Surging presidential hopeful Rick Santorum took a shot at frontrunner Mitt Romney during a stop in Coralville, Iowa this morning, arguing that a president should not repeal the Affordable Care Act by issuing waivers to the states, as the former Massachusetts governor has suggested. Instead, Santorum promised to use the reconciliation process to eliminate the law if Republicans fail to gain a 60-seat majority in the Senate:

SANTORUM: It won’t be a waiver. I know some — Governor Romney has said, “oh we can just waive it.” Well, that’s again, experience does help and the experience of waivers is that some states will waive it and some states won’t…I suspect California won’t, and New York won’t and Connecticut won’t, and a lot of the other deep blue states won’t wave Obamacare. That means all of the taxes will still be in place for you and I to pay and all the money will go to California… The difference between Rick Santorum and Mitt Romney, is that I come at this cleanly. I’ve been a private sector health care guy from day one…I’ve never dabbled on the dark side when it comes to government health care.

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To be fair, Romney has also pledged to use reconciliation to repeal reform, despite the fact that the budget reconciliation bill would only apply to the budget-related elements and leave many provisions intact. The method would also create “a chaotic environment driven by enormous uncertainty over just which parts of the new health care law would be implemented–for consumers, health care providers, and insurers.”

Still, Romney would have an even harder time undoing Obamacare with waivers. For a state to be granted a waiver, “it must show that it will provide coverage that is at least as comprehensive and affordable as under the federal law,” and would not be able to apply for the exemption before 2017. A recent report from the Congressional Research Service confirms that issuing broader waivers through executive authority would “likely conflict with an explicit congressional mandate and be viewed ‘incompatible with the express … will of Congress.’”

2011 marked a banner year in the Republican war on woman’s health. Close to 1,000 anti-abortion bills sped through state legislatures as the GOP-led House led a “comprehensive and radical assault” on a federal level. But in surveying their arsenal this year, 10 bills stood out as particularly perturbing and far-reaching efforts to stymie women’s access to abortion services, birth control, and vital health services like breast cancer screenings. Here are ThinkProgress’s nominations for the most extreme attacks on a woman’s right to choose:

– Redefining Rape: Last May, every House Republican and 16 anti-choice Democrats passed H.R. 3, the No Taxpayer Funding For Abortion Act. Anti-choice activists Rep. Chris Smith (R-NJ) tried to narrow the definition of rape to “forcible rape,” which meant that women who say no but do not physically fight off the assault; women who are drugged or verbally threatened and raped; and minors impregnated by adults would not qualify for the rape and incest exception in the Hyde Amendment. Smith promised to remove the language but used “a sly legislative maneuver” that essentially informs the courts that statutory rape cases will not be covered by Medicaid should the law pass and be challenged in court.

– Abortion Audits: The No Taxpayer Funding For Abortion Act also bans using tax credits or deductions to pay for abortions or insurance. Thus, a woman who used such a benefit would have to prove, if audited, that her abortion “fell under the rape/incest/life-of-the-mother exception, or that the health insurance she had purchased did not cover abortions.” This requirement turns the Internal Revenue Service into “abortion cops” who, agents noted, would have to force women to give “contemporaneous written documentation” that it was “incest, or rape, or [her] life was in danger” which made an abortion necessary.

– Let Women Die: This October, House Republicans also passed the “Protect Life Act”, known by women’s health advocates as the “Let Women Die” bill. The measure allows hospitals that receive federal funds to reject any woman in need of an abortion procedure, even if it is necessary to save her life. Though federal law already prohibits federal funding of abortions, the GOP insisted that the health care law “contains a loophole that allows those receiving federal subsidies to use the money to enroll in health care plans that allow abortion services.”

– Personhood: Mississippi entertained the idea of passing a “personhood” amendment to its constitution this year, one that defines a person as “every human being from the moment of fertilization, cloning, or the functional equivalent thereof.” The measure’s “profoundly ambiguous” language regarding the definition of fertilization not only would ban all abortions, it could potentially outlaw birth control, stem cell research, and in vitro fertilization for couples struggling to conceive. Mississippians rejected the amendment but personhood activists are making headway with versions for other states and GOP presidential candidate Newt Gingrich is championing a national personhood amendment.

