This was especially surprising to me because I read this week that the nation’s teen birthrate actually dropped by 17% between 2007 and 2010 to 34.3 births per 1,000, the lowest rate ever recorded. How could there be such great dissonance between the fact that in New York State, teen birthrates have dropped 13% over that period and my friend’s first-hand experience with her students?

Of course I’ve been around health statistics long enough to know that anecdotal evidence often has little to do with larger-scale trends or findings. Take the case of mammography and its contribution to saving women’s lives: when I wrote about the wealth of evidence pointing out that yearly mammograms for women under 50 actually has little impact on reducing breast cancer mortality but does increase the rate of false positives and over-treatment, I received phone calls and emails from plenty of women whose own experience told them otherwise. “My life was saved by a mammogram that caught my cancer before it could spread,” a close family friend argued. “I don’t believe these studies and I think what you’re writing is dangerous.”

But back to teen pregnancy—after all, May is National Teen Pregnancy Month. This dissonance between the encouraging large data picture and the local experience got me thinking about what is becoming an important part of all public health and disease interventions. The imminent expansion and also specificity of the data pool as more and more information is recorded and dumped into large computerized repositories begs for a new kind of analysis that identifies “hot-spots” and outliers that resist the trends; local areas, single hospitals, particular members of ethnic or racial populations and other demographic subsets that defy the odds when it comes to national health outcomes or usage of medical services.

We’re already seeing this in the realm of Medicare payment data; the Dartmouth Atlas has for years been identifying regional variations in the cost of care in different parts of the country and even between neighboring towns. Now, as the first step toward linking reimbursement to efficient care, the Center for Medicare and Medicaid Services has released new findings from its own study of hospital and post-discharge cost variation. According to coverage in Kaiser Health News, “the figures show wide variance among hospitals around the country, even ones just a few miles apart. In Los Angeles, for example, the average patient admitted to Los Angeles Community Hospital cost Medicare nearly $24,644 during the stay and in the month afterward, 37 percent above the national median. Across town, according to the data, an essentially similar patient admitted to Ronald Reagan UCLA Medical Center cost Medicare $17,628, or 2 percent below the median.”

There is still much controversy over what leads to these cost variations; hospitals in particular have a lot at stake in 2014 when CMS begins using this kind of data to determine which providers receive financial bonuses for efficient care and which are penalized for being high spenders. But the data do spur further examination and changes that might focus on better discharge coordination in one hospital for example, or reducing excess testing in another.

The power of this new focus on what I’ll call “micro-data” is that it naturally follows that interventions should be more effective because they can be focused on unique problems. Last year I wrote about a laudable effortin San Francisco to identify the highest users of the city’s safety-net services; ambulances, emergency rooms, homeless shelters and detox centers. In order to do this, all the safety net providers had to agree to take their own electronic patient data and dump it into a central repository for analysis. San Francisco still struggles with the high cost of caring for its almost 230,000 “high utilizers across multiple systems” or HUMS; many are homeless, alcohol and/or drug abusers, mentally ill and suffering from chronic disease. But once a sub-population like HUMS is identified, tailored interventions can be rolled out, for example establishing a medical home at a community health center or safety-net hospital that helps coordinate all the services accessed by a given individual—substance abuse treatment, mental health care, medical care and housing.

To deal with teen pregnancy and birthrate there needs to a similar emphasis on micro-data and, if you will, micro-interventions. It’s great that the teen birthrate is going down in the country as a whole, but the fact is that American teens are still two and a half times as likely to give birth as compared to teens in Canada, around four times as likely as teens in Germany or Norway, and almost ten times as likely as teens in Switzerland. There has been progress, yes, but in South Georgia, for example, the pregnancy rate among 15-17 year-olds is still 40 per 1,000l (the national average in this age group is about 25 per 1,000). In Yuma, Arizona, a county along the Mexican border, the teen pregnancy rate (15-19 year-olds) is 66.6 per 1,000 females  , almost twice the national average. And in New York City, my social worker friend is seeing girls from high-poverty neighborhoods who, according to the latest report from the NYC Department of Health, “are three times more likely to become pregnant than teens in low-poverty neighborhoods.”

According to the Centers for Disease Control, the declines we’ve seen in teen pregnancy and birthrates are primarily due to the effect of stronger pregnancy prevention messages in schools and more teens using effective forms of birth control like oral contraceptives. That means that comprehensive sex ed and policies that promote easier, cheaper access to birth control pills and other contraceptives have had the desired effect. For those who continue to champion abstinence-only education, there is no evidence that this has any effect on reducing teen pregnancy rates—and in fact, may actually may deter contraceptive use among sexually active teens.

So why does teen pregnancy still continue to be so high in the U.S., and particularly in certain “hot-spots?” In a paper that is set to appear in the May 22 issue of the Journal of Economic Perspectives, two economists suggest that it’s actually a symptom of underlying social and economic problems. The root problem, they determined, is that the U.S., unlike its European counterparts, has a very high level of income inequality. This in turn, creates a sense of hopelessness and despair in teens that the researchers found is closely related to higher rates of teen pregnancy.

According to Phillip B. Levine, an economics professor at Wellesley College, “If a young woman sees little chance of improving her life by investing in her education and career skills, or by marriage, she is more likely to choose the security, immediate gratification and happiness of parenthood. Our work captures this idea in a standard economics model of decision-making.”

I don’t know if this theory of opportunity applies to other areas around the country where teen pregnancy rates are far higher than the norm—for example, the entire state of Mississippi where the rate is a nation high of 55 per 1000—but my social worker friend told me it rings true to her. The girls she sees have had pregnancy prevention education, they have easy access to contraceptives and are pretty sophisticated in their knowledge about sex. But they are also far behind in the credits they need to graduate high school, many have difficult home lives, some abuse alcohol and drugs, and they live in poverty in a city that also lays claim to some of the wealthiest people in the world.

So what kinds of social policies might help lower the teen pregnancy and birthrate further? The researchers conclude; “opportunity is the most effective birth control for teens.” A summary of the journal study concludes: “If the problem is perceived lack of economic opportunity, then policy interventions need to attack that. Access to early childhood education programs and college financial aid, for instance, have proven to be successful in improving the earnings–and sense of hope–of participants. Our findings show that these programs may also have the added benefit of lowering teen pregnancy rates. Giving teens a sense of opportunity and hope may be a much more powerful prescription than abstinence-only, sex education, or birth control combined.”

This is not a simple solution. It certainly is a lot easier for the federal government to throw $50 million at abstinence education programs; cross our fingers and hope that kids learn to “Just Say No.” But in specific areas that continue to buck the trend when it comes to teen pregnancy and birthrates, it might be necessary to put policies in place that do address the deeper socio-economic issues that make having a baby the only rewarding choice for teens facing an otherwise bleak future.

(This post is excerpted from a series that originally appeared on Healthinsurance.org)

When Vice President Joe Biden told President Barack Obama that health reform is a BFD, he wasn’t kidding—especially for women. Currently, state law decides what insurers have to cover. Under the Affordable Care Act, federal law will call for equal benefits in all states.

The male body has long been considered the “standard” for health care coverage. Having a woman’s body is seen as an expensive anomaly, and women pay dearly for being different. When they buy their own health insurance in the individual market, women must lay out an extra $1 billion a year, simply because they are women.

Take maternity care: In the 41 states where such benefits are not mandated, a 30-year-old woman will find that only 6 percent of plans in the individual market now offer coverage. Guess how expensive those plans are? Under the ACA, maternity care will be considered an “essential benefit” that all insurers selling policies to individuals and small businesses must cover, without charging extra, beginning in 2014.

Some argue that charging women more for insurance is only fair: after all, a woman could become pregnant, and labor and delivery are costly.

