Moments ago in a vote of 245 to 189, the House passed H.R. 2 ‘Repeal the Job Killing Health Care Law Act after just seven hours of floor debate and without allowing Democrats to offer any substantive amendments to the legislation. The bill will now got to the Senate, where Majority Leader Harry Reid (D-NV) has said he would not schedule it for a vote. Just three Democrats voted in favor of repeal.

Before the final vote, the minority unsuccessfully offered a motion to recommit that would have prevented the law from being repealed unless a majority of members gave up their government-sponsored health coverage. So far, only nine Republicans have said that they would opt out of the tax payer subsidized Federal Employee Health Benefits Plan (FEHBP). Watch the vote:

Republicans will soon vote on another measure instructing the committees of jurisdiction to draft up reform “replacement” legislation, but have not said when or if the measure would be considered by the full chamber. Republicans see their repeal effort as a multi-year campaign and have promised to target or defund different portions of the law — including the 1099 reporting requirement and the abortion provisions — that could attract bipartisan support in Congress.

Democrats, meanwhile, are also planning to keep health reform in the headlines. Yesterday, the Vermont Congressional delegation offered a bill that would allow states greater flexibility to adopt innovative solutions to the health care crisis, including constructing a single-payer health care system. Sens. Ron Wyden (D-OR) and Scott Brown (R-MA) have offered a similar bill in the Senate.

Yesterday, the Department of Health and Human Services released a new report showing that up to 129 million Americans have a pre-existing condition and would likely be denied coverage in the individual health insurance market. According to the analysis, examples of what may be considered a pre-existing condition include, “heart disease, cancer, asthma, high blood pressure, and arthritis.”

Republicans have questioned the results of the report by arguing that many Americans with pre-existing conditions already have insurance coverage, but during this afternoon’s floor debate in the House, Rep. Phil Gingrey (R-GA) took the argument one step further, belittling the ailments:

GINGREY: One hundred and twenty nine million people with pre-existing conditions! They would all have to have hang nails and fever blisters to have pre-existing conditions and if you believe those statistics, I’ve got a beach to sell you in Pennsylvania.

These comments prompted Rep. Frank Pallone (D-NJ) to defend the report by reading off the actual ailments that would be considered a pre-existing condition. Watch it:

As Kathleen Sebelius, Secretary of Health and Human Services, explained yesterday, while many of the 129 million Americans already have insurance, they would have a hard time finding coverage if the law were repealed and they were to lose their job. “A number of people are in jobs with large employers where people can’t be underwritten because of their health condition, that’s good news. But those folks frankly can’t look at leaving that jobs, can’t start their own business, can’t have the freedom to retiring early before they have qualify for Medicare because they are terrified they will lose that insurance coverage,” Sebelius said, pointing out that insurers deny coverage to 1 out of every 7 who apply for it in the individual market.

And while Gingrey’s “hang nail” comments are certainly ridiculous, insurance companies are not above denying coverage for fairly elementary ailments. Insurers will disqualify you for just taking certain medicines because of the possibility of future costs, including common drugs as Lipito and Nexium and often deny coverage to individuals in high risk occupations, such as firefighting, lumber work, telecom installation, and anything more dangerous than office work.

As the House prepares to repeal health care reform, Education and Workforce Ranking Member Rep. George Miller (D-CA) offered the most impassioned defense of the Affordable Care Act, warning lawmakers that the vote was a matter of “life and death” for Americans who are fighting against the bureaucracy of the existing health care system:

MILLER: The other side of the aisle said this is a bureaucratic system. Has anybody, any family in America, any single mother, any spouse, any child, any grandparent, met a more bureaucratic system than the American health care system? There is no more bureaucratic system! [...]

Everyone has been run around the block by their insurance company, it’s something they all share. It’s almost the problems they share with their cable company. Not quite, it’s not as dramatic here. Because this is life and death, this is the security of your family, this is whether or not you can change jobs, this is whether or not your children will be protected, this is whether or not your parents will be able to afford the prescription drugs. Because that is what this legislation enables and gives the freedoms to American families to have. Repeal, we’d go back into the clutches of these bureaucrats spread across the world. [...]

Nobody wants to go back there, ladies and gentlemen. They’ve been there for 50 years and health care costs have gone up faster than any other segment in our economy. Faster than anything you can imagine. Faster than a speeding rocket, faster than a speeding airplane, faster than Superman. Health care costs have gone up because of the insurance bureaucracies.

Watch it:

Miller’s tone was surprising, given the more controlled rhetoric of this weeks’ health care debate, but is a welcome change following the Democrats’ failed strategy of selling the law in very academic terms.

While Republicans have relied on the same old arguments against reform, they’ve avoided describing the repeal measure as “job killing” and have generally stopped accusing Democrats of rationing health care. Some have even gone out of their way to mention that Democrats didn’t harbor any sinister motivations in passing the law. For their part, Democrats are using debate as a review of the laws most popular provisions, arguing that Republicans are wasting time on legislation that will never pass in the Senate and taking away benefits from their constituents.

Miller has been particularly punchy, tweeting out how many people would lose their health benefits from Republican districts if the law were repealed.

Last week, the Kaiser Family Foundation reported that Arizona was the only state to cut health insurance for children and one of two (along with New Jersey) to reduce services for low-income families in 2010. Now, Gov. Jan Brewer (R-AZ) — who has been criticized for cutting mental health programs and transplant coverage — has proposed to balance the state budget by dropping 280,000 residents from Medicaid. Later today, the Arizona legislature will meet in a special session to allow Brewer to seek a two-year waiver “from a requirement under federal health-care reform that states maintain current eligibility levels”:

The governor’s spokesman did not respond to a request seeking an interview with Brewer about her budget, which starkly painted her response to the federal constraints: Seek a way out from under federal rules so she can reduce the Arizona Health Care Cost Containment System, the state’s Medicaid alternative, and save the state $1.5 billion over the next two years. She wants a waiver that would allow Arizona to drop coverage of childless adults and curb funding to some low-income parents, and blind and disabled people.

