The Congressional Budget Office released two separate 75-year spending projections this morning. One estimated what would happen under current law; the other predicted what the deficit would look like if Congress patched the doc fix, ignored the cost controls in the health care law and extended the Bush tax cuts:

The cynic in me believes that the bottom graph is probably more accurate than the top graph , but even that does not take into account all the possible changes — at least when it comes to the health care law. The problem is that CBO doesn’t score things like prevention and payment reform and relies on a narrow spectrum of evidence to estimate the costs and savings. This kind of math has gotten the agency in trouble before. For instance, CBO has consistently underestimated the savings from Medicare hospital payments in the early 1980s, (which ended up saving more in just one year than CBO predicted for three years) and the Medicare Part D legislation. In this report, it notes that “A wide range of changes could occur—in people’s health, in the sources and extent of their insurance coverage, and in the delivery of medical care—that are almost impossible to predict but that could have a significant effect on federal health care spending, both under the legislation and under prior law.”

Indeed, there is a whole body of research that quantifies the savings from the provisions that the CBO largely ignores. In May, the Commonwealth Fund and the Center for American Progress Action Fund released a study that relied on business literature about the inefficiency in the health care sector, experiences of health practitioners, and the real world experiences of Geisinger Health System, Health Partners, Denver Health and others and estimated higher savings from modernization and payment reform. As a result, they found that the annual growth rate in national health expenditures falls from 6.3 percent absent reform to 5.7 percent under the health law. Similarly, the administration’s Council of Economic Advisers also released a report last year which found that health reform would reduce health care spending by 1 “percentage point over an extended horizon.”

The point of this is to say that the 75-year estimate is a rough guesstimate that’s based on a very specific and narrow interpretation of data. It should be seen as such.

A new Kaiser Health News poll is at least the third survey to show that approval for health care reform is increasing, despite the GOP’s continued effort to paint the law as a failure. The new results show that “48% of the public had a favorable view of the law in June while 41% had an unfavorable opinion. A month earlier, the split was 41% favorable to 44% unfavorable”:

Moreover, just 27% of Americans want to repeal the law entirely and 12% of those who have an unfavorable impression said that the “law should be given a chance to work, with Congress making necessary changes along the way.” For all of the noise we’re hearing about repealing the law and the health care lawsuits, these aren’t very impressive numbers. On the whole, most Americans believe that the law will have a neutral impact but think that the country as a whole would be better off.

I’ve argued before that reform will need to deliver some early benefits to truly turn the numbers around and this poll suggests that it’s unclear if anyone is paying any attention to all the discussion about pending benefits (from the GOP and the administration). For instance, the number of individuals who recognize some of the oft-talked about provisions like extending dependent coverage until age 26, and the individual mandate actually decreased. The number who know about the high risk pools for individuals with pre‐existing conditions increased by just one percentage point.

Earlier today, in an effort to placate party conservatives, House Minority Leader John Boehner (R-OH) and House Minority Whip Eric Cantor (R-VA) signed onto two discharge petitions offered by Reps. Steve King (R-IA) and Wally Herger (R-CA). The petitions will need to attract 218 members to force the House to take up repeal legislation that would eliminate the entirety of the health law. Herger’s measure would also replace the law with “common-sense reforms.”

The move is a significant departure for the Republican leaders who have previously claimed that they would like to preserve the more popular elements of health care reform and repeal “the other” mandates. For instance, back in January, Cantor told Politico’s Mike Allen that Republicans “WILL NOT campaign for full health care repeal, but will demand partial repeal, including mandates for health coverage.” Boehner sang a similar tune as recently as April:

BOEHNER: Both of those ideas [ending rescission and extending dependent coverage], by the way, came from Republicans, and are part of the common sense ideas that we ought to have in the law.

INSKEEP: Well, are you going to repeal those two specific things?

BOEHNER Uh, what I want to repeal are the other 158 mandates, commissions, boards that set up all the infrastructure for the government to take control of our health care system.

Boehner’s and Cantor’s new position represents a significant victory for conservative activists like King, who have complained about the leadership’s reluctance to support full repeal, but some grassroots activist are still not pleased. Red States’ Eric Ericson complains that Boehner and Cantor “want to bully Republican House members into signing the Herger petition and undercut the repeal effort with a “replace and replace with lame legislation” effort. In effect, this undercuts a unified repeal effort and muddies the waters.”

But the leadership’s endorsement of the discharge petition also pits the GOP against popular provisions like access to insurance for people with pre-existing conditions and dependent coverage and may create more divisions within the caucus. Back in March, Rep. Phil Gingrey said, “When we say start over, we don’t mean throw everything out – throw out the baby with the bath water. We mean, take the best of this bill and combine it with our ideas.” In April, Rep. Jack Kingston (R-GA) told a town hall meeting, “there are a lot of things in this bill I think you and I certainly like.” “I think as a practicality you’re going to have trouble repealing the whole deal,” Kingsdale said. “But there ought to be areas where Democrats and Republicans can come together.”

