A rose by any other name: ACOs to receive kickbacks for reducing short-term Medicare expenditures

Let’s start with the basics:

“ACO” stands for “Accountable Care Organization”. This is a new type of entity designed to allow the government to pay kickbacks to certain organizations that provide health care to Medicare patients, as authorized by §§ 3022 and 10307 of the Patient Protection and Affordable Care Act of 2010 (“PPACA”), a.k.a. Pub L. 111-148, a.k.a. H.R. 3590 ENR, a.k.a. the “health care reform” law. (This is a lovely example of PPACA amending itself; for even more “fun”, check out § 10309, all its references, and the additional amendments made by the Reconciliation Act, Pub. L. 111-152).

At its core, an ACO is a “group[] of providers of services and suppliers”—in Medicare-speak, that’s (very) generally hospitals, nursing homes and similar facilities, and doctors or other professional practitioners—who can get kickbacks from Medicare for incurring lower than average costs to treat their Medicare patients. Of course, the statute gets a bit more specific on eligible “providers ... and suppliers”, goes into a bit more detail than “average”, and it doesn’t call the payments “kickbacks”, but that is the gist of the program, which is due to start in 2012. (Note: The ACO model seems likely to run afoul of civil and criminal statutes that prohibit kickbacks and certain referral arrangements, but Congress has authorized HHS to “waive” the application of those statutes to allow ACOs to operate. This will likely begin to get sorted out over the next 16 months or so in the regulatory process that is scheduled to begin in the fall of 2010.)

Like any good government program, the ACO payment arrangement has an appropriate euphemism: the “shared savings program.” Why? Because the Medicare program saves money on patient treatment and shares some of that money with doctors and hospitals.

How does an ACO work?

For (a very basic) example, person A with diabetes and a heart condition visits an ACO doctor 3 times in a year, and person B with diabetes and a heart condition sees a “regular” doctor 5 times in a year; both A and B have the same outcome (let’s assume that neither A nor B go into a diabetic coma or have a heart attack).

The ACO and Medicare split the difference between the cost of treating A and the cost of treating B. That is, the ACO doctor gets paid for 3 visits, and the ACO gets paid some portion of the difference between 3 and 5 visits. The exact ratio, as well as some additional conditions, will start to be determined by regulation within the next 16 months or so. The doctor treating B would still get paid for 5 visits, assuming the visits were not “not reasonable and necessary” (the statute that authorizes all Medicare reimbursement is written in the double negative) and met other coverage criteria.

So, why would a doctor choose to join an ACO, if he or she might get paid less (in the short run) for treating the same kind of patients?

There are other components to the “shared savings program” that may help explain. Medicare will only pay the “shared savings” to an ACO that meets certain to-be-determined “quality” standards, which require Medicare to collect patient outcome data from the ACO. Thus, Medicare gets data on patient outcomes that it will (one hopes) use to adjust payment policies to encourage health care provider behavior that leads to better outcomes; you could look at this as Medicare paying a consulting fee to efficient health care providers for data on best practices. You could also look at it as a kickback for skimping on care, but these are ACOs, not HMOs, right? Well, maybe; we’ll get to that in a bit....

In the meantime, what’s in it for the ACOs? Medicare will likely “assign” patients to them, so the ACOs have a built-in referral source (which raises some interesting issues that the coming regulations will almost surely address). This means that the ACO members may see higher volume than they otherwise would. That is, theoretically, ACOs could treat more people less often, resulting in an overall increase in revenue.

One potentially exciting aspect of the program is that Medicare would finally be allowed to step into the 20^th century: ACOs will be encouraged to use practices such as “telehealth”, that is, telephone and video (e.g., Skype) conversations with patients. Medicare generally only pays for those now if you, as a patient, are physically present in an area so remote that there is likely no telephone or internet service, and happen to be named Yossarian. (I exaggerate slightly, but under current law, it is exceedingly rare for Medicare to pay for “telehealth” services). The “shared savings program” also encourages “remote monitoring” (e.g., check your blood sugar at home, electronically send results to your doctor), for which Medicare does not currently pay at all.

These technologies can, theoretically, cut down on the need for costly office visits, so patient A, above, might only actually physically see the ACO doctor one time a year, and the ACO would split the difference with Medicare for the difference between 1 office visit and 5 office visits—again, ratio TBD, but add that up over a few hundred patients, and now you, as a doctor or hospital, are quite possibly doing less work for more money, not to mention keeping your patients healthier.

What’s not to like?

