Affordable Care Act

Medicare-for-All Debate Reflects Voter Interest in Health Care

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Health care was a major issue in the 2018 midterm elections and promises to be center stage in the upcoming 2020 presidential election, as reflected by growing support for concepts behind Medicare-for-All legislation.

Medicare-for-All has become a campaign battle cry, even though what it actually means is far from clear.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

Senator Bernie Sanders made radical health care reform a top-rung political priority in his 2016 presidential bid. Sanders is running for president again and now has a lot of company in calling for a major health care insurance overhaul.

First off, the Medicare-for-All version espoused by Vermont Senator Bernie Sanders isn’t actually an extension of Medicare, which now covers 50 million Americans, but would be phased out over four years. His bill contains provisions, such as coverage for long-term care, that aren’t covered now by the landmark health insurance plan created in 1965. Sanders is short on details of how to pay for more robust and costly benefits.

Most advocates of “Medicare-for-All” are expressing support for a single-payer system under which the federal government would assume the role of a giant, publicly funded health insurer. Sanders and others want to see expanded coverage for current Medicare enrollees as well as universal coverage. An enlarged pool of patients under a Medicare-for-All system would give government officials even more leverage to negotiate lower and more consistent pricing for medical services and prescription drugs.

Elimination of all private insurance, including insurance policies provided through employers, has been branded as “socialism” by Medicare-for-All opponents. For context, opponents said the same thing about Medicare.

Some Medicare-for-All proponents would like to see an expansion of Medicare eligibility and benefits, but not necessarily elimination of all private insurance, which provides coverage for 150 million American workers and their families.

Democrats who pushed through the Affordable Care Act (ACA) in 2010 made a similar political calculation, though they stopped short of including a “public option” that would have provided a government-sponsored health insurance plan. Instead, they opted for expanding Medicaid eligibility on a cost-sharing basis with states.

Some present-day Democrats, including House Speaker Nancy Pelosi who steered the ACA through Congress earlier this decade, still prefer an incremental approach as the logical and politically achievable next step towards universal health insurance. That might involve increased federal funding for Medicaid expansion, restoration of the mandate for everyone to have health insurance coverage or creation of some form of reinsurance pool to smooth out the cost of high-cost patients.

These variations, combined with 23 Democratic presidential candidates running around the country talking about health care while attempting to differentiate themselves from the herd, have created understandable confusion among voters. That confusion is compounded by continuing efforts by the Trump administration to take the ACA (Obamacare) off the books.

What’s clear is that some provisions of the ACA are very popular, notably preventing people with pre-existing conditions, often chronic illnesses or cancer survivors, from being denied affordable health insurance coverage. That has created a conundrum for congressional Republicans who tried unsuccessfully to repeal and replace Obamacare. Republicans express support for retain the pre-existing condition provision, yet they haven’t successfully landed on a larger platform to address health insurance access – and rising health care costs.

Beyond the debate over Medicare-for-All, health care in America is confusing. There are multiple public players (Medicare, Medicaid, Veterans Health Care, Indian Health Service, public health clinics, hospitals affiliated with public universities, public mental health clinics and public school clinics) and private players (for-profit corporations, nonprofit organizations, medical practices, medical laboratories, hospitals affiliated with private universities and integrated health care systems). 

The divide between health insurance and health care delivery is a blurred line. Many private health insurance policies come with their own networks that limit choice of medical providers.

Adding to this dizzying picture are soaring drug prices, with their own cast of characters that include pharmaceutical companies, pharmacy benefit managers, self-insured corporations, foreign-based internet retail outlets and prescription drug patent attorneys.

The end result is a health care system that is costly, suffers from a lack of coordination and isn’t equitable. One report concluded, “Disparities in access to services signal the need to expand insurance to cover the uninsured and to ensure that all Americans have an accessible medical home.” 

Oregon has pioneered approaches to health care that respond to broader criticisms of the US system, or lack of a “system.” Under a federal waiver, Oregon has promoted increased in-home care for older adults and physically disabled persons that enables independent living and avoids more expensive institutional care. Oregon was among the first states to expand Medicaid eligibility, as permitted under the ACA, and has steadfastly defended that expansion despite rising costs.

