The Truth about Health Insurance Premiums and Profits

The Truth about Health Insurance Premiums and Profits, by Alan Reynolds

Cato, Mar 15, 2010

On a recent Fox News debate about health insurance, Democratic political strategist Bob Beckel explained that, "The president needed an enemy, and the insurance companies are it."

Proving that point in a Pennsylvania stump speech, President Obama asked, "How much higher do premiums have to go before we do something about it? We can't have a system that works better for the insurance companies than it does for the American people."

On February 20, President Obama used his weekly radio show to express outrage that a fraction of Californians buying individual Anthem Blue Cross Blue Shield (BCBS) plans "are likely (sic) to see their rates go up anywhere from 35 to 39 percent." He used those figures to justify preempting state regulation "by ensuring that, if a rate increase is unreasonable and unjustified, health insurers must lower premiums, provide rebates, or take other actions to make premiums affordable."

There was always something peculiar about this desperate effort to demonize certain health insurers. Individual plans account for only 4 percent of the insurance market. So why do they account for 100 percent of the president's fulminations about insurance premiums? Could it be because insurance premiums for the other 96percent have not been rising much?

Nonprofit BCBS plans account for a third of the private health insurance market. Michigan's nonprofit asked for 56 percent premium hike without the national media taking that Hail Mary pass too seriously. But even Obama finds it difficult to accuse nonprofits of being too profitable, so he needed to pin his enemy badge on a for-profit firm – one of Wellpoint's "Anthem" BCBS plans.

Anthem of California's requested rate increase on individual policies was actually 20-35 percent. The only way it could get to 39percent would be if a policyholder insisted on a gold-plated Cadillac plan and also happened to move up into a higher age group. Besides, requesting a rate hike means nothing. Even Obama's radio address mentioned two requests that had been cut in half. Many are denied.

So, how many Californians have actually been faced with a 39 percent increase in their premiums? Exactly zero.

How many are really "likely" to be faced with even a 35 percent increase after state insurance regulators have their say? My forecast: Zero.

The president highlighted the "likely" increases of "35 to 39 percent" to suggest insurance companies in general were asking for huge premium increases just to boost their lavish profits. He complained that in the $1.2 trillion health insurance industry, "the five largest insurers made record profits of over $12 billion." But that puny sum includes WellPoint's sale of its pharmacy benefits management company NextRX to Express Scripts for $4.7 billion last April. Adding that $4.7 billion to WellPoint profits is like saying a family's income rose by $1 million because they sold a million-dollar home.

University of Michigan economist Mark Perry calculated that without the sale of NextRX, "WellPoint's profit margin would have been only 3.9 percent, the industry average profit margin would have been closer to 3percent"— $100 per policy. Yet Obama concluded that, "The bottom line is that the status quo is good for the insurance industry and bad for America."

The media echoed the president words endlessly, and wrote as though one company's hypothetical request for increases of 35 percent-39 percent were a nationwide threat—even to those with group insurance—rather than an unique and highly unlikely request that might (if magically approved) touch a miniscule number in a hostile state for health insurers.

"It doesn't take too many 39 percent increases, like the recent one proposed in California that has garnished so much attention, to put insurance out of reach," exclaimed a New York Times report. That same paper's editorial added, "The recently announced plan by Anthem Blue Cross in California to raise annual premiums by 35 to 39 percent for nearly a quarter of its individual subscribers is a chilling harbinger of what is to come if reform fails." Really?

Grasping for confirmation of the 39 percent figure, some reporters cited a Feb. 24 memo about Wellpoint written by journalist Scott Paltrow for The Center for American Progress Action Fund. Paltrow gathered news clippings suggesting premiums are "expected to" increase by "up to" some scary number in various states. For California, however, Paltrow's source was the president's speech. This Action Fund is a is no "liberal think tank," as the Wall Street Journal put it, but a 501(c)4 lobby which can participate in campaigns and elections. Founded by Bill Clinton's former chief of staff John Podesta, it's a propaganda arm of the Democratic Party.

A Wall Street Journal story about Wellpoint's wish list for higher premiums cites the Department of Health and Human Services as its source. That means a shoddy four-page polemic at HealthReform.gov, "Insurance Companies Prosper, Families Suffer." That pamphlet, like another from the Commonwealth Fund, cites Duke Helfand, an L.A. Times reporter who wrote on Feb. 4 that, "brokers who sell these policies say they are fielding numerous calls from customers incensed over premium increases of 30percent to 39 percent."

So, the president's 39 percent figure came from Duke Helfand, who heard it from insurance brokers who, in turn, said they heard it from customers. The 39 percent figure referred to one person named Mary. After rounding Helfand's 30 percent up to 35 percent, however, that was good enough for the president's purposes.

Like Obama, the "Insurance Companies Prosper" pamphlet repeatedly confuses asking with getting. "Anthem Blue Cross isn't alone in insisting on premium hikes," it says; "Anthem of Connecticut requested an increase of 24 percent last year, which was rejected by the state." So what? If you went to your boss and insisted on a 24 percent raise, would that constitute proof that wages are rising too fast?

If Obama has been reduced to basing the redistribution of health care on the cost of health insurance premiums, he will need much better facts. Fortunately, credible statistics on health insurance premiums are readily available from the Centers for Medicare and Medicaid Services (CMS) and Bureau of Labor Statistics.

CMS statistics (Table 12) reveal that the net cost of private health insurance – premiums minus benefits – fell by 2.8percent in 2008. Furthermore, CMS Health Spending Projections predict that spending on private health insurance will rise 2.5percent in 2010, while prices of medical goods and services rise by 2.8percent.

Consumers' cost of health premiums is also part of the detailed consumer price index. After all the overheated rhetoric about "requested" or "expected" increases of "up to" 39 percent, who would have imagined that the average consumer cost of health insurance premiums fell by 3.5 percent in 2008 and fell by another 3.2 percent in 2009?

The president's health insurance proposals hoped to use stern command-and-control techniques to run the health insurance system. It was all about minimizing free choice and maximizing brute force—forcing people to buy certain kinds of politically-designed insurance, forcing insurers to cover services many consumers do not want to pay for, and forcing insurers to curb or roll back premiums even as medical costs go up. The whole shaky apparatus was built upon even shakier statistics—including the purely hypothetical 39 percent increase in premiums that Mary's insurance agent reported to Duke Helfand.

"The President's Proposal" on health-care

ObamaCare at Ramming Speed. WSJ Editorial
The White House shows it has no interest in compromise.WSJ, Tuesday, February 23, 2010 As of 3:09 AM

A mere three days before President Obama's supposedly bipartisan health-care summit, the White House yesterday released a new blueprint that Democrats say they will ram through Congress with or without Republican support. So after election defeats in Virginia, New Jersey and even Massachusetts, and amid overwhelming public opposition, Democrats have decided to give the voters what they don't want anyway.

Ah, the glory of "progressive" governance and democratic consent.

"The President's Proposal," as the 11-page White House document is headlined, is in one sense a notable achievement: It manages to take the worst of both the House and Senate bills and combine them into something more destructive. It includes more taxes, more subsidies and even less cost control than the Senate bill. And it purports to fix the special-interest favors in the Senate bill not by eliminating them—but by expanding them to everyone.

The bill's one new inspiration is a powerful federal board that would regulate premiums in the individual insurance market. In all 50 states, insurers are already required to justify premium increases to insurance commissioners, who generally have the power to give a regulatory go-ahead, or not. But their primary concern is actuarial soundness and capital standards, making sure that companies have enough cash to pay claims.

The White House wants to create another layer of review that will be able to reject any rate increase that is "unreasonable or unjustified." Any insurer deemed guilty of such an infraction by this new bureaucracy "must lower premiums, provide rebates, or take other actions to make premiums affordable." In other words, de facto price controls.

Insurance premiums are rising too fast; therefore, premium increases should be illegal. Q.E.D. The result of this rate-setting board will be less competition in the individual market, as insurers flee expensive states or regions, or even a cascade of bankruptcies if premiums are frozen and the cost of the care they are expected to cover continues to rise. For all the Dickensian outrage about profiteering by WellPoint and other companies, insurance is a low-margin business even for health care, and at least 85 cents of the average premium dollar, usually more, is devoted to actual health services.

Price controls are always the first resort of national health care—i.e., Medicare's administered prices for doctors and hospitals. This new White House gambit is merely a preview of ObamaCare's inevitable planned medical economy, which will reduce choice and quality.

The coercive flavor that animates this exercise is best captured in the section that purports to accept the Senate's "grandfather clause" allowing people who like their current health plan to keep it. Except that "The President's Proposal adds certain consumer protections to these 'grandfathered' plans. Within months of legislation being enacted, it requires plans . . . prohibits . . . mandates . . . requires . . . the President's Proposal adds new protections that prohibit . . . ban . . . and prohibit . . . The President's Proposal requires . . ." After all of these dictates, no "grandfathered" plan will exist.

Meanwhile, the new White House plan further vitiates the remnants of cost-control that remained in the House and Senate bills. Now the highly vaunted excise tax on high-cost insurance plans won't kick in until 2018, whereas it would have started in 2013 in the Senate bill, and this tax will only apply to coverage that costs more than $27,500.

Very few plans ever reach that threshold, and sure enough, this is the same $60 billion deal the White House cut in December with union leaders who have negotiated very costly benefits. Now it is extended to all to avoid the taint of political favoritism.

While the White House claims to eliminate the "Cornhusker Kickback," the Medicaid bribe that bought Nebraska Senator Ben Nelson's vote, political appearances are deceiving. As with the union payoff, what the White House really does is broaden the same to all states, with all new Medicaid spending through 2017 and 90% after 2020 transferred to the federal balance sheet. Governors will love this ruse, but national taxpayers will pay more.

And more again, because the White House has adopted the House's firehose insurance subsidies. People earning up to 400% of the poverty line—or about $96,000 for a family of four in 2016—will qualify for government help, and, naturally, this new entitlement is designed to expand over time.