If approved, the coverage reductions would last two years. After that, federal Medicaid dollars would help cover Arizona patients under the terms of federal health-care reform. [...]

Brewer’s plan is silent on emergency funding for certain medical transplants that Democrats and others have pushed, and it does not address the anticipated impact of any of the tax cuts and incentives Brewer and lawmakers have promised as a way to energize the economy.

Several conservative governors have asked the feds for a waiver to cut back on their existing Medicaid program without losing federal funding, and Arizona has previously jumped through some fairly small legislative hoops to avoid giving up this revenue stream. In March, the Arizona legislature eliminated funding for KidsCare, the state’s CHIP program, only to reestablish it months later in order to avoid losing billions of dollars in federal matching funds. The health law requires states that want to continue receiving federal health care funds to maintain eligibility in Medicaid and CHIP.

Arizona is cutting back its health care programs while challenging the constitutionality of federal health care reform — the Arizona Attorney General has now joined the Florida-led multi-state challenge against the law — and asking the federal government to leave health policy to the states. It’s one heck of a deal for the 280,000 residents who could be eliminated from the state’s program — Arizona is going to eliminate their state coverage and then argue that the federal government should be allowed to step in and help.

This morning, as the House of Representatives begins debating H.R. 2 Repealing the Job-Killing Health Care Law Act, the majority of Republicans in the House will still be receiving insurance through the Federal Employees’ Health Benefits Plan — a federal exchange which offers subsidized coverage to federal government workers, including members of Congress. According to a ThinkProgress analysis, seven, or just three percent of all the Republicans in the House have agreed to give up their insurance while they vote to repeal coverage for some 32 million Americans. “Because I think that when you have Americans that are struggling, why should I get a cost saving because I just got elected to the United States House of Representatives?,” Rep. Richard Nugent’s (R-FL) — one of the seven Republicans — explained two weeks ago. Rep. Bobby Schilling (R-IL) agreed, saying that Congress “shouldn’t have anything better than the American people.”

But the majority of the GOP still sees nothing wrong in purchasing tax-payer subsidized insurance while trying to deny coverage to the taxpayer. In fact, a number of Republicans are defending their right to stay insured by citing the very arguments put forward by proponents of reform:

– REP. VICKY HARTZLER (R-MO): Freshman Congresswoman Vicky Hartzler (R-MO) said she would not forgo her congressional health care plan. Hartzler spokesman Steve Walsh explained the congresswoman’s decision because “The issue was and always has been government-RUN health care …not government providing PRIVATE insurance to its employees.” [PolitcoMo, 1/7/11]

– REP. AARON SCHOCK (R-IL): Congressman Aaron Schock (R-IL) said he continue to receive health care through his congressional health plan, noting that by doing so would help reduce the costs for everyone else. “So I think it’s kind of interesting how people make such a big deal out of the health care coverage we have, which is not bad by any means. But I haven’t given it much thought because quite frankly I think I’m helping out the institution by lowering the risk pool for some of my older guys,” he said. Later, Schock added that the Affordable Care Act was “completely different” than the type of coverage Members of Congress receive. [Think Progress, 1/7/11]

– REP. MICHAEL GRIMM (R-NY): Freshman Congressman Michael Grimm (R-NY) rejected claims that it was hypocritical for him to receive health coverage that provided the same consumer protections he was trying to repeal for others. “What am I, not supposed to have health care?” Later, he said the reason to have coverage is “practicality. I’m not going to become a burden for the state because I don’t have health care and, God forbid I get into an accident and I can’t afford the operation…That can happen to anyone.” [Hotline On Call, 1/6/11]

Indeed, by 2014, uninsured Americans will be able to enroll in “PRIVATE insurance” through a series of state-based exchanges that will attempt to attract younger and healthier enrollees — like Schock — who could bring down premiums for the entire risk pool. The mandate will require these individuals to purchase insurance so that they don’t “become a burden for the state” once they require medical attention.

The seven Republicans who have opted out of their Congressinal plans include: Richard Nugent (FL), Sandy Adams (FL), Bill Johnson (OH), Mike Kelly (PA), Bobby Schilling (IL), Joe Walsh (IL) and Daniel Webster (FL), and Rep. Frank Guinta (R-NH).

This morning, the Department of Health and Human Services released a new report showing that up to 129 million Americans have a pre-existing condition and would likely be denied coverage in the individual health insurance market. During an appearance this morning on MSNBC, Secretary Kathleen Sebelius admitted that most of these individuals already have coverage, but argued that they would have a hard time finding insurance if the law were repealed and they were to lose their job. “A number of people are in jobs with large employers where people can’t be underwritten because of their health condition, that’s good news. But those folks frankly can’t look at leaving that jobs, can’t start their own business, can’t have the freedom to retiring early before they have qualify for Medicare because they are terrified they will lose that insurance coverage,” Sebelius said, pointing out that insurers deny coverage to 1 out of every 7 who apply for it in the individual market.

House Rules Committee Chairman Rep. David Dreier (R-CA) dismissed these concerns while responding to the report on Fox News, but apart from questioning the timing of the release of the study, Dreier didn’t challenge the report’s conclusion or provide a clear explanation for how Republicans would help the 129 million Americans find access to affordable insurance:

DREIER: I think that if you look at policy providers they’re saying that many of those people who fall into that category are already insured and it’s very interesting, very interesting that that study has come out literally the day that we begin the debate on this issue. We all want to ensure that people with pre-existing conditions have their needs addressed and I think we can find effective ways to do just that.

Watch it:

Republicans have suggested that they would cover sicker Americans in high-risk insurance pools, which are already part of the existing legislation and are designed to provide insurance to the sickest Americans before the exchanges become operational in 2014. Unfortunately, the high premiums associated with covering only sick people has kept these programs out of reach for most of the eligible population.

