Citizens United Foundation is steadfastly opposed to government-operated health care as a matter of principle.

Simply stated, we believe that government does not have the ability to handle something as large and complex as our nation’s health care system. The federal government should never take such a central role in our lives to begin with, particularly when it comes to our most personal decisions concerning medical care. Obamacare, while taking over one sixth of our economy, is causing the complete destruction of our free market-based health care system. America’s Founding Fathers would fall ill at the thought of their once-limited federal government intruding in the lives of private citizens to this degree. The specter of Big Government has never loomed as large as it has under the Obamacare regime, and Americans should be gravely concerned about how massively destructive this law will ultimately become. President Obama’s callous attack on the American health care system – once the envy of the world – has now begun wreaking havoc on people’s lives. Sadly, it comes as no surprise to us how disastrous the rollout of Obamacare has been. Even after more than a month’s worth of “tech-surging,” the Obama Administration still can’t get their health care website to function properly, and the personal information being provided to the government is insecure at best. Millions of Americans are receiving cancellation notices from their health care providers and employers, removing them from plans they have held for years. People of all ages and backgrounds are seeing their health care premiums increase. The facts show President Obama lied to get this fatally flawed law through Congress. Unfortunately for our nation, Obamacare will only continue to falter as its key provisions continue taking effect this year and beyond. This paper is meant to brace you for the most detrimental impacts of Obamacare, while also educating and preparing you for what is to come. I would like to offer special thanks to our Deputy General Counsel, Catherine Crane, and Deputy Research Director, Matt Naugle, who put so much time and effort into this report. Some on the Left are now claiming the best way to fix the Obamacare mess is to allow it to collapse into a single-payer, European-style system. We predict that this is the big fight to come, as the Obama Administration attempts to provide life-support to its ailing, and failing, health care law. When that happens, it is imperative that we redouble our efforts for the cause of liberty and American free market health care solutions.

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David N. Bossie

Introduction Our nation’s health care system is no exception to American Exceptionalism. The accomplishments of America’s best and brightest shine through brilliantly in the U.S. health care system, boasting achievements such as a 50 percent decline in coronary heart disease deaths in the last three decades of the 20th century. Even more impressive, the American health care system decreased the infant mortality rate by 90 percent, and the maternal mortality rate by 99 percent, from 1900 to 1999. 1 Explaining the innumerable successes of this system would probably take a lifetime. Health care also means big business for the American economy. This industry composes one-sixth of our economy today, and it will capture 20 percent of the share in less than a decade. 2 Almost 12 percent of all private sector employment is attributed to the health care industry. 3 In the United States, people’s lives – and for many, their livelihood as well – depend on this vital industry. Then why, many Americans are asking, is President Obama dead-set on implementing the Affordable Care Act (ACA), sure to eviscerate the core foundations of our robust and successful health care system? Considering that most Americans oppose Obamacare, 4 and less than half of moderate and conservative Democrats now support the law, 5 there exists growing bipartisan agreement that President Obama’s signature legislative achievement has got to go. The President and his allies in Congress, however, continue to play politics to a frightening level to defend Obamacare. Why? Seen as the Left’s only real opportunity to get a single-payer, European-style, health care system in America, Senate Majority Leader Harry Reid (D-NV) confirmed that Obamacare’s unworkable structure will indeed devolve into a singlepayer system. 6 That is, the same type of system that British surgeons say risks lives because of

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the ‘“arbitrary”’ nature of health care rationing in that country. Decisions over who gets medical procedures are being ‘“compromised by financial pressure”’ at an alarming rate in Britain. A recent study revealed 9 in 10 Primary Care Trusts – Britain’s version of Obamacare’s Independent Payment Advisory Board (IPAB) – “are rationing access to common operations.” 7 This desperate desire of the Left for socialized medicine in America provides the only explanation for why President Obama and liberals are lobbying so hard for Obamacare’s full implementation. The policy ramifications of Obamacare on health care, the economy, and even privacy, thoroughly demonstrate how disastrous Obamacare really is for America. Obamacare’s impact on patient care is abysmal at best. The law drastically expands the number of covered lives without any regard to the growing doctor and health care provider shortage in America, or allowing provider pay rates to be adequate enough for existing physicians to have the capacity to see them. We are hurtling toward a situation in which millions will have cards that entitle them to health care but a severe lack of providers available or capable of accepting them. The alternative for this large host of patients will be to clog emergency rooms where health care costs are the highest for a number of reasons. In other words, Obamacare supporters can claim that more people are covered under the law, but that coverage will entail fewer doctors to provide fewer services to new patients swept into the system under the individual mandate. Quality and quantity of care will decrease for everyone, while prices skyrocket for all to cover everyone. All patients will be paying more for less. Because the law also perversely incentivizes businesses to stop offering health insurance to their employees – through tax hikes, fines, and overly convoluted regulations – millions of hard-working Americans could lose their current coverage and be forced into the Obamacare

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exchanges. Health care options will dwindle for seniors as well, thanks to the Obamacare IPAB’s focus on yearly cost-cutting benchmarks over care. Obamacare’s impact on the economy is also of grave concern. The law forces certain employers to slash hours for their employees, in order to avoid facing steep fines for not offering health insurance to employees working 30+ hours per week. Those employers are also cutting back on benefit packages to avoid millions of dollars in extra health care costs they cannot afford. Subway franchises, UPS, and even countless state and local governments, are implementing such changes now to escapes massive Obamacare cost increases later. While the Obama Administration adamantly denies causing the “Part-Time America” phenomenon, 8 numerous businesses cite the law when asked about these sudden employment changes. As if Obamacare’s deleterious effects on health care and the economy were not enough to convince liberal Members of Congress to repeal the law, the Obamacare exchanges and the Federal Data Services Hub (the Hub) – where the social security numbers, tax information, and other data of millions of Americans will be stored – could be goldmines for data thieves. The administration promised everything would be okay when the exchanges opened up on October 1, 2013, but many – including the Inspector General of the Department of Health and Human Services (HHS) – raised serious concerns that the final security certification would take place only one day before the exchanges opened. But the Obama Administration did not see any problem with having only 24 hours to fix any problems, and widespread glitches in the exchange sign-up system thus far suggest its critics may have been right. This theme of irresponsibly rushing to the finish line also emerges with the hiring of the health exchange navigators: hired, and soon to be hired, government operatives located throughout the country to help Americans sign up for these exchanges. For some reason, the

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Obama Administration does not require navigators to go through any background checks or fingerprinting in order to qualify for the job. So these Obamacare cheerleaders, who will be trusted with millions of Americans’ social security numbers and tax information, will not even have to prove they are not identity thieves in order to start “navigating.” (This scenario reeks of the same stench as the recent IRS political targeting scandal. The IRS will also have access to the information collected by the navigators. This is yet another reason to repeal Obamacare.) For all these reasons and more, every part of Obamacare must be delayed, defunded, and ultimately repealed. Conservatives in the House, hearing the loud and clear outcry of the American public against Obamacare, have voted at least 40 times to repeal or revise the flawed law. 9 As hard as many liberals are fighting to save Obamacare, increasing numbers – including President Obama – sense its growing unpopularity and see a need to cover their political hides by delaying scores of Obamacare provisions. Already by November 2011, the non-partisan Congressional Research Service (CRS) tabulated that HHS had missed more than one-third of its Obamacare-mandated deadlines. 10 An updated CRS Memo from June 2013 reported that half of the Obamacare deadlines had been missed as of May 31, 2013. 11 And more delays and waivers seem to pop up every day, ranging from the employer mandate to Obamacare Medicare cuts. 12 (The award for the most hypocritical waiver goes to the President: while Congressional Members and their staffers will still be forced to join the Obamacare exchanges, President Obama told his Office of Personnel Management (OPM) to continue allowing the federal government to pick up the tab for 75 percent of their health care costs. 13 This is nowhere near the percentage the Obamacare subsidies will cover for the health care costs of the average middle-class American.

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In fact, Obamacare subsidy rates drop drastically once an individual makes about $28,000+/year. 14) Evidently, the administration realizes ramming through Obamacare regulations is a surefire way for President Obama to lose the ability to work with Congress next year. Whatever the President’s motivations are, sparing the nation from Obamacare for as long as possible is certainly a step in the right direction. But, America’s health care system, and every area health care impacts, will not be truly saved from ruin until Obamacare is gutted and removed from every legislative and regulatory crevice. With the full Obamacare implementation date of January 1, 2014, looming, we must act now. Or else, the health care system that is the envy of patients and health care providers around the world may be lost forever. I. Fixing What’s Not Broken & Making Worse What’s Already Broken: Why Obamacare Only Destroys What’s Working in the American Health Care System & Completely Ignores What Actually Needs to be Fixed A. Obamacare Tries to Fix What “Ain’t Broke” President Obama once told the American Medical Association (AMA), “My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.” 15 Then why is he tearing down, instead of “build[ing] on,” the countless positive aspects of the American health care system? Regardless of his claimed good intentions and ability to produce pleasant sound bites, President Obama needs to face the reality that his law decimates the beneficial characteristics of a world-renowned medical system. Because for all of its shortfalls, as Johns Hopkins Medical International’s CEO, Steve Thompson, sees it, “[t]he U.S. arguably has the world’s best medical research infrastructure, the world’s best-trained doctors and nurses, and many of the world’s best-equipped and -run hospitals.” And while Thompson admits the American system is far from perfect and can be

