"Obamacare"/ Affordable Health Care Act Changed The American Health Care System Forever

Pres. Barack Obama signed the Health Care Reform bill into Law on March 23, 2010.


Health reform at 2: Why American health care will never be the same

In February 2009, Michael Zucker told a group of high-paid surgeons something they did not want to hear: The way they earned a salary was about to change.

Zucker is the chief development officer at Baptist Health System, a five-hospital network in San Antonio. For 37 common surgeries, such as hip replacements and pacemaker implants, it would soon collect “bundled” Medicare payments. Traditionally, hospitals and doctors had collected separate fees for each step of such procedures; now they would get a lump sum for treating everything related to the patient’s condition.

If a hospital delivered care for less than the bundled rate, while hitting certain quality metrics, it would keep the difference as profit. But if costs were high and quality was too low, Baptist would lose money. For the first time in their careers, the doctors’ paychecks depended on the quality of the care they provided.

Four surgeons quit in protest.

“I’d describe the reception as lukewarm at best,” Zucker says. “There was a lot of: ‘How could you do this?’ and ‘I’m not going to participate.’ ”

The program launched in June 2009 with a checklist of quality metrics. To earn a bonus, surgeons would, among other things, need to ensure that antibiotics were administered an hour before surgery and halted 24 hours after, reducing the chances of costly complications.

Only three doctors hit the metrics that first month, but their bonuses caught the attention of others. “There was a lot of, ‘Why are those doctors getting more, and I’m not?” Zucker says. Eight doctors got bonus payments in July; two dozen got them in August. Compliance with certain quality metrics steadily climbed from 89 percent to 98 percent in three months.

Two-and-a-half years later, Baptists’ surgeons have earned more than $950,000 in bonuses. Medicare, meanwhile, has netted savings: Its bundled rate is about 5 percent lower than all the fees it used to pay out for the same services. “It wasn’t a home-run,” says Zucker, noting the start-up costs in administering the program — not to mention a handful of lost employees. “But I’d call it a solid triple.”

The Affordable Care Act is mostly known for its mandate to expand health insurance to 30 million more Americans within a decade. That’s the side of the legislation Democrats touted last week, when the law hit its two-year anniversary. It’s also the point that has roused the most ire from opponents. Insurance expansion is at the heart of legal challenges the Supreme Court will take up on Monday, which argue that forcing people to buy insurance coverage is unconstitutional.

But much of the law’s 905 pages are dedicated to an effort that’s arguably more ambitious: an overhaul of America’s business model for medicine. It includes 45 changes to how doctors deliver health care — and how patients pay for it. These reforms, if successful, will move the country’s health system away from one that pays for volume and toward one that pays for value. The White House wants to see providers behave more like Baptist Health Systems, rewarding health care that is both less costly and more effective.

The health-care industry was moving toward value-based payments even before health reform passed. But the Affordable Care Act has played an important role, economists say, by signalling that America’s biggest health-care spender — the federal government — is also headed in that direction.

“The Affordable Care Act is like two laws in one,” former Medicare administrator Don Berwick said. “There’s the coverage piece, and I think that’s proceeding well. On the other side, there’s health-care delivery reform.”

Even as Congress was debating the Affordable Care Act, economic and demographic trends were steering the industry’s business model off a cliff. As costs ticked higher, Americans were losing insurance coverage. They were making fewer trips to the doctor, which meant less revenue. Baby Boomers landed in Medicare, which pays less than private insurance, further shrinking health-care providers’ income. Health systems reevaluated their volume-dependent bottom lines.

“There was a patient mix shift happening that, unless hospitals changed, they were going to be losing money in about five years,” says Chas Roades, chief research officer at consulting firm the Advisory Board Co.

In Washington, the Obama administration was facing a different problem: Medicare was eating up a growing share of the federal budget. The program’s costs had more than doubled in a decade, from $212 billion in 1999 to $499 billion in 2009. Since it started in 1965, the program has paid providers based on volume. Most private insurance works this way, too: In 2008, 78 percent of health plans paid for coverage on a fee-for-service basis. That system, economists argued, was driving up costs: It pushed doctors to provide as much care as possible, regardless of whether it was effective.

Across the country, however, a few health-care systems had made high-profile moves in another direction. Places like Kaiser Permanente in California and the Mayo Clinic in Minnesota were setting strict budgets for their patients and demonstrating, in study after study, that they could deliver higher quality outcomes at a lower cost than other hospitals and doctors.

What these systems had in common was a model called integrated care, where doctors, hospitals and insurers work together to deliver the most cost-effective treatments. In integrated care systems, doctors are often paid a flat salary, rather than charging for each procedure they perform. They often receive incentive payments for hitting certain quality metrics.

Alongside a handful of success stories, there were dozens of cautionary tales. Health-care costs did decrease in the mid-1990s, when Health Maintenance Organizations limited patients’ access to more costly, speciality providers, but patients left such payment plans in droves, which encouraged providers to stick with a volume-driven system.

For the Obama administration, this represented an opportunity. Insurance premiums had grown by 131 percent between 1999 and 2009. If Congress was going to extend insurance to millions more Americans, it wanted a guarantee that those benefits would be affordable. The integrated-care model, they hoped, could control those costs even as it improved the quality of care. No “rationing” needed.

Payment reforms became “massively and unstoppably important,” says Bob Kocher, a former White House health-care adviser. “There was a sentiment among the Democrats that the problem is spending, and a real desire to finance the coverage expansion, as much as possible, from delivery system reforms.”