In fact, Republicans — who have long championed the pools as a means of extending coverage to those who don’t qualify for insurance in the individual market — have criticized the programs as ineffective and underfunded. The ACA provides $5 billion to run the temporary pools for three and a half years while the Republicans have proposed spending $25 billion over 10 years to keep the pools running on a permanent basis.

Last night, Fox News’ Greta Van Susteren pressed Rep. Steve King (R-IA) on how repeal of health care reform would help the uninsured or the poorest Americans who can’t afford to purchase coverage. King tried to dodge the question by arguing that just 12 million would be left without coverage should the law be eliminated. “That’s less than 4 percent of the population. And it’s wrong for us to try to change 100 percent of the policy to address less than 4 percent of the population in America,” King said.

But Van Susteren pressed further, asking, “With that 4 percent, that 12 million, what would you do with them?,” and exposing the GOP’s lack of a solution for extending coverage to the uninsured:

KING: You know, that’s a little bit different kind of a situation, and the states can deal with that. And we can subsidize some of that. Some of those people that are in that list are those who have pre-existing conditions.

VAN SUSTEREN: What do we do about them?

KING: We can step in and help the states establish those policies to address those high risk pools. That’s one of the ways to deal with preexisting conditions, and I think that will go a long ways towards — and it’s constitutional.

VAN SUSTEREN: What about the very poor?

KING: The very poor have always had access to Medicaid. And the Medicaid policy is there, and there’s something like 9.7 million Americans who qualify for Medicaid that just simply don’t sign up. So that policy’s there for those who are the very poor. We will take care of those. But we need to also make sure that the incentives for those who will take care of themselves are there, that we don’t lower everybody down to the lowest common denominator and punish people for being personally responsible.

Watch it:

King’s solution to help states establish insurance programs for the sickest Americans — so-called high-risk insurance pools — is already part of the Affordable Care Act, but the programs have thus far failed to attract enough enrollees. The problem is that insuring large groups of sick people who need constant medical attention is expensive and even though the law requires premiums for the high-risk plans “to track those charged by private insurance plans for customers in good health, those rates have still proven unaffordable for many,” charging approximately $300 per month for coverage.

A more sustainable solution would be precisely what King suggests — ensuring that there are incentives “for those who will take care of themselves” that don’t “punish people for being personally responsible.” He is inadvertently making the case of an individual mandate, without which it’s very difficult to encourage healthy people to enter the risk pools and offset the costs of treating the sick.

Over at The Incidental Economist, Aaron Carroll points to this study which argues — as the government has in its many briefs defending the health law — that you can’t reform the insurance market without requiring (or encouraging in some other way) healthy people to purchase health insurance coverage:

The above results show that community rating was associated with a worsening of the non-group risk pool as younger and healthier individuals left the individual market while older and sicker individuals joined or remained in the market. To test the robustness of this conclusion, we used data from the National Health Interview Survey (NHIS) to compare changes in detailed measures of health status and utilization for people with non-group coverage in several community rating and non-community rating states. We found that those maintaining non-group coverage after the adoption of community rating were significantly more likely to have days when they were restricted to bed or when their activities were otherwise restricted because of health problems as well as more doctor visits and hospital stays. In other words, community rating in the non-group insurance market led to a pool of enrollees in poorer health. [...]

Our results provide a compelling portrait of the distortions that can result from community rating and guaranteed issue regulations in the non-group market when there are no provisions in place to keep people enrolled in coverage. The deterioration of the risk pool is consistent with predictions from economic theory and potentially lays the foundation for an adverse selection death spiral.

Indeed, there is an extensive history of states trying to exclude pre-existing condition exclusions without also instituting a minimum benefit requirement, and almost all cases have resulted in higher prices or issuers leaving the market. In Maine, many insurance providers doubled their premiums in three years or less, and all but one of the state’s HMOs experienced “at least one rate increase of 25% or more in 1998 or 1999.” New Hampshire was nearly left with no carriers in the market when Blue Cross Blue Shield of New Hampshire announced it was withdrawing from the individual market. And after New Jersey’s preexisting conditions provision took effect in 1993, the state’s individual insurance market became plagued by skyrocketing premiums. Between 1996 and 2001, the cost of the most generous individual insurance plans rose by more than 350 percent.

Conversely, a new analysis from a team of Massachusetts economists published today in the New England Journal of Medicine “concludes that the Massachusetts 2006 health law’s requirement that most residents buy coverage or pay a tax penalty has been pivotal to the law’s success.” The study found a “greater increase in the number of healthy people who signed up for coverage in the state’s subsidized health insurance program in 2007 — the first full year of the ‘individual mandate’ — than chronically ill people, compared with the months before.” The greatest spike in enrollment of healthy enrollment occurred in 2007 — “just before the tax penalty kicked in for failing to get coverage.”

As Carroll put it, if “one is in favor of a well-functioning insurance market in which everyone can obtain affordable insurance, one cannot advocate guaranteed issue and community rating and nothing else. One needs some way to keep adverse selection under control. To be blunt, one can’t just take the favorable parts of the ACA and reject the unfavorable part (the mandate), at least not with suggesting a replacement that will do the same job.”

Before the Affordable Care Act was signed into law, there existed no expedited pathway for approving generic versions of brand name biologic drugs — a new class of ‘wonder drugs’ that contain living organisms and could one day help treat everything from cancer to Parkinson’s disease. A provision in the health law tries to strike a compromise that would lower costs while giving brand-name manufacturers the patent protection they need to continue researching and developing new medicines. Under the law, generics can enter the market “after a brand-name biologic enjoys exclusivity for 12 years,” but now, biologics manufacturers and a bipartisan group of Senators — Orrin Hatch (R-UT) and Kay Hagan (D-NC) — are urging the Food and Drug Administration (FDA) to grant companies “an additional 12 years of exclusivity if manufacturers alter an existing product to improve safety or potency.” The Wall Street Journal has more:

Proponents of generics say they fear brand-name companies may continually tweak their products to get 12 more years of protection. Companies often try such “evergreening” with chemical drugs, putting out extended-release or extra-strength versions to stay ahead of generic competition. [...]