– Race/Sex Abortions: Taking their queue from Arizona, House Republicans introduced the Susan B. Anthony and Frederick Douglass Prenatal Nondiscrimination Act (PRENDA) — a so-called “civil rights” bill that bans physicians from performing abortions based on the fetus’s race or sex. The problem of selective abortion is virtually non-existent, as not one state official or independent research offered any evidence of race-based abortions. Only 5 percent of abortions occur after the point when a fetus’s sex can be determined. Arizona’s measure, now law, sends doctors and clinicians to jail for three years if they knowingly provide such abortions. The federal bill PRENDA allows for civil suits against the physicians.

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Florida Governor Rick Scott (R) is one of the most vocal opponents of the Affordable Care Act, rejecting millions of dollars in federal grants and failing to implement key infrastructure that could help lower the state’s ballooning uninsurance rate and control costs.

Now, a new report from the Florida Health Care Insurance Advisory Board finds that the state’s health care picture is only getting bleaker: enrollment in health insurance has dropped for the fifth straight year in a row, from 4.5 million in 2006 to 3.7 million in 2010:

The drop last year stemmed primarily from losses in the in-state small-group market, which saw enrollment decline by almost 19 percent. The individual market saw a 3 percent increase in 2010. But the report, which is updated annually, said the uptick in individual coverage is linked to the drop in the small-group market. “Because of the natural link between small business coverage and individual coverage, enrollment gains in the individual market can be reflective of a somewhat weakening small group market as smaller employers drop coverage,” the report said.

The 2010 Census found that Florida is home to the third-highest percentage of residents without health insurance and 3 of the top 10 highest-spending metropolitan areas in the country. Meanwhile, Scott — a former health care executive whose for-profit health care hospital chain was charged with excessive government fraud — refuses to even recognize the legality of the federal health care reform law. As he told the Palm Beach Post in November, “It’s not the law of the land,” Scott said. “I don’t believe it will ever be the law of the land.”

Our guest blogger is Lindsay Rosenthal, a Special Assistant for Domestic Policy at the Center for American Progress.

With lawmakers determined to curb spending, legislation to prevent Medicare providers from taking a 27 percent cut in 2012 has been swept up in congressional battles over the payroll tax, bringing a new urgency to the debate surrounding how best to reform the Sustainable Growth Rate formula (SGR). Since 2002, when the cost of health care skyrocketed beyond the nation’s economic growth rate, Congress has sheltered doctors from the excessive payment cuts required by the SGR, continuously voting to prevent full cuts to Medicare reimbursement payments and kicking the can down the road through so-called “doc fixes.”

Sarah Kliff of the Washington Post raises the question of whether we should “fix doc fix” at all. As she argues, we already pay doctors, particularly specialists, much more than other countries pay their physicians, without achieving better health outcomes. But surveys conducted by the American Medical Association (AMA) also show that cutting doctors’ payments could cause some to flee the system and exacerbate the Medicare doctor shortage (which is quite pronounced in some geographic areas).

Ultimately, fixing the doc fix is a problem we need to tackle, if only to free ourselves from the perennial headache that the legislation has caused. But the fix should be part of a larger package of reforms in which doctors accept changes in the way that health care is paid for and delivered. Effective payment and delivery system reforms would build on the measures already put in place by the Affordable Care Act and improve the quality of care for patients, while lowering the health care growth rate over the long term. For example, bundling payments would ensure that doctors are reimbursed for the quality of services they deliver, rather than the volume and quantity of (often unnecessary and unproven) tests and services they provide.

In a system where one-third of Medicare spending is excessive and unnecessary and over 56 percent of annual spending on health care goes to labor costs, examining how we pay providers for their services should be part of any conversation that takes place around reforming the SGR.

Despite the plasted pictures of fetuses that are so ubiquitous at anti-abortion protests and literature, nearly 90 percent of all Americans abortions occur in the first tri-mester of pregnancy. The 10 percent who undergo the procedure at 13 weeks gestation or later tend to be “women with lower educational levels, black women and women who have experienced multiple disruptive events in the last year, such as unemployment or separating from a partner,” a new comprehensive survey from the Guttmacher Institute finds. Second-trimester abortions are more expensive, pose greater health risks, and are offered by fewer providers.