It was unclear how quickly the federal government could move. Medicare’s whole infrastructure, from its billing software to its reimbursement levels, is built around paying doctors a fee for each service. Kocher remembers suggesting that the law should require that 20 percent of Medicare’s payments be bundled by 2015. A senior Medicare official, he recalls, nearly had an “allergic reaction” to that timeline.

The Affordable Care Act ultimately included 45 delivery system reforms. Fifteen of those change how Medicare doctors and hospitals are paid, according to an analysis by Sen. Sheldon Whitehouse (D-R.I.). The six that have rolled out thus far are largely voluntary, allowing those who think they can deliver more cost-efficient care to opt-in to new payment models.

But the remaining changes will be mandatory. Beginning in October, hospitals stand to lose 1 percent of their Medicare revenue if they can’t hit key metrics on “preventable readmissions” — patients who turn up at the hospital with a complication from an earlier procedure. That’s a big change from the current, volume-based system in which those readmissions generate additional revenue for a hospital.

Although it’s not fully implemented, some say the Affordable Care Act has already significantly catalyzedthe health-care system. Leaders know where Medicare wants to go, even if they didn’t chart an especially aggressive path for how it would get there. “Forever and a day, everybody had been saying we had to change the way we paid for health care,” Roades says. “Now, we have a sense of direction of where the country’s biggest payer is headed. And that provides cover for everybody else to move in that direction.”

Roades calls the past two years ones of “breathtaking change.” When the Advisory Board Co. surveyed 69 hospital executives in November, just 16 percent said they had bundled payments in place. But of those who didn’t, 75 percent expected to within two years. Two-thirds expected they would have such payment arrangements with Medicare.

The health-care system has become increasingly integrated, with hospitals and insurance plans buying up doctors’ offices. Consulting firm Irving Levin Associates saw health-care merger activity shoot up 11 percent, from $205 billion in 2010 to $227 billion. Their analyst, Stanford Steever, attributed that largely to the Affordable Care Act.

Others, however, point out that it’s too early to see any data on health-care outcomes, as only a handful of the payment reforms have come online. And there are signs that the industry may not be ready to leave the payment model it’s depended on for decades.

The Obama administration stumbled in launching its most sweeping effort, the Accountable Care Organization program. The hope was to get health-care providers to band together and accept a flat fee for all the care provided to a set population of Medicare patients. That way, different providers would have an incentive to coordinate the care a given patient was getting by different specialists. Currently, individual patients can be treated by many different doctors who aren’t full aware of what the others are doing, much less working in close cooperation with them.

“Initially, there was a lot of euphoria about the ACO concept,” says Anders Gilberg, senior vice president of government affairs at the Medical Group Management Association.

When draft regulations came out, providers balked, contending in thousands of comment letters that it was too much of a gamble. If patients’ care costs didn’t decrease, health systems would find themselves in the red.

“There’s a lot of risk, and it’s frankly for an unknown reward,” Gilberg says.“So I’d question, as this is structured, whether it will fundamentally change our health-care system.”

The White House revised the rule, and eventually attracted 32 health systems to kick off the program, as so-called ACO Pioneers. But those systems, so far, report little change in how they deliver care: The ones who felt confident enough to participate were already delivering integrated care and, with the start up costs of administering the program, are not certain they’ll see significant savings.

“We’re not projecting this to be a windfall,” says Mark Eustis, president of Fairview Health System in Minnesota, an ACO site. “We’re hopeful we’ll cover the revenue lost that we would have received in a fee-for-service plan. We’re not expecting big increases in what we’re actually paid.”

Other providers who like the idea of more value-based reimbursement also question its limits. Baptist Health Systems managed to net $8 million in savings when it started accepting flat fees. But most of that came from negotiating lower prices on the medical devices it used. Only about 10 percent of savings came from making the hospital’s care model more efficient. “What we got first was the low-hanging fruit,” Zucker says.

Value-based reimbursement comes with a bevy of logistical challenges. A health-care system must figure out what counts as quality care, the metrics by which it ought to judge its doctors and hospitals. It also has to decide who gets what share of the savings. At Baptist, surgeons have questioned how the hospital divvies up its own savings (which is, in some ways, constrained by the terms Medicare set).

“The hospital got $8 million, and the surgeons got $1 million,” says Ty Goletz, a orthopedic surgeon at Baptist. “That’s not necessarily looked on favorably by physicians.”

The obstacles likely explain why, for its part, Medicare does not expect volume-driven medicine to disappear overnight. “For the time being and the future, we’re going to have a large proportion of Medicare who are paid through fee-for-service,” Medicare’s deputy administrator Jonathan Blum said.

But the system, he says, is shifting away from it. “The goal, quite simply, is to improve our quality metrics and bring down per-capita costs,” Blum continued. “That’s going to be the ultimate success.”

When Baptist Health Systems started down this path in 2008, it had little idea where it would lead or whether the doctors would revolt. Now that 78 percent of his doctors have received bonus checks, Zucker is more confident.

“It’s created a different relationship between us and our physicians,” he says. “For a long time, we’ve kept each other at arm’s length. And this really changed how we looked at physicians.”

Baptist Health System recently applied for the Affordable Care Act’s new bundled-payment program, which will shift more procedures to flat fees. That program will also expand the amount of cost savings that doctors are allowed to receive. It’s another step in the right direction, says Goletz, who has operated at Baptist for three decades.

“The way I look at it, Medicare used to pay a bunch of money into a bunch of little buckets, and some were ours, and some were theirs,” he says. “We decided that rather than paying into those little buckets, we should pay into one big bucket. We cleaned up the waste, saved money and lowered our costs.”