A new report from the Robert Wood Johnson Foundation finds that “adult obesity rates increased in 28 states in the past year, and declined only in the District of Columbia.” And “more than two-thirds of states (38) have adult obesity rates above 25 percent,” a figure practically unheard of 20 years ago when “no state had an obesity rate above 20 percent.” Other key findings:

- Adult obesity rates for Blacks topped 40 percent in nine states, 35 percent in 34 states, and 30 percent in 43 states and D.C. Rates of adult obesity for Latinos were above 35 percent in two states (North Dakota and Tennessee) and at 30 percent and above in 19 states. No state had rates of adult obesity above 35 percent for Whites. Only one state-West Virginia-had an adult obesity rate for Whites greater than 30 percent.

- The number of states where adult obesity rates exceed 30 percent doubled in the past year, from four to eight –Alabama, Arkansas, Kentucky, Louisiana, Mississippi, Oklahoma, Tennessee and West Virginia.

- Ten of the 11 states with the highest rates of diabetes are in the South, as are the 10 states with the highest rates of hypertension. Northeastern and Western states had the lowest adult obesity rates; Colorado remained the lowest at 19.1 percent.

Look at their colorful map of childhood obesity rates (which is interactive on their website):

The report also finds that the public is fairly receptive to using taxpayer dollars to help bring down obesity rates. For instance, 56% says that “a comprehensive program to combat childhood obesity is worth the financial investment, even if it would increase government spending by billions of dollars a year (and this during a difficult economic period in which many voters have been hesitant to support more government spending).” (The very same ‘difficult economic period’ that may have pushed some consumers towards cheaper and less healthy foods). Fifty-eight percent believe preventing childhood obesity is “a very important” priority.

This all sounds good, but it’s easy to support general obesity reduction efforts that don’t have any specific proposals or cost estimates attached to them — particularly when you see the whole thing as someone else’s fault. The survey also found that 84% of parents believe their children are at a healthy weight, “but research shows nearly one-third of children and teens are obese or overweight.”

The city of San Francisco requires employers with “at least 20 workers that do not provide health care” to “give part of each employee’s wages to the city as a fee to help pay for the $200 million program.” The mandate is part of the city’s Healthy San Francisco program, which like national reform, seeks to expand universal coverage to lower income Americans.

For the last four years, the requirement has been the subject of a legal battle, with business groups accusing the City of overstepping its authority and violating the federal Employee Retirement Income Security Act (ERISA). The 9th U.S. Circuit Court of Appeals in San Francisco had ruled in favor of the city and yesterday the Supreme Court refused to take up the case, effectively preserving the City’s mandate. As Emma Sandoe observes, the decision marked an important victory not just for the city, but also for local rights and authority:

The fact that the Court defended state law over federal restrictions does not hurt the proponents of health reform and the constitutionality of national reform.  These are separate questions on federal versus state powers.  In fact, a repeal of the San Francisco employer mandate would have hurt the case for the Attorney Generals.  It would have been a blow to the health insurance regulatory power of the states, in favor of federal law. So in this case, conservatives hoping for a repeal of health reform should have been rooting for San Francisco. I imagine that image does not appear likely.

In other words, if the Supreme Court had accepted the case and then ruled that the power to mandate employers to pay a fee for failing to provide health insurance coverage rested with the federal government, it could have bolstered the fed’s standing in the cases challenging the individual insurance mandate.

The other point worth noting — and this is what makes this case so uncomfortable for conservatives — is that in San Francisco, the employer mandate has not resulted in the kind of job loss that Republicans are pinning on national reform’s far more limited free-rider requirements. Some restaurants have added “a four percent health care surcharge on menus” but there is no evidence that the provision is adversely affecting employment. In fact, “Neighborhood restaurants, where restaurants tend to be affordable and supported by locals, have generally received pretty good acceptance of the program,” while “restaurants in tourist and business travel areas are getting a lot more negative push-back.” Even so, they have not reported a decline in sales.

Ian Millhiser argues that during the first day of Elena Kagan’s Senate confirmation hearing, conservatives tried to paint her as a “judicial activist” and if they can convince her to overturn the health care law, then she will be. Republicans have made the nomination’s view of the individual health insurance mandate a litmus test and are expected to ask Kagan if she believes Congress has the authority to impose an individual mandate under its authority to regulate interstate commerce. As Sy Lazarus argues in today’s Politico, the GOP’s preferred answer would have the effect of reversing years of precedent and lead to some very far-ranging ramifications:

Technically, the cases challenge just the health reform law. But the radical legal theories they advance can extend much further. If accepted by the Supreme Court, these theories could shatter the constitutional foundations of landmark programs like Social Security, Medicare, civil rights and environmental protections. [...]