But the truth is that, even when maternity benefits are excluded, one-third of all health plans charge women at least 30 percent more, according to a report released last month by the National Women’s Law Center. In 36 states, “92 percent of best-selling plans charge 40-year-old women more than 40-year-old men,” the Center reports, and “only 3 percent of these plans cover maternity services … One plan in South Dakota charges a woman $1252.80 more a year than a 40-year-old man for the same coverage.”

Today, less than half of American women can obtain affordable insurance through a job, which explains why millions buy their own insurance in the individual market. In that market, just 14 states ban gender rating:  California, Colorado, Maine, Massachusetts, Minnesota, Montana, New Hampshire, New Mexico, New Jersey, New York, North Dakota, Oregon, Vermont, and Washington.

Pricing based on gender also plagues the small group market, where insurers frequently jack up premiums if a small or mid-size business employs too many women. This means that many of these employers just cannot afford to offer insurance. Only 17 states address the problem.

Insurers explain that women cost them more, even if policies don’t cover maternity, because “they are more likely to visit doctors, get regular check-ups, take prescription drugs, and have certain chronic illnesses.” In other words, women are penalized for taking care of themselves. As for those “female chronic ailments,” men also are more vulnerable to certain diseases – including many caused by smoking (23 percent smoke vs. 17 percent of women). But insurers ignore male vulnerabilities. As Soraya Chemaly points out on BlogHer: “In most markets if you are a non-smoking female you will pay more than a smoking male of the same age because you possess ovaries and not testes.”

And that is if you can get insurance.

All too often, women are closed out of the individual health insurance market because their medical history reveals a pre-existing condition. Rules discriminate against millions of women for a long list of commonplace reasons including:

In 45 states, insurers can reject a woman because she has had a C-section – even if it was medically mandated.

• If a woman has survived breast cancer, this is a pre-existing condition
• If she is pregnant when she applies, this also is considered a pre-existing condition, just like cancer.  Most likely, she will be turned down.
• If she is of child-bearing age and has children, this may well viewed as a pre-existing condition, leading to higher premiums
• On the other hand, if she is infertile, this too, can be labeled a pre-existing condition.

Not long ago, House Minority Speaker Nancy Pelosi summed up the hurdles: “If you’re a woman, it’s a pre-existing condition.”

The Affordable Care Act (ACA) would help fill many of the coverage gaps we currently experience in women’s health care. Important provisions include:

Preventive services with no co-pays or deductibles: New Policies (issued or renewed on or after September 23, 2010) are required to cover services that many women need  – mammograms, Pap smears, at least one well-woman care visit a year, contraceptive products and counseling, and screening and counseling for interpersonal and domestic violence. In 2018, these requirements will apply to all plans.

Essential benefits: In 2014, both all plans sold inside the new state-run health insurance exchanges and all new plans sold outside of the exchanges will be required to cover a specific set of essential health benefits. For women, these include maternity and newborn care; mental health services (including counseling for post-partum depression); preventative and wellness services; contraception; chronic disease management; and pediatric services for her children, including dental and vision care.

At the same time, the legislation bans:

Gender rating: In 2014, charging women more because they don’t have a Y chromosome will be outlawed both in individual and small employer markets. After 2017, if a state lets large employers into its exchange (and many will), the rule will apply to all large-employer coverage in the state.

Charging more for pre-existing conditions: Starting in 2014, insurers cannot charge higher premiums, or deny coverage due to a person’s pre-existing conditions.

The bottom line: Under the Affordable Care Act, women’s bodies will no longer be viewed as exotic, costly deviations from the norm that just don’t fit into a health care system designed by, and for, men.

What happens if the Supreme Court overturns the individual mandate?

The Court might rule that if everyone is not forced to buy coverage, insurers shouldn’t be forced to cover everyone—especially if they are suffering from pre-existing conditions. (Without a mandate, the reasoning goes, many Americans will wait until they fall ill, and only then purchase coverage, secure in the knowledge that insurers will have to cover them, and can’t charge them more).

Even if you don’t like the mandate, you should consider what it would mean for women if insurers can charge patients suffering from a “pre-existing condition” whatever they like.

For example, a recently divorced 62-year-old woman who is no longer covered by her husband’s insurance may find that she is closed out of the insurance market because she is a breast cancer survivor. Even if she can find an insurer who will take her, the penalty for having a pre-existing condition may well be more than she can afford. In insurance parlance, she will have to “go naked” until she is eligible for Medicare, keeping her fingers and toes crossed that her cancer does not recur or spread over the next three years. (If it does, she will have to spend down whatever savings she has, and perhaps sell her home, before she will be eligible for Medicaid.)

Or consider the case of a young woman who discovers that she is pregnant. She and her husband were not planning on having a child so soon. Suddenly, they find themselves facing thousands of dollars in medical bills. If the woman needs a C-section they may wind up owing as much as $24,400. (Five percent of U.S. hospitals actually charge more.) And that is if there are no serious complications.

It is extremely unlikely that the Supreme Court will declare the entire Patient Protection and Affordable Care Act unconstitutional. Whatever the Court decides in June, women will retain protection against much of the sexual discrimination embedded in our current health care system – unless lawmakers set out to eviscerate the ACA.

As Chemaly points out on BlogHer: “The openly stated primary priority of the Republican Party is to overturn this law.” If that happens, “these discriminatory practices will continue and women will pay in complex ways.”

Even if President Obama is re-elected, Republicans and Democrats who oppose reform could constitute a majority in both houses, and might even have enough votes to overturn a veto on certain controversial issues—such as gender rating, or essential benefits. Many men believe that women should pay more. And they are not happy about covering maternity benefits, contraception, or post-partum depression.

Meanwhile, without the Affordable Care Act, we cannot count on insurers to mend their misogynistic ways. Four years ago, the Women’s Law Center issued a national report titled “Nowhere to Turn: Insurance Companies Treat Women like a Pre-Existing Condition.”

Back then, the Center reached conclusions very similar to what it said in the report released last month. In 2008, “Some insurance executives ‘expressed surprise at the size and prevalence of the disparities,’” Chemaly notes, but “apparently these executives weren’t surprised enough to do anything about it. . . By failing to rectify clearly discriminatory policies despite years of awareness, they continue to demonstrate their untrustworthiness.”

This is why, in the run-up to this fall’s election, voters should take a close look at their Senators’ and Representatives’ records when voting on major health legislation. Not only women—but the many men who care deeply about their daughters, wives, mothers, and sisters—should think carefully about what repeal could mean for those they love.

Maggie Mahar is a notable health care policy blogger as well as the former Health Fellow at The Century Foundation where she was editor of HealthBeat. She is the author of  “Money-Driven Medicine: The Real Reason Health Care Costs So Much” (Harper Collins 2006)

First Warren Buffett, 81, announced to his Berkshire Hathaway shareholders that after a routine PSA test, followed by a surgical biopsy, he had been diagnosed with early-stage prostate cancer and planned to undergo a two-month course of radiation therapy.

This announcement immediately set off controversy as prostate cancer experts weighed in on Buffet’s case and bemoaned the precedent it sets. In 2008, the United States Preventive Services Task Force (USPSTF) and other medical organizations began discouraging men over age 75, and their doctors, from using the PSA test. Although it can detect silent prostate cancer, the false positive rate is high and the vast majority of these older men would die of something else in the 10 to 20 years that it would generally take for the cancer to even cause clinical symptoms.

Meanwhile, as Marc B. Garnick, professor of medicine at Harvard Medical School and a prostate cancer expert writes on the Harvard Health Blog, “Buffett’s PSA test set off a disastrous chain of events that will probably do the legendary money manager more harm than good.” Immediate side effects of radiation treatment, writes Garnick, include fatigue and bowel problems; “Over the long term, about 50% to 70% of men lose the ability to get or sustain an erection or experience rectal bleeding.” The better choice is clearly “watchful waiting”—close surveillance and treatment only when and if the cancer progresses.