Sources: C-Span, Washington Post, White House.gov, Youtube

Happy Birthday Health Care Reform! "Obamacare"/ Affordable Health Care Law Turns 2

Pres. Barack Obama signed the Health Care Reform bill into Law on March 23, 2010.


Health reform turns 2


Health-care reform turns two today, and it's not going to be a particularly happy birthday. On Monday, the Supreme Court will begin to hear oral arguments on the constitutionality of the individual mandate.

The law remains unpopular among the public and loathed by Republican politicians, who have pledged that repeal will be their first order of business if given power in 2012. Implementation is proceeding jerkily, in part because many states are waiting till the legal and political uncertainty clears to commit to the law.

And yet, out in the health-care system, the law's second birthday will be a happy one. As Sarah Kliff reports, the hundreds of pages devoted to moving American health care away from fee-for-service and towards pay-for-quality are having a dramatic effect on the way medical providers across the country actually do business.

The Affordable Care Act included 45 reforms aimed at changing how health care is delivered. Fifteen of those reforms focus on payment practices. At the moment, most are voluntary, but they are quickly becoming mandatory. Starting in October, for instance, hospitals with high rates of "preventable readmission" -- that is to say, high rates of patients returning with complications from earlier procedures -- will lose one percent of their Medicare revenue. In the current system, conversely, a patient turning up with a complication from a previous procedure actually provides the hospital with more revenue.

In answer to some of these reforms and in preparation for others, health-care systems across the country are either undertaking or accelerating long-overdue changes to the way they do business. Kliff follows Baptist Health System, a five-hospital network in San Antonio, Texas, which saw four surgeons quit as they moved to implement the new, quality-based payments metrics, but which has now seen performance on those measures rise to 98 percent.

Kliff's article -- which you should read, now -- is an unusually concrete look at a dimension of the health-care reform law that is often passed over in the public debate but is perhaps the single most ambitious effort ever launched in this country to lower costs and improve quality in the system. And unlike most of the bill, which hasn't been implemented yet and may or may not survive the election, it's happening now, all around us.

Two years later, health care reform has faced some challenges in implementation. "When the health-care overhaul became law after a bitter debate, many Democrats predicted Americans would grow to like it as they started enjoying some of the early benefits. The day after the president signed the bill into law, which happened exactly two years ago, an average of major polls collated by the website Real Clear Politics showed 50.4% of Americans opposed. This week, that had changed only by a tenth of a percentage point, ticking up to 50.5%.

The health law remains a tough sell for reasons that go beyond the drumbeat from Republicans for its repeal and questions about its constitutionality that will be debated next week at the Supreme Court. Several of the law's early pieces, designed to win public support, haven't worked as well in the real world as on paper and have irked even some of the Americans they were designed to help." Janet Adamy and Louise Radnofsky in The Wall Street Journal.

But it is already transforming the health-care system. "The Affordable Care Act is mostly known for its mandate to expand health insurance to 30 million more Americans within a decade. That’s the side of the legislation Democrats touted last week, when the law hit its two-year anniversary. It’s also the point that has roused the most ire from opponents. Insurance expansion is at the heart of legal challenges the Supreme Court will take up on Monday, which argue that forcing people to buy insurance coverage is unconstitutional.

But much of the law’s 905 pages are dedicated to an effort that’s arguably more ambitious: an overhaul of America’s business model for medicine. It includes 45 changes to how doctors deliver health care — and how patients pay for it. These reforms, if successful, will move the country’s health system away from one that pays for volume and toward one that pays for value. " Sarah Kliff in the Washington Post.


Sources: C-Span, Washington Post, Wall Street Journal, Youtube

Bev Perdue (Subtly) Encourages AG Roy Cooper To Sue Obama Over Health Care Law

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Bev Perdue Pretends To Dodge Republican Pressure To Join Health Care Lawsuit


Democratic Gov. Bev Perdue this morning sidetracked a Republican effort to get North Carolina to join 15 other states who have filed a lawsuit challenging the new federal health care law.

Republicans had hoped to get the Council of State — a body of the state's 10 top executive branch elected officials — to appropriate money to pay for legal fees for such a suit, Rob Christensen reports.

But Perdue said it was inappropriate for the council to take up the health care issue because the state's chief lawyer, Democratic Attorney General Roy Cooper, was in Charlotte attending a law enforcement meeting that she said had been scheduled for months.

"This is a legal issue," Perdue said. "Attorney General Cooper is not with us."

That brought a protest from Labor Commissioner Cherie Berry, a Republican, who said a quorum was present and a discussion should be permitted.

But Perdue declined to allow further discussion.

"That is just the way it is....As such that is the end of the question," Perdue said.

The governor said if Berry thought it was important to address the issue immediately, she was free to act independently.

"Anybody here can file a lawsuit," Perdue said, "It's part of being American to sue."

After the meeting, Berry said she didn't think Perdue had followed the rules that allows any council member to bring up an issue for discussion.

She also expressed disappointment that Cooper didn't change his schedule to attend the council meeting. Another council member not present, Secretary of State Elaine Marshall, a U.S. Senate candidate, participated in the meeting by telephone — a common practice for such meetings.

"When Attorney General Cooper approached that microphone on April 11, 2007, and pronounced those Duke lacrosse players innocent I cheered him for doing the right thing," Berry said. "I hope to be able to cheer him again when he steps up and takes leadership that I know he is capable of and protects the rights and freedoms of North Carolina citizens."

She was referring to the famous case in which Cooper exonerated three Duke lacrosse players falsely accused of rape.