Well, that’s just the first part. The rest, hidden down in PPACA § 10307, adds some interesting wrinkles.

The “shared savings” payments under § 3022 were designed to be made based on actual projected savings, but § 10307 authorizes a a “partial capitation” model, where ACOs are “at risk for some or all” of the services furnished to its patients under Medicare Parts A and B. This could be limited to ACOs that are “highly integrated systems of care” or are “capable of bearing risk”, which raises the question: What is a group of hospitals and/or doctors that is a highly integrated system of care that is capable of bearing risk? It sounds quite a bit like an HMO to me.

Granted, these latter two conditions are not “requirements”, but Medicare is authorized to make them requirements in order to make these payments to an ACO. There is also a statutory cap on the capitated payments to prevent a political disaster similar to the one in which Part C plans were getting paid more per patient than the average Medicare Part A & B patient cost the Medicare programs. CMS has also—so far, informally—stressed that unlike an HMO, patients would not be required to go to the ACO for care, which raises some other questions about how “savings” could be reliably measured.... Congress has also given CMS carte blanche to implement “any payment model that the Secretary determines will improve the quality and efficiency of items and services furnished” without incurring additional program expenditures.

Stay tuned for further developments and examples of how the ontolawgy™ platform can help to navigate the coming ACO regulatory system. If you have specific questions or would like a demonstration, please contact me via http://ontolawgy.com or Twitter.

© 2010 Alex M. Hendler. All Rights Reserved.

PPACA your bags, we're headed to Taxes

Now that the Patient Protection and Affordable Care Act (PPACA) has been signed into law, what, specifically, does PPACA do, tax-wise? Let's take a look at the so-called "individual mandate".

Very briefly, under PPACA, you (generally) will be subject to a financial "penalty" if you don't buy or otherwise get health insurance. Some people are not happy about this. Let's look at the law first, and then what people are saying about it.

What the law actually does

Under the current (pre-reconciliation) version of PPACA, specifically, § 1501, which will add § 5000A to the Internal Revenue Code, starting in 2014, for each month you do not have health insurance you must pay a nominal "penalty" of about $8 a month, ramping up to $62.50 per month in 2016 and thereafter. Generally insurance premiums are much higher than that, so this does not provide much incentive to purchase insurance coverage.

Fortunately, PPACA § 10106 addresses that problem: "Section 5000A(b)(1) of the Internal Revenue Code of 1986, as added by section 1501(b) of this Act, is amended to read as follows...." Pardon me? Instead of enacting what you meant to enact, you enact something else, then amend it? In the same piece of legislation? We'll get to that later.

I'll summarize to spare you the pain of reading it yourself: Under PPACA's amendment to its own new § 5000A of the Internal Revenue Code, you would pay either the average nationwide monthly premium, or the greater of a fixed dollar amount or 2% of your income (fully phased in in 2016), if that amount is less than the average nationwide monthly premium. (HR 4872 would make further adjustments to this formula). In fake algebra: penalty = lesser of (average premium or (greater of (fixed dollar amount or percentage of income))).

Alternatively, you could just buy health insurance and not worry about it; if you can't afford insurance, you're likely eligible for a subsidy.

Without ascribing any motive to Congress, there are some potentially interesting things happening here. If Congress is adding a new legal provision, why add the provision in full, then amend it in the same bill? Doesn't this approach just double or triple (or more) the work of someone trying to find out what the law is? Briefly: Yes.

At least one benefit is that this approach conveniently embeds the legislative history within the Act itself, which can aid future inquiries into congressional intent should any litigation arise. Perhaps it could also allow an offending provision to be more easily severed in case of a constitutional or other legal issue. As for other benefits, it could help prepare people for the frustration and confusion of driving in Washington, D.C., or serve as a component of cognitive stimulation therapy—I'm guessing they weren't intentionally headed in those directions, though....

Another potentially interesting issue is Congress's choice to impose a "penalty" under the tax code for failing to purchase insurance, rather than impose a tax and exempt people from that tax if they purchase insurance. Potato, potahto, you might say—it is the same result. That is, unless you are a red-State Attorney General up for reelection this year. Which brings us to....

What people claim the law does

The New York Times recently published an article describing how various State Attorneys General plan to sue to enjoin implementation of provisions of PPACA that these officials allege force people to buy insurance. (See also the Washington Post's opinion piece). The Times article indicates that various constitutional law scholars suggest that these challenges will "amount to no more than a speedbump" on the way to implementing PPACA for a variety of reasons, one of which is that the penalty payment is tied Congress' taxing power authorized by the Constitution.