Sessions and other Republican Senate leaders recently disavowed Rand Paul’s distaste for half-century-old Civil Rights Act protections. But the health reform lawsuits they support, in effect, comprise a second front in which Paul and his libertarian allies hope to bypass the political majorities that overwhelmingly oppose their rollback agenda.

Legal experts, including prominent conservatives, scoff at the merits of Cuccinelli’s case and of Florida Attorney General Bill McCollum’s similar challenge on behalf of 20 other Republican top state lawyers. Yet if the Supreme Court’s right-leaning majority grants the opponents’ claims, or any part of them, then challenges might be filed against other major statutes.

Logically, the next domino targeted could be the guarantees against private discrimination that Paul discussed. For the legal argument devised to strike down health reform could, if accepted, imperil those other laws..

In other words, redefining how the Supreme Court has interpreted Congress’ authority under the commerce clause would bring about the very kind of activism conservatives condemned during the first day of hearings.

Over at BNet, Ken Terry argues that while capping insurance rates may help reduce the number of outrageous rate increases and keep issuers from making those rather embarrassing mathematical errors, policy makers will have to address increasing costs on the provider side to really get spending under control:

Insurance companies do raise rates by ridiculous amounts; their executives earn too much; and the national companies, in particular, are hugely profitable. But it’s also true that, especially in Massachusetts, some hospitals and physician groups have held up insurers and employers for ridiculous payment increases. And there is no doubt that as the economy worsens and fewer people can afford insurance, more healthy people are dropping out of the insurance pool, driving up rates for those who remain covered.

Clearly, we need a new deal in healthcare. Just capping insurance rates won’t do it.

None of this takes away from the importance of ensuring that health premiums are reasonable or pressing for some kind of federal rate review authority, but since premiums are closely tied to the underlying cost of services, we’re going to have to get a hold of spending on the provider side.

Democrats and advocacy groups like HCAN do a commendable job in publicizing the access of some large insurers and a lot of that same energy could also be extended to pressing providers or lobbying for the relevant cost control measures. Stronger rate review provisions will help control costs over the short term and vilifying insurers can reap some political dividends, but we’re gonna have to look very closely at things like reimbursing for outcomes if we’re going to bring costs down over the long haul.

The federal government will unveil the first real benefits from the health care reform law this week, as states begin enrolling sicker individuals into health insurance policies and the federal government rolls out a new web portal designed to help Americans compare and purchase insurance products.

In at least 20 states, uninsured individuals with pre-existing conditions who have been without coverage for six months will be able to enroll in the new pools starting Thursday, but coverage will not begin until sometime in August. Under the new regulations, high-risk insurance pools will not be able to impose preexisting condition exclusions, will have to keep their premiums at “standard rates” (or no higher than the average person of that age would pay for insurance in the private market), limit on out-of-pocket medical costs to $5,950 a year for an individual, and maintain an actuarial value of at least 65%. Issuers will also be prohibited from varying premiums on the basis of age by a factor greater than 4 to 1.

According to Politico’s The Pulse, NASCHIP, a trade organization of high risk pools, is negotiating between the states and the federal government, pressing HHS for a “fair contract in terms of protecting states so that when they enter into this agreement, they’re not exposing themselves in terms of financial or legal liabilities,” and clarifying that states do not have “a financial commitment to run the pool if HHS funds run out.” The health care law gives states $5 billion establish the pools as an interim measure to provide coverage for Americans with pre-existing conditions until the exchanges become operational in 2014. Thirty states have announced that they will be administrating their own pools, but only 20 have submitted proposals to do so. The federal government will administer pools “through a private nonprofit entity” in the 19 states that have decided against implementing the measure.

On Thursday, HHS is also scheduled to unveil it’s new insurance portal, HealthCare.gov. The new website that will allow individuals and small businesses to comparison shop between different coverage options, “including private insurance plans, high risk pools, CHIP and Medicaid.” Initially the site will only list the different insurance plans, but will eventually expand to include information about pricing and quality measures.

Our guest blogger is Mandy Krauthamer Cohen, executive director of Doctors for America.

On Thursday night, the House voted to reverse the 21% pay cut to physicians that went into effect on June 1st. While physicians everywhere appreciate the fact that the House stopped the hemorrhage of the SGR pay cut by voting for the Senate version of the “doc fix”, the fact that it is only a 6 month temporary solution is extremely distressing. What started out as a three and a half year “fix” when it was first introduced in May – with allowances for primary care to grow at higher rate – was whittled away over the past month to a six month temporary fix that expires on December 1st.

When are we going to stop kicking the can down the road and permanently fix the SGR – or at least lay the foundation to make a permanent fix fiscally feasible? The House was able to muster the support for a permanent “doc fix” back in 2009 – though that support has likely vanished as the election draws closer and any mention of the word deficit sends everyone into a tailspin. The Senate voted down a permanent fix for the SGR last year –clearly this is an uphill battle.