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expensive, it still “allows most patients access to the best care available.” 16 But Obamacare, with its inevitable decline into a single-payer system, will soon end that. Furthermore, the benefits of the American system are literally life-saving. According to The Lancet, a British medical journal, the United States beats out all other countries in cancer survivor rates. For instance, more than 66 percent of female cancer patients will survive five years or more in the U.S. The second best country rated in this category, Sweden, lags behind by 6 percentage points. 17 American medicine is constantly trying to spread these life-saving measures around the world, taking the lead on groundbreaking techniques and research. Almost three-quarters of the previous 25 Nobel Prize recipients in medicine conducted their research in the U.S. and/or are U.S. citizens. Patients from around the globe have American pharmaceutical companies to thank for introducing the majority of new important medicines during the previous two decades. Medical professionals in the U.S. also spearheaded four out of five of the most significant nonpharmaceutical health care developments during the past four decades. 18 By contrast Obamacare, by enlisting bureaucrats to cut costs for patients most in need – seniors on Medicare – will discourage expensive, yet innovative, techniques from entering the U.S. medical marketplace. This may be a wake-up call to the Obama Administration, but medical innovations are not cheap. For example, a Swiss drug manufacturer, Roche, reported it spent $600 million on research and development to come up with the new AIDS medication, Fuzeon. The medical community hails Fuzeon as groundbreaking because it caters to patients who are resistant to existing AIDS drugs. The AIDS community already predicts demand for the drug will quickly overtake supply.

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The hefty research and development costs, in addition to the fact that Roche must share profits with the biotech company that developed Fuzeon, help explain why the drug will cost patients $20,000 a year. Even then, Roche will not turn a profit on the drug for at least three years. 19 Research and development costs for new drugs like Fuzeon often result in “significant profit losses,” compared to generic drug companies who simply copy the work of such drug innovators once their patents have expired. 20 But Roche’s Chairman, Franz Humer, says the high price tag will help drug companies like his continue making medical history: ‘“We need to make a decent rate of return on our innovations. This is a major breakthrough…I can’t imagine a society that doesn’t want that innovation to continue.”’ Well, one “society” that will likely not be ordering this new drug is California’s government-funded AIDS Drug Assistance Program. Its leader, Michael Montgomery, stated, ‘“We don’t think we can add Fuzeon (to our drug list) without cutting something else. We are excited about the drug, but we aren’t sure we can afford it.”’ 21 Sadly, participants in this AIDS Program may never get the chance to decide for themselves if the drug is worth the expense: a government program has already made that decision for them. The American health care system’s endless resources and incredibly talented medical professionals also explain why it is so common for world leaders to seek treatment in the United States. Danny Williams, the former Premier of Newfoundland and Labrador in Canada, chose to have heart surgery in America instead of using a doctor in his country’s universal health care system. 22 A former Italian Prime Minister, Silvio Berlusconi, also opted to have heart surgery in the United States over his native country. 23 When given a choice, many of the most powerful leaders in the international community turn to America for their greatest health care needs.

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As a columnist for The Los Angeles Times, David Lazarus, explained, American health care professionals focus on one task: making sick patients better. At the highest levels of the American health care system, no effort will be spared to heal patients, no expert opinion will be left unsought, and no medical test will be denied if our country’s medical professionals feel there is anything they can do to help a person in pain. (Lazarus, a frequent critic of American health care himself, began praising the system after hard-working doctors and nurses at the UCLA Medical Center helped his wife recover from a life-threatening seizure.) While Lazarus admitted “[n]one of this remarkable care comes cheap,” and can perhaps sometimes even be wasteful, he spoke for all of us when he questioned whether anyone would seriously refuse such outstanding, meticulous care if a loved one’s life were at stake. 24 So rather than issue a widespread attack on the American health care system, as Obamacare does, it would be more helpful to focus specifically on a few key problem areas. Patient detachment from price mechanisms and confusing billing structures make our health care system, for all its merits, not without serious problems. But Obamacare, through centralized insurance exchanges and additional bureaucratic mandates, will make these flaws more acute, expediting a health care crisis and the implementation of a single-payer system. B. Obamacare Does Nothing to Address the Heart of the Problem: Price Transparency On any given day, your local newspaper is filled with advertisements for Lasik eye surgery, with exact pricing for care. This transparent pricing model drives down prices, while keeping quality of service levels high. 25 Market-driven solutions are the only way to improve America’s already excellent health care market. This is why a system of free enterprise and market-based policies must be encouraged: to restore important decision-making power to the

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American people and focus on delivering true patient-centered care. When Americans are given the power to make their own decisions in health care, competition between plans and providers will naturally create more options and lower costs. Delivering patient-centered and market-based care will ensure not only that Americans will receive the highest quality care, but also that consumers receive the best price for their health care. Unfortunately, Obamacare does absolutely nothing to address this issue, and instead saddles the American people with an onslaught of regulations, bureaucracy, and hidden costs. While this is not an extensive paper on how to reform the American health care system, ensuring patients know exactly what they are paying for, and how much everything costs, must be at the cornerstone of any reform. When patients fail to understand what they are being charged and why, chaos ensues in the system. Consequently, the most appropriate analogy for our system now is a grocery store without prices, where the only cost for entry and food is paying a premium “grocery insurance” fee upfront. 26 Under this system, without prices to alert the consumer of how much each item costs, grocery store consumers will naturally select the best cuts of meat, organic vegetables, and fine wine because they are detached from the prices. Then when the grocery store realizes they are losing vast amounts of money because the premiums do not cover the cost of everyone selecting the most expensive items, the store will be forced to pass the extra costs to the consumers. This, in turn, results in higher premiums for everyone wanting to gain entry to the store, even for consumers only wanting to buy bologna and milk instead of filet mignon and 20-year-old bottles of Cabernet Sauvignon. Obamacare only exacerbates the price transparency problem by (1) adding more consumers who are also unaware of how much services cost and (2) actually discouraging consumers from knowing the costs of care by providing “free” services. This is why, like the

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grocery store analogy, under the Obamacare scheme the cost of health care coverage will only increase moving forward. One New York Times article further explains how Obamacare completely ignores the issues key to fixing soaring health care costs, such as curtailing the outrageous mark-up process on health care goods that occurs as supplies move from manufacturers to patients. For instance, one hospital charged up to 1,000 times the actual cost of saline solution bags (saltwater), costing patients more than $500 for saltwater bags that should cost between 44 cents and $1 apiece. Hospitals, rather than negotiating prices for supplies themselves, turn to a few powerful middlemen who “not only take their cut, but [also] have a strong interest in keeping most prices high and competition minimal.” (Half of all institutional medical supplies sold in the U.S. are negotiated by three such middlemen.) Patients will never get to see these contracts, as they are kept secret by most negotiator companies. Yet interestingly, supporters of this contracting system claim it saves hospitals billions of dollars, which Obamacare makes the end all, be all, focus of health care reform. Thus the article surmises that Obamacare “encourages these developments [such as this robust middleman system] as it drives toward a reimbursement system that strives to keep people out of hospitals through more coordinated, cost-efficient care paid on the basis of results, not services.” But, as the article continues, this focus on cost-cutting typically translates into cost-shifting from the hospitals to the patients, as proven by the case of the saline bags. 27 The hospitals may appear to be saving money on paper, to satisfy Obamacare requirements, but patients are still paying higher and higher costs to account for these perplexing charges shrouded in darkness.

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II.

Supply & Demand: How Hospitals Shutting Down their Maternity Wards For Financial Survival Foreshadows Declining Patient Care & Services in the Obamacare Era Health care for expectant mothers represents the first wave of collateral damage

stemming from the upcoming implementation of Obamacare. Citing numerous concerns, including that the ACA would make it no longer profitable to deliver babies, one hospital outside Pittsburgh terminated its obstetrics program in March 2013. For the average 200 or so women who give birth at that hospital each year, this translates into fewer doctors to choose from to help them bring their children into the world. Moreover, shutting down its baby-delivering services also means layoffs and job losses for the hospital’s employees. 28 The world-renowned Cleveland Clinic, praised by President Obama in 2009 for its ability to deliver efficient care, 29 also blames Obamacare for a $300 million cut to its 2014 budget. That health care facility will be reducing its operating expenses by 6 percent, with employee layoffs likely to occur next year. 30 A spokeswoman for the clinic summed up the decision by explaining, “‘Health care reform has really changed things, and the burden of cost is going to be falling on patients.”’ These cuts in service, she continues, will help keep health care costs affordable for patients in the Obamacare Era. 31 Likewise, increased Obamacare health care costs are the likely culprit for the highly-regarded Vanderbilt University Medical Center announcement to lay off 1,000 workers. 32 Proponents of Obamacare will predictably counter that such stories are the exception, and not the rule, and that the overall care of most Americans will greatly improve. But a simple analysis of supply-and-demand principles reveals that all patients should expect similar cuts in service.