The Administration also claims to have discarded the House's 5.4-percentage-point surtax on joint-filers earning more than $1 million a year, but it sneaks it back in by expanding the Senate's expansion of the 2.9% Medicare payroll tax to joint income about $250,000. The White House would now apply that tax for the first time to income from "interest, dividends, annuities, royalties and rents," details to come.
***

The larger political message of this new proposal is that Mr. Obama and Democrats have no intention of compromising on an incremental reform, or of listening to Republican, or any other, ideas on health care. They want what they want, and they're going to play by Chicago Rules and try to dragoon it into law on a narrow partisan vote via Congressional rules that have never been used for such a major change in national policy. If you want to know why Democratic Washington is "ungovernable," this is it.

Federal President Admits CBO Cost Estimates of ObamaCare Are Incomplete

Obama Admits CBO Cost Estimates of ObamaCare Are Incomplete

Posted by Michael F. Cannon

Yesterday — day #224 of the ObamaCare Cost-Estimate Watch — President Obama told House Republicans:

You can’t structure a bill where suddenly 30 million people have coverage and it costs nothing.

And just like that, the president admitted that the official Congressional Budget Office estimates of his health care plan do not reflect its full costs.

Both the House and Senate versions of ObamaCare would cover millions of uninsured Americans by requiring them to purchase private health insurance. As President Obama notes, even if you force people to spend their own money on health insurance, it still costs something to cover them. And if the government partly subsidizes those premiums, the remaining mandatory premium is still part of the cost of covering them.

Yet Democrats have systematically blocked the CBO from including those costs in its official cost projections. The Senate bill’s estimated price tag of $940 billion, for example, includes only the costs that bill would impose on the federal government. By my count, that’s only 40 percent of total costs. By Mr. Obama’s admission, that’s not the full cost of the bill.

Now that the President of the United States has acknowledged that the CBO’s cost estimates are incomplete, could we maybe get a complete cost estimate? Maybe just for the Senate bill?

Michael F. Cannon • January 30, 2010 @ 8:07 am

The Harvard School of (Unscientific) Public Health (Activism)

The Harvard School of (Unscientific) Public Health (Activism). By Elizabeth M. Whelan, Sc.D., M.P.H.
ACSH, Jan 27, 2010

FDA Decision on Chemical BPA Gets Mixed Review: "ACSH scientists are glad a ban was avoided but remain disappointed"

FDA Decision on Chemical BPA Gets Mixed Review: "ACSH scientists are glad a ban was avoided but remain disappointed."
ACSH, January 15, 2010

New York NY -- January 15th, 2010. The American Council on Science and Health applauds today's decision by the Food and Drug Administration (FDA) not to ban the plastic hardener bisphenol-A (BPA). Despite heavy pressure from various activist "environmental" groups, the FDA has not placed any restrictions on the chemical's use in consumer products but rather decided to "support" industry's decisions to reduce exposure to BPA in food-related products aimed at infants and children. FDA is also "facilitating" the development of alternatives to BPA in infant formula cans.

FDA stopped well short of a ban on this common and useful chemical, which has been in safe use in a wide spectrum of consumer products for over 50 years. ACSH scientists are pleased but remain disappointed that the FDA review and recommendations deviated at all from sound science -- by showing concern for hypothetical and non-existent health risks. ACSH's medical director, Dr. Gilbert Ross, said: "BPA has been among the most well-studied substances known to man, and repeated evaluation by respected scientific bodies worldwide has without fail deemed BPA safe as typically used. Our publication on BPA remains quite relevant today: we found that BPA is safe for all ages, including infants and children."

Another key fact is that since BPA became commonplace in the lining of canned goods, foodborne illness from canned foods -- including botulism -- has virtually disappeared. Any possible new replacement could not have the same record of testing and safety as has been shown for BPA.

ACSH's president, Dr. Elizabeth M. Whelan, added, "The fear campaign against BPA promoted by a few activist groups has been based solely on flimsy animal research. Recently, lacking real science to support their alarmist claims, some labs have tried 'novel approaches to test for subtle effects,' as the FDA report states. This is not how human risk assessment should be carried out. If there were any real adverse health effects from exposure to BPA, such effects would have become manifest long ago and would not have required bizarre tests in a few advocate's labs."

ACSH's associate director, Jeff Stier, pointed out: "This finding should put the matter to rest. The current FDA is very cautionary. After taking all this extra time to re-study the issue, the fact that they are keeping BPA on the market speaks volumes about the safety of the product. If BPA were endangering children, they'd have never left it on the market."

See also: ACSH's earlier official statement on The Facts About Bisphenol A.


For media contact, including interviews, please call:

Dr. Elizabeth Whelan (WhelanE[at]ACSH.org): 917-439-8043
Dr. Gilbert Ross (RossG[at]ACSH.org): 516-581-8400
Jeff Stier (StierJ[at]ACSH.org): 646-245-1443

Health Experts and Double Standards - Jonathan Gruber, Peter Orszag and the press corps

Health Experts and Double Standards. WSJ Editorial
Jonathan Gruber, Peter Orszag and the press corps.
The Wall Street Journal, page A18, Jan 14, 2010

The press corps is agonizing, or claims to be agonizing, over the news of Jonathan Gruber's conflict of interest: The MIT economist has been among the foremost promoters of ObamaCare—even as he had nearly $400,000 in consulting contracts with the Administration that weren't disclosed in the many stories in which he was cited as an independent authority.

Mr. Gruber is a health economist and former Clinton Treasury hand, as well an architect of Mitt Romney's 2006 health plan in Massachusetts that so closely resembles ObamaCare. His econometric health-care modelling is well-regarded. So his $297,600 plum from the Department of Health and Human Services in March for "technical assistance" estimating changes in insurance costs and coverage under ObamaCare, plus another $95,000 job, is at least defensible.

However, this financial relationship only came to wide notice when Mr. Gruber wrote a commentary for the New England Journal of Medicine, which has a more stringent disclosure policy than most media outlets. Last week the New York Times said it would have disclosed Mr. Gruber's financial ties had it known when it published one of his op-eds last year. Mr. Gruber told Politico's Ben Smith that "at no time have I publicly advocated a position that I did not firmly believe—indeed, I have been completely consistent with my academic track record."

We don't doubt Mr. Gruber's sincerity about his research, though the same benefit of the political doubt wasn't extended to, say, Armstrong Williams when it was revealed that the conservative pundit had a contract with the Department of Education during the No Child Left Behind debate. Any number of former Generals-turned-TV-analysts were skewered in the New York Times in 2008 merely because of continuing contact—and no financial ties—with the Pentagon.

The political exploitation of Mr. Gruber's commentary is another matter. His work figured heavily into a recent piece by Ron Brownstein in the Atlantic Monthly that the Administration promoted as an antidote to skepticism about ObamaCare's cost control (or lack thereof). White House budget director Peter Orszag has also relied on a letter from Mr. Gruber and other economists endorsing the Senate bill.

In a December conference call with reporters, Mr. Orszag said that "I agree with Jon Gruber that basically everything that has been put forward in health policy discussions for a decade is in this bill." He also praised "the folks who have actually done the reporting and read the bill and gone through and done the hard work to actually examine, rather than just going on buzz and sort of loose talk, but actually gone through and looked at the specific details in the bill," citing Mr. Brownstein in particular. Which is to say, the journalists who had "done the reporting" were those who agreed with the Gruber-White House spin.

Mr. Orszag never mentioned Mr. Gruber's contract. Nor did HHS disclose the contract when Mike Enzi, the ranking Republican on the Senate health committee, asked specifically for a list of all consultants as part of routine oversight in July. His request noted that "Transparency regarding these positions will help ensure that the public has confidence in the qualifications, character and abilities of individuals serving in these positions."

We're not Marxists who think everyone's opinion depends entirely on financial circumstances. But if Mr. Gruber qualifies as a health expert despite his self-interest, then the studies of self-interested businesses deserve at least as much media attention. The insurer WellPoint has built a very detailed and rigorous model on the likely impact of ObamaCare, using its own actuarial data in regional markets, and found that insurance costs will spike across the board. The White House trashed it, and the press corps ignored it.

This is a double standard that has corroded much of the coverage of ObamaCare, with journalists treating government claims as oracular but business arguments as self-serving. We'll bet Messrs. Orszag and Brownstein that WellPoint's analysis will more closely reflect the coming insurance reality than the fruits of Mr. Gruber's government paycheck.

Where U.S. Health Care Ranks Number One - Isn't 'responsiveness' what medicine is all about?

Where U.S. Health Care Ranks Number One. By MARK B. CONSTANTIAN
Isn't 'responsiveness' what medicine is all about?
WSJ, Jan 08, 2010

Last August the cover of Time pictured President Obama in white coat and stethoscope. The story opened: "The U.S. spends more to get less [health care] than just about every other industrialized country." This trope has dominated media coverage of health-care reform. Yet a majority of Americans opposes Congress's health-care bills. Why?

The comparative ranking system that most critics cite comes from the U.N.'s World Health Organization (WHO). The ranking most often quoted is Overall Performance, where the U.S. is rated No. 37. The Overall Performance Index, however, is adjusted to reflect how well WHO officials believe that a country could have done in relation to its resources.

The scale is heavily subjective: The WHO believes that we could have done better because we do not have universal coverage. What apparently does not matter is that our population has universal access because most physicians treat indigent patients without charge and accept Medicare and Medicaid payments, which do not even cover overhead expenses. The WHO does rank the U.S. No. 1 of 191 countries for "responsiveness to the needs and choices of the individual patient." Isn't responsiveness what health care is all about?

Data assembled by Dr. Ronald Wenger and published recently in the Bulletin of the American College of Surgeons indicates that cardiac deaths in the U.S. have fallen by two-thirds over the past 50 years. Polio has been virtually eradicated. Childhood leukemia has a high cure rate. Eight of the top 10 medical advances in the past 20 years were developed or had roots in the U.S.