Agriculture Commissioner Steve Troxler, a Republican, also urged the council to consider the health care law.

Two blocks away from the council meeting, about 150 opponents of the health care law held a rally urging Perdue and Cooper to join the law suit. The rally, sponsored by the state chapter of Americans for Prosperity, a conservative advocacy group, attracted key GOP lawmakers including Senate Republican leader Phil Berger of Eden and House Republican leader Paul "Skip" Stam of Apex.

Republicans have said they will introduce legislation when the legislature reconvenes in May to allow citizens to opt out any mandates of the new health care law.

Those attending the rally carried such signs as "Obamacare is socialism" and "Kill The Bill."


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Sources: MSNBC, McClatchy Newspapers, Whitehouse.gov, Google Maps

Obama To Appoint Dr. Donald M. Berwick As Medicaid/ Medicare Director

Obama To Name Medicare/ Medicaid Director


President Obama will soon name Dr. Donald M. Berwick, an iconoclastic scholar of health policy, to run Medicare and Medicaid, the programs that serve nearly one-third of all Americans, administration officials said Saturday.

Dr. Berwick, a Pediatrician, is president of the Institute for Health Care Improvement in Cambridge, Mass. He has repeatedly challenged doctors and hospitals to provide better care at a lower cost. He says the government and insurers can increase the quality and efficiency of care by basing payments on the value of services, not the volume.

Mr. Obama plans to nominate Dr. Berwick to be administrator of the Centers for Medicare and Medicaid Services, a unit of the Department of Health and Human Services that has been without a permanent chief since October 2006, when Dr. Mark B. McClellan stepped down.

If confirmed by the Senate, Dr. Berwick would have a huge plate of responsibilities under the new health care law.

The law, signed Tuesday by Mr. Obama, will expand Medicaid to cover 16 million more people, squeeze nearly a half-trillion dollars out of Medicare in the next 10 years and establish many demonstration projects to test innovative ways of delivering health care.

Dr. Berwick’s nomination would be subject to Senate confirmation. Senators would almost surely use a confirmation hearing as a forum to debate the merits of the new health care law and to investigate how the administration plans to carry it out.

Steven D. Findlay, a health policy analyst at Consumers Union, said: “This would be a spectacular appointment. Don has been an intellectual force in health care for decades. He helped forge many ideas incorporated in the new health care law.”

As examples, Mr. Findlay cited provisions of the law intended to reduce readmissions to hospitals, prevent hospital-acquired infections and hold doctors and hospitals more accountable.

Dr. Elliott S. Fisher, director of the Center for Health Policy Research at Dartmouth Medical School, said Dr. Berwick was “a visionary leader who can motivate people to change.”

However, he does not appear to have experience managing a large bureaucracy.

The Medicare and Medicaid agency has about 4,400 employees and spends more than $800 billion a year, making it the largest purchaser of health care in the country. As administrator, Dr. Berwick would spend much of his time defending the health care overhaul, writing regulations to carry it out and fielding calls from members of Congress.

Dr. Berwick has denounced “the insanity of health care that costs too much and achieves too little.” But at the same time, he celebrates the work of hospitals that have reduced medical errors and deaths by the systematic application of proven techniques. And he wants to disseminate the secrets of communities that provide high-quality care at low cost.

Dr. Berwick could help shield the White House from Republican charges that Mr. Obama’s policies would lead to the rationing of care or even a government takeover.

At his institute’s annual conference in December, Dr. Berwick issued this challenge to health care providers: “Over the next three years, reduce the total resource consumption of your health care system, no matter where you start, by 10 percent. Do that without a single instance of harm, without rationing effective care, without excluding needed services for any population you serve.”

He said he had learned from his own medical problems, which include osteoarthritis in his right knee. “It comes from medical error, botched surgery when I was a medical student, aggravated by years of jogging,” he said.

Doctors urged him to have a knee replacement operation several years ago, but he decided instead to have just a “steroid injection,” and the outcome has been fine, he said.

In 1998, Dr. Berwick was a member of an advisory commission appointed by President Bill Clinton that recommended a patients’ bill of rights and steps to reduce medical mistakes.

He was also a member of a blue-ribbon panel that focused national attention on medical errors and patient safety in 1999. The panel, created by the Institute of Medicine, an arm of the National Academy of Sciences, said that medical errors caused tens of thousands of deaths in hospitals each year.

From 1996 to 1999, Dr. Berwick was the first independent member of the board of trustees of the American Hospital Association.


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Sources: NY Times, Harvard Medical School, Institute for Health Care Improvement, Boston.com, Youtube, Google Maps

Obama Touts New Health Care Law, Addresses Student Loans

Sources: Whitehouse.gov

Total Cost Of New Health Care Law Will Exceed $1 Trillion

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Sources: MSNBC, C-Span, Youtube

Obama Dares GOP To Push "Repeal & Replace" Strategy, "Go For It!"

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"Go For It"! Obama Dares GOP On Health Care Repeal



President Barack Obama dared Republicans to try to repeal his new health care law, telling them Thursday to "Go for it" and see how well they do with voters in November.

"Be my guest," Obama said in the first of many planned appearances to sell the revamp before fall congressional elections. "If they want to have that fight, we can have it. Because I don't believe the American people are going to put the insurance industry back in the driver's seat."

With emotions raw around the nation over this week's Democrats-only vote to approve the nearly $1 trillion redesign of the health care system, Obama took the opposition to task for "plenty of fear-mongering, plenty of overheated rhetoric."

"If you turn on the news, you'll see that those same folks are still shouting about how it's going to be the end of the world because this bill passed," said Obama, returning to the college town where, as a presidential candidate three years ago, he unveiled his plan to provide health care for all.