For the originalists out there, the 16th Amendment to the U.S. Constitution reads:

The Congress shall have power to lay and collect taxes on incomes, from whatever source derived, without apportionment among the several States, and without regard to any census or enumeration.

The Times article describes legal scholars' views that the Supreme Court has very broadly construed Congress's "power to lay and collect taxes". Congress has been doing this for Medicare for more than 40 years: If you're employed by someone else, you currently pay a 1.45% tax on your income from that employment; if you're self-employed, it's about 2.9%. Under PPACA, if you make more than $200,000 in employment income per year (or $250,000 if you file a joint return), you will pay an extra 0.5% of your income, starting in 2013.

Clearly, that is a tax, and it funds insurance (Medicare Part A). It differs from the PPACA penalty in several respects: 1) This is a mandatory payment to the government; and 2) there's no guarantee that you'll actually become a beneficiary of the system (you and the Medicare program both need to survive until you're 65 or sufficiently disabled). Apparently, these Attorneys General have no problem with Medicare. They seem to accept that the government can make you pay taxes to support a government insurance program that you may never use, but they don't seem to accept that the government can give you a choice: pay tax penalties or purchase private insurance that you could use today.

What is the reasoned basis for this objection? I don't have an answer, but PJ O'Rourke asks a similar question, implying that if the Attorneys General (he singles one out, but I won't) wanted to be ideologically consistent, they would be pushing for a single-payer health care system, like the one we had for sailors more than 200 years ago.

I do not pretend to know enough about the intricacies of the Internal Revenue Code or income tax jurisprudence to opine on Congress's motives for implementing this provision via a "penalty" rather than a "tax", however, based on the plain text of the bill itself and the other provisions surrounding it, imposing a penalty under the tax code does not seem substantially different from directly imposing a tax. Admittedly, neither "tax" nor "penalty" appear to be explicitly defined within the Internal Revenue Code or the Constitution—although we can all agree that both are money that must be paid to the government and are not attached to a criminal offense (i.e., they are not fines).

In case of any doubt about the penalty's status as a "tax", enter the Commerce Clause (U.S. Const. Art. 1 § 8 cl. 3): Congress explicitly incorporated "findings" (see PPACA § 1501) indicating that health insurance and health care services constitute "interstate commerce", and that the penalty is a way to regulate that commerce. So, not only is it a "tax", but it also regulates interstate commerce (at least, Congress intends for it to do so). Belt with suspenders, anyone? If you're curious, U.S. v. Morrison, 529 U.S. 598, 608-09 (2000), presents a good overview of Congress's (very) broad power to regulate interstate commerce; I am no Constitutional scholar, but the penalty provision seems to be well within that power.

The Post's opinion piece (see above) does raise an interesting point, however: "the individual mandate extends the commerce clause's power beyond economic activity, to economic inactivity".

It would be a more interesting point if it did not rest on such shaky ground: 1) The penalty is functionally indistinguishable from a "tax" (see above), and thus, does not necessarily emanate from the Commerce Clause; and 2) the statement incorrectly assumes that people who don't buy insurance don't have an economic effect on health care. For example, if an uninsured person goes to an emergency room to get primary care treatment, and doesn't pay the bill (PDF), that person is engaging in economic activity by causing the emergency room to incur expenses, which then get passed on to paying customers (patients, rather). Sounds like commerce to me. The "penalty" imposed by PPACA is designed to discourage or offset that negative economic activity. Similarly, if the uninsured person does pay, clearly, that is economic activity. Perhaps I'm missing something, but does anyone see a legitimate Constitutional issue here?

Thoughts, comments?

© 2010 Alex M. Hendler. All Rights Reserved.

Health care reform: Cost savings, but at what cost?

On March 11, 2010 the Congressional Budget Office released an “Updated Estimate of Budgetary Impact” for the Senate-passed version of H.R. 3590. Some highlights and analysis follow.

“CBO and JCT [the Joint Committee on Taxation] now estimate that, on balance, the direct spending and revenue effects of enacting H.R. 3590 as passed by the Senate would yield a net reduction in federal deficits of $118 billion over the 2010–2019 period.”

How does it do that? According to the CBO’s analysis, the bill would cut Medicare Fee-for-Service payments by about $186 billion over the next 9 years, reduce Medicare Advantage payments by about $118 billion, and reduce Medicare and Medicaid DSH payments by about $43 billion over the same period, plus about $82 billion in other savings.