While Washington continues to play politics – it is the seniors, military families and physicians who care for them that are caught in the middle. The baby boomers begin entering Medicare in six months, and these new Medicare patients may have difficulty finding a doctor as it is. According to the AMA, about one in four Medicare patients looking for a new primary care physician are having trouble finding one. About one in five physicians are already limiting the number of Medicare patients they treat because of the instability and uncertainty of Medicare payment.

The constant uncertainty about Medicare payment is not only difficult for physicians financially – particularly internists, family physicians and geriatricians — but it also engenders cynicism of government among physicians. Given, that the new reform legislation will greatly increase demand for physicians’ services through expansion of insurance coverage, it doesn’t seem like the best time to be provoking skepticism among physicians.

I was pleased to watch President Obama’s weekly address on June 12th where he discussed the need for a permanent fix for the SGR. He backed that up with his statement last night after the House vote:

OBAMA: I believe we need to permanently reform the Medicare formula in a way that attacks our fiscal problems without punishing our hard-working doctors or endangering the benefits on which so many of our seniors rely. I look forward to working with Congress to achieve that goal, and I’m gratified that in the meantime they’ve taken the provisional step of blocking this pay cut.

Good stuff – but it’s time to turn those supportive statements into action. We can’t wait until Thanksgiving before we continue the dialogue on how to move to a more permanent payment solution — this issue is too complex, expensive and laden with pitfalls. It’s time to get to work.

Over in the comments section of this post, Texas Aggie makes smart observation about another factor that could be driving the Republicans to oppose the health care law:

You may have missed an important point in the analysis of the Republican reaction and why they are so adamantly opposed to universal health care. Back when Clinton was trying to get it through, the Republicans realized that if the Democrats got credit for something that would turn out to be as popular as universal health care, then the Republicans were finished as a viable political party. They decided to not just modify Clinton’s proposals but to destroy them.

The same fact holds today. They know that if health care is implemented, that they are finished for the next generation or two, and they are desperately fighting like trapped rats.

The sentiment may be overstated, but it’s certainly worth considering. During the Clinton era, Republicans followed historical precedent and battled health care reform in the legislative arena. They defeated the bill and saved their party, so to speak. In the past, when they couldn’t defeat a major bill they opposed, they would simply switch their votes and take credit for it. For instance, in that interview with Lester Feder, James Morone recalls how “in the original [Medicare] vote in the House, the legislation passed by some 45 or 46 votes. It got exactly 10 Republican votes in the House. But that was on a preliminary vote on a parliamentary maneuver to stop it from being buried back in committee. When that vote failed, almost all Republicans then crossed over and supported Medicare.” “The thinking was that they had lost, and they wanted to take credit for legislation that was likely to become popular,” Morone explains.

This time may be unique because Republicans didn’t ultimately switch their votes; they simply took their battle into implementation. And if they’re truly interested in protecting their viability and discrediting health care reform, they will have at least 50 different entry points at which they can slow down the process. Whether voters realize (and the president highlights) what that says about them as a party, is a different matter.

Last month, independent analysts in California discovered that WellPoint “overstated future medical costs” to justify its 39% premium increases in the individual health market and committed numerous other methodological errors and now, Aetna has also withdrawn a filing with California insurance regulators “after discovering it had made calculation errors.” “The company had requested a 19% average rate increase, due to go into effect July 1 and covering 65,000 individual policyholders, but said its actuaries found mistakes in how the annual cost of monthly premiums was calculated, among other things,” the Wall Street Journal reports.

A thorough review of insurance rates across the country will likely produce many more of these mathematical anomalies, but as Scott Paltrow details in a new CAP paper few states actually have the authority to block or question large premium hikes in the individual and/or small group markets. In many states, Paltrow explains, insurers have used their money and clout to lobby against tougher review regulations and consequently, states can do very little to protect patients from unreasonable premium increases. “Records show that large health insurers have been major contributors to candidates for state offices. Four of the biggest health insurers—Wellpoint, UnitedHealth Group, Humana, and Aetna— contributed $8.7 million to candidates for state offices and state campaign committees in 42 states from 2005 through 2008, according to a 2010 report by the National Institute on Money in State Politics,” Paltrow writes.

Here is a taste of their influence:

- 23 states do not review and approve premium changes before insurance companies put the changes into effect.

- 30 states and the District of Columbia do not review and approve premium changes to small employer policies before they go into effect.

The health care law changes some this. Health insurance issuers will have to submit to the Secretary and the relevant State a justification for an unreasonable premium increase prior to the implementation of the increase and that information will be “prominently” displayed on their Internet websites. The federal government will encourage states to conduct rate review by offering grants and states themselves can decide to block certain insurers with a poor history of rate increases from participating in the exchanges. The incentives and extra funding are certainly there, but ultimately, very little is done to diminish the insures’ influence over this whole process. Today, even in states that have rate review, “state regulators and others who monitor state regulation say that regulators even in these states often wave through requested hikes—often because of political pressure by large insurers.” The grants will allow reviewers to bolster their staffs, but will it free them from the political pressure?