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A. The Inevitable Uptick in Patients Let’s first address the demand-side: number of covered lives. The Obama Administration initially estimated that 7 million individuals would sign up for insurance coverage on the health care exchanges. In contrast, according to a USA Today study, officials from just 19 states expect that 8.5 million uninsured will seek coverage through the ACA exchanges. California on its own would swallow up almost the entirety of administration’s initial estimate, reporting it expects 5.3 million California residents to sign up. 33 Worse yet, the Association of American Medical Colleges (AAMC) predicts Obamacare will actually insure closer to an additional 32 million people. This ever-expanding group of new sign-ups, combined with an expected 36 percent growth in the senior-citizen population, means more covered lives and more patients with substantial health care needs will soon flood the medical care market. 34 Furthermore, the Obama Administration completely ignored a significant factor sure to explode the total number of people looking for new health coverage: the law incentivizes businesses to stop providing health insurance to employees. Hard-working American employees are already beginning to see these effects, with one in eight small businesses reporting they have, or soon will, terminate employee health insurance plans due to Obamacare. 35 Considering that the number of small businesses currently stands at 23 million,36 that means that the employees of almost 3 million small businesses could lose, or have already lost, their private sector insurance under the Obamacare regime and consequently will be forced into the exchanges. The Congressional Budget Office (CBO) also predicts that up to 2 million fewer people – and not just those working in the small business sector – will get health insurance through their employers in 2014 than originally estimated. 37 Obamacare’s devastating effect on employer-provided health

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care plans even caused the AFL-CIO, which represents 12 million union members and was once a prominent Obamacare supporter, to pass a September 2013 resolution denouncing the law. The powerful labor union organization chastised the ACA for providing employers with “a financial incentive to drop [health care] coverage and force low-wage workers onto the [health care] exchanges,” adding that, “contrary to the law’s intent, [it will] substantially chang[e] the coverage available for millions of covered employees and their families.” 38 These numbers and revelations therefore completely belie President Obama’s claims to the AMA in June 2009 that “[i]f you like your health care plan, you will be able to keep your health care plan. Period. No one will take it away. No matter what.” 39 While we will never know what President Obama’s true intentions were, nothing can explain away the fact that his policies have, in reality, done the exact opposite of his stated intentions: attacked, eroded, and flat-out decimated many employer-provided insurance plans. For other liberals, though, perhaps this was always the plan. Liberals who voted for Obamacare will admit the bill is convoluted and unworkable, with Senate Finance Committee Chairman Max Baucus (D-MT) even calling it a “huge train wreck.” 40 Senator Reid also admitted that Obamacare is ‘“far from having something that’s going to work forever.”’ When asked if America would ultimately abandon the Obamacare health insurance system and move to a single-payer system, Senator Reid responded, ‘“Yes, yes. Absolutely, yes.”’ 41 So what exactly about Obamacare is startling businesses so much that their reaction is akin to a cattle stampede, with employers running in any direction possible and ditching employee health insurance plans along the way in order to escape the impacts of this law? For one, almost 80 percent of small business owners currently offering health insurance to their employees anticipate taxes increasing. Practically an equal number of employers expect the

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health care system to remain as complex, or become more complex, due to Obamacare. 42 An example of the absurd level of Obamacare’s complexity comes with the very definition of “small business.” The Washington Post points out that the law uses several different methodologies to decipher who qualifies as a small business, leaving many business owners clueless about whether the law even applies to them. 43 Senator Baucus, a key architect of Obamacare, even noted, “When I’m home, small businesses have no idea what to do, what to expect. They don’t know what affordability rules are. They don’t know what penalties may apply…” 44 But, there’s a whole lot more for employers to be wary about under Obamacare: while about 40 percent of small businesses say a majority of their full-time employees would need to voluntarily jump to the exchanges before the employers would stop offering health insurance, the actions of business competitors could drastically alter this analysis. 45 As statistics stand now, 86 percent of small businesses providing employees with health insurance pay more than half of each employee’s health care premiums, with 47 percent of those small business employers paying the entire premium for employees. 46 However, under Obamacare there is no requirement that businesses with less than 50 employees continue providing employee health insurance benefits. Consequently, if small business competitors drop employee benefits, causing them to gain an economic advantage by reducing business costs, other small businesses will be incentivized to drop their benefits as well. 47 With more than 170,000 small businesses shutting down between 2008 and 2010 alone, 48 small businesses have more motivation than ever before to axe their employee health insurance benefit plans. B. The Predicted Downtick in Doctors As for the supply-side of the equation – the number of doctors – the statistics paint a bleak picture for patient care in the Obamacare Era. The AAMC estimates there will be a

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shortage of more than 90,000 doctors by 2020, and a shortage of almost 63,000 by 2015. With HHS estimating that the supply of physicians will grow by only 7 percent in the next decade, and with nearly one-third of current doctors planning to retire during the same time frame, clearly there will be fewer experienced doctors to care for this massive influx of new patients. 49 Moreover, according to a recent George Washington University study, the number of new doctors becoming primary care physicians is “‘abysmally low’” and will not be able to keep up with the health care needs of patients across the country. 50 But, most importantly, the “Boots on the Ground” (the doctors) concur with this assessment about the impending doctor shortage crisis: more than 6 in 10 physicians reported in a Deloitte survey that many of their colleagues will abandon their practices in the next 1 to 3 years, and nearly the same amount stated that their colleagues still working will decrease their patient loads. 51 While an aging doctor population, fewer new doctors becoming primary care physicians, and a growing senior-citizen population all contribute to decreased access to physicians, frustrations over salary cuts also factor into the equation. Of doctors surveyed who have seen their income decline recently, 40 percent blamed Obamacare. 52 The doctor shortage thus means more patients, more stress, and longer hours for health care providers like Mary Fey, according to an NBC News report. Fey, a 58-year-old nurse practitioner in Oregon, serves as the sole primary care provider for 30 miles. (As the report explains, nurse practitioners “are registered nurses who hold graduate degrees and can perform virtually all of the functions of front-line family doctors” where no physician is available.) Fey expects Obamacare to force her patient load of 1,500 up 40 percent. This translates into longer wait times for her patients, with patients having to potentially wait a week, instead of a day, to get an appointment with her. But Fey and her patients are not alone in their predicament: NBC

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News notes more than 65 million Americans live in primary care provider shortage areas, meaning more doctors and nurse practitioners like Fey will be swamped with an onslaught of new patients. 53 III. Paying More for Less: As Costs Go Up for Patients, Quality & Quantity of Health Care Services Go Down in the Obamacare Era A. Providing Care by Punishing the Healthy & Hiking Up Taxes Incredulously, patients will be paying more, not less, for fewer health care services under the new Obamacare regime. And no population will be punished more than one of President Obama’s most loyal constituencies, the 30-and-under set. Paying $135/month instead of $56/month 54 might not seem like a big deal to the Obama Administration, but for a generation facing 13.1 percent unemployment as of January 2013, 55 and owing an average of $26,000 in student loans upon their college graduations, 56 an additional 80 dollars a month makes a huge difference. To be fair, the Obama Administration is spreading the pain around to everyone, not just young people. A CNN Money article relayed that Florida will see average premiums increase by 35 percent. 57 Forbes examined a study finding nine of 14 jurisdictions – 13 states + Washington, D.C. – would experience, on average, a 24 percent premium increase. (New Mexico and Vermont could see rate increases of 130 and 97 percent, respectively. Other states, like Ohio and New York, could see decreases around 30 percent each, 58 assuming there are enough young and healthy insurance market participants to off-set the costs of older, sicker patients in those states.) Most of these rate increases come from the law’s mandate that everyone be covered, meaning it will be nearly impossible for states to offer bare-bones plans that exclude the sick to help keep costs down. 59 Rates will also increase for everyone aside from the young and healthy. Lower

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premiums for older and sicker patients will occur only if younger patients participate, but it could be in a young, healthy patient’s economic interest – even in spite of an Obamacare fine – to decline buying insurance until absolutely necessary. Consequently, premiums for everyone will rise in the meantime. In response to these statistics, proponents of Obamacare often tout New York as a sign of the law’s positive impact (the Empire State says its premiums will decrease thanks to Obamacare). 60 However, such claims are misleading: New York already requires health insurers to provide extensive coverage to anyone who signs up, including those with pre-existing conditions, and thus the state will benefit from the forced addition of younger, healthier residents to the insurance pool. Therefore, as the CNN Money article surmises, “New York is more the exception than the rule,” 61 in proving the claim that Obamacare will lower premiums. But even in New York, lower premiums would only occur if low-risk patients do not opt out of coverage to pay a miniscule penalty – a scenario much more likely to occur. Obamacare defenders will also immediately point out those making up to 400 percent of the federal poverty level – around $94,000/year for a four-person family and $46,000/year for a single person 62 – will receive government subsidies to help cover these growing costs. Kaiser Health News estimates a qualifying family of four will receive a $5,500 subsidy. 63 However, as one commentator notes, “those subsidies… merely shift costs; they do not lower them [for medical consumers]. The government is picking up the tab in the same sense that it picked up the tab for the war in Iraq: by handing it off to taxpayers.” 64 For example, Obamacare includes 20 new or higher taxes on small businesses and families to help foot the bill. 65 Among the most egregious is the high medical bills tax: people facing large medical bills previously could deduct