OK, so the government is going to spend less money, but that won't cover all the costs. According to the CBO's analysis, the bill would also substantially increase government revenue through a set of taxes and fees, including an excise tax on certain high-cost health insurance plans (good for about $149 billion through 2019), federally-based reinsurance and risk-adjustment "collections" ($106 billion), "fees" from "certain manufacturers and insurers" ($101 billion), "additional hospital insurance tax" ($87 billion), "other" revenue provisions ($77 billion), penalty payments ($39 billion), and what appears to be a halo of "associated effects of coverage provisions on revenues" ($57 billion).

This is an incomplete list of all the budgetary impacts, but there are other non-government costs that could be significant.

The CBO has provided a very handy itemized section-by-section list of projected budgetary impact, and has projected very little (if any) budgetary impact for the "quality improvement" (i.e., the goal of spending less money for better care) and "program integrity" (i.e., reductions in fraudulent or "abusive" payments under Medicare and Medicaid) provisions of the bill.

Of particular interest to some entities may be new administrative reporting requirements. The CBO is projecting that Title VI, Subtitle A of the bill (§§ 6001–6005) would have little (if any) impact on government revenues. What the CBO has not—and indeed, cannot have—accounted for is the likely burden that these requirements may place on health care providers. Section 6001 would introduce rather complex conditions that must be met to ensure a physician's compliance with the "Stark Law" (Social Security Act § 1877/42 U.S.C. § 1395nn) if the physician has had (as of February 1, 2010) an ownership or investment interest in a hospital. This provision is applicable to physicians who treat Medicare patients.

Section 6002 would require drug, device, biological, or medical supply manufacturers to publicly disclose on a government-run website any "payment or other transfer of value" to physicians by the manufacturers. Manufacturers and "group purchasing organizations" would also need to report any physician "ownership or investment interest" in such entities. With penalties of between $1,000 and $10,000 for each untimely unreported "ownership or investment interest" or "payment or transfer of value" (capped at $150,000 "with respect to each annual submission of information"), and between $10,000 and $100,000 for a "knowing" failure to submit the information (capped at $1,000,000 "with respect to each annual submission of information"), manufacturers and group purchasing organizations should take notice. Furthermore, it appears that the annual caps are applicable only to each physician or covered individual or entity whose interest must be reported, rather than the total of all reportable interests or payments. So if an entity has many physician investors, the penalties could multiply rather quickly: all the more reason to scrupulously report the information. Again, this provision is applicable to entities that sell product/services to Medicare patients.

Section 6003 would require a physician subject to the Stark Law, when making certain referrals for radiology services, to "inform the individual in writing at the time of the referral that the individual may obtain the services for which the individual is being referred from [someone other than the prescribing doctor or group practice] ... and provide such individual with a written list of suppliers ... who furnish such services in the area in which such individual resides". If this provision goes into effect, physicians with in-house radiology capabilities should very carefully review their radiology referral/prescription forms and procedures. They would likely also need to build (or access) a geographical database of radiology providers, likely by zip code, to facilitate the "written list" component of the provision. Free? Not for the physician. Applicable to Medicare patients? Of course.

These are just a few examples. The bill would also introduce other significant administrative reporting requirements for distributors of drug samples, pharmacy benefit managers, and nursing homes, all of whom provide services to (are you seeing a pattern here?): Medicare patients.

Although all this reporting will likely increase the transparency of some of the more opaque institutions in the health care world, there can be no doubt that these new provisions would increase administrative costs. No one in the history of health care has responded to increased administrative costs by voluntarily lowering fees charged to patients.

However, because the health care providers subject to these reporting provisions are by definition providing Medicare services, and Medicare services are the biggest item on the chopping block, these providers would by law almost certainly receive less for each unit of care provided to their patients. It is a rare person who happily does more of the same work for less money, so how much would this really cost? In other words, would there be fewer doctors or nursing homes willing to take on Medicare patients? Probably. How many fewer? How would this affect the quality of care? That depends on the quality and efficiency of the systems available to help Medicare providers comply with these requirements. What would this do to the cost of care provided to other patients? The money to pay for this has to come from somewhere.

Comments? Questions?

© 2010 Alex M. Hendler. All Rights Reserved.

Brace yourself for "dense reading of the most tortuous kind"

Well, not here, I hope, but I thought I should warn you about it. With reports coming in that the House may pass the Senate health care bill with a simple majority and move it to reconciliation in the Senate for a simple majority vote, it seems that meaningful debate on the big issues is essentially over (though the partisan sniping shows no signs of letting up); there may be a few minor tweaks here and there, and some issues may be carved out and addressed separately.