Former Governor John Kitzhaber implemented coordinated care organizations serving low-income Oregonians to “bend the cost curve” through innovation and coordination. Since leaving office, Kitzhaber has pushed for investing to redress “social determinants” of health such as a lack of proper nutrition and early childhood education. Health care systems are striving to integrate physical and behavioral care to improve outcomes.

The Washington Legislature enacted this year a first-in-the-nation state-sponsored long-term care social insurance program. Under the program, Washington residents will pay 58 cents on every $100 of income, with the revenue flowing into a Long-Term Care Trust. Residents who pay into the fund for 10 years (three if a catastrophic disabling event) will be entitled to receive $100 a day up to a lifetime cap of $36,500. The money can be used for in-home care, installation of accessibility ramps, home food deliveries or transportation. The payroll tax is projected to generate $1 billion per year.

For many health care observers, actions such as Oregon’s and Washington’s are akin to bailing water out of a sinking boat. They call for a broader, more holistic approach to reform. That isn’t the same as calling for Medicare-for-All, which remains somewhere on the political spectrum between an aspiration and an abstraction.

What seems inevitable is that Americans have grown restive with gridlock as health care out-of-pocket costs and drug prices continue to rise much faster than inflation or wages. The 2018 mid-term election, which saw Democrats unseat GOP congressional incumbents and capture Republican-dominated seats, could be a bellwether of growing voter interest in tangible action on health care. Most prominent Democratic 2020 presidential candidates have apparently heard that message, which accounts for their support for Medicare-for-All or something like it that is significant and meaningful.

 

 

Best Bipartisan Opportunity: Lowering Prescription Drug Prices

The best opportunity in a fractious Congress for bipartisan legislative success appears to be in an effort to curb prescription drug prices, which critics say are higher than charged in other Western countries and are forcing some Americans to ration prescriptions or even avoid treatment.

The best opportunity in a fractious Congress for bipartisan legislative success appears to be in an effort to curb prescription drug prices, which critics say are higher than charged in other Western countries and are forcing some Americans to ration prescriptions or even avoid treatment.

If a bipartisan deal is going to be struck this year, it will deal with lowering prescription drug prices, according to an Axios report.

“The White House and top lawmakers from both parties think a bill to lower drug prices has a better chance of becoming law before the 2020 election than any other controversial legislation,” says Caitlin Owens of Axios. “Republican politics on drug prices have changed rapidly. The White House has told Democrats it has no red lines on the substance of drug pricing – a position that should leave pharma quaking.”

The only red line for the White House is tying drug legislation to revisions of the Affordable Care Act. But Trump officials have given the green flag to using Medicare negotiations as leverage to lower drug prices.

Axios indicates momentum is growing for legislative action before the August recess, viewed by many as the last fertile moment for compromise before the start of the 2020 presidential election political desert when nothing can get approved. Bills are already moving in Congress aimed at influencing drug prices by limiting extended monopolies and expanding access to generic prescription drugs.

Republicans are introducing bills that previously would have been viewed as liberal. Texas Senator Mike Cornyn proposes giving the Federal Trade Commission the power to bring antitrust suits against pharmaceutical companies that use patents to discourage competition. House GOP leader Mark Meadows is part of a bipartisan group exploring a proposal to tie Medicare reimbursement rates to the international price of prescription drugs. Florida Senator Rick Scott introduced legislation preventing US drug companies from charging higher list prices than in Canada, France, Britain, Japan and Germany.

This spate of activity around drug pricing has put the pharmaceutical industry on high alert. Drug company officials have warned proposed legislation could slow investments in promising new drug treatments and upset the “pharmaceutical ecosystem.” That is an appeal aimed at President Trump who has expressed strong support for drug therapy advancement. 

Getting anything of significance accomplished in Congress is never easy. Partisan fights over what to do in response the Mueller report, health care and border security could derail any bipartisan effort on prescription drugs. The embrace by Democrats for a single-payor Medicare for All system could be a particular problem in that it could exacerbate the existing price differences between Medicare and private health insurance.