Paltrow suggests, and many Democrats agree, that Congress should consider passing Sen. Feinstein and Rep. Schakowsky’s legislation giving the Health and Human Services Department secretary the power to block excessive premium increases. But I suspect this won’t happen unless the insurers really take advantage of the weak review provisions and premiums spiral out of control.

The Washington Post has an interesting overview of how the generosity of states’ existing Medicaid program is affecting their response to the new health care law. Of course everything will depend on how many people actually sign-up for Medicaid and whether the federal government will maintain its funding commitments, but generally speaking, states that have wider eligibility rules will receive more federal Medicaid dollars than those with narrower provisions:

Starting in 2014, anyone making up to 133 percent of the federal poverty line — now $14,400 for a single person and $29,300 for a family of four — will qualify for Medicaid under the new law.

The requirement will affect states differently depending on the generosity of their existing Medicaid program. Virginia enrolls only the blind, disabled, some needy children and deeply indigent parents who make up to 24 percent of the poverty line. State officials have estimated that boosting coverage to the required level means as many as 426,000 people might become part of the program, which includes about 837,000 Virginians.

The change will result in fewer new Medicaid patients in Maryland, which extends some form of coverage to most residents making up to 116 percent of the poverty level. It will have to provide more robust benefits to about 112,000 residents, but state officials estimate that Maryland will have to extend entirely new benefits to only 21,000 — less than one-twelfth the number Virginia faces.

But both states might be engaged in wishful thinking when it comes to residents who are newly eligible for Medicaid. Maryland’s estimate assumes that far fewer than the number eligible will join the program — which matches experience. Virginia’s estimate assumes about 270,000 newcomers to Medicaid, the most conservative of several enrollment models.

This is all very interesting to think about and one wonders if states will actively encourage the eligible expanded population to enroll in the program. Theoretically, states have an incentive to enroll less people and consequently spend less state dollars on Medicaid. Over time, the federal matching fund will decrease and states will have to cover a higher percentage of the cost for the expanded population and so they could be encouraged to launch a massive campaign beginning in 2014, when the federal matching rate is at its highest. Since most applicants stay in Medicaid temporarily, the long term costs of the expanded population may be of lesser concern.

The article goes on to note that the “savings” from the expanded Medicaid provision (in terms of less state spending on uncompensated care) are “fuzzy” and for now states will be busy performing a cost benefit analysis for the new spending requirements. But as we move forward, some states will grow accustomed to spending more money on health care and these kinds of expenditures won’t be seen as too controversial. Or, alternatively, the federal government will step in and provide some extra funds to prevent states from limiting eligibility.

Marco Rubio is now backing away from his claim that he would preserve certain provisions of the new health care law. But as his campaign released a statement clarifying that he “believes the health care law should be repealed – all of it,” the National Review’s Jim Geraghty posted this video of Rubio clearly articulating his support for maintaining provisions that eliminate the pre-existing conditions exclusion and permit children to stay on their parents’ plan up to age 26:

RUBIO: Obamacare should be repealed. It’s going to bankrupt America…..So I think there are a couple of things that stand on their own that people like, like the pre-existing condition clause, I think there’s widespread support for. The idea that people up to the age of 26 should be allowed to stay on their parents’ insurance plan, has widespread support. But beyond that, I think the bill should be scrapped and replaced with much better ideas….

MATT LEWIS: So you wouldn’t scrap the ability for insurance agents — you said there were to — you wouldn’t scrap pre-existing conditions, you would keep that in?

RUBIO: Yeah, and I think there’s broad support for that, Republicans and the American public support that. And I think there’s support for the idea that 26 years old — up to age 26 years of age should be allowed to buy into their parents’ insurance plan. Beyond that, I think Obamacare is unaffordable….So I think we need get rid of these other provisions of Obamacare completely and replace them with these simpler, cheaper, better ideas.

Watch it:

In his ‘clarification,’ Rubio argues that he would replace the entire health law with legislation “establishing universal access programs to guarantee access to affordable health care for those with pre-existing conditions” and touts the House Republican alternative (which included this concept) as a model. But that GOP plan (as opposed to their 1993 proposal) wouldn’t actually prevent insurers from denying coverage based on pre-existing conditions. It relies on state based high-risk pools — and that’s very different than the pre-existing conditions exclusion Rubio supported yesterday.

