The last time the states were rallied to rise up against federal legislation was during the civil rights battle over forced integration of schools. A similar call for organized state-level resistance is now being made in a manifesto recently published by the American Legislative Exchange Council (ALEC), a powerful but “discreet” group that counts some 2,000 conservative state legislators as well as representatives from some of the nation’s largest industries as members.

The Council’s publication, “The State Legislators Guide to Repealing ObamaCare”, urges lawmakers to “Decline to Build the ObamaCare Edifice” and offers 14 practical steps states can take to undo or impede the Affordable Care Act. These steps include having states return federal grants for setting up health insurance exchanges, encouraging them to opt completely out of Medicaid, and urging them to file federal waiver petitions to block the medical loss ratio requirement (the new rule requiring insurers to spend 80-85% of premiums on patient care).

When it comes to health care reform, ALEC is perhaps best known as the group that drafted the “Freedom of Choice in Health Care Act;” model state legislation drawn up in 2008 that would block any state or federal “public option,” bar the individual mandate and obviate other major provisions of the Affordable Care Act. According to the Council, eight states (including Virginia, Idaho, and Arizona) have actually enacted such model legislation and it has been “introduced or announced” in 42 others. The mission of ALEC’s health and human services care task force is to promote “free-market, pro-patient health care reforms at the state level.”

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Below, a guest post by Paul Raeburn, a journalist and author, and a media critic at the Knight Science Journalism Tracker

This weekend, those of us who live in New York and on the East Coast were treated for days to front-page news about Hurricane Irene. Meanwhile, other important stories were mostly ignored or relegated to back pages. (I use the term “front and back pages” figuratively, to refer to the emphasis given to stories in newspapers, radio and television, and on the web.)

Over the past few weeks, scattered stories have begun to appear in the media about one particular event that should, in my view, be front-page news. The U.S. is suffering from a serious shortage of cancer drugs, particularly generic drugs given by injection and used in hospitals to treat serious conditions such as breast and testicular cancer. Patients whose cancer requires a regular schedule of drug administration over a period of weeks are being forced to delay treatment, quit early, or skip treatments. There’s little question that this will cost lives. It’s unilateral disarmament—while treatments are stopped or delayed, tumors take no notice. Their unrelenting growth continues.

Yet the story has received only middling coverage.

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When it comes to reducing health care spending, everyone agrees that ferreting out the fraud and abuse in the system is absolutely imperative. But despite this urgency, because fraud pervades almost every facet of our health care system, routing it out will be a formidable task. Will an injection of funding, new anti-fraud initiatives coming from the Affordable Care Act, and a fundamental change in the way the government pays for certain services allow us to finally make a dent in health care fraud?

First of all, getting a fix on the total cost to taxpayers from health care fraud is like guessing how many jellybeans are in a jar. Some estimates calculate only “improper billing”—payments made in the wrong amount to the wrong person or for the wrong reason—reported by the Medicare and Medicaid programs. Other figures include private insurance fraud in the mix. Still other estimates factor in waste and abuse as well (this includes improper use of procedures and tests, preventable errors and hospital readmissions and defensive medicine costs; for example.)

Louis Saccoccio, executive director of the National Healthcare Anti-Fraud Association—whose members include about 100 private insurers and public health agencies—testified recently at a House Ways and Means Committee hearing that financial losses due to health care fraud range from $75 billion to a staggering $250 billion a year. Meanwhile, the Centers for Medicare and Medicaid Services (CMS) estimated that in fiscal year 2010, government health programs made a total of over $70 billion in improper payments, about $48 billion of them paid by Medicare alone.

Even more confounding, “fraud” can be perpetrated on vastly different scales: by multi-state organized crimes rings that improperly bill Medicare for $40 million dollars of home health care, by a single physician who brings in an extra $20,000 a year by regularly “up-coding” office procedures (i.e. like the dermatologist my daughter used to see who squeezed a pimple at each visit and billed our insurance $250 for “acne surgery”), and by giant health care companies like HCA who systematically defrauded Medicare of hundreds of millions of dollars.

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It is an article of faith, at least among conservatives, that as long as Medicare remains a government program, outlays will rise relentlessly, year after year. Only “the market” could possibly tame Medicare inflation, they say. The fear-mongers argue that unless we either shift costs to seniors; raise the age when they become eligible for Medicare; or turn the whole program over to private sector insurers, Medicare expenditures will bankrupt the country.

Here is the truth: Both Standard & Poor’s (S&P) and the Congressional Budget Office (CBO) now have 18 months of hard data showing that Medicare spending has begun to slow dramatically. Health reform legislation has not yet begun to kick in to pare Medicare payments, but something is changing on the ground. As I pointed out in Part 1 of this post, Medicare spending began to plunge in January of 2010. After levitating by an average of 9.7 percent a year from 2000 to 2009, CBO’s monthly budget reports show that Medicare pay-outs are now rising by less than 4 percent a year. (Over the year ending June 2011, Standard & Poor’s reckons that the cost of Medicare claims rose by just 2.5 percent.  But S&P’s Medicare index does not include Medicare Advantage, the private sector option that costs the government significantly more than traditional Medicare.)

Pessimists argue that Medicare pay-outs often fluctuate, and that this is just a short-term drop.  Moreover, the naysayers insist, over the next few years, a horde of aging Hippies will push Medicare’s outlays higher. But hard numbers fly in the face of their assertions. Over 40 years, Medicare pay-outs have rarely dipped, and even a cursory glance at U.S. birth rates makes it clear that the baby-boom bulge will not have a significant impact on Medicare expenditures for another ten to fifteen years. By then, the Affordable Care Act (ACA) will have had a chance to rein in health care spending.