Now it turns out that Buffet is far from an outlier among men over 75 who, despite recommendations to the contrary, are still getting routine PSA tests. In a research letter published today in the Journal of the American Medical Association, we discover that “Despite the USPSTF recommendation against prostate cancer screening in men aged 75 years or older in 2008, PSA screening rates did not change [in 2010].” In fact, among men 75 and older, some 43% were getting screened in 2008 vs. 44% two years later. This is higher even than the 33% of men aged 50-59 who are getting routinely screened.

In case patients and doctors haven’t kept up with the evidence, here are the undisputed facts about PSA screening and men over 75: The USPSTF gives the test a D-rating and the American Cancer Society holds  that “men with no symptoms who are not expected to live more than 10 years (because of age or poor health) should not be offered prostate cancer screening.” Or as Richard Albin , one of the discoverers of PSA wrote in a 2010 op-ed piece for The New York Times, “men lucky enough to reach old age are much more likely to die with prostate cancer than to die of it.” Finally, all evidence to date has failed to demonstrate that prostate screening actually decreases mortality.

This is not news. Ablin’s op-ed two years ago noted that 30 million American men were getting the test every year at a cost of  $3 billion, much of it paid by Medicare and the Veteran’s Administration. “The test’s popularity,” he wrote, “has led to a hugely expensive public health disaster.”

Otis Brawley, the chief medical officer of the American Cancer Society and an oncologist at Emory University, has been raising the alarm for years about the overuse of PSA testing and the resulting crisis of overtreatment and ensuing harm to men who undergo surgery, radiation and other interventions. In 2009 he wrote in the Journal of the National Cancer Institute : “Prostate cancer screening has resulted in substantial overdiagnosis and in unnecessary treatment. It may have saved relatively few lives.” He urged doctors to have more respect for the scientific process and scientific evidence supporting a more conservative approach. At that time, Brawley was commenting on a study by H. Gilbert Welch and Peter Albertsen in the same journal that concluded that while; “Prostate cancer incidence has increased since the introduction of prostate-specific antigen screening…Much of the excess incidence may represent overdiagnosis.”

Brawley wrote at the time; “Many men who thought their lives were saved by being screened, diagnosed, and treated for localized prostate cancer are perplexed to learn that so few benefit. They may be even more amazed that this is not a new finding. What is new is the fact that many health professionals are finally accepting it as true.”

It is now almost three years later and it seems that a significant portion of health professionals have still either not gotten the message or, more likely, have chosen to ignore it.

Why? For some doctors and patients it’s a case of unshaken belief in the power of early diagnosis. It seems that no amount of evidence or vetted research findings can convince them that PSA testing doesn’t save lives and that early treatment—no matter the physical or financial costs—is of utmost importance. For others, and I suspect this is the majority, the financial rewards of testing and treatment are driving doctors and hospitals to ignore the evidence and push onward with PSA testing—even for an 81-year-old man with no symptoms.

I return to Otis Brawley to help make this point. His new book, “How We Do Harm: A Doctor Breaks Rank About Being Sick in America” sheds a needed light on the financial conflicts that determine the kind of care we receive, and at a recent meeting of the Association of Health Care Journalists, he said that health care today suffers from “a subtle form of corruption.”

Brawley’s entire speech is available on video  and his is one of the sharpest critiques I’ve ever heard of our “failed” health care system. It holds even more weight because it is coming from someone who is the voice of a seriously mainstream group; the $400 million behemoth that is the American Cancer Society. Brawley bemoans the lack of science and evidence to back up many of the most-used treatments and interventions for major ills like diabetes, prostate cancer and heart disease. He calls out drug companies, hospitals and doctors for valuing profits over patient care and calls for a greater emphasis on prevention and evidence-based care.

And then he talks about prostate cancer.

Brawley recounts an experience he had on a site visit to a hospital in 1998 while an Assistant Director at the National Cancer Institute. During the visit a marketing executive explains to Brawley the publicity value and financial rewards of a free prostate screening program offered by the hospital at a local mall. The plan is to screen the first 1,000 men over 50 who come to the mall for testing. I’ve transcribed Brawley’s recollections from the video and they provide a great explanation for the profit-driven practices that continue to occur today, 14 years later:

“If they screen 1,000 men they’re going to have 145 abnormals. They’re going to charge about $3,000 to figure out what is abnormal about these abnormals, that’s how they pay for the free screening. About 10 of the 145 won’t come to this hospital so that’s business for their competitors, but they’ll get 135 times $3,500 on average. Of the 135, 45 are going to die of prostate cancer and the other percentage are going to get radical prostatectomy at about $30-40,000 a case; there’s a percentage that’s going to get seeds at about $30,000 a case; a percentage were going to get radiation therapy that (at the time) was about $60,000. Then [the marketing executive’s] business plan goes further, he knows how many guys are going to have so much incontinence that diapers aren’t going to do it so he had in his business plan how many artificial sphincters urologists were going to implant. And then he was a little apologetic because there was this new thing called Viagra that screwed up his estimates for how many penile implants he was going to sell because guys were upset about impotence related to prostate cancer treatment.”

Brawley says, “this is 1998, I ask him, if you screen 1,000 people how many lives are you going to save? He took off his glasses and looked at me like I was some kind of fool and said, ‘Don’t you know, nobody’s ever shown that prostate cancer screening saves lives, I can’t give you an estimate on that.’”

These kinds of profit-driven screening programs continue today; radio advertisements paid for by urology practices, hospitals and other interested parties urge testing for all men and early treatment. Ads for the latest robotic surgeries, radiation therapies and other cutting edge treatments for prostate cancer—all paid for by Medicare—that earn hundreds of millions of dollars for health care providers also fill the airwaves. Testimonials from men whose lives were “saved” by testing and early treatment feed the natural desire for consumers to believe in the benefits of testing and technology. Until we begin to create disincentives for testing and treatment that is unnecessary, wasteful and harmful, while at the same time rewarding doctors who provide evidence-based care, our health care system will continue to be “corrupted”.

Last August I wrote an in-depth piece about the American Legislative Exchange Council (ALEC), “a powerful but ‘discreet group’ that counts some 2,000 conservative state legislators as well as representatives from some of the nation’s largest industries as members.” The focus of that post was the prominent role ALEC has taken in organizing state-level resistance to the health reform law. The Council drafted model legislation entitled the “Freedom of Choice in Health Care Act” that has served as the basis for laws passed by eight states (including Virginia, Idaho, and Arizona) and has been “introduced or announced” in 42 others. This law would block any state or federal “public option,” bar the individual mandate and obviate other major provisions of the Affordable Care Act. According to the Council, the mission of ALEC’s health and human services care task force is to promote “free-market, pro-patient health care reforms at the state level.”

Today, Common Cause, a political watchdog group, filed a complaint with the Internal Revenue Service accusing the American Legislative Exchange Council of violating its tax-exempt status by lobbying state legislators. The Council, which is registered as a public charity under section 501(c)(3) of the tax code, recently made headlines because of its support of gun-rights bills similar to the “Stand Your Ground” statute at the center of the Trayvon Martin killing in Florida; advancing laws that weaken labor unions; and support for tougher voter registration rules. Most recently, ALEC has been under scrutiny for its intensive lobbying efforts to convince state legislators to oppose legislation  that would make it easier to recover money from businesses that defraud the state.

The New York Times reported yesterday that documents and records obtained by an investigation by the paper and Common Cause  “offer a glimpse of how special interests effectively turn ALEC’s lawmaker members into stealth lobbyists, providing them with talking points, signaling how they should vote and collaborating on bills affecting hundreds of issues like school vouchers and tobacco taxes.

“The documents — hundreds of pages of minutes of private meetings, member e-mail alerts and correspondence — were obtained by the watchdog group Common Cause and shared with The New York Times. Common Cause, which said it got some of the documents from a whistle-blower and others from public record requests in state legislatures, is using the files to support an Internal Revenue Service complaint asserting that ALEC has abused its tax-exempt status, something ALEC denies.”

