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Articles on Health Care Reform
The Director has published three books and more than  80 articles on the state of health care reform and the trends that motivate certain important changes. This section allows you to review some of those articles. [See Director's Resume section of this website for his CV and  List of Publications.]

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SUPREME COURT RUILING ON NEW HEALTH CARE REFORM LAW


From the Bloomberg News 6/28/2012

To contact the reporter on this story: Greg Stohr in Washington at gstohr@bloomberg.net

To contact the editor responsible for this story: Steven Komarow at skomarow1@bloomberg.net


The U.S. Supreme Court upheld the core of President Barack Obama’s health-care overhaul, giving him an election-year triumph and preserving a law that would expand insurance to millions of people and transform an industry that makes up 18 percent of the nation’s economy.

.The justices, voting 5-4, said Congress has the power to make Americans carry insurance or pay a penalty. That requirement is at the center of the law, which also forces insurers to cover people with pre-existing medical conditions. The court modified the law’s extension of the Medicaid program for the poor by saying the federal government can’t threaten to withhold existing money from states that don’t fully comply.

The ruling frames the health-care issue for this year’s elections and is a victory of symbolism as well as substance for Obama. Chief Justice John Roberts, a Republican appointee, joined four Democratic-selected justices to give Obama a majority on a law that has divided the country along ideological and partisan lines throughout his presidency.

Roberts, writing for the court, said Congress had the authority to impose the insurance requirement under its power to levy taxes. “Because the Constitution permits such a tax, it is not our role to forbid it or to pass upon its wisdom or fairness,” he wrote.

Longest Arguments
“The highest court in the land has now spoken,” Obama said afterward in a televised statement from the White House.

“We will continue to implement this law,” and search for improvements, Obama said. “What we won’t do, and what the country can’t afford to do, is re-fight the political battles of two years ago or go back to the way things were.”

The decision on the Patient Protection and Affordable Care Act is the climax to an epic legal fight that featured the longest courtroom arguments in 44 years, a record number of briefs and extraordinary public interest in a Supreme Court case. The case tested both the constitutional powers of Congress and the willingness of the Roberts court to overrule the other two branches of the federal government.

Republican-appointed Justices Antonin Scalia, Anthony Kennedy, Clarence Thomas and Samuel Alito dissented, saying they would have struck down the entire statute.

“The fragmentation of power produced by the structure of our government is central to liberty, and when we destroy it, we place liberty at peril,” the dissenters wrote. “Today’s decision should have vindicated, should have taught, this truth; instead, our judgment today has disregarded it.”

Unusual Step
Among the majority, Justices Ruth Bader Ginsburg and Sonia Sotomayor voted to uphold the entire statute. Justices Stephen Breyer and Elena Kagan agreed with Roberts in limiting the Medicaid expansion.

Kennedy and Ginsburg each took the unusual step of reading a summary of their opinion from the bench. All told, the justices took more than an hour to announce the ruling before a packed courtroom that included members of Congress, retired Justice John Paul Stevens and Solicitor General Donald Verrilli, the Obama administration lawyer whose defense of the law drew criticism.

The dispute marked the first time the Supreme Court had considered a president’s defining legislative accomplishment in the middle of his re-election campaign. The court hadn’t taken up a law of comparable scope since the justices overturned part of the National Industrial Recovery Act in 1935 during President Franklin Roosevelt’s New Deal.

Biggest Since Medicare
The law marks the biggest change to the U.S. health system since Medicare and Medicaid were established in 1965. It was designed to expand coverage to at least 30 million people -- primarily by expanding Medicaid and setting up online markets where consumers could buy insurance -- while controlling the soaring costs of health care.

Republicans, including presidential candidate Mitt Romney, have called for its repeal, and House Majority Leader Eric Cantor, a Virginia Republican, scheduled a vote on that effort for the week of July 9.

Romney said he disagreed with the Supreme Court’s decision. He said what the justices failed to do he would “do on my first day if elected president of the United States.”