The Nobel Prizes in medicine and physiology have been awarded to more Americans than to researchers in all other countries combined. Eight of the 10 top-selling drugs in the world were developed by U.S. companies. The U.S. has some of the highest breast, colon and prostate cancer survival rates in the world. And our country ranks first or second in the world in kidney transplants, liver transplants, heart transplants, total knee replacements, coronary artery bypass, and percutaneous coronary interventions.

We have the shortest waiting time for nonemergency surgery in the world; England has one of the longest. In Canada, a country of 35 million citizens, 1 million patients now wait for surgery and another million wait to see specialists.

When my friend, cardiac surgeon Peter Alivizatos, returned to Greece after 10 years heading the heart transplantation program at Baylor University in Dallas, the one-year heart transplant survival rate there was 50%—five-year survival was only 35%. He soon increased those numbers to 94% one-year and 90% five-year survival, which is what we achieve in the U.S. So the next time you hear that the U.S. is No. 37, remember that Greece is No. 14. Cuba, by the way, is No. 39.

But the issue is only partly about quality. As we have all heard, the U.S. spends a higher percentage of its gross domestic product for health care than any other country.

Actually, health-care spending now increases more moderately than it has in previous decades. Food, energy, housing and health care consume the same share of American spending today (55%) that they did in 1960 (53%).

So what does this money buy? Certainly some goes to inefficiencies, corporate profits, and costs that should be lowered by professional liability reform and national, free-market insurance access by allowing for competition across state lines. But the majority goes to a long list of advantages that American citizens now expect: the easiest access, the shortest waiting times the widest choice of physicians and hospitals, and constant availability of health care to elderly Americans. What we need now is insurance and liability reform—not health-care reform.

Who determines how much a nation should pay for its health? Is 17% too much, or too little? What better way could there be to dedicate our national resources than toward the health and productivity of our citizens?

Perhaps it's not that America spends too much on health care, but that other nations don't spend enough.

Dr. Constantian is a plastic and reconstructive surgeon in New Hampshire.

A tax increase that will cause many seniors to lose private benefits

ObamaCare on Drugs. WSJ Editorial
A tax increase that will cause many seniors to lose private benefits.
The Wall Street Journal, page A10, Jan 02, 2009

Democrats are starting to mash together the Senate and House health-care bills, all of the negotiations taking place in secret. One reason to keep quiet is so voters don't discover items like the Senate's destructive change in the way retiree health benefits are taxed. This is a revenue grab that will cost many retirees their private drug benefit coverage, with knock-on harm for the federal budget and financial markets.

When the Medicare prescription drug benefit was created in 2003, one concern was that businesses that provided private drug coverage for seniors would dump them into the new taxpayer-funded plan. So Congress created a modest tax subsidy—equal to 28% of the total cost of a drug plan—to encourage employers to maintain coverage for retirees who would otherwise enroll in Medicare. On average, this subsidy will cost the government about $665 per person in 2011, according to the Employee Benefit Research Institute, while the same Medicare coverage would run about $1,209.

Currently, the $665 a business gains by providing benefits—and keeping one senior off Medicare—is not taxed. By instead treating the subsidy as income taxed at the 35% corporate rate, Democrats expect to raise about $5.4 billion for ObamaCare—and while that's a pittance in the scheme of a new multitrillion-dollar price tag, it's also based on a static tax analysis that is surely wrong.

The cost of offering drug benefits will rise by about $233 per retiree, making Medicare a far more attractive option for businesses. Private drug coverage is already on the decline, but Verizon, Xerox, Boeing, Metlife, Caterpillar and other companies are already warning that they may be forced to cut benefits. (Consider this another reward for the Business Roundtable's decision to promote ObamaCare.)

As more employers drop drug coverage, Congress won't be dispensing as many subsidies with the one hand that it can tax with the other, so revenue will fall. The retirees who lose private benefits will simply move onto Medicare, so public drug spending will also rise. The American Benefits Council, which represents the largest employers, estimates the tax will be a net loser for the government if just one out of four retirees is crowded out of private coverage.

That $233 may not sound like a lot, but under an accounting rule established in 1990, companies are required to report and expense their long-term retiree health liabilities on their financial statements, including actual paid claims and certain future payments. The deferred losses from the tax change thus must be immediately reflected on their balance sheets, which would take a huge bite out of reported earnings in 2010. Given the shaky economy, not to mention the political uncertainty that Washington continues to generate, is this really the best idea?

This is merely one example of how careless Democrats have been about the details as they dash to pass ObamaCare, even as they behave as if the results of their major changes to the health market will match perfectly with their perfectly unrealistic rhetoric.

"One of the things I've learned is that the Econ 101 approach to life where all that matters is the direct financial incentives or penalties is just wrong," Obama budget director Peter Orszag said in December. "Not to say that it doesn't matter, but exclusive focus on rational, perfectly optimizing behavior is just not, not where it's at."

When even the budget scorekeeper spurns economic incentives, you know pure politics is in charge. We suspect the White House will discover soon enough that everyone is a lot more rational, and a lot smarter, that it presumes.

Why the Health-Care Bills Are Unconstitutional. - If the government can mandate the purchase of insurance, it can do anything

Why the Health-Care Bills Are Unconstitutional. By Orrin Hatch, J Kenneth Blackwell and Kenneth Klukowski
If the government can mandate the purchase of insurance, it can do anything.
The Wall Street Journal, page A11, Jan 02, 2009

President Obama's health-care bill is now moving toward final passage. The policy issues may be coming to an end, but the legal issues are certain to continue because key provisions of this dangerous legislation are unconstitutional. Legally speaking, this legislation creates a target-rich environment. We will focus on three of its more glaring constitutional defects.

First, the Constitution does not give Congress the power to require that Americans purchase health insurance. Congress must be able to point to at least one of its powers listed in the Constitution as the basis of any legislation it passes. None of those powers justifies the individual insurance mandate. Congress's powers to tax and spend do not apply because the mandate neither taxes nor spends. The only other option is Congress's power to regulate interstate commerce.

Congress has many times stretched this power to the breaking point, exceeding even the expanded version of the commerce power established by the Supreme Court since the Great Depression. It is one thing, however, for Congress to regulate economic activity in which individuals choose to engage; it is another to require that individuals engage in such activity. That is not a difference in degree, but instead a difference in kind. It is a line that Congress has never crossed and the courts have never sanctioned.

In fact, the Supreme Court in United States v. Lopez (1995) rejected a version of the commerce power so expansive that it would leave virtually no activities by individuals that Congress could not regulate. By requiring Americans to use their own money to purchase a particular good or service, Congress would be doing exactly what the court said it could not do.

Some have argued that Congress may pass any legislation that it believes will serve the "general welfare." Those words appear in Article I of the Constitution, but they do not create a free-floating power for Congress simply to go forth and legislate well. Rather, the general welfare clause identifies the purpose for which Congress may spend money. The individual mandate tells Americans how they must spend the money Congress has not taken from them and has nothing to do with congressional spending.

A second constitutional defect of the Reid bill passed in the Senate involves the deals he cut to secure the votes of individual senators. Some of those deals do involve spending programs because they waive certain states' obligation to contribute to the Medicaid program. This selective spending targeted at certain states runs afoul of the general welfare clause. The welfare it serves is instead very specific and has been dubbed "cash for cloture" because it secured the 60 votes the majority needed to end debate and pass this legislation.

A third constitutional defect in this ObamaCare legislation is its command that states establish such things as benefit exchanges, which will require state legislation and regulations. This is not a condition for receiving federal funds, which would still leave some kind of choice to the states. No, this legislation requires states to establish these exchanges or says that the Secretary of Health and Human Services will step in and do it for them. It renders states little more than subdivisions of the federal government.

This violates the letter, the spirit, and the interpretation of our federal-state form of government. Some may have come to consider federalism an archaic annoyance, perhaps an amusing topic for law-school seminars but certainly not a substantive rule for structuring government. But in New York v. United States (1992) and Printz v. United States (1997), the Supreme Court struck down two laws on the grounds that the Constitution forbids the federal government from commandeering any branch of state government to administer a federal program. That is, by drafting and by deliberate design, exactly what this legislation would do.

The federal government may exercise only the powers granted to it or denied to the states. The states may do everything else. This is why, for example, states may have authority to require individuals to purchase health insurance but the federal government does not. It is also the reason states may require that individuals purchase car insurance before choosing to drive a car, but the federal government may not require all individuals to purchase health insurance.

This hardly exhausts the list of constitutional problems with this legislation, which would take the federal government into uncharted political and legal territory. Analysts, scholars and litigators are just beginning to examine the issues we have raised and other issues that may well lead to future litigation.

America's founders intended the federal government to have limited powers and that the states have an independent sovereign place in our system of government. The Obama/Reid/Pelosi legislation to take control of the American health-care system is the most sweeping and intrusive federal program ever devised. If the federal government can do this, then it can do anything, and the limits on government power that our liberty requires will be more myth than reality.

Mr. Hatch, a Republican senator from Utah, is a former chairman of the Senate Judiciary Committee. Mr. Blackwell is a senior fellow with the Family Research Council and a professor at Liberty University School of Law. Mr. Klukowski is a fellow and senior legal analyst with the American Civil Rights Union.

2009: Health Year in Review

2009: Health Year in Review
Innovation.org, December 16, 2009

In the midst of the high-profile health care reform debate, 2009 quietly marked another year of important advances against serious diseases and conditions.

There have been advances across diseases and life expectancy reached an all time high of 77.9 years.^[i] Findings like this demonstrate the progress we are making as a result of prevention, early detection and better treatments. Likewise, we’ve seen positive trends in many disease areas this year. Here are just a few examples:

HIV/AIDS: The Centers for Disease Control and Prevention reported this year that between 2006 and 2007 the HIV/AIDS death rate fell 10%, which was the largest single-year decline since 1998.^[ii] Antiretroviral drugs have been instrumental in bringing death rates down and the disease has become a chronic condition for many, rather than an acute fatal illness. Since the mid-1990s, when researchers developed this new wave of medicines to treat HIV/AIDS, the U.S. death rate from AIDS dropped by more than 70 percent.^[iii]

Cancer: The American Association for Cancer Research published a study in August 2009 showing that for people in their 40s, cancer mortality rates have been falling by 26% per decade.^[iv] Although most age-adjusted mortality figures show that cancer deaths were rising until the mid-1990s, this study emphasized the fact that among younger age groups death rates have been falling since perhaps the mid-1950s and continues today. The authors attribute the trend to improvements in cancer detection, treatment and prevention.