The Hatch-Hagan letter calls on the FDA to interpret the law’s reference to “exclusivity” as “data exclusivity.” Under that interpretation, generics companies might be barred for 12 years from citing the brand-name maker’s data, effectively delaying any application for a copycat version, said lawyers for the generics industry.

“It appears that the brand biologics interests are attempting to parse the meaning of exclusivity to pervert the stated intent of the statute,” said Robert Billings, interim director of the Generic Pharmaceutical Association. The brand-name makers said they are clarifying the law.

Progressives like Firedoglake’s Jane Hamsher raised this concern during the health reform debate, arguing that an earlier version of the bill included an “evergreening” clause that “grants drug companies a continued monopoly if they make slight changes to the drug (like creating a once-a-day dose where the original product was three times per day), they will never become generics.” In fact, a Federal Trade Commission report released last year found that “the 12- to 14-year regulatory exclusivity period is too long to promote innovation by these firms, particularly since they likely will retain substantial market share after FOB [generic drugs'] entry” and recommended against establishing an exclusivity period. Brand name drugs are “expected to respond and offer competitive discounts to maintain market share and are likely to retain 70 to 90 percent of their market share and will continue to reap substantial profits, even after FOB entry,” the report concluded.

Sen. Sherrod Brown (D-OH) is preparing to send a letter to the FDA laying out his opposition to extending the exclusivity period and gave this statement to the Wonk Room: “As it stands, brand-name pharmaceutical companies will enjoy a 12-year monopoly on life-saving drugs that treat cancer, Multiple Sclerosis, and rheumatoid arthritis before generic alternatives can be sold at affordable prices. But that isn’t enough for them. Now, brand-name pharmaceutical companies are seeking to further delay the development of affordable generic alternatives. To be clear: these biologic drugs are expensive and they are often developed with taxpayer-funded support. By preventing generic competition, American patients suffer and our federal health programs incur additional costs at a time of record deficits.”

The biologics issue was largely overshadowed by the more emotional public option debate, but as Brown suggests, the FDA’s decision could keep life-saving drugs out of reach for thousands of chronically ill patients. During House Energy and Commerce Committee’s mark-up of the health care bill, Rep. Henry Waxman (D-CA) “had pushed to shield biologics for no more than five years — the same amount of time that traditional pharmaceuticals get under the Hatch-Waxman law,” but Rep. Anna Eshoo (D-CA)’s 12-year shield prevailed. President Obama had originally suggested a 7-year exclusivity provision as a possible compromise, before increasing that number to 10, and eventually signing a law with a 12-year exclusivity window.

This morning, the Institute of Medicine began its second day of deliberations into defining what would constitute “essential health benefits” under the Affordable Care Act. Even though the law identifies general categories that insurers will have to cover beginning in 2014 — emergency services, mental health care, outpatient and inpatient care — these meetings are designed to help HHS reach more specificity on the issue. The agency is also required to ensure that the scope of essential health benefits “is equal to the scope of benefits provided under a typical employer plan.”

During this morning’s second session, John Kingsdale — the former director of the Massachusetts Connector Authority — predicted that defining “essential health benefits” will be “one of the more challenging parts in implementing the ACA” and warned the agency against “overreaching” in detailing which benefits insurers will have to provide:

KINGSDALE: The nation is highly divided by this and so whatever is put into the essential health benefits package that can be portrayed by those who tend to oppose ACA as unfairly burdening those employers or individuals, who want a different benefit package will be used as political fodder to tear down the ACA and I strongly believe that overreaching…could doom implementation. [...]

There is a tendency to think about benefits in the context of negotiation for something more someone else would pay for and I think it continually surprises people to understand, ‘oh there are real people who cannot afford what we consider to be an ideal benefit package and they actually have to pay for it in premiums. ….This was very much about giving people decent coverage as opposed to primarily a policy of it just being about raising the standards of coverage and it seems to me when you have to make close calls about benefits, it’s important to return to that principle. Secondly, obviously, most benefits cost dollars no matter what you will hear about how they will save money and that the ACA will live or die on affordability. And thirdly, that there is a fair degree of consensus about minimum benefit steps and so that you will find most states don’t even mention most of the things that are covered typically by commercial insurance and there are additionally very few benefits that significantly improve [inaudible] or save dollars. So, I think it’s not difficult to find that essential minimum benefits package and then, as you can tell from my other principles, I would advise you to be very conservative about adding on to it. [...]

My experience suggests revisiting and learning from cases and some flexibility and even phasing in would all be very helpful as you go down the path of defining a minimum benefit that will be extremely controversial.

Indeed, as CQ Healthbeat reported, it’s still unclear “if officials will seek a specific list of treatments or ask insurers to mirror benefits in particular plans, such as the Federal Employee Health Benefits Program.” Either way, they will have to balance Kingsdale’s suggestions with the concern that too loose of a definition would allow insurers to design plans differently — possibly even in such a way that would lead to adverse selection.

IOM will publish recommendations for HHS “by September, and HHS will issue its proposed rules by the end of the year, giving insurance companies time to adjust plans before the provisions take effect.”

Former Minnesota governor and potential presidential candidate Tim Pawlenty (R) thought he was laying out a conservative vision of government and health reform during his speech at the National Press Club today, but he inadvertently made the case for the Affordable Care Act, which he would like to repeal. Watch it:

Let’s go through his claims one by one:

1) CLAIM 1– MORE TRANSPARENCY/KNOWLEDGE NEEDED: “If you have a system where people get to consume things without knowledge and responsibility about making wise choices about price and quality and the provider has no incentive other than to provide more volume of whatever is being consumed or given and the myth is the bill goes somewhere else and that it is all free, that is a system that I assure you is doomed to fail. That unfortunately is most of government, it is particularly most of health care system.”