No Republican lawmakers voted for the 10-year, sweeping package that Obama signed Tuesday and will shape how almost every American will receive and pay for medical treatment. Many in the GOP are predicting it will prove devastating in November for the Democrats who voted for it.

Senate Republican leader Mitch McConnell of Kentucky said the GOP won't give up "until this bill is repealed and replaced with common-sense ideas" that won't dismantle the current system and increase the debt.

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Some Democratic lawmakers have faced threats and vandalism because of their votes. Obama didn't mention the incidents.

The president stressed the notion of a promise kept. As the crowd broke into a chant of "Yes we can!", Obama corrected them: "Yes we did!"

Challenged by a young man in the audience who shouted several times, "What about the public option," a liberal-backed proposal for the creation of a government-sponsored plan to compete with private insurers, Obama said: "We couldn't get it through Congress."

"This legislation is not perfect, as you just heard," the president said. "But what this is, is a historic step to enshrine the principle that everybody gets health care coverage in this country, every single person."

Afterward, Obama visited Prairie Lights Books -- killing two birds with one stone. He had highlighted the store in his speech as a small business that has offered coverage to full-time employees for 20 years, but is struggling to continue to do so after its premiums rose last year by 35 percent. Obama also has frequently complained of his inability as president to do regular things -- like browse a bookstore.

The White House suggests it has the upper hand on the issue politically, arguing the GOP risks a voter backlash because a repeal would take away many benefits. Among them are tax credits for small businesses to provide health care to their workers and $250 rebates for seniors to help pay for their presciption medications.

Obama spoke as Democrats in Washington raced to complete the overhaul with a separate package of fixes to the main bill.

Senate leaders finished work Thursday on the fix-it legislation, already approved in the House. But Republican attempts to derail the bill resulted in minor changes, meaning the House must vote on it again before Obama can sign it. The House vote was expected by evening.


Sources: MSNBC

Democrats' Health Care Fight Victory Was Political Game Changer

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Dems Victorious In Final Health Care Bill "Fixes" Vote


Capping an epic struggle, congressional Democrats put the final touches Thursday to historic legislation enshrining health care as the right of every citizen. Republicans vowed to campaign for repeal in the fall election season, drawing a quick retort from President Barack Obama: "I welcome that fight."

The president spoke in Iowa as the Senate voted 56-43 for legislation making changes, including better benefits for seniors and low-income and middle-class families, to the bill he signed into law with a flourish at the White House on Tuesday.

The House added its approval a few hours later, 220-207, clearing the way for Obama's signature on the second of two bills that marked the culmination of what the president called "a year of debate and a century of trying" to ensure coverage for nearly all in a nation where millions lack it. Obama is expected to sign the legislation early next week.

Taken together, the two bills also aim to crack down on insurance industry abuses and to reduce federal deficits by an estimated $143 billion over a decade. Most Americans would be required to buy insurance for the first time, and face penalties if they refused.

The second of the two bills also presented Obama with another victory, stripping banks and other private lenders of their ability to originate student loans in favor of a system of direct government lending.

After a monthslong battle in Congress, the political struggle was morphing into a new phase, where public debate was tinged with violence — and politicians accused one another of seeking to exploit it for their own advantage.

Triumph for Obama

Apart from their impact on nearly every American and an estimated one-sixth of the American economy, the week's events marked Obama's biggest political triumphs since he took office more than a year ago. A pending arms control agreement with Russia, announced on Wednesday, added to his resume, and White House officials said they hoped the momentum would translate into further political successes in the run-up to the midterm elections.

More than 10 lawmakers in the House said they had received threats or worse as a consequence of the health care debate, most of them Democrats who voted in favor of the legislation. There were reports of bricks through windows, a cut propane line to a grill and numerous obscene and threatening phone calls and faxes. An undisclosed number of lawmakers were under increased police protection.

Speaker Nancy Pelosi, D-Calif., and the GOP leader, Rep. John Boehner of Ohio, both denounced the threats and incidents of violence. But Democrats said Republicans had been too slow to respond, drawing an outraged response in return.

"By ratcheting up the rhetoric, some will only inflame these situations to dangerous levels," said Republican Whip Eric Cantor of Virginia. "Enough is enough. It has to stop."

An aide to Rep. Chris Van Hollen of Maryland, head of the Democratic 2010 campaign effort, responded: "This is straight out of the Republicans' political playbook of deflecting responsibility and distracting attention away from a serious issue."

"Repeal and replace" was the new slogan for Republicans as they pivoted away from earlier attempts to kill the health care legislation. Officials said it was meant to appeal to tea party activists — who staged an occasionally unruly demonstration outside the Capitol over the weekend — as well as to independent voters eager for changes in the health care system but fearful the Democrats went too far.

"Republicans fought on behalf of the American people this week and will continue to fight until this bill is repealed and replaced with commonsense ideas that solve our problems without dismantling the health care system we have and without burying the American dream under a mountain of debt," said Senate Republican leader Mitch McConnell of Kentucky.

Repeal was far-fetched in the extreme since Republicans are now deep in the minority in both houses and would need a two-thirds majority to overcome a certain veto by Obama.

But Republicans circulated polls showing public backing for the overhaul at no better than 40 percent, despite months of Democratic efforts to rally support. Attacking the bill as a government takeover of health care paid for in higher taxes and Medicare cuts, they taunted House Democrats who voted for it, saying those lawmakers had cleared the way for their own defeat this fall.