Cardiovascular disease: The number of hospitalized patients with coronary artery disease (CAD) declined by 31% in the last decade, knocking CAD from the top cause of hospitalization to third place, according to new data from the Agency for Healthcare Research and Quality. In an interview with HealthLeaders Media, AHRQ analyst Anne Elixhauser said, "A lot of people think it's because we have better control of risk factors…. We've decreased smoking, we have better control of cholesterol, and blood pressure," which she said is credited to better lifestyle awareness and the use of drugs like statins.^[v]

Other cardiovascular diseases showed great progress in the AHRQ report as well. For example, hospitalizations for stroke and heart attacks are down 14% and 15%, respectively, compared with ten years ago.

These examples demonstrate some of the improvements that are happening in the health of Americans as a result of improvements in lifestyle, prevention, detection and treatments. There are, however, many challenges on the horizon as the nation ages, obesity becomes more prevalent and chronic diseases affect more people. New treatments will be an important part of combating these worrisome trends. Today, in the US, there are over 2,900 medicines in clinical trials or awaiting FDA approval.^[vi] Researchers are using new strategies to attack disease. They are working on dozens of different approaches to treating Alzheimer’s disease, they are searching for an HIV vaccine, they are studying promising drugs to treat Lou Gehrig’s disease and lupus, and they are using genetics to better target treatments for many diseases. Although the challenges are many, progress promises to continue in the coming years.

---

^[i] HHS, Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, J. Xu, et al. “Deaths: Preliminary Data for 2007,” National Vital Statistics Reports, 58, no. 1, p. 1, (19 August 2009) http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf (Accessed 4 December 2009).

^[ii] HHS, Center for Disease Control and Prevention, National Center for Health Statistics, National Vital Statistics System, J. Xu, et al. “Deaths: Preliminary Data for 2007,” National Vital Statistics Reports, 58, no. 1, p. 5, (19 August 2009) http://www.cdc.gov/nchs/data/nvsr/nvsr58/nvsr58_01.pdf (Accessed 4 December 2009).

^[iii] Centers for Disease Control and Prevention, National Center for Health Statistics, Health United States, 2008, (Hyattsville, MD: HHS, 2008).

^[iv] Kort et al, “The Decline in U.S. Cancer Mortality in People Born after 1925,” Cancer Research, 69: 16 (2009): 6500-6505.

^[v] C. Clark, “Heart Disease is No Longer Leading Reason for Patient Admission,” HealthLeaders Media, 24 September 2009, http://www.healthleadersmedia.com/content/239484/topic/WS_HLM2_QUA/Heart-Disease-is-no-Longer-Leading-Reason-for-Patient-Admission.html (Accessed 4 December 2009).

^[vi] Adis R&D Insight Database, 4 December 2009.

The 'Cost Control' Bill of Goods - How Peter Orszag and the White House sold a health-care illusion

The 'Cost Control' Bill of Goods. WSJ Editorial
How Peter Orszag and the White House sold a health-care illusion.

ObamaCare's core promise—better quality care for everyone at lower costs—is being exposed as an illusion as it degenerates into the raw exercise of political power. Naturally, the White House and its media booster club are working furiously to prop up this fiasco, especially on cost control.

As Obama budget director Peter Orszag put it at a revealing media breakfast earlier this month, the Senate bill does everything the experts recommend to "get at the underlying drivers of health-care costs." While he admitted that "we don't know enough" to produce results right away, the key is to encourage "continuous improvement" through pilot programs and demonstration projects. Cost containment will actually take "years to decades," Mr. Orszag conceded.

The torch was then passed to Ron Brownstein of the Atlantic Monthly, David Leonhardt of the New York Times and editorial writers for the New England Journal of Medicine, among others. Last week the New Yorker ran a 5,000-word apologia from Atul Gawande, who likewise owned up to the fact that there is "no master plan for dealing with the problem of soaring medical costs," only "a battery of small scale experiments." Keep in mind, this is an argument in favor of ObamaCare.

They might have piped up earlier: What they're finally admitting is that all the grandiose talk about "bending the curve" used for months to sell ObamaCare really comes down to their hope that bureaucratic improvisation will make a difference over the long term. Yet the liabilities of the greatest social spending program in American history will be added to the budget almost immediately, and what happens if Mr. Orszag's technocratic revolution doesn't work as promised? Or rather, when it doesn't?

Forgotten in ObamaCare's march-to-the-sea campaign is that during the transition and early on, the White House was divided on whether to pursue health reform at all. Opponents included Larry Summers, worried about the economy and deficits, and David Axelrod, worried about the politics. Another faction led by Tom Daschle preached from the conventional social-equity church of liberalism.

Mr. Orszag proposed another option, citing academic research observing that as much as 30% of health spending is "waste" that doesn't affect outcomes. He argued the country could save $700 billion a year without harming quality—more than enough to pay for universal coverage.

Thus cost control migrated from Orszag theory to free political lunch. Mr. Gawande wrote an influential New Yorker essay on the topic in June, and the theme shaped both the case for a new entitlement and especially the appeal to potential opponents in business.

But then Congressional Budget Office director Douglas Elmendorf testified in July that "the curve is being raised," given that ObamaCare lacks "the sort of fundamental changes" necessary to tamp down costs. Meanwhile, it became clear that Mr. Orszag's favored research was always more nuanced and qualified than his pose of papal infallibility. One of his main gurus, Jonathan Skinner, mused recently that "the key lesson" from a new study challenging some of his findings "is how little we know about the science of health-care delivery."

Well, sure. A field as dynamic and innovative as U.S. medicine, in which costs are largely driven by new technologies and better ways of caring for patients, is rife with complexities and uncertainties. But no one bothered to strike that note of caution when Washington was hopped up on a cost-control gambit that was too painless to be true.

The new cost-control apologists concede that there isn't any actual plan for controlling costs: Throw enough speculative policies against the wall, they say, and some breakthrough will stick. Yet Mr. Orszag's no-less-confident predecessors spent decades trying to pull down Medicare spending with little to no success. Technocracy rarely if ever works as intended. Mr. Gawande points to the case study of U.S. farm policy, and if politically sacrosanct agriculture subsidies and rural price-supports are the best to hope for, then what's the worst?

More relevant examples include Medicare's "relative value" payment scale, which was designed in 1985 by the Harvard economist William Hsiao to encourage more primary care. That's this year's rallying cry too. "Diagnosis-related groups" were introduced into Medicare in 1983 to alleviate hospital cost growth, and what a monumental success that turned out to be. With only brief periods of relatively slower growth, nominal Medicare spending has risen on average at an annual rate of 9.6% since 1980. Over the same period total Medicare spending has grown 13-fold, climbing from 1.2% of the economy to 3.2% today.

Congress lacks the stomach for serious cost control in any case. One policy Mr. Orszag favors—Medicare penalties for hospitals that re-admit certain patients—is limited to only three conditions in the Senate bill, and the penalties are trivial.

Another—a putatively independent commission that is supposed to enforce cost cutting—is barred from going after costs incurred by doctors and hospitals, which leaves out more than half of Medicare spending. Earlier this year Mr. Orszag got into a heated debate with Henry Waxman over such a commission at a dinner party hosted by Connecticut Rep. Rosa DeLauro, precisely because the House baron enjoys the political power that flows from controlling health spending.

Even if Mr. Orszag's Princeton and Yale Ph.D.s really do cook up some hope-and-a-prayer savings plan, it will invariably offend one constituency or another and Congress will block it. Thereupon the political class will do what it always does when costs run over: Tighten price controls across the board, before moving on to denying patient access to costly treatments that will be defined as "wasteful." That is, ration care.

"Basically everything that has been put forward in health policy discussions for a decade is in this bill," Mr. Orszag said on a conference call shortly before Thanksgiving. He then asked critics pointedly: "What specifically else would you do?"

Hmmm. One liberal sage noted in a 2007 paper that "four decades of empirical research" have shown that insulating people through third-party insurance coverage "from the full cost of health care has been responsible for anywhere from 10% to 50% of the large increase in health expenditures." Ultimately, he concluded, increasing cost-sharing would give individuals a direct stake in more prudent purchasing, as opposed to today's invisible health dollars that vanish as more expensive premiums, foregone wages and higher taxes.

Those are the words of Jason Furman, now the White House deputy economic director who seems to have been put into witness protection. Every serious health economist in the country recommends reforming the tax exclusion for employer-sponsored insurance, perhaps by converting it to a deduction or credit. Cost control will never stick unless it is extricated from politics and transferred to individuals to make their own trade-offs.

Such reforms were ruled out by union opposition, so the Senate gestures at them with a 40% excise tax on high-cost insurance plans, on the theory that two wrongs will make a right. But this untargeted tax will simply raise the cost of coverage for all workers in a given pool—it's too clever by 40%—while doing nothing to stem the distortions from first-dollar, third-party insurance.

No doubt there are efficiencies to be had in health care, and maybe Mr. Orszag has even identified some of them. But all of his bright ideas could be taken for a whirl without adding trillions of new liabilities to the federal balance sheet. And the bad faith of the White House and its acolytes is breathtaking.