In my piece I explain how as part of their campaign against the Affordable Care Act, ALEC  published “The State Legislators Guide to Repealing ObamaCare”, which urges lawmakers to “decline to build the ObamaCare edifice” and offers 14 practical steps states can take to undo or impede the Affordable Care Act. These steps include having states return federal grants for setting up health insurance exchanges, encouraging them to opt completely out of Medicaid, and urging them to file federal waiver petitions to block the medical loss ratio requirement (the new rule requiring insurers to spend 80-85% of premiums on patient care). At that time I wrote, “The last time the states were rallied to rise up against federal legislation was during the civil rights battle over forced integration of schools.”

I am reposting much of this piece below because it illustrates how ALEC consistently flaunts its tax-exempt status; relying primarily on industry funding to lobby conservative legislators to protect their interests–very often at the expense of public health, education and civil rights:

“Although ALEC bills itself as the voice of conservative state legislators, the real voice—and most of the money—comes from powerful corporate interests. ALEC’s membership lists ‘thousands of state legislators,’ who pay token dues of $50 each that account for slightly more than 1% of the group’s funding. According to the Center on Media and Democracy, a non-profit investigative reporting group, the other 98% of ALEC’s funding comes from hundreds of large corporations including Exxon Mobil, Kraft and Altria (formerly Phillip Morris); conservative foundations like Heritage and those bankrolled by Koch Industries and Peter Coors; as well as trade associations like the American Petroleum Institute, the American Rifle Association and PhRMA. Only membership dues are reported in tax filings; ‘gifts’ from corporate members that in some cases have totaled well over $1 million in the past decade add to the group’s coffers and have only recently been unearthed by groups like CMD and the National Institute for Money in State Politics. ‘Those funds help subsidize legislators’ trips to ALEC meetings, where they are wined, dined, and handed ‘model’ legislation to make law in their state,’ writes CMD’s executive director Lisa Graves. “

[The recent Times investigation provides more detail: "Some companies give much more, all of it tax deductible: AT&T, Pfizer and Reynolds American each contributed $130,000 to $398,000, according to a copy of ALEC’s 2010 tax returns, obtained by The Times, that included donors’ names, which are normally withheld from public inspection."]

“Corporate representatives sit on and co-chair (with Republican state legislators) ‘task forces’ that approve ‘legal rules that reach into almost every area of American life: worker and consumer rights, education, the rights of Americans injured or killed by corporations, taxes, health care, immigration, and the quality of the air we breathe and the water we drink,’ according to Graves. Click here to see the CMD’s full report on ALEC, details on the Council’s membership, funding and, for the first time, listings of over 800 ‘model bills’ jointly crafted by its corporate and state legislative members.

As a veritable font of pro-industry legislation (826 bills either drafted or backed by the group were introduced in the states in 2009 and 115 were enacted into law) ALEC is deeply in the pocket of private interests. Elected officials who introduce their bills are disingenuous if they claim to be acting in the interest of their voting constituents. They are more likely to be advancing the agenda of corporate America—often to the detriment of consumers, the environment and public health.

According to the American Association for Justice (a trial lawyers group), ‘ALEC’s campaigns and model legislation have run the gamut of issues, but all have either protected or promoted a corporate revenue stream, often at the expense of consumers.’ Initiatives have included working on behalf of oil companies to undermine the science of climate change; helping pharmaceutical companies block states from importing cheaper prescription drugs; and reducing taxes on tobacco products.

In terms of health care, Wendell Potter, a former health care executive and CMD’s Senior Fellow on Health Care, writes in The Nation, ‘As its archive reveals, ALEC has been at work for more than a decade on what amounts to a comprehensive wish list for insurers: from turning over the Medicare and Medicaid programs to them—assuring them a vast new stream of revenue—to letting insurers continue marketing substandard yet highly profitable policies while giving them protection from litigation.’ This includes model bills that allow insurers to sell products across state lines—including “junk insurance” and very high-deductible plans—even though they may not meet the standards of state insurance commissions.

The 2011 ALEC manifesto is more of the same from this group. But thanks to the treasure trove of information now made public by the Center for Media and Democracy’s “ALEC Exposed” site, the Council’s work has been put under a brighter spotlight. ProPublica has published a “Step-by-Step Guide” for journalists to help them (and the public) understand how ALEC influences state laws—as well as a searchable database of ALEC corporate members donations and the state legislators they influence. Consumer groups and media outlets are starting to delve into this newly available data and publicize the outsized influence of ALEC’s corporate partners on state legislation.”

In my original post I wrote that in July 2011 Common Cause had “called for an Internal Revenue Service audit of ALEC, charging that the group ‘may have filed false tax returns and put its tax-exempt, charitable status at risk.’ In a letter to the IRS, the government watch-dog group wrote, ‘it seems incontrovertible that ALEC is substantially and indeed primarily engaged in attempting to influence legislation [i.e. engaged in lobbying]… All of its efforts are geared toward developing and promoting favored state legislation. These proposals are generated in a private process where the business interests of its corporate members are highlighted, then shared only with the organization’s legislator members so they can take the proposals back to their states and introduce them as their own idea.’

Supporters of health reform and its planned roll-out in the states need to cut through the consumer-friendly façade of proposed laws that mimic ALEC’s legal models, and they need to highlight the complicit role of national corporate interests. Rather than protecting patient rights, ALEC’s recent call to state legislators to block the “ObamaCare edifice” is nothing more than a brazen attempt to protect the profits of insurance companies, pharmaceutical companies and other entrenched players whose actions have helped drive up health care spending to the crisis levels we are currently experiencing.”

It’s heartening that now, some nine months later, ALEC is finally feeling the heat of an IRS investigation. Perhaps it was the recent unwanted attention the Council has received for its lobbying in support of “Stand Your Ground” laws; perhaps it’s the group’s insidious efforts to get states to repeal new rules that make it easier to get money back from fraudulent businesses. But as the national health reform law faces an uncertain future, it’s even more important that efforts by shadowy groups like ALEC to effect state-level health policy be unmasked as the self-interested doings of industry-funded lobbyists; not the consumer advocates they pretend to be.

By John McDonough

(This post originally appeared on the blog Health Stew)

Lots of folks ask me why I think the Affordable Care Act/ObamaCare is so unpopular. I first assert that it’s not as unpopular as popularly characterized (see Kaiser Family Foundation monthly tracking polls) and then I refer to the deliberate and false claims about the law being widely circulated around the nation, particularly aimed at senior citizens. I wrote about one particular falsehood last month. Now, my newfound pals at the GE Retirees Association yesterday sent me another they have been receiving in their email inboxes:

Subject: Medicare Premiums —FYI
MEDICARE
Look clearly at the 2014 rate compared to the 2013 rate.

For those of you who are on Medicare, read the following. It’s short, but important and you probably haven’t heard about it in the Mainstream News:

“The per person Medicare Insurance Premium will increase from the present Monthly Fee of $96.40, rising to:

$104.20 in 2012

$120.20 in 2013

And

$247.00 in 2014.”

These are Provisions incorporated in the Obamacare Legislation, purposely delayed so as not to confuse the 2012 Re-Election Campaigns. Send this to all Seniors that you know, so they will know who’s throwing them under the bus.

Peggy Riehle
Internal Representative
Network Contracting
205-220-6778

Could I verify or contradict the message, my GE Retiree friends wanted to know. Didn’t sound right to me, so I did some investigating. My contacts in the Obama Administration and the U.S. Senate said it’s a viral email lie that has been going around for more than one year now. Independently, FactCheck.org did their own investigation last year of these claims, and here is their conclusion:

This widely circulating message is similar to a falsehood-filled screed that went around last year, urging “retribution” against members of Congress in the 2010 midterm elections. This message makes somewhat different accusations — also false — and urges voters to “remember” in November 2012. …

It claims that “those of you who are on Medicare” can thank “Obamacare” for increases in the per-person monthly Medicare premium — “to a wonderful $247.00 in 2014.” This is also false. The basic premium for Medicare Part B (which covers physician services) was indeed $96.40 in 2009. But the other numbers are all wrong. It was $110.50 last year, for example, and not $104.20 as claimed. And it is $115.40 this year, not $120.20 as claimed.

