully implemented.

The link in this one leads to Americans for Tax Reform, a partisan political action committee founded by Grover Norquist, who never met a tax that he liked.  He also doesn’t believe in government. And he doesn’t have a grasp of economics, being a firm believer in the Reagan era policy of “starve the beast” that has led to record deficits.
  

Many of the taxes listed at this website are real, although they make it tough to research by failing to provided references to the document so you can analyze their claims for accuracy.  So we’re going to scrutinize this one in a separate article later.  But suffice to say, almost all the taxes it references only come in to play if you don’t have insurance if you’re an individual, or don’t provide insurance if you’re a large company.
  

So #4 is correct that there ARE new taxes, but incorrect that they mean you will be paying higher taxes.  Stay tuned for closer examination.

#5 In an attempt to “control costs” and “promote efficiency”, Obamacare limits the treatment options that doctors and patients can consider.  This is likely to result in a decrease in life expectancy in the United States.

Oooh, another whopping lie.  And this shows very clearly that the person making this claim has never read the ACA.

SEC. 1554. ACCESS TO THERAPIES.
Notwithstanding any other provision of this Act, the Secretary of Health and Human Services shall not promulgate any regulation that—
(1) creates any unreasonable barriers to the ability of individuals to obtain appropriate medical care;
(2) impedes timely access to health care services;
(3) interferes with communications regarding a full range of treatment options between the patient and the provider;(4) restricts the ability of health care providers to provide full disclosure of all relevant information to patients making health care decisions;
(5) violates the principles of informed consent and the ethical standards of health care professionals; or
(6) limits the availability of health care treatment for the full duration of a patient’s medical needs.

This can be found under Title 1, Subtitle G, on page 141 of the ACA. As you can see, this states in no uncertain terms that treatment will not be limited to “control costs” or to “promote efficiency.
  

But what does the link say?  It’s a blog that quotes a letter by Senator Tom Coburn published in the Wall Street Journal.  Dr. Coburn claims that section 3403 and 2021 “explicitly empowers Medicare to  deny treatment based on cost.”
  

What can we find in the ACA about this?  First, section 3403, which starts on page 372 of the ACA.  Here are the parts that specifically address Dr. Coburn’s claims.

SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD.

(a) BOARD.—
(1) IN GENERAL.—Title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.), as amended by section 3022, is amended by adding at the end the following new section:

‘‘INDEPENDENT MEDICARE ADVISORY BOARD

Section 1899A

‘‘(c) BOARD PROPOSALS.—

‘‘(2) PROPOSALS.—
‘‘(A) REQUIREMENTS.—Each proposal submitted under this section in a proposal year shall meet each of the
following requirements:

(ii) The proposal shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary cost- sharing (including deductibles, coinsurance, and copay-ments), or otherwise restrict benefits or modify eligibility criteria

‘‘(B) ADDITIONAL CONSIDERATIONS.—In developing and submitting each proposal under this section in a proposal year, the Board shall, to the extent feasible—
‘‘(i) give priority to recommendations that extend Medicare solvency;
‘‘(ii) include recommendations that—
‘‘(I) improve the health care delivery system and health outcomes, including by promoting integrated care, care coordination, prevention and wellness, and quality and efficiency improvement; and
‘‘(II) protect and improve Medicare beneficiaries’ access to necessary and evidence-based items and services, including in rural and frontier areas;

Dr. Coburn must be referring to some OTHER section 3403, because THIS section 3403 does the exact opposite of what he claims.
  

Now for section 2021.  The relevant section is found on page 668, under TITLE VI, Subtitle H- Elder Justice Act.

‘‘PART I—NATIONAL COORDINATION OF ELDER JUSTICE ACTIVITIES AND RESEARCH
‘‘Subpart A—Elder Justice Coordinating Council and Advisory Board on Elder Abuse, Neglect, and Exploitation
‘‘SEC. 2021. ELDER JUSTICE COORDINATING COUNCIL.

‘‘(a) ESTABLISHMENT.—There is established within the Office of the Secretary an Elder Justice Coordinating Council (in this section referred to as the ‘Council’).

And reading through it, it says nothing about explicitly denying care; this is as close as it gets:

‘‘(f) DUTIES.—
‘‘(1) IN GENERAL.—The Council shall make recommendations to the Secretary for the coordination of activities of the Department of Health and Human Services, the Department of Justice, and other relevant Federal, State, local, and private agencies and entities, relating to elder abuse, neglect, and exploitation and other crimes against elders.