Under “universal access,” (and according to the bill the GOP House leadership introduced), insurers can continue denying coverage for pre-existing conditions but states are required to establish high risk pools to insure those who cannot find coverage on their own. The bill abolishes waiting lists and specifies that the pools must provide at least two coverage options, one of which must be a high deductible plan with HSA. Premiums can be set at no higher than 150% of (state) average and the federal government will provide $15 billion in funding — a paltry sum, considering that very sick people are very expensive to insure. In fact, just recently, Republicans penned a letter to HHS complaining that the health care law’s $5 billion appropriation to run high risk pools for just 3 years is insufficient, do they really think that states can stretch $15 billion over 10 and buy insurance for all those who need it?

Rubio is trying to conflate “universal access” with an outright ban — the kind that he supported yesterday afternoon. But the two are not the same, and if Rubio really wants to prevent insurers from excluding chronically ill patients, he’ll have to support the individual mandate.

Florida senatorial candidate Marco Rubio, once a strong advocate for repealing the entire health care law and replacing it with “real reforms,” is now telling reporters that he would not repeal the law’s pre-existing conditions exclusions and the provisions that allow children to stay on their parents’ policies until age 26. From National Review’s Jim Geraghty:

A small group of reporters in a D.C. coffee shop, chatting with Florida Republican Senate candidate Marco Rubio. He just mentioned that there are two parts within the Obamacare legislation that he doesn’t want repealed. The first is the ban on insurance companies denying coverage based on preexisting conditions and the second is that he thinks that children up to age 26 should be allowed to “buy into” their parents’ coverage.

Politics Daily’s Matt Lewis:

Rubio says he would NOT get rid of the pre-existing condition provision of Obamacare. Also wouldn’t overturn 26-yr-olds on parents insur.

The statements seem to contradict Rubio’s previously calls to completely scrap the law and start over. In January, Rubio signed a Club For Growth’s pledge to repeal the bill and after it passed, issued a statement reiterating his “strong support for repealing it when I get to Washington and offering alternative reforms to make health care more accessible and affordable.” Similarly, during a March 28th appearance on Fox News Sunday, Rubio told Chris Wallace, “I think the first step is to repeal it. We need to win a few elections before we can get there. But we certainly need to start campaigning and talking about it.”

Rubio’s recent comments also highlight the rift in the Republican party between repeal purists like Rep. Steve King (R-IA) and the Republican leadership, which has been reluctant to embrace complete repeal. King has filed a discharge petition on legislation he has drafted to repeal the law and is now lobbying to secure the 218 votes necessary to force House Speaker Nancy Pelosi (D-CA) to bring repeal to the floor. King has not yet convinced Minority Leader John Boehner (R-OH) to support the discharge petition.

Govs. Chris Gregoire (D-WA), Jennifer Granholm (D-MI), Ed Rendell (D-PA) and Bill Ritter (D-CO) have filed a joint motion asking the District Court of Northern Florida to reverse its decision disallowing interested parties to file amicus briefs and permit a “friend of the court” brief in the lawsuit challenging the constitutionality of the new law. The governors will argue that the court “should reject the attorney generals’ request that implementation of the health care reform law be prevented from moving forward” and will “provide specific examples showing why the health-care law is constitutional as a matter of interstate commerce.”

The request also highlights the tension between attorneys general and their governors, who often find themselves on different sides of the case. Washington AG Rob McKenna joined the lawsuit over the objections of the governor and in the press release announcing the ‘friend of the court’ request, Gregoire distances herself from his actions. “I’ve said from the beginning – the action of the Attorney General in filing this lawsuit does not represent the Governor, the Insurance Commissioner, legislative leadership, or thousands of Washingtonians in our state that would benefit from national health care reform,” Gregoire said. “We need to move forward. This legislation not only provides necessary care to millions of Americans who desperately need it – it protects our tax payers from the skyrocketing costs of health care.” The release offers some more details:

The governors worked to ensure the federal health reform law met the needs of the states, and will point to numerous benefits to the states from the federal-state partnership including:

Health insurance coverage for pre-existing medical conditions, which experience shows can only be sustained if individuals are discouraged from waiting until they become sick or injured to obtain health insurance.

Federal funding for programs that are now wholly state-funded or have waiting lists because of lack of funds, such as Washington’s Basic Health Plan that provides subsidized health insurance for low-income individuals.

Significant reductions in the “hidden tax” on the medical and insurance costs of those who pay their bills when the uninsured do not pay for health care they receive

Measures to control the skyrocketing costs of health insurance, which will help the economies of their states.

At least three attorneys generals are also petitioning the Florida court in the matter. AGs from Oregon, Iowa and Vermont hope to file a brief and make the case that the PPACA “is both constitutional and important to the health and welfare of their citizens.” “The brief argues that states are familiar with the ‘longstanding relationship between the federal government and the states in the healthcare arena and are similarly familiar with the strengths and limitations of a state-by-state approach to healthcare reform.’” “[W]ithout a national solution to the healthcare crisis,” the brief claims, “the Amici States would be forced to spend more and more on health care and yet slide farther and farther away from their obligation to protect the health and well being of their citizens.”