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For a while now, diabetes has been at epidemic proportions in this country, with nearly 24 million Americans currently suffering from the disease. The great majority have Type-2 diabetes, the kind that is linked to obesity and physical inactivity and is responsible for 90-95% of all cases in people over 40. The costs associated with this epidemic are also enormous: $218 billion each year in medical expenses and lost productivity. In fact, about 10 percent of all U.S. health care spending and a whopping one-third of Medicare dollars is spent on people with diabetes.

The epidemic shows no signs of abating. In the next 25 years, the number of cases is expected to double. According to a report on obesity released last month by the Trust for America’s Health, “Since 1995, diabetes rates have doubled in eight states. Then, only four states had diabetes rates above 6 percent. Now, 43 states have diabetes rates over 7 percent and 32 have rates above 8 percent.

Finally, according to the Robert Wood Johnson Foundation, as a result of the U.S. having the highest rate of obesity among all developed countries, we now have the highest rate in the world of hospitalization of diabetes patients.

The only glimmer of hope in this epidemic is that for a while now there has been incontrovertible evidence that relatively inexpensive community-level prevention efforts can really pay off. This evidence includes results of a national comparative effectiveness trial that included 27 centers with over 3,000 participants, all at high risk of contracting diabetes. The trial, funded by the National Institutes of Health back in 1999, compared how effective three interventions were in preventing the onset of diabetes in these high-risk  individuals: 1) basic advice that you might get at the doctor’s office once a year or twice a year, 2) diabetes medication to lower blood sugar levels and 3) an intensive lifestyle intervention.  It was the intensive lifestyle intervention that worked the best.

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Imagine that you been in labor for 18 hours, and the resident who will be delivering your baby tells you that he hasn’t had any sleep for 25 hours. Would you ask for a new doctor?  On the one hand, this resident has been checking you since the beginning of labor. You like him. But, he confides, that this is his second 28 hour shift in three days. He adds that he hasn’t had 24 hours off for two weeks.
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An Institute of Medicine (IOM) investigation released in December 2008 concluded that physician fatigue accounts for a growing number of medical errors: “the scientific evidence base establishes that human performance begins to deteriorate after 16 hours of wakefulness” wrote the authors of the report. They called for elimination of resident shifts exceeding 16 hours without sleep. The Accreditation Council for Graduate Medical Education (ACGME), the organization charged with setting and enforcing standards for graduate medical education, has finally responded. New rules regulating how long residents and interns can be asked to work while caring for patients went into effect last month.

In the past, the ACGME let residents work 30 hours at a stretch. But as of July 1, interns (a.k.a first year residents) will be limited to 16-hour tours of duty, following IOM’s recommendation. But, to the dismay of patient safety advocates, under the new rules second and third-year residents still will be permitted to work 28 hours at a time. Moreover, “time off” in between long shifts has been cut from ten hours to eight. This gives residents eight hours to go home, sleep, shower, grab something to eat, and get back the hospital for another 28 hour shift. At best, they may catch seven hours of sleep.

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Once again free speech within the intimate confines of a doctor’s office is under attack.

In Florida, the Journal of the American Medical Association reveals today, doctors can risk losing their medical licenses or be fined up to $10,000 if they ask a patient either verbally or on a form whether they or a family member keep a firearm in the house.

According to JAMA, “the law states that licensed Florida health care practitioners and health care facilities ‘should refrain from making a written inquiry or asking questions concerning the ownership of a firearm or ammunition by the patient or by a family member of the patient, or the presence of a firearm in a private home or other domicile of the patient or a family member of the patient.’ Additionally, practitioners and facilities are instructed against recording such information (if disclosed) in the medical record.” Alabama, Minnesota, North Carolina, Oklahoma, and West Virginia have all introduced similar bills that would prohibit physicians from asking about guns in the home.

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The short-lived reprieve for Medicare and Medicaid is over. The no-longer sacrosanct government health programs will most definitely face cuts of some sort by this coming November when the new 12-person congressional “Super Committee” is charged with trimming at least another $1.2 trillion from the national budget.

On Monday, President Obama made his priorities clear: He called for “tax reform that would ask those who can afford it to pay their fair share,” (i.e. get rid of Bush-era tax breaks for the wealthy) and “modest adjustments” (i.e. cuts) to entitlement programs like Medicare and Social Security.

Senate Majority Leader Harry Reid (D-Nev.) is set to appoint Sens. Patty Murray (D-Wash.), Max Baucus (D-Mont.) and John Kerry (D-Mass.) to the congressional debt-reduction "super committee" and more appointments will be announced by other Congressional leaders as the August 16 deadline gets closer. Whatever its make-up, the committee's battle over entitlement cuts will occur on familiar territory. In a comprehensive—but ultimately depressing—post for Politico, David Nather writes that the super committee will likely start with “a list of the standard ideas that are already ‘out there’” for cutting Medicare and Medicaid.

“There’s a pretty long menu of ideas to choose from, thanks to the work that’s already been done by the bipartisan negotiations led by Vice President Joe Biden,” writes Nather. “And the supers will also be able to draw from the suggestions of other bipartisan groups, like President Barack Obama’s fiscal commission and the Senate Gang of Six.”

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