Last night, Rachel Maddow observed that the number of Democratic lawmakers who have joined Rep. Bart Stupak’s (D-MI) crusade to bring down health care reform unless Congress amends the Senate bill’s abortion language, keeps shrinking. Stupak began the debate with that 15 to 20 supporters, then that number fell to “at least 12,” and as of yesterday, it’s dwindled even lower. A senior House aide told Maddow, “We do not see more than four or five members standing with Bart when this bill is actually brought to the floor.”

Indeed, it seems like a shrinking number of moderate Democrats are willing to take part in Stupak’s effort to lie about the provisions in the Senate bill in order to strip abortion coverage from private health insurance. On Tuesday, Rep. Dale Kildee (D-MI), “a ‘yes’ vote on reform who backed the Stupak language,” told reporters that “the Senate language will restrict the federal funding of abortions and that he’ll probably vote for the final bill” and today, Rep. Jason Altmire (D-PA), who also supported the Stupak language, said that the Senate bill does not spend federal dollars on abortion:

ALTMIRE: I am pro-lifer. I voted for the Stupak amendment and I’m not going to support a final bill that allows one penny of tax payer funding to be used for abortion. There is no question, the Stupak amendment was air tight. It was much cleaner and it was something that you could not dispute at all. The Senate bill is worded awkwardly, it is not written in a good way. But I am not convinced that it allows taxpayer funding of abortions. It doesn’t go as far as Stupak clearly it’s not as air tight as Stupak….I still haven’t seen good evidence that the Senate language, as is, allows a taxpayer funding for abortion. It could be worded better and less awkwardly, but I don’t know if there is even an indirect abortion funding in it.

Watch it:

Altmire’s tone is important. He’s admitting that the Senate bill is in fact a compromise that doesn’t go as far as the Stupak amendment, but still maintains current law. Meanwhile, pro-choice groups are arguing that the Senate bill goes too far in restricting women’s access to abortion coverage. On Tuesday, “a coalition of more than 50 women’s rights groups wrote Pelosi, Senate Majority Leader Harry Reid and Obama to ask for major revisions to the Senate bill because the current restrictions impose “unacceptable obstacles for women who wish to purchase insurance that includes abortion coverage and for plans that wish to offer it.’” “We are calling on you to make improvements that would ensure that under reform, women will not lose the private health insurance coverage for abortion that they now have,” the groups wrote.

With both sides objecting to the Senate bill, it’s become difficult for Stupak and his gang of four (or five) to perpetuate the fundamentally dishonest claim that the Senate bill spends federal dollars to fund abortions. As a result, honest pro life advocates have begun to admit the truth.

Yesterday, Virginia became the fist state in the nation to pass a law banning “any requirement that its residents carry health insurance policies.” The legislation — which was approved by the Virginia Senate on March 8 — passed by an 80-17 vote in the Virginia House of Delegates and now goes to Governor Bob McDonnell for his signature.

Legislatures in approximately 30 states have introduced similar initiatives and Congressional Republicans have pledged to support their efforts, promising to “spend the rest of the year in the campaign to try to repeal.” I’ve previously argued that these campaigns to repeal reform are more about energizing the base and raising campaign funds than registering a serious policy disagreement. After all, Republicans had supported the individual health insurance mandate as recently as August 2009, and any successful state measure to repeal parts of health care reform will be superseded by federal legislation.

My colleague Emma Sandoe makes one additional point. She argues that if the 30 plus states considering nullification successfully pulled out of reform, they “would be left out of federal programs that would help them expand coverage for more of their residents, essentially refusing more than $28 billion a year in federal funds from the Medicaid program alone.”

Her report includes this very swanky interactive map, which calculates the number of people left uninsured because of state nullification efforts (you’ll have to go here for the interactive features):

Conservatives will argue that states like Virginia don’t need a one-size-fits all option. They should be allowed to develop their own unique solutions to the health care crisis.