Democrats said any unease was the result of months of Republican distractions — as far back as last summer's debunked charges of "death panels" — and predicted the public would warm to the new law once its first benefits take effect.

That was Obama's pitch in Iowa, where he trumpeted a "set of reforms" that will take effect before the elections.

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He said small businesses would be eligible for tax credits to help them cover the cost of insurance for employees, including a $250 rebate from the government for seniors with high prescription drug costs.

"This year, insurance companies will no longer be able to drop people's coverage when they get sick, or place lifetime limits or restrictive annual limits on the amount of care they can receive," he said.

"This is the reform that some folks in Washington are still hollering about. And now that it's passed, they're already promising to repeal it. ... Well, I say go for it," he said.

Party Line Vote

Senate passage of the follow-up measure was nearly along party lines. Democratic Sens. Blanche Lincoln and Mark Pryor of Arkansas and Ben Nelson of Nebraska joined 39 Republicans in opposing the legislation. Republican Johnny Isakson of Georgia, who is hospitalized, did not vote.

The House vote followed the same pattern, with 32 Democrats joining 175 Republicans in opposition.

Democrats had hoped the Senate's vote would end their yearlong campaign to overhaul the health care system. But Republicans forced the deletion of two minor student loan-related provisions, and that required a revote in the House.

The day's events marked the final stages of a rescue mission that Obama and Democratic leaders mounted more than two months ago, after Republicans unexpectedly won a Massachusetts Senate seat and with it, the ability to slow final action on health care legislation.

Under a revised strategy, the House agreed to approve a Senate-passed bill despite numerous objections, on the condition that both houses would follow quickly with a fix-it measure. The one finally brought to a vote on Thursday added more than $20 billion to subsidies for lower- and middle-income individuals and families who will be required to purchase insurance and about $8 billion over a decade for states that already provide more generous than average Medicaid benefits.

The Senate vote took place with Vice President Joe Biden presiding, a symbolic gesture since his vote was not needed.

Moments before approving the legislation, the Senate paused for a moment of silence in memory of Sen. Edward M. Kennedy of Massachusetts, who died last year after a career of more than 45 years in which he relentlessly pursued legislation to enact national health care.


Sources: MSNBC

Obama Sells Health Care Reform Law Benefits To Iowa Voters

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Obama Hits The Road To Sell Health Care Overhaul



President Barack Obama mocked Republicans' campaign to try to repeal his new health care law, saying Thursday they should "Go for it" and see how well they fare with voters.

"Be my guest," Obama said during the first of many appearances around the country to sell the overhaul to voters before the fall congressional elections. "I welcome that fight. Because I don't believe the American people are going to put the insurance industry back in the driver's seat."

With emotions raw around the nation over the party-line vote to approve the nearly $1 trillion, 10-year law, Obama took the opposition to task for "fear-mongering and overheated rhetoric."

"If you turn on the news, you'll see that those same folks are still shouting about how the world will end because we passed this bill," said Obama, appearing before thousands in this college town where he first, as a presidential candidate three years ago, unveiled his health care proposals.

No Republican lawmakers voted for the overhaul, a sweeping package that will change how almost every American will receive and pay for medical treatment. Many in the GOP are predicting it will prove devastating in November for the Democrats who voted for it.

But the president stressed the notion of a promise kept, saying the legislation he signed into law on Tuesday is evidence he will do as he said. "This is the place where change began," Obama said.

The White House suggests it has the upper hand against Republicans politically, arguing the GOP risks a voter backlash because a repeal would take away from small businesses and individuals the benefits provided to them immediately under the new law.

"We've been there already and we're not going back," Obama said.

Obama spoke as Democrats in Washington raced to complete the overhaul with a separate package of fixes to the main bill.

Senate leaders had planned to finish work on the fix-it legislation, already approved in the House, by midday Thursday. But Republican attempts to derail the process resulted in minor changes to the bill, which means the House will have to vote on it again before it can go to Obama for his signature.


Sources: MSNBC

Senate Reconciliation Bill Passes 56 To 43! Its Officially The Law!

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Reconciliation Bill Passes Senate


The Senate approved a package of fixes to the health care reform law Thursday, drawing to a close the chamber’s year-long effort to overhaul the nation’s insurance system.

But the work isn't done quite yet.

The bill passed 56 to 43, with Vice President Joe Biden presiding over the chamber. Senate Republicans forced a pair of changes to the reconciliation bill overnight, sending it back to the House for a final vote later Thursday.

Democrats believe the minor changes – to language regarding Pell Grants for low-income students – won’t derail House passage, meaning that Democrats are set to finally conclude the legislative struggle needed to make health reform a reality.

"We all made history," Sen. Chuck Schumer (D-N.Y.) told a group of Democrats on the floor, as they celebrated the vote. "We could do nothing else."

Three moderate Democrats voted against the reconciliation bill – Nebraska’s Ben Nelson and the two senators from Arkansas, Mark Pryor and Blanche Lincoln. Lincoln faces a tough re-election fight this fall. Republican Johnny Isakson of Georgia is ill and wasn’t in the chamber.

No Republicans voted for the reconciliation bill, just as no Republican voted for the underlying health reform law. Sen. John McCain (R-Ariz.) criticized the the measure until the end, saying, “It is the most unsavory sausage-making, Chicago-style bill I have ever seen."

He said the GOP mantra would be to “repeal and replace” the bill going forward. "We can't just have the status quo," McCain said.

The vote came as President Barack Obama took the stage in Iowa City, Iowa – his first stop since he signed the legislation Tuesday – hoping to promote the bill to the American public, which polls show is deeply skeptical of reform. He told Republicans he welcomed the chance to debate them on the merits of the plan, particularly if they insist on pressing for a repeal of the law.