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any expenses more than 7.5 percent of their annual adjusted gross income; under Obamacare, the threshold is now 10 percent. 66 Americans should also expect even more tax hikes than those already thrown into Obamacare: the CBO recently revised its 2010 average subsidy estimate from $3,970 to $5,510 per individual, 67 meaning it will now cost taxpayers $1 trillion over the next decade to pay for these Obamacare subsidies. 68 The exponentially growing costs of Obamacare thus parallel the gross miscalculations Congress projected for Medicare costs. The House Ways and Means Committee estimated back in 1967 that Medicare would cost $12 billion in 1990; the actual price tag in that year ended up being $110 billion, or 916 percent of its projected estimate. 69 B. IPAB’s Focus on Cost Over Patient Care Means Seniors Will Suffer Greatly Obamacare’s IPAB – criticized by some as rationing panels – will further exacerbate the dearth of health care service quality and availability under the ACA. Charged with the task of achieving specified savings in Medicare without affecting coverage or quality, IPAB comprises a 15-member panel, appointed by the President, set to start making binding cost-cutting decisions as early as FY 2015. Unless Congress overrides IPAB’s fiscal decisions through either a supermajority vote in the Senate, or by passing an alternative proposal in both Congressional chambers making the equivalent amount of monetary cuts, the HHS Secretary must implement IPAB’s recommendations every year. 70 Senator Jay Rockefeller (D-W.Va.), an architect of IPAB in Obamacare, stated the board will downgrade the influence of ‘“special interests”’ on Medicare financial policy, which he says have prevented Congress from making necessary decisions to reduce federal spending. 71 Though unclear to which evil ‘“special interest”’ individuals or groups Senator Rockefeller is referring in his assessment, some of the most vocal opponents to IPAB’s expansive cost-cutting powers are

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not insurance companies, but rather doctors and patients themselves. The AMA, a proponent of Obamacare, has written Congress at least five times steadfastly opposing IPAB. 72 More than 500 organizations also signed onto a Healthcare Leadership Council (“HLC”) letter opposing IPAB. Some of these dubious “special interests” include the likes of the AMA, countless national associations of physician specialists, the Alzheimer’s Dementia & Resource Center, the Council for Affordable Health Coverage, the Disabled Rights Action Committee, the Massachusetts Health Council, the National Association for Home Care & Hospice, The AIDS Institute, the Veterans Health Council, and some left-leaning liberal organizations. 73 These health care providers, patients, and their advocacy groups adamantly believe IPAB “will not only severely limit Medicare beneficiaries’ access to care but also increase health care costs that are shifted onto employers and working men and women in the private sector.” They also assert “[w]hile we all recognized the need for more sustainable health care costs, we do not believe IPAB is the way to, or will, accomplish this goal.” The HLC letter further explains that requiring IPAB to make arbitrary spending cuts every year will inevitably slash payments to Medicare providers, affecting “access to care and innovative therapies.” The organization then cites an AMA survey revealing that 17 percent of all doctors, and almost one-third of primary care physicians, have already restricted the amount of Medicare patients they will treat due to low reimbursement rates. These cutbacks in care, they argue, will only increase as IPAB faces pressure to make yearly cost-cutting decisions. 74 Moreover, as the AMA argues in one of the letters it sent to Congress, there is not even a guarantee that IPAB will calculate cuts correctly: Congress had to enable the Centers for Medicare & Medicaid Services (“CMS”) to correct $54 billion in Medicare cost projection errors back in 2003. 75

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Most damning to the core foundation of IPAB’s purpose, however, lies in HLC’s prediction that “[r]equiring IPAB to achieve scoreable savings in a one-year time period is not conducive to generating savings through long-term delivery system reforms.” Focusing on the short-term game, the HLC letter argues, will sacrifice innumerable measures supported by the medical community that need several years of implementation to achieve actual savings. Considering that the CBO has stated that IPAB will focus its recommendations on payment rate and service methodology changes, 76 Medicare patients can already see how Obamacare’s emphasis on numbers over patient care will result in fewer doctors to provide care for them. Thus despite protests to the contrary, Obamacare’s yearly focus on the bottom-line numbers encourages IPAB to embrace Return on Investment (ROI) strategies to determine who gets certain types of care. More likely than not, novel medical procedures – potentially helpful for senior health care – will face the chopping block to achieve the quickest and greatest savings. IV. More Collateral Damage: Welcome to Part-Time America, Complete with Little to No Benefits and Decreased Opportunities for Willing & Able Americans to Earn a Living As if patients did not have enough to worry about with Obamacare, President Obama’s signature legislative work also perversely incentivizes employers to slash hours and axe benefit packages for their employees. Investor’s Business Daily highlighted this trend back in January 2013, noting a not-so-coincidental surge in part-time employment with an Obamacare deadline looming right around the corner. It found that while more people were working in the retail and leisure/hospitality sectors, they were working fewer hours per person: just slightly more than 30 hours/week. 77 Under the ACA, companies with 50+ full-time employees must pay hefty fines if they don’t provide health insurance to their employees. 78 As The Wall Street Journal explains, thanks to Obamacare, thousands of American small businesses are looking to slash employee

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hours or layoff employees to avoid financial Armageddon. With the dour state of the small business economy, as discussed previously, it therefore also makes good business sense to outsource all but the most vital of work to contractors. Pushing more work to contractors will help employers avoid Obamacare fines since contractors would not get the pre-tax benefits and discounts of employee group health insurance plans. 79 A. Both the Private & Public Sectors Slash Hours in Preparation for Obamacare Unsurprisingly, employers big and small cite Obamacare when asked why they are cutting back hours. An owner of 21 Subway franchises told NBC News that Obamacare forced him to cut the hours of 50 employees down to 29 a week to avoid triggering provisions in the law. Although the article states the Obama Administration dismisses such stories as anecdotal, NBC News notes it “spoke with almost 20 small businesses and other entities from Maine to California, and almost all said that because of the new law they’d be cutting back hours for some employees.” Other anecdotes include St. Petersburg College cutting back hours for 250 faculty members to avoid more than $750,000 in health care costs, with one math professor saying “she will lose half of her income because of the cuts.” 80 The owner of the Red Lobster and Olive Garden restaurants – who employs 180,000 people, 75 percent of whom are part-time employees – is similarly cutting down part-time employee hours to under 30 per week in several markets to avoid dramatic cost increases caused by Obamacare. 81 Joseph Hansen, the president of the United Food and Commercial Workers union, which boasts a 1.2 million membership, cautions the Obama administration to take these stories seriously or else: ‘“Wait a year. You’ll see tremendous impact as workers have their hours reduced and their incomes reduced. The facts are already starting to show up. Their [the Obama Administration’s] statistics, I think, are a little behind the time.”’ 82

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Not even government employees are immune to the “Part-Time America” phenomenon rapidly growing under Obamacare. The Washington Post found that Middletown Township, New Jersey, is cutting back the hours of 25 workers to avoid three-quarters of a million dollars in health care cost increases, and Bee County, Texas, is pushing down part-time employee hours to 24 hours per week. Brevard County, Florida, is scrambling to cut back part-time employee hours to avoid $1.38 million in health care costs increases, and Chippewa County, Wisconsin, is slashing hours for 15 part-time employees to avoid more than $160,000 in extra health care costs. 83 Despite these examples, the White House Council of Economic Advisers Chairman Jason Furman denied there was any evidence that Obamacare is ushering in the era of Part-Time America, saying “nearly 90% of the gain in employment has been in full-time positions,” since the ACA became law in 2010. 84 Evidently, the Obama Administration feels it is only necessary to analyze past employment data, rather than data projections from now until the law takes full effect in 2015, to properly assess the impact of its legislation on employers. (By the way, Reuters recently reported that 75 percent of the 1 million new hires in 2013 were for part-time positions. Interviews with numerous staffing firm executives also confirmed Obamacare is “a frequently cited factor in requests [from businesses] for part-time workers.”) 85 B. So Much for Comprehensive Benefit Packages That impact of Obamacare also extends to benefit packages. UPS recently announced that Obamacare forced them to boot 15,000 working spouses of UPS employees off the company’s health insurance plan. Facing an additional $60 million expense for continuing to cover those spouses, UPS determined that “rising medical costs ‘combined with the costs associated with the Affordable Care Act, have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost.”’ 86 Although UPS only eliminated

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coverage for working spouses who could gain health insurance elsewhere, 87 the overall downshift in hours and employee benefits happening in American businesses could certainly cause severe disruptions in the health care coverage of those working spouses. The University of Virginia took similar steps in cutting off spouses eligible for health insurance elsewhere, citing that Obamacare will add $7.3 million in health care costs next year for the public university. Upon hearing the news, conservatives on the House Ways and Means Committee commented it shows ‘“the stark reality that [American families] will lose the coverage they have and like.”’ 88 C. Why Obamacare Encourages Such Employer Behavior The genesis of this frantic scrambling by employers to cut hours and chop benefits stems from the ACA’s “Employer Mandate” provision. Employers with 50+ employees must pay a penalty of $2,000/employee (excluding the first 30 employees) if the employer fails to offer health care coverage to full-time employees and at least one full-time employee receives a premium tax credit in the new marketplace. 89 Another even more convoluted penalty hits employers of 50+ employees who offer health coverage, but don’t offer what qualifies under Obamacare as “affordable” coverage. If any employee under this scenario qualifies for an Obamacare subsidy – which can be given to a family of four making up to around $94,000/yr – then an employer must pay a penalty of $3,000 per each employee receiving a subsidy. (The employer would pay the $2,000 penalty described previously if the total amount under that penalty structure would be lower than the total amount under the $3,000 penalty structure.) Employers can avoid this penalty by ensuring that their employees pay less than 9.5 percent of their incomes to receive the employer-provided health care plan. Employees having to pay more than this amount can apply for Obamacare subsidies, triggering the penalties explained here. 90