‘Urgency’ of Repeal
Obama’s health-care legislation “puts the federal government between you and your doctor,” Romney told reporters in Washington. Though he pushed through a similar plan when he was governor of Massachusetts, he has said such a measure isn’t applicable nationally.

“The president’s health-care law is hurting our economy by driving up health costs and making it harder for small businesses to hire,” House Speaker John Boehner, an Ohio Republican, said in a statement.

The law was challenged by 26 Republican-controlled states and a small-business trade group. They contended the measure exceeded Congress’s constitutional powers to regulate interstate commerce and impose taxes.

The challenge focused on the insurance mandate, which requires Americans to get coverage by 2014 or pay a penalty. The concept was championed by Republicans years ago as an alternative to Democratic proposals for a single government-run health system.

Roberts’ Reasoning
Roberts accepted the Republicans’ commerce argument, while voting to uphold the mandate under Congress’s taxing power.

While the federal government “does not have the power to order people to buy health insurance,” Roberts wrote, “the federal government does have the power to impose a tax on those without health insurance.” The law “is therefore constitutional because it can reasonably be read as a tax.”

Roberts said that, for most Americans, the amount of the penalty will be far less than the cost of insurance.

“It may often be a reasonable financial decision to make the payment rather than purchase insurance,” he wrote. “Although the payment will raise considerable revenue, it is plainly designed to expand health insurance coverage. But taxes that seek to influence conduct are nothing new.”

The ruling will shape Roberts’ legacy as much as Obama’s. The 57-year-old chief justice -- whose 2005 nomination Obama opposed as a senator -- has been a leader of the court’s conservative wing on other issues.

Medicaid Expansion
The Medicaid expansion was designed to extend eligibility to those with incomes up to 138 percent of the federal poverty line. States that didn’t comply with the new expansion would have lost all or part of their share of federal Medicaid funding.

Roberts said Congress can require states to meet conditions to receive new Medicaid money, though it can’t take away existing funding. He said Medicaid spending accounts for more than 20 percent of the average state’s total budget, with the federal government covering at least half those costs.

“The financial ‘inducement’ Congress has chosen is much more than ‘relatively mild encouragement’ -- it is a gun to the head,” Roberts wrote. “What Congress is not free to do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding.”

The ruling removes some of the uncertainty the health industry had faced about the future of government policy. By upholding the individual mandate, the court left intact a provision that will give insurers such as UnitedHealth Group Inc. (UNH) millions of relatively healthy, low-cost policyholders.

Other parts of the law will help the drug industry, including the Medicaid expansion and the system of online insurance markets that will make it easier for people to buy policies. Hospitals also may benefit from the expansion, as will insurers that focus on managing states’ Medicaid programs, including Amerigroup Corp. (AGP) and Centene Corp. (CNC)

Market Reaction
Hospital companies led by HCA Holdings Inc. (HCA) jumped in New York trading, and Medicaid insurers paced by Molina Healthcare Inc. (MOH) rose. Commercial carriers such as WellPoint Inc. (WLP) fell in the face of the law’s new regulations. HCA, the biggest U.S. hospital chain, rose 9.1 percent to $29.03 at 12:28 p.m., after the Nashville, Tennessee-based company earlier climbed as much as 12 percent.

Tenet Healthcare Corp. (THC), the third-biggest chain, jumped as much as 13 percent, while Long Beach, California-based Molina rose as much as 9 percent. Indianapolis-based WellPoint, the second-largest U.S. health insurer, declined 4.9 percent to $64.58.

Some parts of the law have already gone into effect, including provisions that close a gap in prescription-drug coverage under Medicare, allow 2.5 million young adults to stay on their parents’ insurance until age 26, and provide free mammograms, colonoscopies and flu shots.

Long Sought
The health-care measure’s enactment in March 2010 marked the culmination of decades of efforts by Democrats and Republicans alike to put in place a universal health-care program. For Obama, congressional approval marked a victory that had eluded presidents from Harry Truman to Bill Clinton.