FACT 1 — The new HealthCare.gov, which is probably the most successful element of the law thus far, allows families and individuals to compare plans in their geographic areas bases on price, quality, benefits — that’s the “knowledge” part. By 2014, consumers will enter more organized state-based exchanges — or new insurance marketplaces — where insures will have to offer a standard benefits package that are even easier to compare. Here comes “responsibility”: Americans will have to purchase an insurance policy to ensure that the bill does not “go somewhere else” or is shifted throughout the system. That pretty much busts the “myth” that “it is all free.”

2) CLAIM 2 — HEALTH COSTS ARE OUT OF CONTROL: “If you look at what’s driving much of government spending for cities, for school districts, for counties, for states, for the federal government, it is indeed the health care issues. It is driving budgets at a pace that exceeds almost everything else. And if we don’t solve this problem, really solve this problem, it will take down the country or at least impair it from within.”

FACT 2 — Health care costs are increasing government spending and the Affordable Care Act will slow the rate of growth for health spending. A September report from the Center for Medicare & Medicaid Services (CMS) found that while the government will spend more on care during the initial period of coverage expansion, once the cost savings and efficiencies kick in, costs will “decelerate.” Moreover, the actuaries predicted that as a result of these savings, Medicare spending will decline $86.4 billion from previous projections due to reforms. “Specifically, average annual Medicare spending growth is anticipated to be 1.4 percentage points slower for 2012–19 than we projected in February 2010. By 2019, it is projected to grow 7.7 percent—0.9 percentage point more slowly than we projected in February 2010,” the report concluded.

3) CLAIM 3 — PROVIDERS HELD ACCOUNTABLE FOR RESULTS: “We need to have systems where consumers, or at least purchasers are in charge. They have user-friendly information about price and quality. That the providers of the service have incentive to do more than just provide volume. That they have to be held accountable for better results and better health and that the money is in alignment in those goals.”

FACT 3 — For an example of “user-friendly” information click over to HealthCare.gov and see Fact 1. The law also addresses the complaint that our health care system rewards quantity over quality by establishing demonstration projects that experiment with different ways of paying providers so that they don’t have an incentive to over-prescribe services or medications. Specifically, it allows providers organized as accountable care organizations (ACOs) that voluntarily meet quality thresholds to share in the cost savings they achieve for the Medicare program and has created an Innovation Center to test, evaluate, and expand in Medicare, Medicaid, and CHIP different payment structures and methodologies to reduce program expenditures while maintaining or improving quality of care.

Pawlenty may wish to tweak some of these provisions to reflect his more conservative ideology, but he wants you to believe that reform doesn’t begin to address any of these concerns and instead gives everyone a free ride on the government’s dime.

In the wake of the Tucson tragedy, we’ve criticized Arizona for cutting back on its mental health services in the midst of the economic recession, but this morning on Washington Journal Michael Fitzpatrick — executive director of the National Alliance On Mental Illness — said the shooting may have been prevented if Jared Lee Loughner’s, behavior had been reported to the proper authorities:

FITZPATRICK: Arizona has one of the broadest civil commitment laws in this country. It’s actually very easy to get someone evaluated in Arizona. The standard for getting someone before a mental health professional is actually broader and actually simpler. What’s interesting is that in a number of points along the way Mr. Loughner could have been evaluated by a mobile team, they have 24-hour crisis programs, in Arizona. The college police could have called in a mobile crisis team to evaluate Mr. Loughtner, at some point the University could have taken that responsibility.

Watch it:

Fitzpatrick pointed out that Loughner had been involved with the campus police five times before the shooting and numerous instructors “knew he was having significantly mental health problems.” “What we know is that in any given day half the people in this country who have mental health problems, receive no treatment,” he added, stressing that the general public doesn’t understand mental illness. “And much of that has to do with the pervasive stigma around mental illness and really the lack of knowledge.”

Over at Mother Jones, Stephanie Mencimer laments that Congress will likely ignore this reality. “Instead, members of Congress are calling for laws that would ban bringing guns near members of Congress or regulating talk radio. ” “Yet of all the possible solutions to such mass violence, real mental health reform holds the most promise for saving lives by ensuring that people with brain diseases get the care they need before they seek out the always easily accessible American firearm,” she writes.

Interestingly, even members of Congress who support mental health issues are not optimistic that the tragedy will change how lawmakers think about the issue. As Sen. Sherrod Brown (D-OH) pointed out on Monday, “It’s only going to get worse because of state budget cuts. That’s a pretty easy place for people to go after, let’s cut some of the mental health outreach. Might mean some more homelessness but most people that dress like this in politics don’t see them, don’t talk to them, don’t know them.”

The federal government has made some headway on the issue in 2008, when it passed the federal mental health parity law and voted to expand it to the uninsured through the Affordable Care Act. Fitzpatrick called the parity legislation a “game changer,” adding “We thing it will make a tremendous impact on the lives of people in this country.”

This morning, U.S. Chamber of Commerce President Tom Donohue, who just yesterday announced the organization’s support for the GOP’s health care repeal bill, hinted that his group is more interested in tweaking the measure than eliminating it outright. Asked why he was endorsing a measure that had no chance of becoming law, Donohue reminded MSNBC host Chuck Todd that the Chamber spent “a fortune and a great deal of our intellectual commitment to make that bill not happen” and said that repeal was a way to “get everybody’s attention”:

DONOHUE: We’re going to support them on some of the things they’re gonna have to do to work out the health care deal, because I think there is a way to get there. We’re going to support a vote against it…and our release, will say ‘and here are the five things we then have to get together and fix.’

TODD: Well, they seem to be on the same page with you on this 1099 issue.

DONOHUE: Exactly, they’ve already issued 220 exemptions because they’ve figured out it doesn’t work. We’re going to work with these guys on a lot of the issues that are going to have to be dealt with.