The White House hawked a permanent entitlement expansion on flimsy and speculative theories that its own partisans now admit—albeit when it is nearly too late—aren't more substantive than the triumph of hope over experience, while simultaneously writing off the one policy that has been effective in the real world. The cost control mantra of ObamaCare was always a political bill of goods, and its result will be the opposit

"[C]reating a new entitlement program, which, once established, will be virtually impossible to rescind"

Confessions of an ObamaCare Backer. WSJ Editorial
A liberal explains the political calculus.
The Wall Street Journal, page A24

The typical argument for ObamaCare is that it will offer better medical care for everyone and cost less to do it, but occasionally a supporter lets the mask slip and reveals the real political motivation. So let's give credit to John Cassidy, part of the left-wing stable at the New Yorker, who wrote last week on its Web site that "it's important to be clear about what the reform amounts to." [http://www.newyorker.com/online/blogs/johncassidy/2009/11/some-vaguely-heretical-thoughts-on-health-care-reform.html]

Mr. Cassidy is more honest than the politicians whose dishonesty he supports. "The U.S. government is making a costly and open-ended commitment," he writes. "Let's not pretend that it isn't a big deal, or that it will be self-financing, or that it will work out exactly as planned. It won't. What is really unfolding, I suspect, is the scenario that many conservatives feared. The Obama Administration . . . is creating a new entitlement program, which, once established, will be virtually impossible to rescind."

Why are they doing it? Because, according to Mr. Cassidy, ObamaCare serves the twin goals of "making the United States a more equitable country" and furthering the Democrats' "political calculus." In other words, the purpose is to further redistribute income by putting health care further under government control, and in the process making the middle class more dependent on government. As the party of government, Democrats will benefit over the long run.

This explains why Nancy Pelosi is willing to risk the seats of so many Blue Dog Democrats by forcing such an unpopular bill through Congress on a narrow, partisan vote: You have to break a few eggs to make a permanent welfare state. As Mr. Cassidy concludes, "Putting on my amateur historian's cap, I might even claim that some subterfuge is historically necessary to get great reforms enacted."

No wonder many Americans are upset. They know they are being lied to about ObamaCare, and they know they are going to be stuck with the bill.

A ground-breaking study shows that New York City's calorie labeling law is ineffective

After Calorie Warnings, Diners Order More Calories. By ALLYSIA FINLEY
A ground-breaking study shows that New York City's calorie labeling law is ineffective.
WSJ, Nov 06, 2009

Before food czars get any more punch-happy on their own Kool-Aid, they need to be purged of the illusion that their laws are actually working. Last month, New York University and Yale medical professors published a ground-breaking study, which shows that New York City's law requiring fast food chains to post calories on their menus doesn't reduce their customers' caloric intake.

Lawmakers everywhere should take note. Efforts to require fast food restaurants to post nutritional information on their menus have been gaining ground across the country. Sixteen municipalities including California, Seattle, and Portland have passed laws similar to NYC's, and the Menu Education and Labeling Act, which would impose labeling regulations nationwide, is pending in Congress. The bill would extend the Nutrition Labeling and Education Act of 1990, which requires food manufacturers to include nutritional information on their packaging, to restaurants. We all know how effective that law was. Since 1990, obesity has more than doubled.

Published online in the journal Health Affairs, the NYU and Yale study is noteworthy because it considers the practical significance of food labeling laws. The researchers examined 1,100 restaurant receipts from McDonald's, Wendy's, Burger King and KFC franchises in low income, high-minority neighborhoods where obesity is most prevalent. They found that the poor fast-food customers that the law intended to help weren't affected.

Only half of the customers said they noticed the caloric information, and only about 15% said they used the information. But the researchers' most striking finding was that customers actually ordered more caloric items after the law went into effect than before, despite the fact that nine out of ten customers who reported using the information said they made healthier choices as a result of the law. This disconnect can partly be explained by response bias in which people tell surveyors what they think the surveyors want to hear.

But the problem may also be more complex. It's possible that people who are less educated may actually think they are eating more healthily than they are notwithstanding the calorie numbers staring them in the face. Calories as a measure of food intake (or more precisely, energy consumption and output) may be as foreign to them as the metric system is to many Americans.

The poor are also extremely price sensitive---especially in a bad economy. Give them the choice between a $2 double quarter pounder with cheese and a $5 chicken salad, and they'll make an economically rational decision and order the $2 burger. And with the extra three bucks saved, they'll order a side of fries and a Coke. Why should they care how many calories they're eating if they're getting good value?

Under pressure to subvert the NYU and Yale study, the New York City Health Department last week came out with its own report, which it nicely packaged in a press release and power point presentation (evidently, the Department didn't want to confuse the media with an actual scientific study). Though the Department's results are equivocal, New York City lawmakers are using the data to argue the efficacy of the law.

The Department is boasting that 56% of customers saw the caloric information and that 15% said they used it. But these figures demonstrate the law's failure---not success. Despite the fact that people were readily presented with the nutritional information, 85% of them ignored it.

The lawmakers who enacted the calorie posting regulations succumbed to the fallacy that everyone thinks like them. They probably reasoned that because they would make healthier choices if presented with nutritional information, everyone else would as well. But maybe what consumers actually want is a delicious meal at a low price.

While information is important, even fully informed people won't always act as lawmakers think they should, especially if it's economically irrational. Any public health legislation won't significantly change people's behavior unless it 1) provides proper incentives for people to put their long-term well-being above temporary gratification and 2) takes into account the economic rationality of people's behavior.

Unfortunately, many lawmakers refuse to swallow this inconvenient truth, preferring the taste of their Kool-Aid.

Ms. Finley is Assistant Editor of OpinionJournal.com

Implementing US Gov't Wildlife Surveillance Project to Detect and Predict Emerging Infectious Diseases

Implementing USAID Wildlife Surveillance Project to Detect and Predict Emerging Infectious Diseases
USAID, November 3, 2009

[There is a collection of articles on this. This is one of them, titled Implementing USAID Wildlife Surveillance Project to Detect and PREDICT Emerging Infectious Diseases, using Predict as an acronym. Other articles are here and here]

Washington, D.C. - The United States Agency for International Development (USAID) Bureau for Global Health is pleased to announce a partnership with UC Davis to monitor for and increase the local capacity in "geographic hot spots" to identify the emergence of new infectious diseases in high-risk wildlife such as bats, rodents, and non-human primates that could pose a major threat to human health. UC Davis leads a coalition of leading experts in wildlife surveillance including Wildlife Conservation Society, Wildlife Trust, The Smithsonian Institute, and Global Viral Forecasting, Inc. This is a five-year cooperative agreement with a ceiling of $75 million.

This project, named PREDICT, is part of the USAID Emerging Pandemic Threats Program - a specialized set of projects that build on the successes of the Agency's 30 years of work in disease surveillance, training and outbreak response. PREDICT will focus on expanding USAID's current monitoring of wild birds for H5N1 influenza to more broadly address the role played by wildlife in spreading of new disease threats.

PREDICT will be active in global hot spots where important wildlife hosts species have significant interaction with domestic animals and high-density human populations. In these regions, the team will focus on detecting disease-causing organisms in wildlife before they lead to human infection or death. Among the 1,461 pathogens recognized to cause diseases in humans, at least 60 percent are of animal origin. Predicting where these new diseases may emerge , and detecting viruses and other pathogens before they spread to people, holds the greatest potential to prevent new pandemics.

PREDICT will be led by Dr. Stephen S. Morse of Columbia University Mailman School of Public Health, a leading emerging disease authority. Other key staff include Dr. Jonna Mazet, the project's Deputy Director; Dr. William Karesh, Senior Technical Advisor; Dr. Peter Daszak, Technical Expert; and Dr. Nathan Wolfe, Technical Expert.

Al From: Democrats Don't Need the Public Option - Transformational reforms have always passed with bipartisan majorities

Democrats Don't Need the Public Option. By AL FROM
Transformational reforms have always passed with bipartisan majorities.
WSJ, Oct 16, 2009

Now that the Senate Finance Committee has voted for a health-care bill that does not include a government-run plan, it would be a mistake for Democrats to insist on adding the public option to reform legislation this year.

By insisting on the public option, liberal Democrats will allow the Republicans, who have no ideas of their own, to cloud the prospects for reform. If this happens, Republicans will be able to divert attention away from reforms most Americans want and instead focus on what Americans disagree on—whether we need a new government-run health plan.

As President Barack Obama has made clear, we need to reform. Right now, health insurance is too costly and the health-insurance market is not competitive enough. Too many people lack insurance or the chance to choose a plan that best suits their needs. Too many people are denied coverage because of pre-existing conditions or lose their coverage when they become sick. And our most successful public program—Medicare—is on the road to going broke. Doing nothing is not acceptable.

With control of the White House and Congress, the American people will rightly hold Democrats accountable for the outcome of the health debate. At the same time, the focus on the public option and level of discord it has generated is already taking a toll on the president's approval ratings and hurting the party more generally. In January, Democrats enjoyed a double digit lead on the "generic ballot"—a measure of support for a party. Last week, a Gallup poll showed that Democrats are now essentially in a dead heat with Republicans on the generic ballot. Particularly significant, the poll showed a nearly 20-point drop in Democratic support since the last election among independents, the key to our victories in 2006 and 2008. Insisting on the public option could cost many Blue Dogs in the House and a number of red-state moderates in the Senate their seats.

Now is the time for Mr. Obama to lead the way to historic health-care reform. He's the only one who can. I'd suggest he do so by taking these three steps:

• First, say unequivocally that he wants a plan that jettisons the public option and contains real reforms to cut health-care costs. As the Senate Finance Committee bill shows, a public option is unnecessary to expand coverage. Dropping it should win support of most centrist Democrats.
• Second, make clear that he does not want Congress to use parliamentary maneuvers, like the budget reconciliation process, to ram through a bill that can't command 60 votes in the Senate. Health-care reform needs broad support; it is too important and too controversial for Congress to pass by resorting to legislative chicanery or short-circuiting the legislative process.
• And finally, make one more effort to bring moderate Republicans along. Transformational reforms, such as civil rights legislation and Medicare in the 1960s, have always been passed with bipartisan majorities. Health-care reform should be no exception. The president promised a post-partisan politics. What better place to forge it than on his most important initiative?

If Mr. Obama takes these steps, I'm convinced Congress would pass a bill that requires every American to buy insurance, offers consumers a choice of plans through a new health exchange like the successful Commonwealth Connector in Massachusetts, provides subsidies that assure everyone can afford a basic plan, and prevents insurance companies from denying coverage to people with pre-existing conditions or dropping coverage for people who become sick. All of these are reforms most American can agree on.