Basically, this section deals with creating a panel to administer complaints and failures of the system, and says nothing about limiting health care for anyone for any reason.
  

So I must conclude that reason #5 is false.
  

This ends the first part of the dissection; we’ll handle “Reasons 6-10” next.

Reasons 1-5 * Reasons 6-10 * Reasons 11-15

Hobby Lobby Holier Than Thou

Moses never did this.

Perhaps you know someone who is an avid hobbiest.  Someone who takes his hobby so seriously that friends might joke that "it's his religion."   Like golf.  I'm sure you know someone who spends a lot of time improving his game.  "Golf is his religion," you might say.

Of course, no one really believes that a hobby is a religion. 

Unless, of course, you're Judge Joe Heaton of the Tenth US Circuit Court of Appeals.  Hizzoner ruled that Hobby Lobby should be exempt from certain provisions of the Affordable Care Act intended to apply only religious institutions.

The action by US District Judge Joe Heaton came after the full Tenth US Circuit Court of Appeals ruled Thursday that forcing Hobby Lobby and its Christian owners to pay for certain kinds of contraceptive methods would substantially burden their religious rights.
-- The Christian Science Monitor, June 28, 2013

In case you are unaware, one of the provisions of the ACA is that health plans must include contraceptives. Some religious institutions (and, apparently, hobby stores) claim that this mandate basically infringes on their religious beliefs.  Of course, this is utter nonsense.

Let's examine the relevant section of the First Amendment, which conveniently is the first part of the amendment:

Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof...

The argument being made by these religious institutions is that since they do not believe that people should use contraception, their rights are being violated by being forced to pay for health coverage that allows the person using that coverage to get contraceptives, including oral or implanted contraceptives, if they so choose.

This means that Hobby Lobby et al must show that paying for health care for its employees prohibits them from exercising their religion.

The first clarification that must be made is that these institutions are not being forced to pay for contraception.

That is to say, contraception has been defined to be a part of all health plans, much like spare tires are included in the cost of a car.  Like a spare tire, you don't have to use contraceptives if you don't want to.  No one is saying that anyone has to use contraception.

The Catholic Church, as you can imagine, has been vocal in its opposition.  But the fact is, having contraceptives bundled into the cost of health care does not prevent the church from its practices.  No one is saying that nuns must take The Pill, or that novices should use Norplant.  There are any number of services bundled into a health plan that might never get used for one reason or another.

No matter how you slice it, the ACA does not stand the test of interfering with the practice of any religion, any more than mandatory car insurance does.  Does it prevent anyone from praying in a manner of their choice? No.  Does it prevent anyone from gathering in a place of worship?  No.  It does not force anyone to do anything at all, and does not prevent them from any activity required of them by their faith.

But because President Obama is accommodating to a fault, he directed that religious employers - intended to be primarily houses of worship - should be exempt from having plans that include contraception coverage.  So special plans will be created for priests and ministers and nuns and monks so they won't have health plans that may tempt them.

And Judge Heaton apparently feels that people who sell HO gauge model trains and remote control planes need that same kind of consideration.

Hobby Lobby has more than 500 stores and employs 13,000 workers nationwide. The injunction also Bapplies to Mardel, Inc., which runs 35 Christian bookstores and employs 400 workers. Both companies are owned and run by the Green family, who are devout Christians.

The family believes that life begins at conception and that any interference with the implantation of a fertilized egg is intentionally causing the death of a human being.
-- The Christian Science Monitor, June 28, 2013

Of course, they are entitled to believe anything they choose.  If they choose not to use certain forms of medication, that is their right. No one is arguing otherwise.

But what the Greens are arguing is that they should be free to demand their employees - not adherents to a religion, but employees - accept and abide by the rules of the Green family's religion. That is tantamount to creating a corporate faith.  Believe, or be fired.

While the Constitution is intended to limit the powers of Government, we can not forget that the government is us.  By the people, for the people.  Ultimately, the Constitution is a limit on what we can do to each other.  It's meant to prevent us from ganging together to force other people to the collective will - our collective will.

And by demanding an exemption from the Affordable Care Act, the Greens are violating the rights of every single one of their employees.  They are not the government, but they are a collective, and they are ganging up to violate the freedom of others. And with his order, Judge Heaton has effectively approved of this violation.