The US Department of Justice filed a motion to dismiss the case earlier this month and it’s scheduled for oral argument on Sept. 14, 2010.

Reiterating President Obama’s claim that the interim Patients’ Bill of Rights regulations shouldn’t provide insurers with an excuse to increase premiums, Washington and Lee Professor Timothy Jost takes a closer look at the text of the interim final regulations and concludes that “most of the reforms are expected only to increase premiums by tenths or hundreds of a percent.” That’s because:

- Relatively few individuals are directly affected by most of the regulations.

- Plans have the option prior to 2014 of avoiding the impact of some of the requirements by simply eliminating coverage for services or conditions (although they might lose grandfathered status by doing so).

- Some of the practices are already restricted in many states.

- Some of the regulations really do not impose additional costs (such as allowing individuals to choose their primary care provider or allowing children to be treated by a pediatrician)

“Individuals who may have benefited by some of these regulations, such as the ban on pre-existing condition exclusions for children or the removal of lifetime limits and restriction on annual limits, may be faced with high premiums when they seek to purchase or renew individual coverage,” he speculates, but “[i]n states that require some form of community rating, this barrier will be limited.” And “most insurers limit premium increases for persons in poor health to twice the standard rate.”

The most surprising aspect of the regulations, however, is the pre-existing condition provision. These interim rules prohibit insurers from denying coverage to children with pre-existing conditions; adults will receive this protection beginning in 2014, which is also when insurers will be required to offer a set of essential benefits. But before 2014, Jost notes that issuers can still get around this rule by excluding coverage for a certain conditions as long as they do not violate state law or other federal laws.

Kaiser Health News’ Phil Galewitz has more on the cost of the regulations here.

Lester Feder of Georgetown Law Center’s O’Neill Health Law Institute has an interesting new interview with James Morone — a professor of political science at Brown University — who points out that while we have seen partisan politics break out over past social reforms, never before has the partisan rhetoric extended into implementation:

Normally in our political system, when we have enormous battles over legislation, most political actors consider the politics done when the legislative battle is over. What’s new here is the idea that the battle goes on into the implementation phase. This wasn’t true for Social Security, it wasn’t true for Medicare, it wasn’t true for civil rights. Of course, interest groups always continued to fight to get the best deal possible in implementation. But that’s very different from it being Democrats versus Republicans or liberals versus conservatives. Today’s situation is very different.[...]

I’m not sure the Democrats have been quite this insistent after losing legislation. To have the Republican Party be this forceful about a position after the normal political process has run its course is pretty extraordinary.

Morone goes on to explain why he thinks this is in parts I and II of Lester’s interview (both of which are very much worth reading), but I just want to underscore the passion with which the GOP is opposing this law. When I spoke with some Republican staffers on the hill last week about what could only be described as relatively futile legislative effort to repeal the law, they practically screamed at me that they will never, ever, accept that reform has become law and will work very hard to repeal the measure. “Why should we accept something that’s unconstitutional,” they asked.

Indeed, Republicans are using every single obscure regulation and appointment to re-litigate the health care reform debate. In addition to Sen. John Barrasso’s (R-WY) weekly ‘Second Opinion’ speech, prominent Republicans take to the floor and pen op-eds on a daily basis to condemn the new law and celebrate the states that are refusing to implement it. On Monday, Sen. Jon Kyl (R-AZ) argued that the new grandfathering regulations would cause many Americans to lose the coverage they have. Yesterday Sen. John McCain (R-AZ) proclaimed, “we’re not going to quit on this issue, we’re not going to quit on this issue. It’s going to be repeal and replace.” And today, House Minority Leader John Boehner issued a 43-page report rehashing the GOP’s health care talking points.

It’s important not to overstate the cohesion of the GOP campaign, since different factions have adopted different strategies, but it’s safe to say that their larger goal is to goad Democrats into rehashing the 2009 health care legislative debate, rather than looking ahead towards implementation. But that kind of discussion, in which we argue back and forth about CBO scores, diminishes the legislative accomplishment and adds extra weight to the GOP critique. It’s not the role of the minority party to set the terms of debate — particularly when they’re doing so for such transparently political purposes.

President Obama said it best when he framed the discussion this way: “They want to go back to the system we had before.” “Would you?” he asked during yesterday’s Patients’ Bill Of Rights unveiling. Would you want to go back to discriminating against children with preexisting conditions? Would you want to go back to dropping coverage for people when they get sick? Would you want to reinstate lifetime limits on benefits so that mothers like Amy have to worry? We’re not going back. I refuse to go back.”

If the GOP continues to press ahead with repeal, they might slow down the implementation process, but they’ll also run the risk of fading into historical irrelevancy. Who remembers the legislators who led the fight against Social Security or Medicare and better yet, who celebrates them?