I'd personally like to see health-care reform include fees (as the president proposed) on Cadillac health-care plans, incentives to replace fee-for-service payments with more cost-effective models (the best way to bring down health-care costs over the long haul), and measures to limit abuses in malpractice suits (which Republicans have long called for).

Such a plan would meet the objectives the president has already outlined—expanding coverage, lowering costs, and improving quality—without adding to the federal deficit. With centrist Democrats signed on, such a plan should garner the 60 votes necessary to pass the Senate. Even without a public option, it would achieve most of what liberals have long fought for. Open-minded Republicans might even find it hard to resist.

Mr. From, the principal of The From Company LLC, is the founder of the Democratic Leadership Council.

Robert Reich, 2007: if you're very old, [i]t's too expensive, so we're going to let you die

Robert Reich, 2007: if you're very old, [i]t's too expensive, so we're going to let you die
WSJ, Oct 15, 2009

Robert Reich, who served as President Clinton's labor secretary, delivered on the subject in 2007:

I will actually give you a speech made up entirely--almost at the spur of the moment, of what a candidate for president would say if that candidate did not care about becoming president. In other words, this is what the truth is, and a candidate will never say, but what candidates should say if we were in a kind of democracy where citizens were honored in terms of their practice of citizenship, and they were educated in terms of what the issues were, and they could separate myth from reality in terms of what candidates would tell them:

"Thank you so much for coming this afternoon. I'm so glad to see you, and I would like to be president. Let me tell you a few things on health care. Look, we have the only health-care system in the world that is designed to avoid sick people. [laughter] That's true, and what I'm going to do is I am going to try to reorganize it to be more amenable to treating sick people. But that means you--particularly you young people, particularly you young, healthy people--you're going to have to pay more. [applause] Thank you.

"And by the way, we are going to have to--if you're very old, we're not going to give you all that technology and all those drugs for the last couple of years of your life to keep you maybe going for another couple of months. It's too expensive, so we're going to let you die. [applause]

"Also, I'm going to use the bargaining leverage of the federal government in terms of Medicare, Medicaid--we already have a lot of bargaining leverage--to force drug companies and insurance companies and medical suppliers to reduce their costs. But that means less innovation, and that means less new products and less new drugs on the market, which means you are probably not going to live that much longer than your parents. [applause] Thank you."

Libertarian: The major provisions of ObamaCare already have been tried. They've led to increased costs and reduced access to care

The Lesson of State Health-Care Reforms. By PETER SUDERMAN
The major provisions of ObamaCare already have been tried. They've led to increased costs and reduced access to care.
WSJ, Oct 07, 2009

Supreme Court Justice Louis Brandeis famously envisioned the states serving as laboratories, trying "novel social and economic experiments without risk to the rest of the country." And on health care, that's just what they've done.

Like participants in a national science fair, state governments have tested variants on most of the major components of the health-care reform plans currently being considered in Congress. The results have been dramatically increased premiums in the individual market, spiraling public health-care costs, and reduced access to care. In other words: The reforms have failed.

New York is exhibit A. In 1993, the state prohibited insurers from declining to cover individuals with pre-existing health conditions ("guaranteed issue"). New York also required insurers to charge those enrolled in their plans the same premium, regardless of health status, age or sex ("community rating"). The goal was to reduce the number of uninsured by making health insurance more accessible, particularly to those who don't have employer-provided insurance.

It hasn't worked out very well, according to a Manhattan Institute study released last month by Stephen T. Parente, a professor of finance at the University of Minnesota and Tarren Bragdon, CEO of the Maine Heritage Policy Center. In 1994, there were just under 752,000 individuals enrolled in individual insurance plans, or about 4.7% of the nonelderly population. This put New York roughly in line with the rest of the U.S. Today, that percentage has dropped to just 0.2% of the state's nonelderly. In contrast, between 1994 and 2007, the total number of people insured in the individual market across the U.S. rose to 5.5% from 4.5%.

The decline in the number of people enrolled in individual insurance plans, the authors say, is "attributable largely to a steep increase in premiums" because of the state's regulations. Messrs. Parente and Bragdon estimate that repeal of community rating and guaranteed issue could reduce the price of individual coverage by 42%.

New York's experience with guaranteed issue and community rating is not unique. In 1996, similar reforms in Washington state preceded massive premium spikes in the individual market. Some premiums increased as much as 78% in the first three years of the reforms—or 10 times medical inflation—according to a study presented at the annual meeting of the Association for Health Services Research in 1999. Other results included a 25% drop in enrollment in the individual market, and a reduction in services offered. Within four years, for example, none of the state's major carriers offered individual insurance plans that included maternity coverage.

A 2008 analysis by Kaiser Permanente's Patricia Lynch published by Health Affairs noted that in addition to Washington and New York, the individual insurance markets in Kentucky, Maine, Massachusetts, New Hampshire, New Jersey and Vermont "deteriorated" after the enactment of guaranteed issue. Individual insurance became significantly more expensive and there was no significant decrease in the number of uninsured.

Supporters of federal health-care reform argue that the problems associated with these regulations can be addressed with the addition of an individual mandate, which is part of every ObamaCare bill in Congress. This would require every individual to purchase health insurance.
Guaranteed issue alone, the argument goes, results in slightly more expensive premiums, which drives healthier individuals out of the risk pool, which in turn further drives up premiums. The end result is that many healthy people opt out, leaving a small pool of sick individuals with very high premiums. An individual mandate, however, would spread those premium costs across a larger, healthier population, thus keeping premium costs down.

The experience of Massachusetts, which implemented an individual mandate in 2007, suggests otherwise. Health-insurance premiums in the Bay State have risen significantly faster than the national average, according to the Commonwealth Fund, a nonprofit health foundation. At an average of $13,788, the state's family plans are now the nation's most expensive. Meanwhile, insurance companies are planning additional double-digit hikes, "prompting many employers to reduce benefits and shift additional costs to workers" according to the Boston Globe.

And health-care costs have continued to grow rapidly. According to a Rand Corporation study this year, the growth now exceeds state GDP by 8%. The Boston Globe recently reported that state health-insurance commissioners are now worried that medical spending could push both employers and patients into bankruptcy, and may even threaten the system's continued existence.

Meanwhile, survey data from the Massachusetts Medical Society indicate that the state's primary-care providers are being squeezed. Family doctors report taking fewer new patients and increases in wait time.

Reform measures in other states have proven to be expensive duds. Maine's 2003 reform plan, Dirigo Health, included a government insurance option resembling the public option included in the House health-care bill. This public plan, "DirigoChoice," was supposed to expand care to all 128,000 of Maine's uninsured by 2009. But according to the U.S. Census Bureau, the 2007 uninsured rate remained roughly 10%—essentially unchanged. DirigoChoice's individual insurance premiums increased by 74% over its first four years—to $499 a month from $287 a month—according to an analysis of Dirigo data by the Maine Heritage Policy Center. The cost of DirigoHealth to taxpayers so far has been $155 million.

Tennessee's plan for universal coverage, dubbed TennCare, fared even worse in the 1990s. The goal of the state-run public insurance plan was to expand coverage to the uninsured by reducing waste. But the costs of expanding coverage quickly ballooned. In 2005, facing bankruptcy, the state was forced to cut 170,000 individuals from its insurance rolls.

Despite these state-level failures, President Barack Obama and congressional Democrats are pushing forward a slate of similar reforms. Unlike most high-school science fair participants, they seem unaware that the point of doing experiments is to identify what actually works. Instead, they've identified what doesn't—and decided to do it again.

Mr. Suderman is an associate editor at Reason magazine.

How the U.S. Government Rations Health Care

How the U.S. Government Rations Health Care. By SCOTT GOTTLIEB
The agency that would likely run the 'public option' was slow to pay for implantable cardiac defibrillators.
WSJ, Oct 01, 2009

President Barack Obama deflects criticism that his health-care plan will bring on government rationing of medical care by arguing that insurance companies ration care. Everyone knows private payers limit access to some health care. But government does it in far more byzantine and arbitrary ways.

Consider the $450 billion Medicare program. It provides a model for—indeed its bureaucracy could well end up running—the "public option" health plan that Mr. Obama wants to offer all Americans under the age of 65. In recent years, Medicare's staff has been aggressively restricting coverage for costly treatments. Looking for ways to control spending on medical products—and preserve the illusory "trust fund" that pays Medicare claims—is what shapes the culture of the organization and motivates the agency's staff.

This often means limiting access to the costliest technologies. To do this Medicare relies on its rationing and pricing systems. National coverage decisions (NCDs) are assessments issued by Medicare's medical staff that define who is eligible for new but often expensive treatments. Medicare then assigns medical products and procedures with "codes" that determine which regulated category they fall into. Finally, price "schedules" are developed by Medicare's staff each year to assign each unique code with its own updated payment rate. The process for getting a favorable code on a new product is a source of intense lobbying. It can make or break a technology.

For a remote agency like Medicare, far removed from clinical practice, it's easier to try and manage the use of a high-cost but specialty treatment than a much lower-cost but very widely used product. Yet cheaper, more commonly used products can still be mispriced and account for more total cost to the agency. For example, low-tech orthotic devices and other "durable medical equipment" are a known source of wasteful spending. These medical products often evade Medicare's attention in favor of less used but more expensive items such as a biological cancer drug.

Take the agency's tortured decisions concerning the use of implantable defibrillators that jump-start stopped hearts during cardiac arrest. Medicare sharply restricted their use in the 1990s. Mounting research proved that the $30,000 devices could be saving many more lives. So in 2003 Medicare adopted a novel theory to expand coverage to some, but not everyone, who needed one. The agency said only patients with certain measures on their electrocardiograms (called "wide QRS") seemed to benefit.