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In other words, to avoid all these penalties, employers could (1) cut employee hours down below the magic number – you guessed it – 30 hours per week to qualify them as part-time employees not required to have health insurance under the ACA, or (2) determine employee income thresholds, whether any employee would qualify for a subsidy, and whether there is a need to offer employees more “affordable” health insurance as per the ACA. The path of least resistance clearly appears to be scaling back employee hours, and it should come as no surprise the domino effect Obamacare is causing on employers preferring part-time employees over fulltime employees. House Minority Leader Nancy Pelosi (D-CA) once famously said Obamacare would “create 4 million jobs, [and] 400,000 jobs almost immediately.” 91 Perhaps Rep. Pelosi should have added the word “part-time” to her false promise to make her statement at least somewhat true. V. Security Concerns for Patients: Obamacare Exchange Sign-Ups Face a Discernible Possibility their Personal Information Could Be Stolen by Identity Thieves from the Health Care Exchanges and the Hub A. Data Security Problems On top of all the other concerns about Obamacare, recent reports reveal that the health care exchange’s Federal Data Service Hub – a network charged with transmitting sensitive patient information for everyone signed up in the exchanges – could be a playground for data thieves unless serious and immediate action is taken to address huge gaps in data security. 92 In August, the Hub was so far behind in its testing that an HHS Inspector General report declared: CMS is working with very tight deadlines to ensure that security measures for the Hub are assessed, tested and implemented by the expected initial open enrollment date of October 1, 2013. If there are additional delays in completing the security assessment and

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testing, the CMS CIO may have limited information on the security risks and controls when granting the security authorization of the Hub. 93 Stated otherwise, the HHS IG was not even able to properly assess the Hub’s potential data security concerns before Obamacare coerced Americans to start handing over their social security numbers and other personal information to the health care exchanges on October 1, 2013. It is no surprise that this report caused a firestorm in Congress, prompting Senate Minority Leader Mitch McConnell (R-KY) to write a letter to CMS insisting the exchange launch be delayed until all data security testing has been thoroughly completed. He highlighted that the final security testing report for the system would not arrive until 10 days before the system launched, and that CMS would certify the security system a mere day before the launch on October 1st. He also raised concerns that CMS contracted with a company, having little to no experience with HHS, for $1.2 billion to organize exchange data, and that this same company had the personal information of more than 120,000 federal Thrift Savings Plan enrollees stolen from its computers in 2011. All this information also explains why a former HHS general counsel and Social Security commissioner warned The Weekly Standard that ‘“unless [the Obamacare exchanges are] delayed and fixed, [they will] inflict on the public the most widespread violation of the Privacy Act in our history.”’ 94 Members of the House of Representatives also raised alarm bells about the potential for data security breaches in a USA Today Op/Ed by Reps. Diane Black (R-TN), and Patrick Meehan (R-PA) Chairman of the Cybersecurity, Infrastructure Protection and Security Technologies Subcommittee. The piece emphasized that “[t]he potential for abuse of personal information is staggering.” They explain that the data “will be used and accessed by thousands of bureaucrats”

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in HHS, the Department of Justice, the IRS, the Department of Homeland Security, and state governments, 95 which include, of course, several of the same government agencies involved in the recent data security scandals. This is why, they continue, the House has sponsored legislation to protect the security of Americans’ personal information, and 13 state attorneys general wrote Health and Human Services Secretary Kathleen Sebelius outlining their concerns over potential data security lapses. 96 B. Navigators: Leading Americans Towards Disaster Reps. Black and Meehan also seized upon one of the foundational concerns over data security: the mysterious “navigators” who will be signing up Americans to the Obamacare health exchanges. To presumably allow HHS to speed things up and stop blowing deadlines for security verification, the Members of Congress point out that these navigators do not even have to go through background checks. 97 Florida Attorney General Pam Bondi, who joined the state attorneys’ general letter to HHS Secretary Sebelius, echoed these statements. Underscoring that HHS stopped both the background check and fingerprinting requirement for navigators, she worries identity thieves could potentially become navigators and gain access to the tax return information and Social Security information of countless Americans. 98 Unsurprisingly, concerns over these navigators comprise the entirety of the 8-page letter Bondi signed onto from the team of AGs to HHS. Led by West Virginia Attorney General Patrick Morrisey, the letter illustrates that HHS’s relaxed standards for navigator hiring, and vague standards for navigator training, make the system ripe for fraudulent activity. 99 He further explains in a Forbes article that many navigators will come from “community groups,” who will “take to the phones, streets, and hospitals to sign people up for Obamacare.” But, he adds, there is not even a requirement that these Obamacare promoters be “licensed, bonded, or insured”

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health insurance agents. Worse yet, he writes, these community groups did not even receive funding to hire and train these navigators until 32 business days before the exchanges opened on October 1st. 100 Reports further justify Morrisey’s concerns by revealing that the administration cut down the amount of required initial base training hours for navigators from 30 to 20 hours. 101 With $67 million in funds recently doled out to pay these individuals, 102 and California estimating it alone will hire 21,000 navigators, 103 the process raises serious questions about who these navigators are and how much taxpayer money they will receive to promote President Obama’s agenda. A host of such concerns thus prompted Attorney General Morrisey to request answers from Secretary Sebelius on these issues by the end of August 2013. 104 Conclusion This paper sought to explain to the American public, in plain language, why Obamacare is a pill the American health care system must not swallow. From patient care, to the economy, to privacy, Obamacare destroys more areas central to the American way of life than can be discussed in one sitting. What we hope has been made clear, however, is that Congress must not rest until it has defunded, delayed, repealed, and replaced this monstrosity with patient-centered, free-market reforms. For example, Health Savings Accounts increase access to quality health care for all Americans by providing cost-effective opportunities. Through additional innovation and price competition, patients and their doctors will be able to make informed health care decisions without highly proscriptive federal regulations and government bureaucrats interfering. Unless Congress replaces Obamacare, our nation will pass the point of no return in remedying this vicious assault on patients, employees, and the average American simply wanting his private information free from the hands of data thieves. Congress must conduct aggressive oversight into the inherent and systematic flaws in Obamacare, stand against the implementation

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of this damaging legislation, and stand for patient-centered reforms. This fight isn’t finished; it’s only just begun.
1

Centers for Disease Control and Prevention, “Ten Great Public Health Achievements – United States, 1900-1999” (Apr. 2, 1999) <http://www.cdc.gov/mmwr/preview/mmwrhtml/00056796.htm> (Last Accessed: Sept. 9, 2013). 2 Alex Wayne, “Health-Care Spending to Reach 20% of U.S. Economy by 2021,” Bloomberg.com (Jun. 13, 2012) <http://www.bloomberg.com/news/2012-06-13/health-care-spending-to-reach-20-of-u-s-economy-by-2021.html> (Last Accessed: Sept. 9, 2013). 3 U.S. Bureau of Labor Statistics, “Spotlight on Statistics: Health Care,” Nov. 2009 <http://www.bls.gov/spotlight/2009/health_care/> (Last Accessed: Sept. 9, 2013). 4 “Poll: Do you support or oppose the health care law?” CNN.com (May 27, 2013) <http://politicalticker.blogs.cnn.com/2013/05/27/poll-do-you-support-or-oppose-the-health-care-law/> (Last Accessed: Sept. 9, 2013). See also Susan Page, “USA Today/Pew Poll: Health care law faces difficult future,” USA Today (Sept. 16, 2013) <http://www.usatoday.com/story/news/politics/2013/09/16/usa-today-pew-poll-health-carelaw-opposition/2817169/> (Last Accessed: Sept. 9, 2013). 5 Scott Clement, “Moderate Democrats are quitting on Obamacare,” The Washington Post (Jul. 23, 2013) <http://www.washingtonpost.com/blogs/the-fix/wp/2013/07/23/moderate-democrats-are-quitting-on-obamacare/> (Last Accessed: Sept. 9, 2013). 6 Karoun Demirjian, “Reid says Obamacare just a step toward eventual single-payer system,” The Las Vegas Sun (Aug. 10, 2013) <http://www.lasvegassun.com/news/2013/aug/10/reid-says-obamacare-just-step-toward-eventualsing/> (Last Accessed: Sept. 9, 2013). 7 Stephen Adams, “Lives at risk due to ‘arbitrary’ health rationing, say surgeons,” Telegraph.co.uk (Jun. 20, 2012) <http://www.telegraph.co.uk/health/healthnews/9344902/Lives-at-risk-due-to-arbitrary-health-rationing-saysurgeons.html> (Last Accessed: Sept. 9, 2013). 8 Many articles have adopted the phrase “Part-Time America” to explain Obamacare’s impact on part-time job growth. For example, see “Part-Time America: A better jobs report in June, except for the impact of ObamaCare,” The Wall Street Journal (Jul. 7, 2013) <http://online.wsj.com/article/SB10001424127887324399404578587513698345272.html> (Last Accessed: Sept. 23, 2013). 9 Jake Miller, “GOP: Obamacare hurts employers and employees alike,” CBSNews.com (Aug. 3, 2013) <http://www.cbsnews.com/8301-250_162-57596865/gop-obamacare-hurts-employers-and-employees-alike/> (Last Accessed: Sept. 9, 2013). 10 U.S. Senator Tom Coburn, M.D., “Administration Fails to Meet Deadlines In Its Own Health Law,” Coburn.Senate.gov (Nov. 2, 2011) <http://www.coburn.senate.gov/public/index.cfm/rightnow?ContentRecord_id=3e699ea5-55d1-445c-a07f5ae693e893cf&ContentType_id=b4672ca4-3752-49c3-bffc-fd099b51c966&Group_id=00380921-999d-40f6-a8e3470468762340> (Last Accessed: Sept. 9, 2013) (citing “Deadlines for the Secretary of Health and Human Services in the Patient Protection and Affordable Care Act (P.L. 111-148, PPACA) from Enactment to January 1, 2011,” Congressional Research Service (Oct. 1, 2010) <http://www.coburn.senate.gov/public//index.cfm?a=Files.Serve&File_id=54103bf6-ae3a-47be-916e72548ba34b5b> and “Deadlines for the HHS Secretary and Other Federal Entities in the Patient Protection and Affordable Care Act: Addendum to CRS Congressional Distribution Memorandum Dated April 5, 2011,” Congressional Research Service (Nov. 1, 2011) http://www.coburn.senate.gov/public/index.cfm?a=Files.Serve&File_id=68f1c359-1164-4ee3-b22a-b1769ead5919). 11 Avik Roy, “Unpublished CRS Memo: Obama Administration Has Missed Half of Obamacare’s Legally Imposed Implementation Deadlines,” Forbes.com (Aug. 18, 2013) <http://www.forbes.com/sites/theapothecary/2013/08/18/unpublished-crs-memo-obama-administration-has-missedhalf-of-obamacares-legally-imposed-implementation-deadlines/> (Last Accessed: Sept. 9, 2013) (citing “Deadlines for the HHS Secretary and Other Federal Entities in the Patient Protection and Affordable Care Act Through March 23, 2013: Addendum to CRS Congressional Distribution Memorandum Dated April 5, 2011,” Congressional