“Anything that gets done would need to be passed before the August recess, which itself is growing more unlikely as time passes and fights over the ACA and other issues erode whatever bipartisan collaboration that might have existed," a former Trump administration official told Axios.

The prospect of legislative action on drug pricing, supported by the Trump administration, has taken its toll on the stock prices of major pharmaceutical companies – and sharply lowered the multi-million compensation of their CEOs.


Looking Behind the Fuss over the CBO

The Congressional Budget Office, created in the Nixon era, has become a headline-grabber with its dramatic scoring on the number of Americans who would lose health insurance under various GOP health care plans.

The Congressional Budget Office, created in the Nixon era, has become a headline-grabber with its dramatic scoring on the number of Americans who would lose health insurance under various GOP health care plans.

GOP health care legislation has elevated the Congressional Budget Office (CBO) from an obscure arm of government to front-page news and a subject for snarky presidential tweets.
 
The ferocity of attacks on CBO’s integrity and accuracy prompted all eight former CBO directors to send a letter to Congress protesting the assaults, which most recently came from House Speaker Paul Ryan who called the scoring of Republican health care legislation “bogus.” A House member has filed an amendment to a major spending bill that would trim $15 million from CBO’s $48.5 million budget and result in a loss of 89 CBO jobs.
 
CBO was created in 1974 amid a fight between President Nixon and a Democratically controlled Congress over congressional competence to write budgets. CBO was made nonpartisan to produce independent analysis of budgetary and economic issues in support of the congressional budget process. The agency also provides cost estimates for legislation, but it offers no recommendations on policy questions.
 
CBO directors have been both Democrats and Republicans. Current CBO Director Keith Hall, a Republican who took over in 2015, served on President George W. Bush’s Council of Economic Advisers and was a critic of the Affordable Care Act, also known as Obamacare. Vermont Senator Bernie Sanders called Hall “outside the economic mainstream.” When a GOP-controlled Congress installed Hall, it came with a direction to embrace dynamic scoring when evaluating the macroeconomic effects of legislation.
 
“CBO’s approach produces consistent comparisons of competing legislative proposals and unbiased projections of the impact of policy changes,” the former directors wrote.
 
The directors concede “even nonpartisan and high-quality analysis cannot always generate accurate estimates,” but they add that CBO estimates are “more accurate, on average, than estimates or guesses by people who are not objective and not as well informed as CBO’s analysts.” They noted CBO is transparent in its analytic techniques to make estimates and often turns to outside experts for advice.
 
The current fight over CBO was ignited with its scoring of various GOP health care bills to replace parts of Obamacare. Those scores showed huge drops in the number of Americans who would be covered by private health insurance and Medicaid. President Trump, administration officials and congressional leaders have questioned the accuracy of the predictions.
 
Mick Mulvaney, director of the Office of Management and Budget, singled out a CBO analyst and questioned her objectivity because she previously worked at the Department of Health and Human Services under President Clinton. Douglas Holtz-Eakin, a Republican former CBO director who signed the letter, posted a tweet calling Mulvaney’s characterization a “disgrace.” Mulvaney subsequently apologized.
 
Republican sensitivities about CBO estimates on health care legislation date back to the Affordable Care Act, which critics note sharply under-estimated the cost Medicaid expansion and over-estimated the number of Americans who would enroll in the individual health insurance exchanges. Critics say CBO has a poor track record of predicting consumer behavior. Democrats have quarreled with CBO estimates, too.
 
Supporters believe that CBO continues to serve the purpose of giving a nonpartisan analysis of legislation that may not please either side of the political aisle, but arms congressional budget writers with a tool they can use to defend the constitutional prerogative of controlling the public purse. MIT economist David Autor says, "CBO has a good track record with a very difficult assignment. It errs, but not systematically or with partisan intent."
 
The kerfuffle over the CBO may be reprised as the Trump administration and congressional Republicans bring up tax legislation later this year. That process is guided by CBO’s cousin, the Joint Committee on Taxation, which scores tax proposals and effects on federal government deficits.