Actually, only 27 percent of Medicare beneficiaries are paying the basic rate. The rest — 73 percent — are paying less under a “hold harmless” provision triggered by the lack of a cost-of-living increase in Social Security this year or last year. Most are still paying $96.40.

As for the future, nobody can say with precision what the basic Part B premium will be next year or the year after, let alone in 2014. The premium is set each year at a level calculated to pay for 25 percent of the cost of the coverage. Medicare officials do keep close watch on the trends, however.

And when we contacted Medicare’s Office of the Actuary, we were given these projections — the most recent available — which are current as of the president’s budget for fiscal year 2012 issued in mid-February:

Medicare Part B Standard Premium (projected, February 2011)
2012 $108.20
2013 $112.10
2014 $117.10
Source: Center for Medicare & Medicaid Services

I was particularly intrigued because the vital email in question included the insignia of Blue Cross Blue Shield of Alabama. I called the number in question and it has been disconnected. I contacted the public affairs office of BCBS-Alabama and a lovely woman informed me that the individual in question received the viral email on her home computer, and then inappropriately re-distributed it via her work email with the identifying information. The public affairs office emphasizes the BCBS-Alabama “does not endorse” the message at all, is instituting new rules of conduct for all employees based on this incident and will be holding training sessions for all their associates on the new code in June.  They have been overwhelmed with inquiries regarding the viral message and sincerely wish it would all go away.

The lie, meanwhile, has taken on a life of its own and will not die anytime soon.

And people continue to wonder, why is the ACA so unpopular?

John E. McDonough is a professor at the Harvard School of Public Health. He is the author of the book “Inside National Health Reform”, published in 2011, and was a senior adviser on national health reform to the US Committee on Health, Education, Labor & Pensions (HELP), where he worked on passage of the Affordable Care Act.

The study, published this week in Health Affairs, found that U.S. spending on cancer care, in 2010 dollars, increased by 49% from 1983 through 1999, from $47,000 per cancer case to $70,000 per case. Meanwhile, in the European countries, spending on cancer care (also in 2010 US dollars) increased 16% from $38,000 per cancer case to $44,000. But the sharp increase in cost seems to come with clear benefits; for patients diagnosed with cancer between 1995 and 1999, average survival from time of diagnosis in the U.S. was 11.1 years, while in Europe it was 9.3 years. These gains were greatest in patients with prostate and breast cancer, as well as chronic and acute myeloid leukemia.

At first glance, this study, which was partially funded by cancer-drug maker Bristol-Myers Squibb, should give ammunition to those stalwarts who continue to insist that America’s health care is the very best that money can buy—at least when it comes to cancer. But despite the findings that the “value of survival” far outweighs the skyrocketing financial costs of cancer care (the National Cancer Institute puts it at $125 billion in 2010)—many questions remain.

First of all, the Health Affairs authors do note some limitations of the study; for example, even though the results suggest that survival gains for U.S. cancer patients have been “worth it” in terms of cost, “this does not imply that all treatments are cost-effective. Additionally, we could not examine the extent to which better outcomes were the result of earlier diagnosis due to screening or newer treatments,” they write. I would add, the data analyzed are more than a decade old—cancer treatments and diagnostic technologies have changed both in cost and efficacy since then. How do we factor in the “value” of a brand new $90,000 cancer drug that keeps a small percentage of very sick patients alive for at most two or three more months?

There are other problems with reading too much into this report.

Here’s something interesting I found in the study: “US mortality rates for cancer are lower than those in Europe, despite higher rates of cancer incidence in the United States.” My first question was why do we have higher rates of cancer incidence in this country? Is it our diet, exposure to pollutants, smoking rates or other environmental or even genetic determinants? None of these seems likely (especially the smoking bit), but there is one major difference. We do a lot more cancer screening in the U.S. than in Europe and this can be a double-edged sword.

While it is true that screening tests like mammography and PSA testing can catch cancers at an earlier, more treatable stage, early diagnosis can also lead to seemingly longer survival times. The researchers explain that they avoided so-called lead-time bias—meaning a person appears to survive longer if they are diagnosed 6 months before another—by comparing changes in mortality rates overall. “By analyzing population mortality rates, which are insensitive to lead-time bias, we show that US cancer mortality rates fell faster than cancer mortality rates in the European Union. This must be due to real improvements in cancer survival.”

But lead-time bias isn’t the only factor that can skew survival data and the authors leave out a very important factor: In the U.S. where preventive screening is used far more frequently than in Europe, there is also a documented rise in over-diagnosis of cancer. A recent study in the Annals of Internal Medicine  found that over-diagnosis accounted for 15% to 25% of breast cancer cases identified by a large screening program. For example, a woman who is diagnosed with a tiny growth in her breast that is unlikely ever to progress (a so-called pseudo-cancer), or progresses so slowly that she will die of something else, would be counted as one who has been “cured” of cancer through early diagnosis and better treatment in the Health Affairs study. She will have undergone surgery, radiation, and perhaps chemotherapy that cost tens of thousands of dollars—treatment that likely caused physical and psychological harm, but in the end added no “value” in terms of extra life-years.

The same is true for prostate cancer, where some 70% of men diagnosed with a prostate-specific antigen (PSA) test have a low-risk form of the disease. According to a report in the journal Oncology, “over 90% of these men will be treated for their disease at diagnosis although it is estimated that up to 60% of men may not require therapy, even over the long term.” The report adds that a recent cost-effectiveness analysis of PSA screening estimated that the cost of diagnosis and treatment is over $5,227,306 per patient to prevent one death from prostate cancer.

The Health Affairs authors, led by Tomas Philipson, professor of public policy at the University of Chicago and senior economic adviser for the FDA and CMS during the second Bush presidency, do not consider that survival rates might be inflated partially due to this considerable problem of over-diagnosis in the U.S., a country far more enamored with screening mammography and PSA testing than their counterparts in Europe. Instead they find the opposite; “Finally, earlier detection and management associated with increased screening for breast cancer through mammography, and for prostate cancer through prostate-specific antigen testing, in the United States relative to Europe also could have been responsible for improved US patient outcomes.”

There is one more important question about cancer treatment and survival that was not addressed in the Philipson, et. al. study: If you include the pain, suffering and loss of quality of life some cancer patients experience during those extra months of survival, is the cost of care still “worth it?”

To help answer this, I urge you to read a companion story in Health Affairs by Amy Berman, a 51-year-old registered nurse and senior program officer at the John A. Hartford Foundation who was diagnosed with incurable inflammatory breast cancer and has chosen to take a palliative approach to treatment of her disease. She writes;

“Is there a downside to aggressive treatment? You bet. In the case of incurable cancer, it can mean rounds of radiation or chemotherapy, or both, with side effects of crushing fatigue, overwhelming nausea, burned and peeling skin, permanent pain or numbness of fingers and toes, and the cognitive impairment known commonly as “chemo brain.” The ‘treat aggressively’ approach can leave patients bruised and battered, wishing they were dead.”

She adds, “Yes, perhaps, a few months of added life come with it—but at what cost?”

Finally, doctors who treat cancer patients note another, less corporeal “toxic” effect of high-cost cancer treatment in America. Two oncologists from the Duke Cancer Institute wrote in Kaiser Health News last August; “We know that the experience of receiving cancer treatment can result in a physical toxicity, but recent data suggest that cancer treatment might also cause financial toxicity that affects the daily lives of patients and their families.” The Duke doctors cited a study they conducted where they found that although 99% of the mostly older cancer patients were insured (83% with prescription drug benefits), they still paid an average of more than $700 a month for their cancer care out of pocket. Most reported going through their life savings to foot the bill; 11% described cancer care as a catastrophic financial burden.