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Research Service (Jun. 5, 2013) <http://b-i.forbesimg.com/theapothecary/files/2013/08/CRS-2013-06-05-ACAdeadlines.pdf>). 12 Avik Roy, “Yet Another White House Obamacare Delay: Out-Of-Pocket Caps Waived Until 2015,” Forbes.com (Aug. 13, 2013) <http://www.forbes.com/sites/theapothecary/2013/08/13/yet-another-white-house-obamacare-delayout-of-pocket-caps-waived-until-2015/> (Last Accessed: Sept. 9, 2013). 13 David Lawder, “Update 1 – U.S. Congress wins relief on Obamacare health plan subsidies,” Reuters.com (Aug. 7, 2013) <http://www.reuters.com/article/2013/08/07/usa-health-congress-idUSL1N0G820F20130807> (Last Accessed: Sept. 9, 2013). 14 Julie Appleby, “How Much Of A Subsidy Will You Get In Obamacare? Here’s An Estimate,” WebMD News from Kaiser Health News <http://www.webmd.com/health-insurance/20130814/how-much-of-a-subsidy-will-you-get-inobamacare-heres-an-estimate> (Last Accessed: Sept. 9, 2013). 15 Mary Lu Carnevale, “Obama: ‘If You Like Your Doctor, You Can Keep Your Doctor,”’ The Wall Street Journal (Jun. 15, 2009) <http://blogs.wsj.com/washwire/2009/06/15/obama-if-you-like-your-doctor-you-can-keep-yourdoctor/> (Last Accessed: Sept. 9, 2013). 16 Steve Thompson, “Is U.S. Health Care Really Among the World’s Worst? Wrong Question,” Johns Hopkins Medicine International (Apr. 2, 2013) <http://international.blogs.hopkinsmedicine.org/2013/04/02/is-u-s-healthcare-really-among-the-worlds-worst-wrong-question/> (Last Accessed: Sept. 10, 2013). 17 Michael D. Tanner, “Despite Flaws, U.S. Health Care the Best,” The Cato Institute (Oct. 18, 2011) <http://www.cato.org/publications/commentary/despite-flaws-us-health-care-best> (Last Accessed: Sept. 9, 2013) (citing “Cancer Survival in five continents: a worldwide population study,” The Lancet (August 2008) <http://www.thelancet.com/journals/lancet/article/PIIS1470-2045(08)70179-7/abstract>). 18 Tanner, “Despite Flaws, U.S. Health Care the Best.” 19 “Anxiety Over Cost of New AIDS Drug,” CBSNews.com (republishing an Associated Press article) (Feb. 11, 2009) <http://www.cbsnews.com/2100-204_162-543887.html> (Last Accessed: Sept. 9, 2013). 20 Larry Davidson and Gennadiy Greblov, “The Pharmaceutical Industry in the Global Economy,” prepared for the Indiana Economic Development Corporation, Summer 2005, at 6 <http://www.bus.indiana.edu/davidso/lifesciences/lsresearchpapers/pharmaceutical%20industryaug12.doc> (Last Accessed: Sept. 9, 2013). 21 “Anxiety Over Cost of New AIDS Drug,” CBSNews.com. 22 Tanner, “Despite Flaws, U.S. Health Care the Best.” See also “Danny Williams going to U.S. for heart surgery,” Canadian Broadcasting Corporation News (Feb. 2, 2010) <http://www.cbc.ca/news/canada/newfoundlandlabrador/story/2010/02/01/nl-williams-heart-201.html> (Last Accessed: Sept. 9, 2013). 23 Tanner, “Despite Flaws, U.S. Health Care the Best.” See also “Burlusconi has surgery at Cleveland Clinic,” UPI.com (Dec. 19, 2006) <http://www.upi.com/Top_News/2006/12/19/Berlusconi-has-surgery-at-ClevelandClinic/UPI-14431166586389/> (Last Accessed: Sept. 9, 2013). 24 David Lazarus, “U.S. health system has flaws, but not in quality of care,” The Los Angeles Times (Jul. 2, 2013) <http://articles.latimes.com/2013/jul/02/business/la-fi-lazarus-20130702> (Last Accessed: Sept. 10, 2013). 25 Devon M. Herrick, “Health Care Entrepreneurs: The Changing Nature of Providers,” National Center for Policy Analysis (December 2008) <http://www.ncpa.org/pdfs/st318.pdf> (Last Accessed: Sept. 9, 2013). 26 John Stossel, “Insurance is No Answer,” ABCNews.com (Jul. 7, 2009) <http://abcnews.go.com/2020/Stossel/story?id=8026098> (Last Accessed: Sept. 9, 2013). 27 Nina Bernstein, “How to Charge $546 for Six Liters of Saltwater,” The New York Times (Aug. 25, 2013) <http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html> (Last Accessed: Sept. 9, 2013). 28 “Southwestern Pennsylvania hospital to stop baby deliveries,” FOXNews.com (in collaboration with The Associated Press) (Jan. 16, 2013) <http://www.foxnews.com/politics/2013/01/16/southwestern-pa-hospital-to-stopbaby-deliveries/> (Last Accessed: Sept. 9, 2013). 29 Sarah Jane Tribble, “Cleveland Clinic praised by President Barack Obama for efficiency, control of costs,” The Plain Dealer (Jun. 4, 2009) <http://www.cleveland.com/medical/index.ssf/2009/06/cleveland_clinic_praised_by_ pr.html> (Last Accessed: Sept. 23, 2013). 30 Lylah Alphonse, “Citing Obamacare, Cleveland Clinic to Cut $300M, Warns of Layoff,” U.S. News & World Report (Sept. 18, 2013) <http://www.usnews.com/news/articles/2013/09/18/citing-obamacare-cleveland-clinic-tocut-300m-warns-of-layoffs> (Last Accessed: Sept. 18, 2013). 31 Id. (quoting Eileen Sheil’s statement in Brie Zeltner, “Cleveland Clinic to cut $330 million from next year’s budget, may cut jobs,” The Plain Dealer (Sept. 18, 2013)