The Commonwealth Fund is out with a new report showing that the United States spends twice as much as any other country on health care, but still has a system with unbearably low quality, efficiency and equality standards:

For $7,290 per person, we’re buying a system that leaves 45 million uninsured and produces less quality and efficiency than a country that spends half as much ($3,000) and covers everyone. Germany, for instance, spends just $3,588 per person even though it has higher smoking rates and higher instances of chronic disease than the United States.

We should be spending less money and spending it differently, but any time you talk about diverting resources elsewhere or appropriating them in accordance with proven effectiveness, you’re met with charges of rationing care and death paneling seniors. The proponents of smaller government and responsible spending all rally (in fact, continually praise as the best in the world) behind a system that costs and wastes untold billions — all the while vilifying the more economically sound models of care.

Despite this opposition, there is certainly some sense that the payment reform demonstration projects and comparative effectiveness research provisions in the new health care law will begin to slowly push Medicare into paying for outcomes and lower spending over time. But that transformation is a slow crawl that will have to overcome the forces — politicians, providers — that are so determined to keeping America’s health care system in last place.

Ezra Klein notes that despite the orchestrated GOP campaign to transform any small regulatory change or news report into a ‘health care law is failing’ storyline, health-care reform is actually getting more, not less, popular:

But by coincidence, I had been looking at some of the polling on health-care reform moments before the report landed in my inbox. A USA Today/Gallup poll that came out this morning showed that 49 percent of Americans think the Affordable Care Act is a “good thing,” while 46 percent think it’s a “bad thing.”

This poll comes on the heels of an Associated Press-GfK poll showing the same movement. So that’s two recent polls showing a lift in the bill’s popularity, taking it from a slight plurality in opposition to a slight plurality in favor. Two polls is enough to make me curious, so I headed over to Pollster.com, and it does seem we’re looking at a trend. The site’s aggregate chart of recent polls doesn’t yet show support overwhelming opposition, but it does show support rising and opposition falling. In fact, the bill’s spread looks better than at any point in the past year.

Look:

This all sounds right, but I want to link back to my criticism of how the press covered health care reform. During the actual legislative debate, political tensions and negative stories received the majority of the coverage and that’s still the case today.

Just consider this WSJ report about the Gallup poll Klein references. It’s headlined ‘Gallup: Health Care Overhaul Support Flatlines,’ implying that ‘the reform patient is dead’ — despite the fact that the poll shows that a majority support the new law. This could be one in-artful headline, to be sure, but you can imagine that if the numbers were flipped, we’d be seeing more sensational accounts about how the Democrats’ top domestic accomplishment is floundering. But here, with support increasing, even in the face of daily GOP attacks, the press is running mixed stories at best.

Earlier today, I expressed concern that the new ‘Patient Bill of Rights’ regulations would give insurers an excuse to raise premiums while leaving the federal government relatively powerless to rein in excessive and unreasonable increases. But this afternoon, during a conference call with reporters, HHS Secretary Kathleen Sebelius stressed that the added cost of the new regulations would only amount to “less than 1%” in added costs:

SEBELIUS: We anticipate that the cumulative impact is likely to be less than 1%. The actuarial studies that our folks have asked to engage in, looking at this indicates that while there are clearly some cases where there are some expenses, relatively few and far in between given the number of people impacted and effected. Again, part of the meeting today was to call on insurance companies to use their market strategies to put people in larger pools to make sure that folks particularly in the individual and small pool markets weren’t isolated and separated as the sickest possible population.

During his remarks, President Obama conceded that while “there are genuine cost-drivers that are not caused by insurance companies,” “we’ve got to make sure that this new law is not being used as an excuse to simply drive up costs.” “None of this is designed to deprive insurance companies of fair rates. And as I mentioned when we were meeting with the CEOs, there are a lot of cost-drivers other than those that are within insurance companies’ control,” he said.

This is true enough, but many insurers simply pass overinflated costs to consumers, without negotiating for better rates, and some are already blaming the health law for premium increases. For instance, in March, CIGNA CEO David Cordani told Neil Cavuto that the law will lead to additional increases and Aetna CEO Ron Williams argued that the new taxes — which don’t kick in until 2014 — will lead to immediate premium hikes. As Sebelius explained on the call, this kind of response is fairly typical:

SEBELIUS: There is no question that we are seeing rate increases that so far exceed the costs of medical inflation in some instances that they’re difficult to justify….In my former insurance commissioner days [I] am very familiar with companies alleging costs well in access of what they ended up being every single mandate passed in my experience at the legislative level was always estimated to be well more costly than tended to be the reality. When we passed mental health parity there were assertions that somehow rates would have to go 20% to cover this. This isn’t new, this tension and dynamic. The new is we are actually calling on insurance commissioners to step up to actually conduct more rigorous rate reviews.

History suggests that insurance commissioners will in fact have to remain vigilante in challenging and reviewing proposed rates. If they don’t, I suspect rates will continue to increase well beyond medical inflation and the “estimated cumulative effect.”