Watch it:

But, Chamber Vice President and Chief Operating Officer David Chavern suggested yesterday on CSPAN’s Washington Journal, “We really need to focus on the more important thing, which is how can we fix what is passed and what may we be able to add to it to improve it.”

Even if Donohue was not able to ultimately kill the measure, the “fortune” the Chamber spent on T.V. ads and lobbying helped move public opinion to the right and is at least partly responsible for the unpopularity of the measure. As Chavern put it, “it’s no secret that ultimately we lost….but at the end of the day, I think we did talk to the public a lot about what was wrong with that bill. I think there is much broader understanding about what’s wrong. So would we do it again? Yes.” Indeed, it’s because of the Chamber’s success in molding opposition to the measure that Democrats may be more willing to “fix” things like the 1099 provision (which does seem like a burdensome requirement) and soften some of the employer responsibility penalties.

Yesterday, the Kaiser Family Foundation released its 50-state survey of Medicaid programs around the country and found that despite tight budgets, “nearly all states maintained or made targeted expansions or improvements in their Medicaid and Children’s Health Insurance Programs (CHIP) eligibility and enrollment rules in 2010.” “This stability in large part reflects the temporary fiscal relief for Medicaid provided by the American Recovery and Reinvestment Act of 2009 (ARRA) that was tied to requirements for states to maintain Medicaid coverage,” Kaiser concluded. Arizona — which has been criticized for cutting mental health programs and transplant coverage — was the only state to cut health insurance for children and one of two (along with New Jersey) to reduce services for low-income families.

The state has not enrolled any new children into its CHIP program since establishing an enrollment freeze on January 1, 2010, “saving $18 million to help balance last year’s budget. Enrollment has since shrunk almost in half, from 40,000 to an estimated 26,000 as of Oct. 1.” The state has also ended coverage for seven types of organ transplants in October 1, which has contributed to the deaths of at least two Arizonans and is leading transplant patients to leave the state.

In March, the Arizona legislature completely eliminated funding for KidsCare (the state’s CHIP program) to help close the state’s $5 billion budget gap. It restored funding several months later following the passage of health reform — which requires states that want to continue receiving federal health care funds to maintain eligibility in Medicaid and CHIP — but was allowed to retain its CHIP enrollment freeze throughout 2010 because it already was in effect and operational before the law went into effect.

Arizona has also reduced funding to the Department of Health Services by $36 million (37% of total budget), severely undermining its mental health programs. According to the Arizona Republic, “residents with mental illnesses who don’t qualify for the state Medicaid program are receiving “only basic doctor visits and generic medicine. People contemplating suicide will be directed to a crisis hotline, but the state will no longer pay for them to be hospitalized.”

Following Saturday’s tragic shooting in Tucson, Arizona, some Republicans have argued that 22-year old assassin Jared Lee Loughner was more affected by his mental illness than the nation’s lax gun control laws or Washington’s divisive and often times violent political rhetoric. “What will solve this problem is removing the politics from it and getting after the crux of this problem and that is somebody who needed mental health services and or legal intervention much earlier in his cycle toward violence,” Rep. Mike Rogers (R-MI) said this afternoon on MSNBC:

ROGERS: If we want to solve this kind of thing from happening, we have to intervene with somebody who has expressed tendencies toward violence, who has a pretty strong history of mental illness. And right now, we’re not talking about that at all. Everybody is talking about ‘oh, this is about people having guns, this is about political speech.’ None of that had a factor here. When you look at the evidence that has been collected up, this wasn’t about politics…If we want to solve this from happening in the future, you can talk about all the gun laws you want — that’s not going to do it. A bad guy is going to get a gun. What we have to do is intervene earlier in that cycle of violence when they have this kind of mental disability.

Watch it:

Newly-elected Rep. Allen West (R-FL) struck a similar note on his Facebook page, saying “The shooter was a very disturbed individual and it appears there were so many warning signs that he was going to do something horrible. We should be focusing on the mental health crisis in our country, not politics.” Indeed, as Sen. Sherrod Brown (D-OH) pointed out this morning, the Tuscon shooting highlights the poor state of the nation’s mental health safety net, which often falls victim to state budget cuts during periods of economic hardship. Congress did not address the issue until 1996, and has been increasing access to mental services ever since — despite Republican opposition.

Fourteen years ago, the late Sen. Paul Wellstone (D-MN) secured passage of a “partial parity” law that “stopped insurance plans from being allowed to pay less to treat mental ailments as opposed to physical ones.” But the industry soon gamed the law by “limiting the number of mental health visits or days in the hospital.” On June 17, 2008, President Bush extended MHPA through the end of 2008, but didn’t sign full parity legislation until later that year as part of the TARP measure. At the time, 146 Republicans voted against full mental health parity, including now House Speaker John Boehner (R-OH), and Rogers.

President Obama’s health reform law — which all Republicans now want to repeal — would go even further in helping Americans with mental illness. By 2014, families and individuals will be able to enroll in insurance through an expanded Medicaid program or the exchanges, where private companies will have to offer mental health and substance use disorder services as part of the essential package of benefits. The law also expands parity to a much wider pool, “making it possible for millions more people to get the same coverage for substance abuse and illnesses like bipolar disorder, major depression and schizophrenia as they would for, say, diabetes or cancer.” As Michael J. Fitzpatrick, executive director of the National Alliance on Mental Illness, or NAMI, told the New York Times shortly after reform was signed into law, reform “can change the mental health system in America and really give families and individuals an opportunity to get a level of access to care we could only fantasize about before this became law.”

Sam Stein is reporting that Chamber of Commerce President Tom Donohue is now calling for the repeal of the Affordable Care Act, despite previous statements that the organization wouldn’t dedicate any resources to the effort. From today’s speech:

DONOHUE: For example, the new health care law creates 159 new agencies, commissions, panels, and other bodies. It grants extraordinary powers to the Department of Health and Human Services to redefine health care as we know it. [...]

By mid-December, HHS had already granted 222 waivers to the law—a revealing acknowledgement that the law is unworkable. And, with key provisions under challenge in the courts by states and others, it’s time to go back to the drawing board.