This begs the question of why are we Americans paying so very much for our cancer care? We won’t really know if it’s “worth it” until we find out which factors are actually responsible for the survival gains over our European counterparts seen in cancer treatment—is it earlier detection? Better chemotherapy drugs? More targeted therapies? Surgical advances? Or are some of our gains really due to over-diagnosis or unwanted treatments that may boost survival a couple of months but destroy a patient’s quality of life?

Instead of witnessing live theater, I read as much as I could before setting off in the morning or before falling asleep that night. And I talked to pretty much anyone I ran into about how they felt about the new health law and how it would impact their lives. Mostly, I learned that for the many young, uninsured people who worked two or three jobs to survive in that town, health reform offered the chance for affordable health coverage. As removed as I was from the doings in Washington, media coverage began to feel like breathless conjecture; the fate of the health law seemed to vacillate widely with every pointed question from one of the justices or a poor performance by the Solicitor General. I am not a constitutional scholar, nor am I an economist. But now, back in New York and a week removed from the reporting frenzy and after digesting commentary by both knowledgeable experts and political hacks (and those in between) the emphasis has shifted to the ramifications of the Supreme Court’s eventual ruling. I will expand on some of these issues in future posts, but first I want to address the science and politics of predictions.

1) On Monday, President Obama said of the health law, “We are confident that this will be upheld because it should be upheld,” adding firmly: “It’s constitutional.” He also warned that an “unelected” group of justices should not overrule the will of Congress. That is tough talk; perhaps the right kind of talk to set the tone for the next few months while the Supreme Court considers the legislation. Nancy Pelosi is also on board: Last week she told reporters, “I have no idea. None of us does,” when asked how the Supreme Court would rule on the health law. But on Tuesday she also expressed this new confidence, telling an audience at The Paley Center for Media, “Me, I’m predicting 6-3 in favor.”

But is the administration’s confidence realistic? I turn to some stalwarts; the legal scholars and policy wonks who have insisted for nearly two years that the constitutional challenge is legally unsupportable. Have they changed their tunes at all?

2) Jonathan Gruber, MIT economist and a chief architect of both Massachusetts’s health plan and the ACA tells the Daily Beast;  “Going into the hearings I was very confident. Now I am less so. Almost all experts have said this was a very clear legal call in favor of the mandate, but the conservative justices appear to be taking a very libertarian stand in their questioning. I still think it will pass muster, but 5–4 at best.”

3) In January, Timothy Jost, law professor at Washington and Lee University School of Law, told Health & Hospital Networks that he suspected that the Supreme Court will hold “everything to be constitutional” and “[t]hat should put to rest the argument that the statute is unconstitutional.”  Jost, who has exhaustively read and analyzed the ACA was not completely sanguine—raising the specter that the Court will uphold all but one or two provisions of the health law like the minimum coverage requirement, but leave the rest of the statute in place. “Then there is a real question as to how that is going to work.”

Last week, after the arguments, Jost wrote in Health Affairs, “I find it hard to predict where the Court will end up. The Court seems to have little appetite for going through the ACA section by section deciding which provisions stay and which go. The justices did not seem to be convinced by the federal government’s textual argument that only the community rating and guaranteed issue provisions had to go with the minimum coverage requirements. Justice Scalia seemed ready to jettison the whole statute, but, although Justice Kennedy seemed troubled by the cost to insurers of dumping only the coverage requirement, the justices did listen respectfully to Mr. Farr’s (court-appointed attorney H. Bartow Farr III) argument that all of the statute should be preserved if the coverage requirement is stricken.”

4) Renée Landers, Professor of Law at Suffolk University Law School and Deputy General Counsel for the U.S. Department of Health and Human Services under Clinton thinks the mandate itself might survive. “It’s very hard to tell what can happen as a result of the oral arguments,” she writes, also in Health Affairs. But based on the arguments, Landers puts Justice Alito “firmly into my ‘no’ vote column.” Yet she adds that either Chief Justice Roberts and/or Kennedy could still vote for the health law—along with the four Democratic appointees. “I don’t think all bets are off yet,” she said. “Reports of its demise are premature.”

Of course there are more partisan commentators who are predicting a clear win or a sure demise for the health law. (On the sure demise side is Ilya Shapiro, a senior fellow in constitutional studies at the Cato Institute who helped write a brief opposing the law, and told Bloomberg that he sees Justices Scalia, Thomas, and Alito “joining together to invalidate the Patient Protection and Affordable Care Act’s individual mandate, with Chief Justice John G. Roberts Jr. and Justice Anthony M. Kennedy likely tagging along.”)

Aside from experts, there is also a cadre of professional odds-makers when it comes to Supreme Court rulings that uses elaborate models to predict how the court will rule. But, as Brian Palmer explains in Slate, “[a]s a general rule, legal scholars are able to call around 60 percent of cases correctly, simply on the basis of their expertise and intuition.” Oral arguments were thought to be less important in how a case will ultimately be decided. But that has recently changed. There is growing evidence that oral arguments do, in fact, offer very useful data for predicting the outcome of a Supreme Court case, writes Palmer. “Drawing on this insight, many political scientists now incorporate language analysis of the arguments into their models.” What do they look for? Justices seem to ask more questions of the side that ultimately loses so analysts might simply perform word counts. The emotional content of the wording of what Justices direct toward lawyers seems to also be important; the side that receives the most “unpleasant” questioning and commentary is more likely to lose. As Palmer notes parenthetically, “(Justice Scalia has a habit of telegraphing his vote by using words like “idiotic” during oral argument.)”

A “state-of-the-art” model that includes language analysis of the Supreme Court arguments “suggests that the court will declare the individual mandate unconstitutional by a 5-4 vote,” according to Palmer. “The big question mark, of course, is swing voter Justice Kennedy. He asked Solicitor General Donald Verrilli Jr. two more questions than he asked the challenger’s attorney, Paul Clement, with 14 percent more negative language, suggesting a slight preference for overturning the law.”

Experts, partisans and computer models are clearly not of one opinion–all are hedging their bets. That’s not surprising when you consider that there are multiple critical issues at play—Medicaid expansion, the individual mandate and important coverage provisions that prevent discrimination against people with ongoing illness, as well as Congressional limits and questions about taxation—in deciding the fate of the health reform law. In the case of the ACA, constitutional law issues are hard to separate from economic issues, which are hard to separate from communitarian vs. individual benefits. And then there is the heightened political atmosphere surrounding this, the signature legislation of President Obama’s term. The Justices have conceded that if the health law is dismantled, the sharply divided Congress will not be able to salvage it any time soon. Either way the decision will factor greatly in the 2012 elections. The first political salvos have already been launched, in late June we will find out their impact.

(This post originally appeared on the blog healthinsurance.org)

In 2009, when someone asked Nancy Pelosi a question implying that health reform legislation might be unconstitutional, she replied: “Are you serious?”

Pelosi wasn’t alone. At the outset, many legal scholars considered the challenge to the Affordable Care Act (ACA) both “implausible” and “frivolous.”

But over the next two years, the notion that state courts might strike down the ACA took on a life of its own. Most people had only a hazy idea of what was actually in the legislation; nevertheless the idea of “health reform” inspired heated rhetoric. Soon, state attorneys general and governors responded to the political opportunities, banding together to make what Slate Senior Editor Dahlia Lithwick calls, “novel arguments in the form of what was always a constitutional Hail Mary pass … It’s no accident that until the lower district courts started striking down the act, none of the challengers really believed that they could succeed.”

Yet somehow, this week, the highest court in the land is hearing oral arguments in a case that even supporters viewed as a long shot. How did this happen?

The media played a major role, fanning political passions by quoting every challenge – including the absurd claim that the bill called for “death panels.” As Rachel Maddow observed Monday night: this case was “built up as the Super Bowl of American partisan politics.” Thus, the Supreme Court was left with little choice: it had to hear “The Case of the Century.”

Why media fanned the flames

Why did reporters latch onto the story? First, the media is in the business of selling newspapers and air time. Health reform is a “hot-button” topic.