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<http://www.cleveland.com/healthfit/index.ssf/2013/09/cleveland _clinic_to_cut_330_mi.html#incart_river_default#incart_m-rpt-2> (Last Accessed: Sept. 18, 2013)). 32 Shelley DuBois, “Vanderbilt University Medical Center cutting several hundred more jobs: This week’s eliminations are part of plan for losing 1,000 positions,” The Tennessean (Sept. 18, 2013) <http://www.tennessean. com/article/20130918/BUSINESS05/309180127/Vanderbilt-University-Medical-Center-cutting-several-hundredmore-jobs> (Last Accessed: Sept 23, 2013). 33 Kelly Kennedy, “States predict more insurance customers,” USA Today (Aug. 20, 2013) <http://www.usatoday.com/story/news/politics/2013/08/19/health-care-law-uninsured-estimates-obama/2671489/> (Last Accessed: Sept. 9, 2013). 34 “Physician Shortages to Worsen Without Increases in Residency Training,” The Association of American Medical Colleges <https://www.aamc.org/download/286592/data/> (Last Accessed: Sept. 9, 2013). 35 William J. Dennis, Jr., “Small Business and Health Insurance: One Year After Enactment of PPACA,” The National Federation of Independent Business Research Foundation (July 2011) at 1 <http://www.nfib.com/Portals/0/pdf/AllUsers/research/studies/ppaca/NFIB-healthcare-study-201107.pdf> (Last Accessed: Sept. 9, 2013). 36 “Small Business Trends: Small Business, Big Impact!” U.S. Small Business Administration, sba.gov <http://www.sba.gov/content/small-business-trends> (Last Accessed: Sept. 9, 2013). 37 Kennedy, “States predict more insurance customers.” 38 “Resolution 54: AFL-CIO Convention Resolution on the Affordable Care Act,” adopted at the AFL-CIO Convention 2013, available at <http://www.aflcio.org/About/Exec-Council/Conventions/2013/Resolutions-andAmendments/Resolution-54-AFL-CIO-Convention-Resolution-on-the-Affordable-Care-Act> (Last Accessed: Sept. 13, 2012). 39 Carnevale, “Obama: ‘If You Like Your Doctor, You Can Keep Your Doctor.”’ 40 “Sen. Baucus Sees a Train Wreck,” Fiscal Year 2014 Health and Human Services Budget Request, C-SPAN.org (Apr. 17, 2013) <http://www.c-spanvideo.org/clip/4435992> (Last Accessed: Sept. 9, 2013). 41 Demirjian, “Reid says Obamacare just a step toward eventual single-payer system.” 42 Dennis, Jr., “Small Business and Health Insurance,” at 7-8. 43 J.D. Harrison, “Obamacare’s many definitions of small business breed confusion, challenges,” The Washington Post (Aug. 23, 2013) <http://www.washingtonpost.com/business/on-small-business/obamacares-many-definitionsof-small-business-breed-confusion-challenges/2013/08/23/0a2c946e-0b40-11e3-9941-6711ed662e71_story.html> (Last Accessed: Sept. 9, 2013). 44 “Sen. Baucus Sees a Train Wreck,” C-SPAN.org. 45 Dennis, Jr., “Small Business and Health Insurance,” at 10-11. 46 Id. at 3. 47 Id. at 11. Another report has already predicted such a result: a survey of all employers (not just small business employers) reveals that almost one-third of employers will find it in their economic interest to drop health insurance benefits for employees. Id. at 17 (citing Shubham Singhal, Jeris Stueland, and Drew Ungerman, “How US health care reform will affect employee benefits,” McKinsey Quarterly, June 2011). 48 G. Scott Thomas, “Recession claimed 170,000 small businesses in two years,” The Business Journals (Jul. 24, 2012) <http://www.bizjournals.com/bizjournals/on-numbers/scott-thomas/2012/07/recession-claimed-170000small.html> (Last Accessed: Sept. 9, 2013). 49 “Physician Shortages to Worsen,” The Association of American Medical Colleges. 50 “New Study Finds Less Than 25 Percent of New Doctors Work in Primary Care,” The George Washington University School of Public Health and Health Services (Jun. 12, 2013) <http://sphhs.gwu.edu/content/new-studyfinds-less-25-percent-new-doctors-work-primary-care> (Last Accessed: Nov. 14, 2013). 51 “Deloitte 2013 Survey of U.S. Physicians: Physician perspectives about health care reform and the future of the medical profession,” Deloitte Center for Health Solutions, at 3 <http://www.deloitte.com/assets/DcomUnitedStates/Local%20Assets/Documents/us_chs_2013SurveyofUSPhysicians_031813.pdf> (Last Accessed: Sept. 9, 2013). 52 Id. at 4. 53 JoNel Aleccia, “Bracing for Obamacare: Nurse practitioners fill doc shortage gap,” NBCNews.com (Aug. 9, 2013) <http://www.nbcnews.com/health/bracing-obamacare-nurse-practitioners-fill-doc-shortage-gap-6C10849957> (Last Accessed: Sept. 9, 2013).

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Sam Baker, “Premiums to rise for cheapest health plans in Colo.,” TheHill.com (Aug. 19, 2013) <http://thehill.com/blogs/healthwatch/health-reform-implementation/317637-premiums-to-rise-for-cheapest-healthplans-in-colo> (Last Accessed: Sept. 9, 2013) (citing a July 23, 2013, U.S. Government Accountability Office (“GAO”) letter at http://www.gao.gov/assets/660/656121.pdf and a Colorado Department of Regulatory Agencies report, “Medical Insurance Premium Summary For Plans Approved by Colorado Division of Insurance for 2014,” at http://cdn.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=ContentDisposition&blobheadername2=Co ntent-Type&blobheadervalue1=inline%3B+filename%3D%22Summary+of+Premiums+for+2014++Medical.pdf%22&blobheadervalue2=application%2Fpdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251 874975262&ssbinary=true). 55 Tyler Kingkade, “Millennial Unemployment in January 2013 Rose Much Faster Than National Rate,” HuffingtonPost.com (Feb. 6, 2013) <http://www.huffingtonpost.com/2013/02/06/millennial-unemployment-ratejanuary_n_2612956.html> (Last Accessed: Sept. 9, 2013) (citing the U.S. Department of Labor). 56 Chris Denhart, “How The $1.2 Trillion College Debt Crisis Is Crippling Students, Parents and The Economy,” Forbes.com (Aug. 7, 2013) <http://www.forbes.com/sites/specialfeatures/2013/08/07/how-the-college-debt-iscrippling-students-parents-and-the-economy/> (Last Accessed: Sept. 9, 2013). 57 Tami Luhby, “Where Obamacare premiums will soar,” CNNMoney.com (Aug. 6, 2013) <http://money.cnn.com/2013/08/06/news/economy/obamacare-premiums/index.html> (Last Accessed: Sept. 9, 2013). 58 Avik Roy, “Interactive Map: In 13 States Plus D.C., Obamacare Will Increase Premiums By 24%, On Average,” Forbes.com (Sept. 4, 2013) <http://www.forbes.com/sites/theapothecary/2013/09/04/interactive-map-in-13-statesplus-d-c-individual-health-premiums-will-increase-by-an-average-of-24/> (Last Accessed: Sept. 24, 2013). 59 Luhby, “Where Obamacare premiums will soar.” 60 Roni Caryn Rabin and Reed Abelson, “Health Plan Cost for New Yorkers Set to Fall 50%,” The New York Times (Jul. 16, 2013) <http://www.nytimes.com/2013/07/17/health/health-plan-cost-for-new-yorkers-set-to-fall-50.html> (Last Accessed: Sept. 9, 2013). 61 Luhby, “Where Obamacare premiums will soar.” 62 Appleby, “How Much Of A Subsidy Will You Get In Obamacare? Here’s An Estimate.” See also Patient Protection and Affordable Care Act (“PPACA”), 42 U.S.C. § 18071 (2010). 63 Appleby, “How Much Of A Subsidy Will You Get In Obamacare?” 64 Bart Hinkle, “Hinkle: In health care, one law is working like a charm,” The Richmond Times-Dispatch (Feb. 10, 2013) <http://www.timesdispatch.com/opinion/our-opinion/columnists-blogs/bart-hinkle/hinkle-in-health-care-onelaw-is-working-like-a/article_d53f3ed2-4b86-575b-95c2-29f0727ffb68.html> (Last Accessed: Sept. 9, 2013). 65 “Full List of Obamacare Tax Hikes: Obamacare law contains 20 new or higher taxes on American families and small businesses,” Americans for Tax Reform <http://www.atr.org/full-list-ACA-tax-hikes-a6996> (Last Accessed: Sept. 10, 2013). 66 Id. (citing the PPACA, H.R. 3590, 111th Cong., § 9013 (2009)). 67 “ObamaCare Subsidy Cost Hiked $233 Bil in New CBO Score,” Investor’s Business Daily (Feb. 5, 2013) <http://finance.yahoo.com/news/obamacare-subsidy-cost-hiked-233-214400778.html> (Last Accessed: Sept. 9, 2013). 68 Stephanie Condon, “On Tax Day, some will see how Obamacare will affect them,” CBSNews.com (Apr. 15, 2013) <http://www.cbsnews.com/8301-250_162-57579518/on-tax-day-some-will-see-how-obamacare-will-affect-them/> (Last Accessed: Sept. 9, 2013). 69 Conn Carroll, “Health Care Reform Cost Estimates: What is the Track Record?” The Heritage Foundation (Aug. 4, 2009) <http://blog.heritage.org/2009/08/04/health-care-reform-cost-estimates-what-is-the-track-record/> (Last Accessed: Sept. 9, 2013). 70 Bara Vaida, “The IPAB: The Center Of a Political Clash Over How to Change Medicare,” Kaiser Health News (Mar. 22, 2012) <http://www.kaiserhealthnews.org/stories/2011/may/09/ipab-faq.aspx> (Last Accessed: Sept. 9, 2013). 71 Id. 72 “Independent Payment Advisory Board: Correspondence on IPAB,” America Medical Association <http://www.ama-assn.org/ama/pub/advocacy/topics/independent-payment-advisory-board.page?> (Last Accessed: Sept. 9, 2013). 73 “Over 500 Organizations Representing Patients, Healthcare Providers, Employers Urge Congress to Eliminate IPAB,” Healthcare Leadership Council (Apr. 25, 2013) <https://www.hlc.org/newsroom/over-500-organizations-