Last year, while strongly advocating health care reform, the Chamber was a leader in the fight against this particular bill—and thus we support legislation in the House to repeal it. We see the upcoming House vote as an opportunity for everyone to take a fresh look at health care reform—and to replace unworkable approaches with more effective measures that will lower costs, expand access, and improve quality.

But the Chamber’s position on the law is more malleable than Donohue’s remarks suggest. For instance, this morning, for instance, during an appearance on CSPAN’s Washington Journal, Commerce Vice President and Chief Operating Officer David Chavern reverted to the organization’s earlier position on repeal when asked about reform:

CHAVERN: Overall, the House Republicans are proposing a bill on repeal of the health care bill, we oppose that bill. We’ll support that repeal effort, but understanding that that’s unlikely to become law law….We really need to focus on the more important thing, which is how can we fix what is passed and what may we be able to add to it to improve it.

Later in the program, Chavern stressed that while the organization is looking to lower the penalties on employers who don’t offer coverage, it supports the individual mandate, a position shared by the health insurance industry, which the Chamber represents. In fact, the “revealing acknowledgment,” to barrow Donohue’s phrase, is that the organization is split on the issue — politically interested in defeating a major Democratic accomplishment, but also encountering some push back from its own members (like health insurance companies) who argue that the law may not be the “job killer” that Republicans claim. After all, businesses are already taking advantage of the law’s early retiree grants, tax credits, and looking forward to the exchanges. They may certainly want to amend the measure, but they may be less inclined to lobby for something as impractical as outright repeal.

This morning during an appearance on MSNBC’s Morning Joe, Sen. Sherrod Brown (D-OH) argued that the Tucson tragedy highlighted the the poor state of the nation’s mental health safety net and said that the shooter, Jared Lee Loughner, “should have been identified at the community college when he was thrown out”:

BROWN: It’s only going to get worse because of state budget cuts. That’s a pretty easy place for people to go after, let’s cut some of the mental health outreach. Might mean some more homelessness but most people that dress like this in politics don’t see them, don’t talk to them, don’t ‘know them. We passed mental health parity, with the health care bill that should help, but most of this is state level mental health programs and we really got to guide against shredding them more than they’ve been shredded.

Q: You’d really put more money into mental health?… Over what though because then you have to cut something on the other end?

BROWN: Well, I’d say over the war in Afghanistan, we should withdraw troops sooner, I mean if you want to go into that kind of sort of macro discussion. But mental health services and issue are just as important as physical issues.

Watch it:

The The National Alliance on Mental Illness has put Arizona at the top of the list of states that are “considered to have made the deepest cuts in mental health care.” In 2010, the state reduced funding to the Department of Health Services by $36 million (37% of total budget), meaning that residents with mental illnesses who don’t qualify for the state Medicaid program are receiving “only basic doctor visits and generic medicine. People contemplating suicide will be directed to a crisis hotline, but the state will no longer pay for them to be hospitalized.”

Since July 1, 2010, 3,800 people with mental illness were “no longer eligible for case management, counseling, employment preparation and support, inpatient treatment or other services.”

The Affordable Care Act does not establish a national public option like many progressive would have hoped, but it does allow states to form their own public plans. Today’s Politico’s Pulse reports that Connecticut is aiming to do just that, and a new report from a state board to the General Assembly argues that such an option could save Connecticut taxpayers up to $355 million in 2014.

The option, called SustiNet, follows a 2009 state law which sought to use a publicly administered health plan to implement health care delivery changes designed to slow the growth of costs. Over the course of three years, the state hopes to expand the program from state-sponsored populations, state employees and retirees, to municipalities, private employers and families:

Effective on January 1, 2014, when most federal reforms become operational, SustiNet will offer comprehensive, commercial benefits to all of the state’s employers and households. This new health insurance choice will be available both inside and outside Connecticut’s new health insurance exchange, established under the ACA. SustiNet will undertake feasibility studies, develop business plans, conduct a risk assessment, and take any other steps needed to ensure that the new competitive option is viable and adds value in the marketplace. [...]

SustiNet will offer all employers and families a new, competitive health insurance option that reforms health care delivery and payment to improve value and slow premium growth. These reforms will spark broader change throughout Connecticut. Leading by example, SustiNet’s innovations will make it easier for others to follow a similar path. Our proposal harnesses the power of competition, ensuring that successful SustiNet reforms will be replicated by private insurers seeking to preserve their market share. SustiNet will also work collaboratively to implement multi-payer reforms that help the state’s providers give their patients high- value, quality care. And by enrolling a large number of consumers, SustiNet will gain the leverage it needs to reform health care delivery and payment.

Connecticut could serve as a test case for the progressive public option talking points we all heard so much about (and repeated) during the national debate. Indeed, Oregon and Vermont are already considering more progressive alternatives than what the ACA allows and if Congress passes legislation offered by Sens. Ron Wyden (D-OR) and Scott Brown (R-MA) to permit states that meet certain benchmarks to opt out of some of the requirements of the law by 2014 (rather than the current date of 2017), we could expect even more state experimentation on the horizon.

Time’s Nathan Thornburgh asks some smart questions about why 22-year-old Jared Lee Loughner, a man who was kicked out of his community college because of his mental state, passed a federal background check and was allowed to purchase the gun with which he killed six people and gravely injured 20 others:

Who else knew of Loughner’s mental illness? What obligations did his college have, and which ones did they fulfill, to report Loughner to other agencies? Most of all: Why is Arizona (along with other states) so far behind in reporting disqualifying mental illness to the federal background-check system? If there is anything that both sides should be able to agree on, it’s that unstable individuals should not have access to any kind of weapon, much less the so-called fourth-generation semiautomatic Glock 19 that Loughner bought. This time, the price for bureaucratic torpor was too high.