"My attitude is: Go for it," Obama said. "If these congressmen in Washington want to come here in Iowa and tell small-business owners that they plan to take away their tax credits and essentially raise their taxes, be my guest."

The reconciliation bill makes a variety of fixes to the health reform legislation, which passed Sunday night in the House. It removed controversial deals like the Cornhusker Kickback and also pushes off implementation of an excise tax on high-cost “Cadillac” health plans until 2018.

The final vote on reconciliation in the Senate came with little drama – but it followed weeks of tough negotiations between House and Senate Democrats over what should be in it, and whether there would be the votes to pass it.

The top leaders in the Senate, Democratic Majority Leader Harry Reid and his counterpart, Republican Sen. Mitch McConnell, worked out a deal in the early morning hours Thursday to hold the vote at 2 p.m. – and it went off on time, with the final outcome not in doubt.

Sen. Robert Byrd (D-W.V.), the longest-serving senator, was wheeled into the chamber by an aide and shook hands with Reid before going to his place and waiting for his name to be called in the roll. There was a humorous moment when Reid's name was called and he said 'no,' before quickly correcting himself. He made the same mistake when the Senate voted on the overall health reform vote, on Christmas Eve. The chamber broke out in laughter.

Senate Republicans found two rules violations in the section of the bill on student loan reform, and Democrats were forced to strike 16 lines of language dealing with Pell Grants.

The House has already passed the reconciliation bill, on Sunday night when it approved the landmark health reform measure. But since the House and Senate must pass identical versions of the reconciliation bill to put the fixes into law, the reconciliation piece must go back to the House for a second vote.

House Speaker Nancy Pelosi (D-Calif.) said her members would approve the package of changes later Thursday and send the measure onto the president.

"Of all the things they could send back, this is the most benign and easily fixed,' Pelosi told reporters Thursday.

The legislative path that brought the Senate to Thursday’s vote was tortuous and politically risky.

The Senate spent months trying to write a bill that could win 60 votes. Democrats succeeded on Christmas Eve, only to lose their filibuster-proof majority a month later.

The White House and congressional leaders revived the bill after deciding on a two-step process – the House passing the Senate bill, followed by both chambers using fast-track rules known as reconciliation to pass a package of fixes. This was the only way House members would agree to approve the Senate bill, and the only way the Senate could make changes that the House wanted.

Reconciliation was fraught with challenges. But Democrats successfully scrubbed the bill of any potential procedural landmines, preventing Republicans from stripping out any major policy pieces that would have endangered its passage in the House or the Senate.

Democrats also held together during the more than 13 hours of amendments, turning each one back. While Republicans implored their colleagues to make changes, Democrats argued that any changes would send the bill back to the House for another vote, an outcome they worked mightily to avoid before the parliamentarian's ruling early Thursday. That meant Democrats had to vote against such campaign ad fodder as a provision barring sex offenders from being given Viagra.

Once Republicans struck two minor provisions from the bill, sending it back to the House, some liberals suggested that Democrats had one last chance to fight for the public option. But no senators took the bait.

Democrats insisted on keeping the bill as clean as possible so the House can give the measure swift approval – and that the party can be done with the health care debate once and for all.

Sen. Bernie Sanders (I-Vt.), a leading proponent of a public option, shook his head Thursday morning when asked whether he’d offer the proposal as an amendment to the reconciliation bill.

Senate Budget Chairman Kent Conrad (D-N.D.) said: “Everybody feels committed, feels we’ve done the right thing, knows that the things that are required to go back to the House are insignificant and the House has already told us, ‘No problem.’ So we don’t want to change that.”

The drama playing on the Senate floor eventually became a battle of wills between Republicans and Democrats, with each side trying to outlast the other.

Reid finally adjourned the marathon session at about 2:45 a.m. Thursday after striking a deal with McConnell to reconvene later in the morning -- news that was greeted with audible sighs of relief from tired senators.

By the time senators filtered into the chamber Thursday afternoon, the final vote felt almost anticlimactic to Democrats who had expended so much energy to get to that point.

Not only had the comprehensive bill already passed the House with fanfare Sunday night, the fixes package still needed to go back to the House, robbing Senate Democrats of their moment to close the book on health care.


Sources: MSNBC, Politico

Can Obama Win Back Former Ardent Supporters?

(Letter to President Barack Obama from a former strong supporter)


Dear President Obama:

Congratulations on the recent passage of your Health Care Reform bill.

I'm a Voter, Blogger and a former ardent supporter you lost during the Health Care Reform debate.

Before I proceed its imperative you know I do not agree with all of the provisions listed in the HC Reform bill (now law).

However since Health Care reform was so desperately needed in our country, at least your law could be considered the framework for a future system that will work well for all legal citizens.

Mr. President in your quest for Bi-Partisanship support, it appears you procrastinated too long during the Health Care Reform bill drafting process.

This procrastination hindered your administration from focusing on Jobs and Education.

Why did you allow this to occur?

When it was evident Republicans were NOT going to support HC Reform, why didn't your administration and other Dems just pass the bill anyway?
After all didn't Democrats have the majority?

Why did you wait until Scott Brown won to finally take charge?

While I do agree that having Bi-Partisan support on major legislation is of vital importance, both parties must fully cooperate and/or compromise to achieve Bi-Partisan success.

Because you allowed the GOP to kill your Health Care message, even I became Angry and began attacking your administration's weakness, or what appeared to be weakness on my Blog.