It was an easily measurable but ultimately imprecise way to allocate the devices. After another major study firmly refuted the QRS theory, Medicare expanded coverage again in 2005, potentially saving 2,500 additional lives according to a press release issued with that decision.
That experience wasn't unique. From 1999 to 2007, Medicare denied access in a third of the treatments it evaluated through its coverage process, taking an average of eight months to complete its reviews. When coverage was granted, in 85% of cases the treatments were restricted, usually to patients with more advanced illnesses.

Medicare is lately increasing its use of the national coverage process and is becoming more tightfisted. Since 2008, according to my review of Medicare data, it conditioned access in 29% of its reviews and denied new or expanded coverage in fully 53% of cases.

Medicare's methods can also be arbitrary. Take the travails of the pharmaceutical company Sepracor and its drug Xopenex, an innovative respiratory medicine that competes with the chemically distinct and much cheaper generic albuterol. Both are inhaled aerosols used to treat asthma and chronic obstructive pulmonary disease. Xopenex has the same benefits as albuterol, but some believe fewer of its cardiac side effects. Medicare didn't agree.

The agency tried to make a "national coverage decision" on Xopenex but couldn't come up with a clinical justification to limit the drug's usage. So Medicare manipulated its payment process, saying it would pay Xopenex a price equivalent to the "least costly alternative" form of generic albuterol, 10 cents a treatment compared to about $2.50 for Xopenex. Then Medicare was sued by a patient, and a Federal court recently ruled the agency exceeded its authority.

Medicare finally succeeded in reigning in the use of Xopenex with its coding system. By issuing Xopenex the same classification as generic albuterol, it was able to pay both products the same "blended" price—an average of the cost of each individual drug. That lowered the price on Xopenex, but ironically increased what Medicare paid for the generics.

It's not a stretch to say that Medicare spent hundreds of cumulative man-hours focusing on Xopenex while other priorities languished. The question is why? There weren't safety concerns. Xopenex may have been used in lieu of a cheaper alternative, but at peak Medicare sales of about $300 million it represented far less than one one-thousandth of the agency's budget. Simply put, a few staffers inside Medicare were consumed with the drug and its higher price—revealing a process that is capricious and often disconnected from science.

Worse still is how impenetrable these programs have become. Drug and device companies spend millions of dollars trying to influence Medicare decisions. The hundreds of consultants they hire to advise them typically command $20,000-a-month retainers.

Formal patient and provider appeals to Medicare took an average of 21 months, according to a report issued in 2003 by the Government Accountability Office (using 2001 data), with delays in "administrative processing" due to "inefficiencies and incompatibility" of data systems eating up 70% of the time spent processing appeals.

There's nothing inherently wrong with a program like Medicare seeking value for taxpayers. But it shouldn't make up the rules as it goes. When private plans ration care, patients can appeal directly to an insurer's medical staff. Only a small fraction of Medicare's denied claims—about 5%—are ever formally appealed because its process is so impenetrable. People can also switch insurers, and in many cases patients chose a policy because it matched their preferences in the first place. These options don't exist in a government health program.

Dr. Gottlieb is a resident fellow at the American Enterprise Institute and a former senior official at the Centers for Medicare and Medicaid Services. He is partner to a firm that invests in health-care companies, and he advises health plans.

Biologics: Diverse and Dramatic Advances

Biologics: Diverse and Dramatic Advances
Innovation.org, September 3, 2009

Research in biologics offers huge promise to patients. As scientists learn more of the molecular underpinnings of disease, our ability to treat diseases with biologics in new and innovative ways rapidly grows. A recent article in the Journal of the American Medical Association stated that biologics “represent an important and growing part of the therapeutic arsenal.”[i]

Biologics are medicines made from living material (plant, animal or microorganism) and may be derived from natural sources or engineered in a laboratory. Because they are structurally so different from most existing treatments and allow for very precise targeting, they have revolutionized treatment for many diseases. In many cases biologics are the first treatment available for a disease or they offer a significantly better way to treat a given disease. And many believe that, with more research, the near future holds many more breakthrough biologics.

Here are just a few examples of biologics that are making an enormous difference for patients:

Bevacizumab (Avastin) represents a completely new approach to attacking cancer tumors by cutting off the blood supply that feeds them. Following three decades of research in this promising area, bevacizumab was approved in 2004 to treat metastatic colorectal cancer. Since then bevacizumab has proved effective against several other forms of cancer.

Approved in 2008 to treat metastatic breast cancer, bevacizumab, in combination with paclitaxel, was shown to double progression-free survival time for women with metastatic breast cancer. The American Society for Clinical Oncology (ASCO) highlighted this a major advance of 2008.[ii]

Another recent study presented at the 2009 American Society for Clinical Oncology annual meeting found that for non-small cell lung cancer patients, bevacizumab combined with chemotherapies can slow cancer growth by up to 25%. According to the study author, "This cancer is very hard to treat. There have been some advances, but we have reached a treatment plateau and we need more agents which may help us to offer better treatment to patients…We were able to confirm that bevacizumab adds efficacy to standard chemotherapy and provides hope for patients suffering from a deadly disease."[iii]

Etanercept (Enbrel), originally approved for treatment of moderate to severe rheumatoid arthritis in 1998,[iv] has since been approved for several other autoimmune diseases, including: plaque psoriasis, psoriatic arthritis, ankylosing spondylitis, and juvenile idiopathic arthritis.[v]

Etanercept has contributed to great strides in treating rheumatoid arthritis. A recent study found that patients treated with combination therapy including etanercept had a 50% chance of complete clinical remission after 52 weeks of treatment, compared with 28% taking an older medicine.[vi] According to an editorial in The Lancet, these results would have been “unthinkable in the 20th century” prior to new disease-modifying biological medicines.[vii]

Trastuzumab (Herceptin) is one of the earliest and most common examples of personalized medicine. About 30% of women have a form of breast cancer that over-expresses a protein called HER2, which is not responsive to standard therapy. Trastuzumab was approved for patients with HER2 positive tumors in 1998 and further research showed in 2005, that it reduced recurrence by 52% in combination with chemotherapy.[viii] A commentary in the New England Journal of Medicine concluded that findings suggested “a dramatic and perhaps permanent perturbation of the natural history of the disease, maybe even a cure.”[ix]

These are just three examples of advances that are already benefiting patients. Based on progress like this, many experts believe that biologics are a key source for potential future advances. According to the Association of American Universities, “Biologics have enormous potential to provide breakthrough medical treatments.”[x] Researchers continue to explore the possibilities of new biologics and the promise for patients is enormous. By fostering such research we can deliver on the potential of biologics for more patients in the coming years.


References

[i]T.J. Giezen, “Safety-Related Regulatory Actions for Biologicals Approved in the United States and the European Union,” Journal of the American Medical Association, 300 (October 2008): 16, 1887-1896.
[ii]American Society of Clinical Oncology, “Clinical Cancer Advances 2008: Major Research Advances in Cancer Treatment, Prevention and Screening,” Journal of Clinical Oncology, 22 December 2008.
[iii]A. Gardner, “New Treatments for Tough Cancers Show Promise,” 23 March 2007, HealthDay, http://abcnews.go.com/Health/Healthday/story?id=4507406&page=1 (Accessed 21 July 2009).
[iv]Food and Drug Administration, Approval Letter, 2 November 1998, http://www.accessdata.fda.gov/drugsatfda_docs/appletter/1998/etanimm110298L.htm, (Accessed 21 July 2009).
[v]Food and Drug Administration, Drugs @ FDA, (Accessed 21 July 2009).
[vi]P. Emery, et. al., “Comparison of Methotrexate Monotherapy with a Combination of Methotrexate and Etanercept in Active, Early, Moderate to Severe Rheumatoid Arthritis (COMET): A Randomized, Double-Blind, Parallel Treatment Trial,” The Lancet, 372 (August 2008): 9636, 375-382.
[vii]J.M. Kremer, “COMET’s Path, and the New Biologicals in Rheumatoid Arthritis,” The Lancet, 372 (August 2008): 9636, 347-348.
[viii]Personalized Medicine Coalition, “The Case for Personalized Medicine,” May 2009, http://www.personalizedmedicinecoalition.org/communications/TheCaseforPersonalizedMedicine_5_5_09.pdf (Accessed 21 July 2009); Piccart-Gebhart MJ, Procter M, Leyland-Jones B, et al. Trastuzumab after Adjuvant Chemotherapy in HER2-positive Breast Cancer. New England Journal of Medicine, 353 (20 October 2005):1659-72; Romond EH, Perez EA, Bryant J, et al. Trastuzumab plus Adjuvant Chemotherapy for Operable HER2-positive Breast Cancer. New England Journal of Medicine 2005; 353 (20 October 2005):1673-84.
[ix]G. Hortobagyi, “Trastuzumab in the Treatment of Breast Cancer,” New England Journal of Medicine, 353 (20 October 2005): 16, 1734-1736.
[x]R. M. Berdahl, Association of American Universities, Letter to Representative Anna Eshoo, 20 July 2009.

Libertarians: A catalog of untruths in health insurance reform

You Mislead!, by Michael F. Cannon and Ramesh Ponnuru
Cato, Sep 29, 2009
This article appeared in the National Review (Online) on September 28, 2009.

It is a good thing that other congressmen did not follow Rep. Joe Wilson's lead. If they yelled out every time President Obama said something untrue about health care, they would quickly find themselves growing hoarse.

By our count, the president made more than 20 inaccurate claims in his speech to Congress. We have excluded several comments that are deeply misleading but not outright false. (For example: Obama pledged not to tap the Medicare trust fund to pay for reform. But there is no money in that "trust fund," anyway, so the pledge is meaningless.) Even so, we may have missed one or more false statements by the president. Our failure to include one of his comments in the following list should not be taken to constitute an endorsement of its accuracy, let alone wisdom.

1. "Buying insurance on your own costs you three times as much as the coverage you get from your employer." The Congressional Budget Office writes, "Premiums for policies purchased in the individual insurance market are, on average, much lower — about one-third lower for single coverage and one-half lower for family policies." It is true that individual insurance policies are generally 30 percent less comprehensive than employer-provided insurance, and comparable individual policies are about twice as expensive. But much of the extra cost is a function of the tax penalty on purchasing such insurance and the stunted market that penalty has yielded.