The data also demonstrates that conservatives and anti-abortion activists seeking to limit access to the procedure through burdensome regulations of abortion facilities or other restrictions are targeting society’s most vulnerable women and are “all but guaranteed to make these women’s lives more difficult“:

– 14 percent of women undergoing second-trimester abortion were under 30; 9 percent were 30 or older.

– 13 percent of women were African American; 9 percent were non-Hispanic whites.

– 13 percent had not graduated from high school; 6 percent had college degrees.

– 15 percent experienced three or more disruptive events; 9 percent experienced no disruptive events.

The study suggests that less educated women “may have had less knowledge about reproduction and taken longer to recognize they were pregnant” or may have had a harder time tracking down abortion providers during the first trimester or faced difficulties paying for the procedure. Similarly, women who underwent disruptive life events likely faced delays “in recognizing the pregnancy as well as delays in accessing services.” [HT: Irin Carmon]

The individual health insurance mandate in the Affordable Care Act has been one of the law’s most unpopular provisions, but a Kaiser Family Foundation survey found that people’s opinions change about the mandate when they know more. Generally, 33 percent support and 65 percent say they oppose the individual mandate. That number jumps to 80 percent saying they oppose it when survey participants are told it “could mean that some people would be required to buy health insurance that they find too expensive or did not want.” But when participants hear that “without the mandate, people might wait until they are seriously ill to obtain coverage, driving up insurance costs for everyone,” 47 percent support the mandate and 45 percent oppose. Another pro-mandate argument tips the public even more in favor of the individual mandate: “Sixty-one percent of those surveyed support it when told most Americans would still get their coverage through their employers and thus wouldn’t be affected by the mandate,” according to the Kaiser poll.

In a year defined by the war on Planned Parenthood, Texas set the example in attacks against the women’s health organization. Not only did the state drastically reduce the state’s family planning funding from $111 million to just $37 million, but Republican lawmakers constructed a “tiered priority system” that ensured Planned Parenthood clinics would be the last to receive any of the remaining Title X federal funding. But Texas clinics can receive funding via another route: the state Women’s Health Program (WHP). Created in 2007, the Medicaid-funded program “provides family planning and primary care to low-income, uninsured women, and it served nearly 125,000 people in 2010 alone.”

So this year, GOP lawmakers decided to insert language into a new Medicaid measure that bans any family planning clinic that is even “affiliated” with an abortion provider from receiving WHP funds. Even though Planned Parenthood “corporately separated its abortion services from its family planning services in 2005,” Republicans wanted the fact that these (strictly family planning) clinics are “affiliated” with organization to disqualify them and asked the Department of Health and Human Services to let the state exclude the clinics accordingly.

Last week, the Department of Health and Human Services delivered it’s answer: No, as doing so “would violate the Social Security Act” which guarantees that a Medicaid patient can obtain health services from any qualified agency. But instead of accepting the decision, health advocates say Republicans may cancel the WHP program entirely out of spite, leaving at least 130,000 low-income Texas women without services:

But Fran Hagerty, chief executive of the Women’s Health and Family Planning Association of Texas, characterized the federal decision — which extends the program for three months while state officials decide whether to back down from their request — as “the ugliest possible scenario.” She fears the state will opt to end the Women’s Health Program rather than allow Planned Parenthood to continue to be part of it, and that 130,000 low-income women may end up losing out on cancer screenings and birth control.[...]

On Tuesday, state health officials said they would consult with Attorney General Greg Abbott to determine how to proceed. But Gov. Rick Perry doesn’t appear to be in a compromising mood. In a statement from the campaign trail, he said Texas is “committed to protecting life in Texas, and state law prohibits giving state dollars to abortion providers and affiliates — a fact the Obama Administration ignores.”