Click over to his full article to read about how states have been slow to report cases of mental illness to the National Instant Criminal Background Check System (NICS), but it’s also worth pointing out that the more important point point is whether the mental illness gets treated. The Treatment Advocacy Center reports that Arizona “is one of the worst states in the nation to be an individual with severe mental illness who needs help.” According to the organization, the state “jails or imprisons 9.3 times more people with severe mental illness than it hospitalizes,” “has 5.9 psychiatric beds per 100,000 population. (the recommended level to meet public need: 50 beds per 100,000,” and “is home to more than 50,000 people with schizophrenia, of whom a minimum of 25,000 are likely to be untreated at any given time.” State budget cuts are further diagonalizing the system.

The situation is even worse for those who don’t have insurance coverage, can’t purchase affordable insurance in the individual market (sometimes because of a mental health condition), or don’t qualify for Medicaid coverage or other forms of state aid. Estimates show that one-fifth to one-third of the uninsured are people with mental and substance use disorders and health reform may help them obtain coverage. Some are undoubtedly receiving insurance through the temporary high-risk insurance pools, and by 2014, they’ll be able to enroll in insurance through the exchanges, where private companies will have to offer mental health and substance use disorder services as part of the essential package of benefits. The law also expands parity — a requirement that benefits for mental illnesses to be on par with benefits for medical illnesses — “to a much wider pool, making it possible for millions more people to get the same coverage for substance abuse and illnesses like bipolar disorder, major depression and schizophrenia as they would for, say, diabetes or cancer.” Reform could also prove a vital tool in fighting the onset of mental illnesses in children and adolescents by defining “prevention broadly and make our focus on prevention a holistic one that includes promoting both physical and behavioral health.”

Experts estimate that four million Americans “have severe psychiatric disorders with a subset of 400,000 homeless and untreated not complying with their needed medications and another sub-sub set of 40,000 considered the most dangerous, not being treated or taking meds and demonstrating very violent behavior.” Of course it’s still unclear if Loughner would have benefited from mental treatment or care could have prevented Saturday’s tragedy. But as Jonathan Cohn points out, “After a major disaster, like an airliner crash or terrorist incident, we conduct thorough investigations to determine what caused the tragedy and how we might avoid another one like it. This occasion calls for a similar response. We may never know whether a better mental health care system would have averted this massacre. But we can be sure that it would avert some future ones.“

Following Saturday’s tragedy in Tucson, Arizona, which led to the death of six people and the serious injury of 20 others, including Rep. Gabrielle Giffords (D-AZ), Rep. Chellie Pingree (D-ME) echoed the growing call for a more civil political discourse by challenging Republicans to change the name of their health care repeal legislation. “The bill, titled the ‘Repeal the Job Killing Health Care Law Act,’ was set to come up for a vote this week, but in the wake of Gabby’s shooting, it has been postponed at least until next week,” she wrote in a blog post on the Huffington Post :

Don’t get me wrong — I’m not suggesting that the name of that one piece of legislation somehow led to the horror of this weekend — but is it really necessary to put the word “killing” in the title of a major piece of legislation? I don’t think that word is in there by accident — my Republican friends know as well as anyone the power of words to send a message. But in this environment and at this moment in our nation’s history, it’s not the message we should be sending.

The GOP has relied on the phrase “job killing” to frame the repeal effort as an economic endeavor that will help create American jobs and sustain the economy, but conservatives probably didn’t give much thought to the implications of the word “killing,” having relied on the rhetoric of ‘life and death’ so frequently throughout the health care reform debate. In fact, if it wasn’t for Saturday’s shooting, few people would have seriously considered the real meaning of the GOP’s words. In the aftermath of “death panels,” suggestions that the law may “cost you your life“, kill more people, and abort babies, the Republicans have downright numbed us all to their frequent use of death imagery as a tool to ferment political opposition. A quick look through the past 18 months or so reveals a stunning array of messages warning Americans that the Democrats’ signature legislation would lead to death.

Speaking at the Center for American Progress on the 15th anniversary of the Oklahoma City bombing which killed 168 people, including 19 children under the age of six, former President Bill Clinton drew parallels between that incident and the current atmosphere of right-wing, anti-government hatred. He specifically pointed to the influence of right-wing media in the 90s, saying that those hate radio hosts “understood clearly that emotion was more powerful than reason most of the time, and it happened that they got much bigger listenership, and more advertisers, and more commercial success, if they kept people in the white heat.” People like Timothy McVeigh were “highly vulnerable to the suggestions and implications of the most militant rhetoric of the time.” “We can’t let the debate veer so far into hatred that we lose focus of our common humanity,” he said. “We can’t ever fudge the fact that there’s a basic line dividing criticism from violence or its advocacy, and that the closer you get to the line and the more responsibility you have, you have to think about the echo chamber in which your words resonate”:

Oklahoma City proved that beyond the law, there is no freedom, and there is a difference between criticizing a policy or a politician, and demonizing the government that guarantees our freedoms and the public servants who implement them. And the more prominence you have in politics or media or some other pillar of public life, the more you have to keep that in mind. I acknowledged that in my political career, I had more on than one occasion, in the face of a government policy I disagreed with or a practice that I thought was insensitive, referred in a disparaging way generally to “federal bureaucrats,” as if all of them were arrogant or insensitive or unresponsive, and I have never done it again. You could not read the stories of the lives of the people who perished in Oklahoma City and not respond in that way.

In 2009, then House Speaker Nancy Pelosi (D-CA) similarly condemned the GOP’s rhetoric saying, “I have concerns about some of the language that is being used. … I saw this myself in the late ’70s in San Francisco. This kind of rhetoric…was very frightening and it created a climate in which…violence took place. … I wish that we would all…curb our enthusiasm in some of the statements that are made, understanding that some of…the ears that it is falling are not as balanced as the person making the statement might assume.”

Republicans will have an opportunity to set a new tone with they take up the health care repeal measure next week, but it remains to be see if they’ll be willing to give up a rather effective massaging strategy in the interest of the public good.