Secondly, as Linda Greenhouse explains in a scathing New York Times Op-ed: “Journalistic convention requires that when there are two identifiable sides to a story, each side gets its say, in neutral fashion, without the writer’s thumb on the scale” – even when “one side of a controversy obviously lacks merit.” (This is what some call “balanced” reporting.)

“Journalistic accounts of court cases … treat the arguments on both sides with equal dignity,” explains Greenhouse, a Pulitzer Prize winner who has covered the Supreme Court for 30 years, and now teaches at Yale’s law school. “So it’s perhaps not surprising that just about half the public apparently believes that … the individual mandate is unconstitutional.” But Greenhouse comes down on the side “truth-telling” over “balance”:

“I’m here to tell you: that belief is simply wrong. The constitutional challenge to the law’s requirement for people to buy health insurance … is rhetorically powerful but analytically so weak that it dissolves on close inspection. There’s just no there there.”

Nevertheless the media succeeded in blowing the story up, and in two years, what constitutional experts thought was a non-story became a Supreme Court case.

Legal minds saw a ‘non-story’

Over that time, the U.S. Constitution hasn’t changed. The challenge is as thin as it was in 2010, when Charles Fried, who served as soliciter general under President Ronald Reagan, told ABC News that “anyone” who questions the constitutionality of the Affordable Care act “is either ignorant – I mean, deeply ignorant – or just grandstanding in a preposterous way. It is simply a political ploy and a pathetic one at that.”

Prominent legal scholars also spoke out: “States can no more nullify a federal law like this than they could nullify the civil rights laws” said Timothy Stoltzfus Jost, a health law expert at Washington & Lee University School of Law.  Mark A. Hall, a law professor at Wake Forest agreed: “There is no way this challenge will succeed in court,” adding that the cases brought by the states seem “sort of an act of defiance, a form of civil disobedience if you will.” In other words, this was a Tea Party demonstration.

Initially, reform’s opponents lost in two state courts where judges appointed by Democrats ruled against them. They also lost their first case in an Appeals Court where Laurence Silberman, a conservative Reagan appointee who is regarded as a serious constitutional scholar, concluded that there is “no textual support” in the constitution “that mandating the purchase of health insurance is unconstitutional.

But other Republican judges sided with the challengers – most importantly in Florida, where that state and 26 partner states won. The mandate was no longer a Tea Party talking point; it had become an issue that Congressional Republicans took seriously.

This was not always the case. Until very recently, scholars who specialize in the history of health reform explain, the proposition that “it is wrong to allow people who can afford insurance to shift the cost of their care to others by refusing to provide responsibly for their future health needs” enjoyed “broad bi-partisan support … Indeed, ten current Republican Senators who now oppose the minimum coverage requirement as unconstitutional previously sponsored or cosponsored legislation that included an individual mandate.”

‘No free riders’ means everyone must pay

Republicans, like Democrats understood that at some point in time, virtually everyone will need health care. If we don’t want to let “free riders” impose the cost of their care on all of us, we must ask everyone to buy coverage.

Yesterday, Chief Justice John Roberts asked if the government has the power to require that everyone buy a cell phone. The answer is “No,” because cell phones are not a necessity. If someone doesn’t have one, the rest of us don’t feel obliged to buy one for him. But health care is a necessity. And in our society, we are not inclined to leave people to bleed to death on the sidewalk because they didn’t buy insurance.

It is only recently, as health care reform became “Obamacare,” that conservatives have disavowed a mandate they once embraced. In other words, it seems that they are objecting, not to the idea everyone who can afford it should purchase insurance, but rather to the fact that President Obama has succeeded in doing what so many past presidents have tried and failed to do.

Could it be that this debate is really not about the Constitution, but instead, about what Senate Minority Leader Mitch McConnell has called Republicans’ “number one goal” – to get Obama out of the White House?

That said, I remain extremely hopeful that when the justices hand down a decision in June, they will act as officers of the court, not as politicians.

Maggie Mahar is an author and financial journalist who has written extensively about the American health care system. Her book, Money-Driven Medicine: The Real Reason Health Care Costs So Much, was the inspiration for the documentary, Money Driven Medicine. She is a prolific blogger, writing most recently for TIME’s Moneyland. Previously she wrote and edited the Health Beat blog for the progressive think tank, The Century Foundation.

It’s just too bad that these could be the first consumer protections to go if the Supreme Court overturns the Affordable Care Act’s individual mandate. That’s because, as Uwe Reinhardt, an economics professor at Princeton points out, “The aim is to create a risk pool in which younger and healthier enrollees subsidize through their community-rated premiums the health care of older or sicker individuals.” Otherwise, people wait until they are sick to buy insurance, quickly using up all the resources of a plan they haven’t contributed to when they were healthy. This inevitably drives up premiums for everyone. The ACA without an individual insurance mandate says Reinhardt, “is about as sensible as the idea of manufacturing two-legged stools.”

Americans haven’t grasped that connection; most consumers still believe that all the things they like about health reform—such as keeping their children on their health plans until they are 26, free preventive care, no lifetime limits on coverage and the promise of subsidies to help lower income people afford insurance—will still be available without the mandate. In fact, the Kaiser poll found that two thirds say they continue to have an “unfavorable view of the individual mandate, including 54 percent who take a ‘very unfavorable’ (up from 43 percent last November)” opinion of the provision.

How do we know that insurer coverage mandates won’t work without an accompanying mandate for all Americans to buy insurance? Just take a look at what Ian Millhiser, a policy analyst at the Center for American Progress calls “Seven Horror Stories” from states that already tried to implement community rating without a requirement that everyone purchase insurance:

• Kentucky: Forty insurers left Kentucky’s market by some estimates, and only two remained before the law was repealed

• Maine: Thirteen of Maine’s 18 major insurance carriers stopped issuing new individual policies. Many also doubled their premiums

• New Hampshire: New Hampshire’s insurance law left it with nearly no carriers in its individual insurance market. The state enacted an emergency tax to compensate insurers for the costs of the law, which was repealed in 2002

• New Jersey: Premiums rose as much as 350 percent in New Jersey after its pre-existing conditions law took effect. Even HMO plans, which tend to resist premium increases, nearly doubled in price

• New York: The percentage of nonelderly New Yorkers without insurance grew 21 percent, with premiums increasing as much as 40 percent per year.

• Vermont: Vermont fared better than other states with similar laws, but its premiums spiked an average of 16 percent in two years.

• Washington: Nonmanaged care options disappeared entirely from Washington’s individual market. Eventually, entire counties had no private individual insurance options at all.

(source: Center for American Progress )

Insurers are already working on contingency plans if the Supreme Court finds the individual mandate unconstitutional. According to the Wall Street Journal;

“Several officials from large health insurers said that if the mandate were struck down, their first priority would be persuading members of Congress to repeal two of the law’s major insurance changes: a requirement to cover everyone regardless of his or her medical history, and limits on how much insurers can vary premiums based on age. The next step, they say, would be to set rewards for people who purchase insurance voluntarily and sanction those who don’t.”

Insurers are also likely to lobby for an end to restrictions on gender rating; i.e. charging women more than men for insurance coverage. According to a new report from the National Women’s Law Center,  in the 37 states that haven’t already banned this practice, 92% of best-selling plans charge women more for coverage. These excess charges vary between states and even between policies in the same state. For example, one plan offered in Arkansas charges 25-year-old women 81% more than men for coverage while another plan in the same state charges women only 10% more for coverage. The Affordable Care Act would prohibit gender rating; a practice that the NWLC report estimates costs women $1 billion a year.

The Obama administration agrees with insurers on the economic ramifications of the Supreme Court striking down the individual mandate. It has filed a brief arguing that if this happens, the requirement that insurers cover everyone who applies and that they use community rating should be overturned.