If state officials decide to forgo the Women’s Health Program in protest, Hagerty said major hospitals like the University of Texas Medical Branch and Parkland in Dallas would be able to maintain some semblance of family planning services, “but nothing like what we have now.” If the program does not extend past March, Hagerty said, community clinics would have to dramatically reduce services, lay off employees or shut down completely.

The program was created as a five year program and is set to expire on December 31. The HHS decision extends WHP for three more months, but Republicans are not accepting HHS’s ruling on the matter. The Texas Humans and Health Services Commission, which requested the waiver, said HHS’s decision is “inconsistent with federal law that gives states the authority to establish qualifications for Medicaid providers.”

State Sen. Robert Deuell (R) said it’s Planned Parenthood’s fault for supporting a constitutionally-protected right. “The problem could be solved tomorrow if Planned Parenthood just renounces abortions and just does family planning and comprehensive care, which they’re capable of,” he said. “Then we could provide a lot of family planning and there wouldn’t be abortions and this problem would go away.”

As the Dallas Observer’s Anna Merlen notes, the program has “served 235,000 women so far and saved the state more than $37.6 million during its first two years by helping women avoid otherwise costly unplanned pregnancies.” Currently, 28 percent of Texas women are uninsured, and without these clinics to provide necessary health care, the health care access problem for women is only going to get worse.

Our guest blogger is Emily Oshima, a Research Associate/Policy Analyst with the Health Policy team at American Progress.

Although Newt Gingrich once publicly championed the individual health insurance mandate, he – and other Republicans – now staunchly oppose the idea. During a town hall in Davenport, Iowa on Monday, the former House Speaker argued that while the mandate can prevent healthy people from free riding the health care system, the provision forces “politicians” to “define health care.” Instead, he endorsed economist John Goodman’s “patient power” solution, which uses tax credits to encourage healthier and younger people to purchase insurance before they become sick and shift the costs of their care throughout the health care system. Under Goodman’s proposal, Americans who go uninsured would store away the credit they would have received for purchasing coverage to later spend on “charity care” -– essentially the high risk pools Republicans proposed as an alternative to the Affordable Care Act.

But Gingrich once supported the mandate for a reason. The mandate is the only mechanism that will move America towards universal coverage and ensure that all people have access to quality care. The Congressional Budget Office (CBO) estimates that eliminating the mandate would reduce coverage by 16 million people. Even generous premium credits –- which likely go beyond what’s included in the Goodman plan — would cover only 40 to 50 percent of the uninsured.

The high-risk pools are no more effective. Since covering large groups of sick people is expensive, the CBO found that Republican high risk pools would cover fewer than 3 million patients, while significantly driving up premiums for all by redistributing the high health care costs of some users more broadly. The Affordable Care Act’s temporary pools have encountered similar cost problems. Further, high risk pools require government funding — given recent attempts to slash Medicaid and states’ tight budgets, can we really believe that Gingrich is committed to funding care for “charity”?

What’s more, there are numerous flaws with the structure of his proposed tax credits: They are inadequate –- keeping insurance prohibitively expensive for some –- and would fail to grow with rising costs. Without the regulatory protections of the ACA, Goodman’s plan would also throw millions of people into “the Wild West” of the individual health insurance market, where millions of Americans will be denied or priced out of coverage altogether.

President Bill Clinton made a surprise admission during an appearance on Fox News’ O’Reilly Factor Tuesday night: he agrees with the Republican proposal of establishing a national health insurance marketplace and allowing companies to sell policies across state lines:

CLINTON: You know let your insurance company compete across state lines.

O’REILLY: That’s right.

CLINTON: In other words, create a national market for insurance…That’s one place where I agree with the Republicans.

O’REILLY: Yes I think you are going to have to defect here, Mr. Clinton. That’s what I’m hearing here.

CLINTON: No, no.

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The Affordable Care Act includes provisions that allow insurers to sell policies within the confines of state compacts, so long as the companies follow the consumer protection standards designed and agreed to by the states. The Republicans are advocating something entirely different. Under their proposal, insurers would be able to circumvent consumer protections in certain states by selling bare-bone policies to the healthiest beneficiaries from states with the fewest regulations. Companies would have little incentive to do business in states that currently require coverage for cancer screenings, mammogram services, or other benefits and and will instead sell empty plans across the country to the most profitable applicants.