If the bill is going to survive in roughly the same form in which the Senate passed it (i.e., likely its best hope for survival), then it is going to present a number of challenges to those who want to understand and implement it, as suggested in a previous post.

The first step in analyzing it is looking at the current laws that it would amend. Among the laws the bill would amend is the Social Security Act, which, among other things, governs Medicare and Medicaid. The bill would make significant changes to how Medicare and Medicaid are funded and reimburse for services. The U.S. Court of Appeals for 4th Circuit has characterized this body of law rather colorfully:

There can be no doubt but that the statutes and provisions in question, involving the financing of Medicare and Medicaid, are among the most completely impenetrable texts within human experience. Indeed, one approaches them at the level of specificity herein demanded with dread, for not only are they dense reading of the most tortuous kind, but Congress also revisits the area frequently, generously cutting and pruning in the process and making any solid grasp of the matters addressed merely a passing phase.

Rehabilitation Ass'n of Va. v. Kozlowski, 42 F. 3d 1444, 1450 (4th Cir., 1994)

"Surely," you might think, "this must be judicial hyperbole." I can assure with great confidence that it is not.

For example, below is a simplified (and rather incomplete) 1-degree semantic map of the term "physician" as it appears in Section 1861 of the Social Security Act, based upon analytical information available on the ontolawgy™ platform. By "1-degree", I mean that the map tracks only direct relationships among element within a system, i.e., A -> B and relationships that A and B share with other elements.


On the right are the terms that require understanding of the term "physician" or that one must understand to understand the term "physician". On the left are the legal provisions—only within Section 1861—that are in some way related to the term "physician". Each of the lines in this diagram represents not only that a relationship exists between elements in the system, but also actually describes what the relationship is. Think of each line as a thought that a lawyer would need to have—consciously or not—in order to actually understand what a term or statutory provision means.

In some instances, it may require 4 or 5 "thoughts" to fully understand the relationship among the elements. The ontolawgy™ platform tracks those thoughts and places them into a searchable database.

If that's a "simplified" map, what does an unsimplified map look like? Well, because you asked so nicely, here's a 2-degree map; it tracks relationships beyond the first degree. For example, A -> B is a 1-degree relationship. A -> B -> C is a 2-degree relationship; the map also tracks common relationships among A, B, or C:


If these diagrams don't look particularly helpful to navigate or understand the law, don't worry: They're not supposed to be (at least not when presented as static images). They are supposed to represent the complexity and interconnectedness of elements of the law and to demonstrate the difficulty that a mere mortal lawyer might encounter when researching Medicare and Medicaid issues.

Now before you jump to any conclusions about the intellectual prowess of lawyers, remember that this diagram just relates to the term "physician" as used in Section 1861 of the Social Security Act. It does not address the term as it may appear in the other 108 sections of Title XVIII of the Social Security Act, nor does it address the term as it might be used in the context of Medicaid, nor in any of the millions of words (no exaggeration) of regulations, rules, Medicare and Medicaid manuals, and other statements of official policy. It may also help to bear in mind that Medicare and Medicaid regulate considerably more than just physicians.

I submit that anyone who can keep track of all of this in his or her head either has a beautiful mind or an unusual affinity for toothpicks. Let's just say that I don't have a little shed out back and I eat with a knife and fork....

© 2010 Alex M. Hendler. All Rights Reserved. No claim to original government works.

An Escherian Dilemma: Health Insurance Access or Health Care Cost?

Access to health insurance is an important problem, as is evident from one insurer's recent announcement that it would raise premiums by up to 39 percent. Improving access to insurance seems to have been the main focus of most health care reform legislation to date, but there is more to the story. According to the insurer that is proposing to raise its rates, the cost of medical equipment and services is the reason behind its proposed premium hike.

Given the dramatic increase in health care expenditures over the last several years, there is no doubt that limiting the growth rate of medical expenditures is extremely important to do. To see why, just take a look at some of the scariest sites on the internet: The Congressional Budget Office's Health page, and the Centers for Medicare and Medicaid Services National Health Expenditure Data page.

If you are not familiar with the CBO, it does some impressive and eye-opening work. If you are at all interested in how the government is proposing to spend your money, take some time to review the CBO's site. The site includes a number of interesting documents relating to health reform efforts, and CBO (thankfully) has the freedom to demystify some of the more confusing language. For example, in one analysis, the CBO notes that the Senate's health reform bill would actually increase the deficit, while nominally preserving the solvency of the "Health Insurance" (that is, Medicare Part A) "trust fund" that has been projected to be bankrupt by 2017.