Passage in the Democratic-controlled Congress came only after months of lobbying, deal-making and parliamentary maneuvering. In the end, not a single Republican voted in favor of the law. The measure passed the House by a 219-212 tally.

From the beginning, the law divided the public, with opposition fueling the Tea Party movement and helping produce the 2010 Republican takeover of the House. A Bloomberg National Poll conducted in March found that 37 percent of respondents said the law should be repealed, 11 percent said it should be left alone and 46 percent said it may need small modifications.

To contact the reporter on this story: Greg Stohr in Washington at gstohr@bloomberg.net

To contact the editor responsible for this story: Steven Komarow at skomarow1@bloomberg.net



"...The justices, voting 5-4, said Congress has the power to make Americans carry insurance or pay a penalty..."



THE MEDICAL PROFESSION CAN'T COPE
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TURNING BACK TO FIND THE FUTURE
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A hearty laugh is healthy
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Who are the uninsured?
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Capitation invites socialization of medicine
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Managed Care Must Be Saved
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ABORTION BREAST CANCER LINK
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WAR AGAINST GIRLS BOOK REVIEW

The War Against Girls

Since the late 1970s, 163 million female babies have been aborted by parents seeking sons

Mara Hvistendahl is worried about girls. Not in any political, moral or cultural sense but as an existential matter. She is right to be. In China, India and numerous other countries (both developing and developed), there are many more men than women, the result of systematic campaigns against baby girls. In "Unnatural Selection," Ms. Hvistendahl reports on this gender imbalance: what it is, how it came to be and what it means for the future.

In nature, 105 boys are born for every 100 girls. This ratio is biologically ironclad. Between 104 and 106 is the normal range, and that's as far as the natural window goes. Any other number is the result of unnatural events.

Yet today in India there are 112 boys born for every 100 girls. In China, the number is 121—though plenty of Chinese towns are over the 150 mark. China's and India's populations are mammoth enough that their outlying sex ratios have skewed the global average to a biologically impossible 107. But the imbalance is not only in Asia. Azerbaijan stands at 115, Georgia at 118 and Armenia at 120.

What is causing the skewed ratio: abortion. If the male number in the sex ratio is above 106, it means that couples are having abortions when they find out the mother is carrying a girl. By Ms. Hvistendahl's counting, there have been so many sex-selective abortions in the past three decades that 163 million girls, who by biological averages should have been born, are missing from the world. Moral horror aside, this is likely to be of very large consequence.

[GIRLS1] Ma Liuming/Sotheby's

'No. 23' (2005-06), a painting by Ma Liuming.

In the mid-1970s, amniocentesis, which reveals the sex of a baby in utero, became available in developing countries. Originally meant to test for fetal abnormalities, by the 1980s it was known as the "sex test" in India and other places where parents put a premium on sons. When amnio was replaced by the cheaper and less invasive ultrasound, it meant that most couples who wanted a baby boy could know ahead of time if they were going to have one and, if they were not, do something about it. "Better 500 rupees now than 5,000 later," reads one ad put out by an Indian clinic, a reference to the price of a sex test versus the cost of a dowry.

But oddly enough, Ms. Hvistendahl notes, it is usually a country's rich, not its poor, who lead the way in choosing against girls. "Sex selection typically starts with the urban, well-educated stratum of society," she writes. "Elites are the first to gain access to a new technology, whether MRI scanners, smart phones—or ultrasound machines." The behavior of elites then filters down until it becomes part of the broader culture. Even more unexpectedly, the decision to abort baby girls is usually made by women—either by the mother or, sometimes, the mother-in-law.

If you peer hard enough at the data, you can actually see parents demanding boys. Take South Korea. In 1989, the sex ratio for first births there was 104 boys for every 100 girls—perfectly normal. But couples who had a girl became increasingly desperate to acquire a boy. For second births, the male number climbed to 113; for third, to 185. Among fourth-born children, it was a mind-boggling 209. Even more alarming is that people maintain their cultural assumptions even in the diaspora; research shows a similar birth-preference pattern among couples of Chinese, Indian and Korean descent right here in America.