Today I wish to offer my deepest apologies but I hope while your still in office you never, ever allow such complacency on important issues to occur again.

You are our President! We believed in you! We voted for you!

Effective Leaders don't second guess themselves, over analyze situations, procrastinate, they're NOT afraid to take risks and they aren't satisfied with being in second place.

Real Health Care Reform, Education Reform, Financial Reform are the CHANGEs we voted for and are still seeking.

Again I apologize but how can you win back millions of American Voters and former supporters like myself?

How can you help make us believe in the substance of your administration's agenda and efforts again?

I live in North Carolina where Public Schools are being Re-Segregated across the board. (Wake County & Charlotte-Mecklenburg, etc.,)

NC BCBS increased their rates but decreased Patient Care & Quality of Care for their members.

(NC Blue Cross, Blue Shield (North Carolina's Health Care Insurance monopoly) increased their rates again prior to the passing of your health care reform bill.)

Will your administration just sit back and allow these injustices to continue or will you as our nation's Leader take charge?

I represent average Americans and we need help!

Please no more procrastination or political games. Please.

As a current resident of Charlotte, North Carolina I've seen enough Corrupt, Slack Leadership to last a lifetime. Now I'm ready for CHANGE.

God Bless

Regards,

Laurel


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Sources: McClatchy Newspapers, Raleigh Telegram, WRAL, SMH.com, Flickr, Google Maps

Democrats Receive Death Threats Following House Health Care Vote

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Democrats Fear For Their Families



The threats against members of Congress who voted for health care reform have turned from a nuisance to a serious law enforcement issue, increasing security concerns as lawmakers prepare to head home for spring recess.

The Federal Bureau of Investigation, the Capitol Police and the House sergeant at arms on Wednesday were brought into a closed-door Democratic Caucus meeting, during which lawmakers expressed fear for their safety and the safety of their families.

The Capitol Police, according to several in the caucus meeting, encouraged members to report any incidents to the department. They also offered security assessments of district offices and even members’ homes.

One Democratic lawmaker, Rep. Phil Hare of Illinois, said he knows several Democrats who have told their spouses to move out of the home districts while the lawmakers are in Washington.

“If this doesn’t get under control in short time, heaven forbid, someone will get hurt,” Hare said.

And House Majority Leader Steny Hoyer of Maryland told reporters after a caucus meeting that members who feel in danger would “get attention from the proper authorities.”

Hare is holding eight town hall meetings in his district over the recess and requested that the Capitol Police coordinate with his local police department to provide security. His wife has pleaded with him to cancel the events.

“My wife is home alone, and I’m worried for her,” he said. “I am about to have my first grandchild. I don’t want to have to be worried.”

Incidents are sprouting up all over the country.

The gas lines were cut at the house of Virginia Democratic Rep. Thomas Perriello’s brother, near Charlottesville, Va., prompting an FBI investigation. Local police are making routine checks of the home. A tea party activist from southern Virginia posted online the address of Perriello’s brother, thinking it was the lawmaker’s.

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Rep. Steve Driehaus (D-Ohio) had his address posted on the Internet, with a message from a right-wing blogger asking people to show up at Driehaus’s Cincinnati “mansion” to protest his health care vote. A photo of Driehaus’s family appeared in a Cincinnati newspaper ad urging the lawmaker to vote against the health care bill last week.

A brick was thrown through the window of the Democratic Party’s Cincinnati office.

And Rep. Bart Stupak (D-Mich.), who negotiated the breakthrough on abortion language in the health care bill, has received numerous death threats and faxes with violent images at his office.

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Rep. Hank Johnson (D-Ga.) suggested to Democrats in the closed-door meeting that they should coordinate an internal security plan — as he did in August.

Rep. Patrick Murphy (D-Pa.) told the caucus, according to a member present, that he feared what was going on in the districts.

Democrats have been quick to blame Republicans for not tamping down the atmosphere. But on Tuesday at the National Republican Congressional Committee dinner, House Minority Leader John Boehner decried the violence.

Boehner met with House Speaker Nancy Pelosi (D-Calif.) on Wednesday but declined to discuss what they spoke about.

“I know many Americans are angry over this health care bill and that Washington Democrats just aren’t listening,” Boehner wrote in an e-mailed statement. “But, as I’ve said, violence and threats are unacceptable. That’s not the American way. We need to take that anger and channel it into positive change. Call your congressman, go out and register people to vote, go volunteer on a political campaign, make your voice heard — but let’s do it the right way.”

Hare said Boehner needs to come to the floor and decry the violence and apologize to Driehaus for calling the Democratic lawmaker a “dead man.” Hare said he thinks Republicans’ riling up of protesters from the Capitol balcony is not helpful.

“If he can’t control his members, they have to find someone who can,” Hare said.

Some members have directly confronted protesters.

Rep. Jim Moran, a fiery Virginia Democrat, got a visit from tea party activists at his office earlier this week. Aides got between the burly lawmaker and the activists. The activists, according to the congressman, asked whether he needed “bodyguards” to protect him.

“We’re not protecting him from you,” the aides said, according to Moran. “We’re protecting you from him.”

It was long known that the health care overhaul vote would be brutal for members of Congress. August brought raucous town halls, folks with guns and heated exchanges to towns across the nation.

Now that the legislation has passed with just Democratic votes, anger is bubbling nationwide.

Hoyer, in response to a question from a reporter, said he thinks members are in danger.

“Yes,” he said, standing next to House Majority Whip Jim Clyburn of South Carolina. “I think that we have very serious incidents that have occurred over the last 48, 72 hours.”


Sources: MSNBC, Politico