So, which should be addressed first, access to insurance or the cost of health care itself? Like almost everything involving paying for health care, the only clear and simple answer is that there is no clear and simple answer: This is a chicken that hatches out of its own egg. Are there any M.C. Escher devotees who want to try their hand at drawing that?

(On another note, here are some interesting additional perspectives on what it would mean to repeal the antitrust exemption for health insurers. Although most of the experts in that article suggest that repealing the exemption would have little, if any effect on the health insurance market, there is only one surefire way to find out what it would do....)

© 2010 Alex M. Hendler. All Rights Reserved.

Brobdingnagian, Leviathan, or just plain enormous?

It is hard to pick an adjective to describe the (finally) published version of the Senate's amended health care bill, a.k.a. H.R. 3590.EAS. For a bill that started off as a few paragraphs to extend the first-time home buyer's tax credit to certain overseas members of the military, it has—in line with one of my earlier predictions—morphed into a beast that weighs in at about 2.4 kilopages (2,407, to be exact, not counting two superfluous pages at the end). I have not yet had a chance to read it, but with the election of Scott Brown to the late Senator Kennedy's seat in the Senate, it would probably not be the best use of time, the general consensus being that his election limits the likelihood that the Senate's version of the bill would survive unscathed a conference with the House.

That said, below are some potentially interesting statistics on the bill that the Senate passed (much of it based on automated analysis):

• Size

As a plain text file, it is about 2.5 MB;

The official PDF of the bill is about 4.3 MB;*

The table of contents is 16 pages long;

The bill is approximately 16,000 lines long;

It contains approximately 379,638 words.

• Complexity

It has 441 Sections of its own;

It adds 173 new Sections to existing law;

I doubt there is any religious significance, but that amounts to 614 sections altogether (one more than the number of commandments commonly held to exist in the Hebrew Bible), a fact that might be interesting to certain factions that oppose this legislation;

It makes approximately 912 amendments to existing law;

It mentions the "Social Security Act" 706 times;

It mentions the "Public Health Service Act" 284 times;

It mentions the "Internal Revenue Code" 195 times;

It mentions the "Employee Retirement Income Security Act" (also known as ERISA) 25 times.

• Money

It contains 360 dollar signs;

It mentions numbers in unrounded millions (i.e., xxx,000,000) approximately 206 times;

It mentions numbers in billions rounded to millions (i.e., xxx,xxx,000,000) approximately 39 times;

Of those 39 times, it mentions numbers in unrounded billions (i.e., xxx,000,000,000) approximately 26 times.

What is the point of reporting all these numbers? Merely to point out that the bill is big, complicated, and addresses numbers of a size more typical of biology, chemistry, physics, and CMBS balance sheets. Why is is so big and complicated?

Unfortunately, the straightforward solutions to the problem of securing universal health insurance coverage (i.e., mandate individual insurance purchases through imposition of a new income tax, refunded in part through vouchers to pay for such insurance, in part to subsidize insurance for those who could not otherwise afford it; get rid of preexisting condition exclusions; completely remove the federal antitrust exception for health insurance), are, for the most part, political non-starters.

While some of the complexity in health reform legislation may stem from earmarks or other concessions to bring certain legislators on board, I submit that a larger part comes from attempting to reach the same results as above in such convoluted—sorry, "creative"—ways that politicians can try to explain their way around the outcome in a manner that would allow them to get reelected.

There are some hints of what a "pared-down", passable bill might do, and while it could be a start, if that is what Congress ultimately does, it is still quite far from where we need to be, i.e., universal (but not necessarily unified, i.e., "single payer") coverage.

So, is Scott Brown's election a good or a bad thing for "health reform"? With that, I leave you to Federalist No. 10 and your own conclusions:

A zeal for different opinions concerning religion, concerning government, and many other points, as well of speculation as of practice; an attachment to different leaders ambitiously contending for pre-eminence and power; or to persons of other descriptions whose fortunes have been interesting to the human passions, have, in turn, divided mankind into parties, inflamed them with mutual animosity, and rendered them much more disposed to vex and oppress each other than to co-operate for their common good.

*Your numbers may differ; my operating system reports sizes in megabytes as if 1 MB = 1000KB; some systems reports sizes as if 1MB = 1024KB; technically, the latter definition is called a "MebiByte", but few people actually use that term.

© 2010 Alex M. Hendler. All Rights Reserved.