'Obamacare’s Kindest Critic'

Obamacare has been assailed from the political right and left, but its namesake took an unusual step in publishing a critique that suggested ways his legacy achievement could be perfected and expanded.

Obamacare has been assailed from the political right and left, but its namesake took an unusual step in publishing a critique that suggested ways his legacy achievement could be perfected and expanded.

Republicans are convening in Cleveland this week and can be expected to bash Obamacare nonstop, but constructive criticism of the Affordable Care Act came last week from an unanticipated quarter – Barack Obama.

Signing his critique as Barack Obama, J.D., the President described how his legacy achievement could be perfected by adding a public health insurance option and allowing Medicare to negotiate prescription drug rates, which is currently prohibited.

The New York Times called Obama “Obamacare’s kindest critic” and said his suggestions have the appearance of a memo to his hoped-for Democratic presidential successor, Hillary Clinton.

“Presidents usually wait until their memoirs to review their work,” the Times editorialized, but in this case Obama used the sixth anniversary of the act to make observations about his handiwork in the Journal of the American Medical Association. "Health care costs are still too high, he wrote, and 29 million people still lack coverage.”

One of Obamacare’s “failings” is an incomplete expansion of Medicaid in 19 states that chose not to accept federal financial assistance to pay for expanded coverage.

But Obama points to the actual failure of providing coverage for 9.1 percent of the U.S. population. Obamacare reduced that total from 16 percent, but there are still people who can’t afford health care, often because they lack the money for co-pays and deductibles in addition to health insurance premiums.

Unsuccessful Democratic presidential candidate Bernie Sanders campaigned hard on a Medicare-for-all health insurance plan that captured a lot of attention and rekindled interest in a single-payer system. Obama’s recommendation to add a public option to the health insurance exchange is a more targeted version of the idea, which possibly could win bipartisan support if aimed at rural areas with few private-sector health insurance choices, the Times said.

Clinton has expressed support for a public option. The Times notes Clinton has also voiced interest in allowing Americans between the ages of 55 and 64 to enroll in Medicare.

The Obama view on Obamacare is that it isn’t going away any time soon, but it should be improved and perfected as part of a continuing drive to put a blanket of health insurance coverage over all Americans.

Not everyone agrees. Leading Republicans continue to call for repeal of Obamacare and replacing it with something else, which has largely been ill-defined. The Obamacare health care exchanges are under pressure as costs continue to rise and some insurers lose money. Efforts in Oregon and elsewhere to promote coordinated care and integration of physical and mental health care have registered some positive results, but are still in an extended trial stage. Employers have largely retained private health insurance coverage for employees, but have blunted cost increases by opting for plans with higher deductibles and co-pays and trimmer provider networks.

“What Mr. Obama has done is unusual – asking someone else to burnish a legacy of which he is personally proud,” the Times said. “If the candidates (and Congress) pay attention, his request may also do a world of good for millions of Americans for whom decent health care remains out of reach."

The Democratic Challenge from Within

Liberal democracy may be the only socio-economic system left standing on the modern world stage, but that hardly insulates it from serious challenges from within, according to Francis Fukuyama.

Communism has receded as an economic challenger and even states such as China that offer expanding economic opportunity to its people in return for obedience to one-party rule are finding it harder to retain control. Liberal democracy is in the global wind. 

However, in his new book, "Political Order and Political Decay," Fukuyama explores how you can lose while winning. He suggests America's political development is going in reverse — and not in ways that the federal government's sharpest critics allege. 

Fukuyama describes the decline with an American government that is weaker, less efficient and more corrupt — not bigger. The evidence of decline, he says, can be seen in a government unable or unwilling to tackle major challenges, while submitting itself to the will of well-heeled special interests at the expense of a population experiencing widening income inequality. 

In his earlier work, "The Origins of Political Order," Fukuyama said liberal democracy rests on three pillars – fair, multiparty elections; political accountability; and the rule of law. His latest work suggests that elections alone don't guarantee a liberal democracy and that their value can be undermined by resulting political dysfunction and chipping away at who actually can vote.