Putting Health Care Into Perspective

Health Care is a part of an employee's compensation package; in other words, employees do not get health care as a gift: employers don't serve it up out of the goodness of their hearts.  It's in exchange for services rendered, just like their actual paycheck.  You do your job, and your employer compensates you for the work you do with a salary and a health care package.

Christian groups basically arguing that they should have the right to tell you what you can and cannot due with your wages.  And that is absolutely a violation of religious freedom. 

The Bacon Clarification

Actually forbidden in the Bible

This exclusion that the Greens are demanding is akin to a Jewish employer asking to allowed not to pay you because you might use part of your wages to buy bacon.  After all, his religion teaches that eating bacon is a sin.  You might use that money to buy bacon to eat. And since he believes that eating bacon is a sin, forcing him to pay you your full wage means that the government is forcing him to bear the unjust burden of violating God's Law.

You may laugh, but in fact this is a far more valid argument than anything offered by any religious organization to date. After all, the Bible actually tells us not to eat pork; it doesn't say anything about contraception.

Look, if the Greens want to hire only Christians of their own denomination, they are within their rights to do so.  And if everyone is of that denomination, they won't be using the contraceptives they believe are evil.  So there would not be a need for the exemption.  And if the Greens don't demand that everyone is a member of their faith, they cannot in good conscience demand that their choices be made in accordance with that faith.

At the end of the day, this is a thinly disguised attempt by a religious minority to instill their religion on the rest of us - something the Constitution won't let them do.  Their argument boils down to "our religious freedom must mean that no one else has religious freedom."

Religious freedom means that you are free to practice your religion; it does not mean that you are free to interfere with the beliefs of others, even when those beliefs are diametrically opposed to yours.

Judge Heaton made a decision that will probably be very popular at his country club - and his church.  But it was a bad decision for this nation, and probably fails to uphold the Constitution.  We'll see if this administration has the will to take this to the Supreme Court.  After all, pacifists are paying taxes, and some of that money is used to fight wars.  Isn't that a violation of their faith?  What about people opposed to the Death Penalty?  Should Florida liberals be exempt from property taxes because they don't want to fund the electric chair?

Where does it end?

The Greens' religious freedom was never in jeopardy.  But this decision means that the Greens and others like them can run roughshod all over everyone else's religious freedoms.

Practical Heresy

Forget any religious connotations; I am not a lapsed something-or-other with an axe to grind or a holy cow to be gored.  Which is not to say that I will not grind an axe or two, or gore the occasional holy cow, merely that this is not my purpose.

I am an American, living in a United States that hasn't been less unified since the middle of the nineteenth century.  Some fear that we are standing on the precipice of a great abyss; that perhaps our great republic has run its course.

If you have been paying any attention at all to the world around us, it may appear to you that we've become mired in a swamp of our own preconceptions.  Some might argue that we are always mired in that swamp.  Still others will simply blink, not perceiving anything wrong with the status quo.

The Right sees nothing but permissiveness and sloth on the Left, and the Left sees bigotry and greed on the Right.  And outside our own country, the rest of the world sees the folly; for we are not divided into Liberals and Conservatives in this country; we are Conservatives, and More Conservatives.

Most of those standing on the so-called Left are in fact standing where the center used to be; Obama is reviled as an arch-socialist, yet most of his policies were written by Republicans of twenty, thirty years ago.  Former Florida governor Jeb Bush himself noted that Ronald Reagan, a veritable patron saint of The Grand Old Party, would probably fail to gain support in today's radically right-wing Republican party.  The party of Lincoln would probably run ol' Honest Abe right of the party on a rail.

But this isn't my purpose, to discuss politics.  Rather, it is to cut through them.  I am not seeking consensus, I am exposing hypocrisy; more, I am seeking answers.  And the answers do not care about party lines, or philosophical leanings, or political pretension.

Let's tip over the apple cart, and sort out the good apples from the bad; let's let the cat out of the bag and see where he leads us.  Let's step outside the box of conformity, and dare to cut to the chase.

Because I believe that all problems have answers; sometimes, we won't like the answers we find.  That's when we examine the questions we've been asking.   Perhaps we've all been looking for places to use our hammer, instead of trying to find a screwdriver or wrench.

This is Practical Heresy; overcoming our societal dogma to find practical solutions to the problems we face as individuals and as a people.