Unnatural Selection: Choosing Boys Over Girls and the Consequences of a World Full of Men

By Mara Hvistendahl
PublicAffairs, 314 pages, $26.99

Ms. Hvistendahl argues that such imbalances are portents of Very Bad Things to come. "Historically, societies in which men substantially outnumber women are not nice places to live," she writes. "Often they are unstable. Sometimes they are violent." As examples she notes that high sex ratios were at play as far back as the fourth century B.C. in Athens—a particularly bloody time in Greek history—and during China's Taiping Rebellion in the mid-19th century. (Both eras featured widespread female infanticide.) She also notes that the dearth of women along the frontier in the American West probably had a lot to do with its being wild. In 1870, for instance, the sex ratio west of the Mississippi was 125 to 100. In California it was 166 to 100. In Nevada it was 320. In western Kansas, it was 768.

There is indeed compelling evidence of a link between sex ratios and violence. High sex ratios mean that a society is going to have "surplus men"—that is, men with no hope of marrying because there are not enough women. Such men accumulate in the lower classes, where risks of violence are already elevated. And unmarried men with limited incomes tend to make trouble. In Chinese provinces where the sex ratio has spiked, a crime wave has followed. Today in India, the best predictor of violence and crime for any given area is not income but sex ratio.

A high level of male births has other, far-reaching, effects. It becomes harder to secure a bride, and men can find themselves buying or bidding for them. This, Ms. Hvistendahl notes, contributes to China's astronomical household savings rate; parents know they must save up in order to secure brides for their sons. (An ironic reflection of the Indian ad campaigns suggesting parents save money by aborting girls.) This savings rate, in turn, drives the Chinese demand for U.S. Treasury bills.

And to beat the "marriage squeeze" caused by skewed sex ratios, men in wealthier imbalanced countries poach women from poorer ones. Ms. Hvistendahl reports from Vietnam, where the mail-order-bride business is booming thanks to the demand for women in China. Prostitution booms, too—and not the sex-positive kind that Western feminists are so fond of.

The economist Gary Becker has noted that when women become scarce, their value increases, and he sees this as a positive development. But as Ms. Hvistendahl demonstrates, "this assessment is true only in the crudest sense." A 17-year-old girl in a developing country is in no position to capture her own value. Instead, a young woman may well become chattel, providing income either for their families or for pimps. As Columbia economics professor Lena Edlund observes: "The greatest danger associated with prenatal sex determination is the propagation of a female underclass," that a small but still significant group of the world's women will end up being stolen or sold from their homes and forced into prostitution or marriage.

All of this may sound dry, but Ms. Hvistendahl is a first-rate reporter and has filled "Unnatural Selection" with gripping details. She has interviewed demographers and doctors from Paris to Mumbai. She spends a devastating chapter talking with Paul Ehrlich, the man who mainstreamed overpopulation hysteria in 1968 with "The Population Bomb"—and who still seems to think that getting rid of girls is a capital idea (in part because it will keep families from having more and more children until they get a boy). In another chapter she speaks with Geert Jan Olsder, an obscure Dutch mathematician who, by an accident of history, contributed to the formation of China's "One Child" policy when he met a Chinese scientist in 1975. Later she visits the Nanjing headquarters of the "Patriot Club," an organization of Chinese surplus men who plot war games and play at mock combat.

Ms. Hvistendahl also dredges up plenty of unpleasant documents from Western actors like the Ford Foundation, the United Nations and Planned Parenthood, showing how they pushed sex-selective abortion as a means of controlling population growth. In 1976, for instance, the medical director of the International Planned Parenthood Federation, Malcom Potts, wrote that, when it came to developing nations, abortion was even better than birth control: "Early abortion is safe, effective, cheap and potentially the easiest method to administer."