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representing-patients-healthcare-providers-employers-urge-congress-to-eliminate-ipab/> (Last Accessed: Sept. 9, 2013) (citing the following letter http://www.hlc.org/blog/wp-content/uploads/2013/04/IPAB-Group-Letter-April25-20132.pdf). 74 Id. 75 James L. Madara, MD, Executive Vice President, CEO of the American Medical Association, “Letter to Congress” (Feb. 27, 2012) <http://www.ama-assn.org/resources/doc/washington/hr452-support-letter27feb2012.pdf> (Last Accessed: Sept. 9, 2013). 76 Healthcare Leadership Council Letter to Congress. 77 Hinkle, “Hinkle: In health care,” (citing Jed Graham, “Retail Workweek Hits 3-Year Low in ObamaCare Shift,” Investors.com (Feb. 1, 2013) <http://news.investors.com/ibd-editorials-perspective/020113-642941-retail-leisurejobs-hours-down-obamacare-looms.htm?ven=benzinga2cp&p=2> (Last Accessed: Sept. 9, 2013)). 78 Hinkle, “Hinkle: In health care.” See also Sam Baker, “A guide to the employer mandate,” TheHill.com (Jul. 3, 2013) <http://thehill.com/blogs/healthwatch/health-reform-implementation/309107-understanding-the-employermandate> (Last Accessed: Sept. 9, 2013). See also “Full List of Obamacare Tax Hikes,” Americans for Tax Reform (citing the PPACA, H.R. 3590, 111th Cong., § 1513 (2009)). 79 Hinkle, “Hinkle: In health care,” (citing Paul Christiansen, “To Outsmart ObamaCare, Go Protean,” The Wall Street Journal (Jan. 28, 2013) <http://online.wsj.com/article/SB10001424127887324461604578193472562389926.html> (Last Accessed: Sept. 9, 2013)). 80 Lisa Myers and Carroll Ann Mears, “Businesses Claim Obamacare has forced them to cut employee hours,” NBCNews.com (Aug. 13, 2013) <http://investigations.nbcnews.com/_news/2013/08/13/20010062-businesses-claimobamacare-has-forced-them-to-cut-employee-hours?lite> (Last Accessed: Sept. 9, 2013). 81 “Olive Garden, Red Lobster putting more workers on part-time because of Obama health care law,” The Associated Press (Oct. 10, 2012) <http://www.wjla.com/articles/2012/10/olive-garden-red-lobster-putting-moreworkers-on-part-time-because-of-obama-health-care-law-80832.html> (Last Accessed: Sept. 11, 2013). 82 Myers and Mears, “Businesses Claim Obamacare has forced them to cut employee hours.” 83 Reid Wilson, “Local governments cutting hours over Obamacare costs,” The Washington Post (Aug. 22, 2013) <http://www.washingtonpost.com/blogs/govbeat/wp/2013/08/22/local-governments-cutting-hours-over-obamacarecosts/> (Last Accessed: Sept. 9, 2013). 84 Id. 85 Lucia Mutikani, “Analysis: Obamacare, tepid U.S. growth fuel part-time hiring,” Reuters (Aug. 21, 2013) <http:// www.reuters.com/article/2013/08/21/us-usa-economy-jobs-analysis-idUSBRE97K05K20130821> (Last Accessed: Nov. 14, 2013). 86 Carla Caldwell, “UPS to drop 15,000 spouses from insurance, cites Obamacare,” The Atlanta Business Chronicle (Aug. 21, 2013) <http://www.bizjournals.com/atlanta/morning_call/2013/08/ups-to-drop-15000-spouses-from.html> (Last Accessed: Sept. 9, 2013). 87 See actual UPS Memo here: <http://capsules.kaiserhealthnews.org/wp-content/uploads/2013/08/UPS-SpousalCoverage.pdf>. 88 Sam Baker, “University of Virginia cuts some health benefits, citing ObamaCare costs,” TheHill.com (Aug. 21, 2013) <http://thehill.com/blogs/healthwatch/health-insurance/318157-university-of-virginia-cuts-some-healthbenefits-citing-obamacare-costs> (Last Accessed: Sept. 9, 2013). See also “Employers dropping coverage for thousands of spouses over ObamaCare costs,” FOXNews.com (Aug. 21, 2013) <http://www.foxnews.com/politics /2013/08/21/employers-dropping-coverage-for-thousands-spouses-over-obamacare-costs/> (Last Accessed: Nov. 14, 2013). 89 Baker, “A guide to the employer mandate.” See also “Full List of Obamacare Tax Hikes,” Americans for Tax Reform (citing the PPACA, H.R. 3590, 111th Cong., § 1513 (2009)). 90 Id. Other employer-related penalties include a $400 tax/employee if the employer requires a waiting period of 3060 days to enroll in coverage. That penalty rises to $600/employee if the waiting period exceeds 60 days. Id. 91 “Pelosi claims that health care reform will create thousands of jobs,” Tampa Bay Times – PolitiFact.com (Feb. 25, 2010) <http://www.politifact.com/truth-o-meter/statements/2010/mar/08/nancy-pelosi/pelosi-claims-health-carereform-will-create-thous/> (Last Accessed: Sept. 9, 2013). 92 Jason Seher, “Rogers: HealthCare.gov isn’t secure,” CNN.com (Oct. 27, 2013) <http://politicalticker.blogs.cnn .com/2013/10/27/rogers-healthcare-gov-isnt-secure/> (Last Accessed: Nov. 1, 2013).

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U.S. Department of Health and Human Services: Office of Inspector General, “Observations Noted During the OIG Review of CMS’s Implementation of the Health Insurance Exchange – Data Service Hub” (August 2013) at 6-7 <http://oig.hhs.gov/oas/reports/region1/181330070.pdf> (Last Accessed: Sept. 10, 2013). 94 John McCormack, “McConnell: Don’t Open Obamacare Exchanges If Privacy Isn’t Protected,” The Weekly Standard (Aug. 12, 2013) <http://www.weeklystandard.com/blogs/mcconnell-dont-open-obamacare-exchanges-ifprivacy-isnt-protected_745961.html> (Last Accessed: Sept. 10, 2013). 95 Reps. Diane Black and Pat Meehan, “ObamaCare poses security threat: Delays will likely prevent HHS from verifying the health care system’s security,” USA Today (Aug. 21, 2013) <http://www.usatoday.com/story/opinion/ 2013/08/21/obamacare-health-care-hhs-delay-column/2678485/> (Last Accessed: Sept. 10, 2013). 96 Id. The Gang of 13 includes the Attorneys General from West Virginia, Alabama, Florida, Georgia, Kansas, Louisiana, Michigan, Montana, Nebraska, North Dakota, Oklahoma, South Carolina, and Texas. See letter here: <http://www.wvago.gov/pdf/Letter%20to%20HHS%20re%20Data%20Privacy_(final%208%2014%2013).pdf>. 97 Reps. Diane Black and Pat Meehan, “ObamaCare poses security threat.” 98 Jordy Yager, “States raise privacy concerns over health law navigators,” TheHill.com (Aug. 17, 2013) <http://thehill.com/blogs/healthwatch/health-reform-implementation/317513-state-attorneys-general-raise-privacyconcerns-over-obamacare-navigators#ixzz2cNXxgeZx> (Last Accessed: Sept. 10, 2013). 99 West Virginia Attorney General Patrick Morrisey, Letter to HHS Secretary Kathleen Sebelius regarding data privacy risks posed by programs assisting consumers with enrollment in health insurance through the new exchanges (Aug. 14, 2013), available at <http://www.wvago.gov/pdf/Letter%20to%20HHS%20re%20Data%20Privacy_(final%208%2014%2013).pdf>. 100 West Virginia Attorney General Patrick Morrisey, “How Obamacare Makes Theft Of Your Identity More Likely,” Forbes.com (Aug. 25, 2013) <http://www.forbes.com/sites/realspin/2013/08/25/how-obamacare-makestheft-of-your-identity-more-likely/> (Last Accessed: Sept. 10, 2013). 101 Amy Schatz, “Preparations for Health Exchanges on Tight Schedule,” The Wall Street Journal (Aug. 7, 2013) <http://online.wsj.com/article/SB10001424127887324170004578638100820728288.html> (Last Accessed: Sept. 10, 2013). Administration officials say navigators will eventually be required to complete 30 hours of training, but it is unclear when navigators will be required to complete the extra 10 hours. See Elise Viebeck, “GOP lawmaker: ‘Irresponsible’ to cut training for ObamaCare ‘navigators,”’ TheHill.com (Aug. 7, 2013) <http://thehill.com/blogs/healthwatch/health-reform-implementation/316031-gop-lawmaker-irresponsible-to-cuttraining-for-obamacare-navigators- > (Last Accessed: Sept. 10, 2013). 102 “New resources available to help consumers navigate the Health Insurance Marketplace: HHS awards $67 million to Navigators and recognizes more than 100 organizations as Champions for Coverage,” CMS Press Release (Aug. 15, 2013), available at <http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-PressReleases-Items/2013-08-15.html> (Last Accessed: Sept. 10, 2013). 103 N.C. Aizenman, “For insurance exchanges, states need ‘navigators’ – and hiring them is a huge task,” The Washington Post (Feb. 4, 2013) <http://articles.washingtonpost.com/2013-02-04/national/36743424_1_insuranceexchanges-navigators-health-insurance> (Last Accessed: Sept. 10, 2013). See also Hinkle, “Hinkle: In health care.” 104 Morrisey, Letter to HHS Secretary Kathleen Sebelius.

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