These beneficiaries will see short term savings, and as long as they don’t become sick, they will be paying less than if they had a more comprehensive policy. But once they do fall ill, these policies won’t offer coverage for the treatments they need and they will either go bankrupt trying to pay for their medical bills out-of-pocket or spend substantially more on comprehensive coverage. Sicker Americans will also see a cost increase, as healthier enrollees leave the risk pool to buy insurance from an unregulated insurer from out of state.

During an interview with NBC’s Chuck Todd this morning, Mitt Romney argued that asking individuals to take personal responsibility for their own health care spending is “more conservative” than having the government pick up the cost of care for the uninsured. “Personal responsibility, is more conservative, in my view than something being given out for free by government,” he reiterated. The former Massachusetts governor — who signed a state law that includes an individual health mandate — also admitted that while he would prefer the states design and administer their own health care reform plans, the approach would not provide coverage to all uninsured Americans:

TODD: Are you concerned that [a state based approach] could create…a sanctuary states? When some states are just going to cover more people than other states? Massachusetts versus a Mississippi, say?

ROMNEY: Well, that’s something that would be worth looking at, of course, for any state to consider. And people have to look at Massachusetts and see what the record has been of their experience. But my understanding is that under federal law, people are able to get covered in virtually every state in America, people who get seriously ill can go to the hospital and get treated, even if they can’t pay for it. In my opinion, that’s a big government solution.

TODD: How do we stop that…

ROMNEY: … There are a lot of different models, one is to have clinics for people to be treated at low cost, or at no cost, the other is to do as I suggest, which is to have tax breaks given to people who have insurance. There are a number of ways to encourage personal responsibility.

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As Romney well knows, the majority of Americans who receive their health insurance through an employer are not taxed on the value of that coverage. His plan — which is really a mandate penalty in reverse in that it is designed to encourage people to buy insurance and penalize those who don’t — would provide tax breaks to individuals and families who purchase coverage on the individual health insurance market. This kind of approach is problematic for a number of reasons, not the least of which are that it will insure relatively few people and do little to offset the costs of ever increasing health care premiums.

Earlier this month, the Mitt Romney-friendly PAC Restore Our Future produced a draft ad targeting Newt Gingrich for his 30 years as a Washington insider and his multiple positions on several issues, including his past support for a national individual health insurance mandate. In an implicit acknowledgment of Romney’s own “mandate problem,” the PAC edited out the reference to the mandate before running the commercial on local stations.

But now, Restore Our Future is back to attacking Gingrich for Romney’s positions. As Politico’s Alexander Burns reports, a new ad titled “Happy” is accusing Gingrich of supporting “taxpayer funding of some abortions,” despite the Massachusetts governor’s own pro-choice past and his current support for abortions in cases of rape, incest, and the life of the mother:

Romney didn’t adopt a “pro-life” position until 2005 and has since followed his base down an increasingly radical road, pledging to advance greater federal abortion restrictions and define life as beginning at conception.

As Matt Yglesias has pointed out, what makes Romney’s now-”staunch” pro-life position so distasteful is how staunchly he defended a woman’s right to choose while running for governor of the left-leaning state of Massachusetts in 2002. He fiercely denied then “that he was even slightly less pro-choice” than his opponent, offering “one of the most passionate defenses of abortion rights” heard from Romney or any male politician in an interview with the late Tim Russert. But Romney’s pro-choice views were not just relegated to one convenient debate answer. As a pro-choice advocates told the Washington Post, Romney actually slammed the entire Republican party for “being so vehemently anti-choice” and viewed any move to overturn the right to an abortion as a “serious mistake for our country.”

Meanwhile, Gingrich has a fairly consistent record of opposing abortion rights, despite backing the availability of federally financed abortions for poor women who are victims of rape or incest and calling for tolerance of pro-choice candidates. Apparently, that’s too much for a governor from Massachusetts who once established his pro-choice bona fides “by solemnly invoking the pre-Roe v. Wade story of a ‘dear, close family relative who was very close to me who passed away from an illegal abortion.’”