But this argument obscures the fact that states don’t have the economic, political or structural capacity to invest in something as big as health care reform. State uninsured rates “vary from just under 8 percent to almost 25 percent and, generally, where those rates are the highest, the states have the least resources in terms of a tax base or population income levels to support funding for needed coverage expansions.” Political considerations, special interest influence and budgetary strains have doomed previous state-based health care reform efforts and governors who believe that nullifying federal reform is in the best interest of their citizens are placing politics ahead of sound policy.

Yesterday, in her introduction of Kathleen Sebelius, AHIP President and CEO Karen Ignagni said that insurers were “very concerned about insurance premiums and the trajectory” of health care spending. “We understand that begins also with us. So we are fully committed to cost containment. No finger pointing to other sectors,” Ignagni promised.

But finger pointing she is. A day earlier, AHIP released a new ad blaming doctors and hospitals for higher health care costs and rising premiums. The ad — part of AHIP’s charm campaign to deflect attention from the industry’s rising profits and egregious business practices — visualizes the drivers of medical costs in a spending pie and argues that insurers are responsible for the Weight Watchers portion.

“Some in Washington say it’s all health insurance, but health insurance is one of the smallest slices [of the health care cost pie],” the AHIP-sponsored ad begins. “Health insurance companies’ costs are only 4% of health care spending. Doctors, hospitals, medicines, and tests are the biggest slices and a government report says their rising prices are a primary driver of primary health care costs.” Watch the ad here.

The ad doesn’t explain how much of that 4% is spent on paying health care claims versus multi-million dollar public relations campaigns or why the industry is spending millions to convince the public that they’re committed to frugal and efficient business practices. But it does make a valid point. Despite their promise not to finger point “to other sectors,” insurers are right to argue that large provider groups use their market leverage to increase reimbursement rates and increase health care costs. But so do insurers.

In fact, yesterday, Mark Miller — executive director of the Medicare Payment Advisory Commission (MedPAC) — took insurers to task for overpaying hospitals and doctors at the AHIP conference:

MILLER: There’s kind of this food fight going on where the private sector since Medicare doesn’t pay enough and it’s a cost-shifting argument. And I would say that the commission has different feelings about that. We have evidence that suggests part of the problem, not always the problem is that there hasn’t been enough restraint on the private side. payment rates have been escalating and costs follow payment rates and I’d be happy to discuss that when we get to questions.

Watch it:

Miller is concerned that insurers are not using their leverage to negotiate with providers for lower prices. Linda Blumberg of the Urban Institute explains why:

- Insurers believe, probably correctly, that they cannot attract enrollees without including flagship hospitals. As a consequence, large and expensive teaching hospitals, have little incentive to negotiate with insurers and lower prices.

- Second, small insurers do not aggressively compete over price. Rather, rising premiums and increased profitability of nondominant firms provide indirect evidence of shadow pricing by smaller insurers; that is, smaller insurers do not seem to compete on premiums to gain market share but rather seem to follow the pricing of the dominant insurer. Competition in insurance markets is often about getting the lowest risk enrollees as opposed to competing on price and the efficient delivery of care.

- Third, the market is affected by the lack of clear information necessary to allow individuals to effectively shop for plans based on benefits, price, and quality. Without active competition, the dominant insurers have no need to bargain aggressively with providers.

- Finally, the consolidation of hospital systems that has occurred in recent years has also severely limited insurers’ ability to negotiate with hospitals for lower rates.

In other words, there is plenty of blame to go around — dominant hospitals and insurers use their leverage to secure higher rates. But as medical costs continue to outpace inflation, insurers have been able to use their market power to pass health costs to policy purchasers and increase their profitability at the same time. So while they’re trying to blame providers for the premium hikes, it’s fairly clear that — at least in some markets — they’re the ones who are overpaying them!

It’s also worth pointing out that a nationally televised ad campaign blaming providers for higher premiums only tarnishes the provider/insurer relationship and creates a hostile environment for negotiating rates. Insurers are frantically trying to point the fingers at providers to avoid a conversation about their failed efforts to control costs and increasing profits. It’s an argument Miller was unwilling to accept.