Despite the contingency plans, many legal and health policy experts believe they will be unnecessary—at least for now. “Most of us who supported the individual responsibility provisions feel the court is going to sustain [the individual mandate],” Ron Pollack, executive director of Families USA tells Kaiser Health News. “There’s no urgent need to define an alternative course at this point.”

The repeal effort, for an advisory board whose function may be limited if Medicare cost growth continues to abate, seems timed for maximum political effect; highlighting a provision of the Affordable Care Act that conservatives use as the poster child for government over-reach and collateral damage to seniors.

Here’s an excerpt from a video series called “Ask Peter” released by Rep. Peter Roskam (R-IL) that “educates” his local constituents about IPAB:

“In a nutshell, it’s 15 unelected bureaucrats who have one job and that is to push cost out of Medicare. While that sounds nice, it will have a direct impact on reimbursement rates which will ultimately impact how doctors practice medicine.

“There was an expert on IPAB that came in and testified before a Committee that I was present, and he said this: IPAB will absolutely restrict a doctor’s ability to administer healthcare. And he went on to say that IPAB will lead to rationed care.”

It’s clearly necessary to revisit the real facts about IPAB and shed some light on Pete’s and his fellow scaremongers’ rationing charges:

1) IPAB’s cost-cutting recommendation process isn’t triggered unless Medicare spending grows faster than the gross domestic product (GDP) plus 1 percent. As Sarah Kliff explains in Ezra Klein’s WonkBlog, “For a while, keeping Medicare cost growth to GDP plus 1 percent was thought to be absurd. Medicare cost growth vastly outstripped the rest of the economy.” But in the last two years, she writes, “health-care costs have grown more slowly than any other point in the past five decades. They rose 3.8 percent in 2009 and 3.9 percent in 2010.” The GDP, meanwhile, grew at 4.2%.

2) The board, which will include health policy experts and consumer representatives, has no authority to limit Medicare benefits; for example, it can’t force Medicare to stop paying for cancer drugs or cut off life-saving treatments to the elderly.

3) The board cannot increase beneficiaries’ out-of-pocket costs.

4) The board is explicitly barred from “rationing” care.

5) IPAB can propose legislation that affects provider payments—for example, adopting payment policies that reward quality and efficiency

6) If Congress fails to enact IPAB’s proposed recommendations, it must come up with its own legislation that achieves the same cost savings.

7) If Congress fails to enact IPAB’s recommendations and fails to come up with it own cost saving measures, then it can decide to let costs continue to rise unchecked. The catch is that this opt-out decision must be approved by three-fifths of the Senate.

8) If this vote fails, then the Secretary of the Department of Health and Human Services must implement IPAB’s recommendations.

9) This action cannot be overruled by the judicial nor the executive branches

The current repeal effort was, until recently, billed as a bi-partisan movement. The board’s ability to bypass Congress if it fails to act is what persuaded some 20 Democrats including Barney Frank (D-MA), Allyson Schwartz (D-PA), Pete Stark (D-CA), the ranking Democrat on the House Ways and Means Health Subcommittee, and Frank Pallone (D-NJ), the ranking Democrat on the House Energy and Commerce Health Subcommittee to sign on to the repeal bill.

As Pallone tells Forbes; “IPAB, like other independent commissions, encroaches upon legislative authority.” Stark, quoted in the same article says, “Congress has always stepped in to strengthen Medicare’s finances when needed. I see no reason why Congress would or should hand that authority over to the executive branch. To do so undermines the separation of powers.”

But as Kevin Outterson explains in the Incidental Economist, the Affordable Care Act created IPAB precisely because Congress has not always acted to strengthen Medicare’s finances (the continual punting of the “Doc Fix” is one recent example):

“Medicare is beset by special interest groups that fight for the continued flow of funds to their narrow range of CPT or DRG codes, without much real concern for the overall health of the program or population. Some Medicare cuts become a political quagmire (DME [durable medical equipment] competitive bidding demonstration projects come to mind) or result in political horse-trading without a coordinated plan.”

Outterson continues, “This is why Congress created the IPAB – choosing to have their hands tied like Odysseus, lest they respond to a Siren song by lobbyists.”

Interestingly, in recent days the House Democrats have mostly abandoned their support for IPAB repeal. That’s because in order to offset the $3 billion that the Congressional Budget Office projects repeal will add to the budget deficit, Republicans are now including malpractice reform to the proposed legislation. They are calling for a cap on punitive damages in health care lawsuits to $250,000 or two times the amount of economic damages awarded, whichever is greater. Tort reform should delight the American Medical Association, which already strongly opposed IPAB and was lobbying for repeal, but adding it to the bill was a deal-breaker for the Democrats. Barney Frank told TPM that the repeal bill had lost his support–and likely that of other Democrats; “He said the two measures are unrelated and decried the move to link them ‘an overreach to appease the right wing.’”

Perhaps the Democrats have also come to realize that jumping on the repeal bandwagon will never end well. They may have thought that showing bipartisan support for an effort to rid the health care law of an unpopular—and maybe unneeded—provision would signal flexibility to voters. But conservatives don’t just want to repeal IPAB; they want to undo all of the health reform law and are using this one small provision to rally their troops as the election approaches and the Supreme Court gets ready to start hearings on the individual mandate and other parts of the ACA.

Their righteous outrage at this “rationing board” is especially galling because in the past, Republicans have embraced and even proposed boards similar to IPAB. For example, Outterson cites the example of the Defense Base Realignment and Closure Commission (BRAC)—an independent board that since 1990 has been evaluating military base requirements and makes recommendations to the President about which ones to close. If the President disagrees with the recommendation, it is sent back to the BRAC. If the President agrees with the recommendation, it goes to Congress. “The Secretary of Defense is then required to follow the BRAC report unless Congress passes a joint resolution of disapproval within a limited time under pre-defined House and Senate rules…The reports have been implemented every time.”

And the idea of an independent board that conducts cost-effectiveness and quality research and then drafts policy and payment guidelines—separate from Congress—is actually an idea that originated in the Republican-sponsored Patient’s Choice Act of 2009. This legislation, sponsored by Rep. Paul Ryan and others, created two oversight boards; the Health Services Commission, and a Quality Forum and included a subcommission comprised of “15 individuals nominated by private sector health care organizations,” with representatives from the health insurance industry, provider groups, non-profits and rural health organizations. According to Don Taylor, also writing for the Incidental Economist, “The bodies proposed in the PCA had more teeth, including provisions to allow for penalties for physicians who did not follow the guidelines, than does the Independent Payment Advisory Board (IPAB)…”

Taylor wrote more recently; “IPAB is a prime example of a policy idea that ended up in the Affordable Care Act (ACA) that had its genesis in a Republican sponsored bill, or line of policy thought. It is an example of something that appeared to be bipartisan in policy terms (the need for boards insulated from Congress) that became politically toxic once it appeared in the ACA.”

Support for repeal—especially from Democrats—could also stem from reasoning by some legislators that since health care costs are now rising more slowly than the gross domestic product (GDP), the IPAB is irrelevant. They argue that fundamental changes already taking place in pricing, payment reform and care delivery are responsible for the slowing we’ve seen in the rise of health care costs. But this could be short-sighted. There is also evidence that the weak economic recovery is playing a role. More people are unemployed, uninsured or have insurance policies with larger co-pays and deductibles. They hold back on going to the doctor, buying medication and undergoing outpatient procedures. As Jack Rowe, former CEO of Aetna and now a professor of health policy at Columbia University’s Mailman School of Public Health asks, “Is this the new normal or an effect of the recession?” His answer; “Most people I know believe we will have a return to the increases we’ve seen in the past.”

If that is even partially the case, then the argument that IPAB is irrelevant doesn’t hold much weight.

In the end, this is not the time to repeal IPAB. This is not the time to scale back on any of the health law’s provisions or to dilute federal power to enact reform. Instead, it is time for the Obama administration and the ACA’s supporters to do a better job educating the public about the law’s benefits and dispelling the rumors and threats spread by its opponents.