2. "There are now more than 30 million American citizens who cannot get coverage." An outright falsehood, whether you use the president's noncitizen-free estimate or the standard, questionable estimate of 46 million uninsured residents.

A study prepared for the federal government estimates that 9 million people counted as "uninsured" in the standard estimate are in fact enrolled in Medicaid. The left-leaning Urban Institute estimates that 12 million are eligible but not enrolled, meaning they could get coverage at any time. Health economists Mark Pauly of the University of Pennsylvania and Kate Bundorf of Stanford estimate that one quarter to three quarters of the uninsured can afford to purchase coverage, but choose not to do so.

3."And every day, 14,000 Americans lose their coverage." The paper that generated this estimate assumed that two months of severe job losses would continue forever. Applying that paper's methodology to a broader period of rising unemployment (January 2008 through August 2009) produces a figure below 9,000.

It also assumes those coverage losses are permanent. Like many of the 46 million Americans we label "uninsured," many of those 9,000 will regain coverage after a number of months. (David Freddoso illustrates the absurdity of assuming that all coverage losses are permanent.)

4. "One man from Illinois lost his coverage in the middle of chemotherapy... They delayed his treatment, and he died because of it." He didn't die because of it. The originator of this false claim, a writer for Slate named Timothy Noah, has admitted he got it wrong.

5. "Another woman from Texas was about to get a double mastectomy when her insurance company canceled her policy because she forgot to declare a case of acne." Scott Harrington supplied more facts in the Wall Street Journal: "The woman's testimony at the June 16 hearing confirms that her surgery was delayed several months. It also suggests that the dermatologist's chart may have described her skin condition as precancerous, that the insurer also took issue with an apparent failure to disclose an earlier problem with an irregular heartbeat, and that she knowingly underreported her weight on the application." The woman deserves sympathy, but Obama has stretched the truth here.

6. Rising costs are "why so many employers . . . are forcing their employees to pay more for insurance." Perhaps no other issue generates as much of a consensus among health-care economists as this one: The "employer's share" of employees' health-care costs comes out of those employees' wages, not out of profits. In this comment and in five others in his speech, Obama contradicts that basic truth. Employers aren't forcing their employees to pick up a larger share of the bill because they can't. Workers are already paying the entire bill.

7. Rising costs are "why American business that compete internationally... are at a huge disadvantage." False. The rising cost of health benefits does not increase employers' labor costs because, again, wages adjust downward to compensate. The Congressional Budget Office, under the leadership of Obama's OMB director, Peter Orszag, confirmed that health-care costs do not hinder competitiveness. Obama economic aide Christina Romer has called this competitiveness argument "schlocky."

8. "Those of us with health insurance are also paying a hidden and growing tax for those without it — about $1,000 per year that pays for somebody else's emergency room and charitable care." That number comes from a left-wing advocacy group. A Kaiser Family Foundation study debunked the group's analysis, reaching an estimate closer to $200 per year for a family. The CBO report mentioned above reached the same conclusion.

9. At this point, Obama said, "These are the facts. Nobody disputes them." This comment continues Obama's already long tradition of trying to curtail debate by denying that anyone disagrees with him.

10. "[Reform] will slow the growth of health-care costs for our families, our businesses, and our government." In July, CBO director Douglas Elmendorf said, "In the legislation that has been reported we do not see the sort of fundamental changes that would be necessary to reduce the trajectory of federal health spending by a significant amount. And on the contrary, the legislation significantly expands the federal responsibility for health-care costs." The CBO projects that the legislation that Sen. Max Baucus (D., Mont.) has since introduced "would reduce the federal budgetary commitment to health care, relative to that under current law, during the decade following the 10-year budget window," but hints that the 40 percent cut in Medicare's reimbursement rates, which helps Baucus achieve that feat, is politically unrealistic. (More on that below.) Health economist Victor Fuchs writes that the proposals before Congress "aim at cost shifting rather than cost reduction." Obama and his allies have yet to demonstrate anything to the contrary.

11. "Nothing in this plan will require you or your employer to change the coverage or the doctor you have. Let me repeat this: Nothing in our plan requires you to change what you have." Obama's wording is lawyerly: While not denying that his plan would cause people to lose existing coverage with which they are satisfied, he leads us to believe that he is denying it. But even on its own terms, Obama's claim is false. The CBO estimates that slashing payments to Medicare Advantage, as Obama advocates, "would reduce the extra benefits that would be made available to beneficiaries through Medicare Advantage plans." It would also cause some people to lose their coverage.

12. Requiring insurers to cover preventive care "saves money." Nope. According to a review in the New England Journal of Medicine, "Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not."

13. "The [bogus] claim... that we plan to set up panels of bureaucrats with the power to kill off senior citizens... is a lie, plain and simple." Sarah Palin claimed that Obama's "death panels" would deny people medical care, not actively kill them. If Palin believes her claim, it is not "a lie, plain and simple." Most important, the substance of Palin's claim is, in fact, true. Obama himself proposed a new Independent Medicare Advisory Council with the authority to deny life-extending care to the elderly and disabled.

14. "There are also those who claim that our reform efforts would insure illegal immigrants. This, too, is false. The reforms I'm proposing would not apply to those who are here illegally." For better or worse, the president's plan would, in his words, insure illegal immigrants. Various federal agencies, immigration critics, and the media all acknowledge that a small number of undocumented aliens obtain Medicaid benefits despite being ineligible. The president seeks to expand Medicaid, which would create greater opportunities for ineligible aliens to enroll.

The House Democrats' health-insurance exchange, which Obama supports, would "apply to" undocumented aliens. The CRS writes that the House legislation "does not contain any restrictions on noncitizens participating in the Exchange — whether the noncitizens are legally or illegally present." Nor does it require that the legal status of people receiving subsidies be verified.

Finally, Obama supports granting legal status to millions of illegal immigrants, which would make them eligible for government benefits under his health plan.

15. "Under our plan, no federal dollars will be used to fund abortions." Unless Obama refers to some draft legislation inside his head, this claim is false. The House bill allows the "government option" to pay for abortions directly from the U.S. Treasury. Both the House and Baucus bills would subsidize private insurance that cover abortions. (See Douglas Johnson's comment on this article.)

16. Critics of the public option would "be right if taxpayers were subsidizing this public insurance option. But they won't be. I've insisted that like any private insurance company, the public insurance option would have to be self-sufficient and rely on the premiums it collects." How quickly we forget the example of Fannie Mae and Freddie Mac. Like those institutions, the public option would benefit from an implicit subsidy: Everyone would know that Washington would not allow the program to fail, and financial institutions would therefore offer it better rates. (During the Clinton administration, Obama adviser Larry Summers reported that a similar implicit guarantee was worth $6 billion per year to Fannie and Freddie.) The public option would thus be able to undercut its less-subsidized competitors.

17. "And I will make sure that no government bureaucrat or insurance company bureaucrat gets between you and the care that you need." Unless the president proposes to abolish insurance, or abolish all care management, there will always be tension between patients, doctors, and public/private insurers over what patients "need." Such tensions are sure to arise under the president's IMAC proposal.

But even if a new program would be "administered by the government, just like Medicaid or Medicare," it would interfere in those decisions. As an administrative-law judge wrote to one of us after Obama's address: "I am a government bureaucrat . . . and I just happen to be reviewing [six] cases, albeit involving Medicare and Medicaid, where the government has inserted itself between the patient and the care prescribed by the physician."

18. "I will not sign a plan that adds one dime to our deficits — either now or in the future." "The plan will not add to our deficit." None of the bills before Congress can credibly claim to keep the deficit from rising. The one that comes closest, the Baucus bill, does so by making the wildly implausible assumption that Congress will allow 40 percent cuts in physician payments under Medicare to take place in 2012. Congress has routinely refused to support much smaller cuts.

19. "Now, add it all up, and the plan I'm proposing will cost around $900 billion over ten years." Even the supposedly parsimonious Baucus bill would cost closer to $2 trillion than $1 trillion once we "add it all up." The CBO says that bill would spend a mere $774 billion over ten years, in part because the spending begins late in that ten-year window. Republican staffers on the Senate Budget Committee estimate that the Baucus bill would cost $1.7 trillion over the first ten years of full implementation.

Moreover, the preliminary CBO score does not measure the full cost of the bill because it does not include the mandates Baucus would impose on states (about $37 billion) and the private sector (not yet estimated, but 60 percent of total costs in Massachusetts). The other bills would cost even more.

20. "The middle class will realize greater security, not higher taxes." Obama would make health insurance compulsory for the middle class (and everyone else). If he thinks that isn't a tax, he should listen to his economic adviser Larry Summers, or his nominee for assistant secretary for planning and evaluation at HHS, Sherry Glied. Both liken the "individual mandate" to a tax, as do other prominent health economists like Uwe Reinhardt (Princeton) and Jonathan Gruber (MIT). The CBO affirms that the penalties for non-compliance "would be equivalent to a tax or fine."
If Obama thinks the middle class wouldn't pay the taxes he wants to impose on the "drug and insurance companies," he should read this CBO report or talk to the junior senator from West Virginia, who accurately describes those levies as a "big, big tax" on middle-class coalminers.

21. "I won't stand by while the special interests use the same old tactics to keep things exactly the way they are." Who are these special interests? In case Obama hadn't noticed, everyone from the drug-makers to the unions to the insurance companies he demonizes are spending millions to build momentum for his version of reform — in no small part because Obama has promised to buy them off with middle-class tax dollars.

When President Obama makes a factual claim about health-care policy, he does not deserve the benefit of the doubt about its accuracy. We do not know whether he has been badly misinformed or is deliberately trying to mislead. Either way, he cannot be trusted to reform American health care.

Michael F. Cannon is director of health policy studies at the Cato Institute and coauthor of Healthy Competition: What's Holding Back Health Care and How to Free It. Ramesh Ponnuru is a senior editor at National Review.