The following year another Planned Parenthood official celebrated China's coercive methods of family planning, noting that "persuasion and motivation [are] very effective in a society in which social sanctions can be applied against those who fail to cooperate in the construction of the socialist state." As early as 1969, the Population Council's Sheldon Segal was publicly proclaiming the benefits of sex-selective abortion as a means of combating the "population bomb" in the East. Overall Ms. Hvistendahl paints a detailed picture of Western Malthusians pushing a set of terrible policy prescriptions in an effort to road-test solutions to a problem that never actually manifested itself.

There is so much to recommend in "Unnatural Selection" that it's sad to report that Ms. Hvistendahl often displays an unbecoming political provincialism. She begins the book with an approving quote about gender equality from Mao Zedong and carries right along from there. Her desire to fault the West is so ingrained that she criticizes the British Empire's efforts to stamp out the practice of killing newborn girls in India because "they did so paternalistically, as tyrannical fathers." She says that the reason surplus men in the American West didn't take Native American women as brides was that "their particular Anglo-Saxon breed of racism precluded intermixing." (Through most of human history distinct racial and ethnic groups have only reluctantly intermarried; that she attributes this reluctance to a specific breed of "racism" says less about the American past than about her own biases.) When she writes that a certain idea dates "all the way back to the West's predominant creation myth," she means the Bible.

Ms. Hvistendahl is particularly worried that the "right wing" or the "Christian right"—as she labels those whose politics differ from her own—will use sex-selective abortion as part of a wider war on abortion itself. She believes that something must be done about the purposeful aborting of female babies or it could lead to "feminists' worst nightmare: a ban on all abortions."

It is telling that Ms. Hvistendahl identifies a ban on abortion—and not the killing of tens of millions of unborn girls—as the "worst nightmare" of feminism. Even though 163 million girls have been denied life solely because of their gender, she can't help seeing the problem through the lens of an American political issue. Yet, while she is not willing to say that something has gone terribly wrong with the pro-abortion movement, she does recognize that two ideas are coming into conflict: "After decades of fighting for a woman's right to choose the outcome of her own pregnancy, it is difficult to turn around and point out that women are abusing that right."

Late in "Unnatural Selection," Ms. Hvistendahl makes some suggestions as to how such "abuse" might be curbed without infringing on a woman's right to have an abortion. In attempting to serve these two diametrically opposed ideas, she proposes banning the common practice of revealing the sex of a baby to parents during ultrasound testing. And not just ban it, but have rigorous government enforcement, which would include nationwide sting operations designed to send doctors and ultrasound techs and nurses who reveal the sex of babies to jail. Beyond the police surveillance of obstetrics facilities, doctors would be required to "investigate women carrying female fetuses more thoroughly" when they request abortions, in order to ensure that their motives are not illegal.

Such a regime borders on the absurd. It is neither feasible nor tolerable—nor efficacious: Sex determination has been against the law in both China and India for years, to no effect. I suspect that Ms. Hvistendahl's counter-argument would be that China and India do not enforce their laws rigorously enough.

Despite the author's intentions, "Unnatural Selection" might be one of the most consequential books ever written in the campaign against abortion. It is aimed, like a heat-seeking missile, against the entire intellectual framework of "choice." For if "choice" is the moral imperative guiding abortion, then there is no way to take a stand against "gendercide." Aborting a baby because she is a girl is no different from aborting a baby because she has Down syndrome or because the mother's "mental health" requires it. Choice is choice. One Indian abortionist tells Ms. Hvistendahl: "I have patients who come and say 'I want to abort because if this baby is born it will be a Gemini, but I want a Libra.' "

This is where choice leads. This is where choice has already led. Ms. Hvistendahl may wish the matter otherwise, but there are only two alternatives: Restrict abortion or accept the slaughter of millions of baby girls and the calamities that are likely to come with it.

—Mr. Last is a senior writer at the Weekly Standard.


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