The Vermont Health Care Option

Pretty much everyone agrees the political battlefront in 2014 and stretching into 2016 will be the future of Obamacare. Democrats want to preserve it. Republicans want to repeal and replace it, though with what isn't certain.

However, looming just over the 2016 horizon is another alternative — the Vermont experiment with a single-payer health care system that could go into effect in 2017.

The Affordable Care Act moves toward universal access to health insurance by trying to fill the gaps in the previous system of employer-provided health insurance, individually purchased self insurance, Medicare and Medicaid. And that doesn't include the health insurance available to military personnel and their families.

Yet gaps remain. There is an entire network of public health clinics serving the homeless, rural poor, low-income children in schools and Native Americans on reservations. And there is gap between those who qualify for Medicaid and who can afford to buy their own insurance under the Affordable Care Act's state health insurance exchanges.

Even sympathetic critics of the current hodge-podge system of health insurance and health care delivery say it is inefficient, doesn't address cost control and fails to establish a reliable pricing system to allow health care to operate in any semblance as a market.

To bridge that final gap requires imposing an entire new system. There aren't a lot of choices.

The Politics and Facts of Obamacare

The bungled rollout of the Affordable Care Act, coupled with a tide of canceled health insurance policies, has put a dozen Democratic senators, including Oregon's Jeff Merkley, in a defensive position a year ahead of the 2014 election.

Merkley has joined other Senate Democrats in supporting legislation to allow people to retain their health insurance plans that have been canceled because they fail to meet the minimum requirements under the Affordable Care Act.

The balky federal Affordable Care Act website is blamed for embarrassingly sluggish sign-ups for health insurance coverage, which totaled only slightly more than 106,000 in October. However, the political panic button has been pushed because the existing health care plan cancellations undercut President Obama's oft-repeated promise than no one would be forced to give up their health plan. No less than former President Bill Clinton says action is needed to make the promise whole.

Republicans have dubbed 12 Democratic senators up for re-election in 2014 the Obamacare Dozen. North Carolina Senator Kay Hagan is already the target of attack ads, which have eroded her poll numbers so she now finds herself in a dead heat with potential GOP challengers.

Several of the 12 Democrats, including senators who just months ago were viewed as invincible in 2014, are pivoting to separate themselves from Obamacare by supporting a fix to the canceled policy problem, advocating for a longer period to enroll in a new health plan or demanding an investigation on why the website rollout tanked.

For his part, Obama has tried to absorb some of the frustration by apologizing for the poor website rollout and admitting "we fumbled the rollout on this health care law," as he unveiled his own fix to allow people to retain current health care plans.

Confusion Undermines Health Reform Understanding

Is the Affordable Care Act good or bad for small business? Political chatter says it's bad, but a careful read of its provisions may change your mind.Since passage of the Affordable Care Act (ACA) in 2010, President Obama’s problem hasn’t been the law itself; it has been selling the law to the public, health care providers and especially small businesses.

Most business owners agree the key to business planning is predictability and clarity. While the ACA attempts to provide a clear framework that would allow small business to flourish under the law, many of those benefits are buried underneath the weight of 1,100 pages of text.

Should small business owners be out pounding the payment in support of Mitt Romney and repeal of Obamacare or will the market reforms in the ACA provide small business owners a respite from the notoriously dysfunctional and expensive small group health insurance market?

To date, discussion of this question has been fueled more by politics than facts.

Opponents of Obamacare contend the rising cost of excessive government regulation will force millions of employers to drop coverage for their employees, while also hindering job creation and economic growth. However, this contention overlooks substantial small business benefits contained in the law.

The Part-Time Worker

Much was made about how many part-time workers contributed to the job growth in September. There are now 8.6 million Americans working on a part-time basis for "economic reasons." Some observers wonder whether this is the new normal or a conscious business response to, among other factors, the Affordable Care Act.

The news last week from the Bureau of Labor Statistics that the U.S. jobless rate dropped below the 8 percent mark for the first time in four years got its own scrutiny. Conservative pundits and some business leaders questioned whether the news was rigged to bolster President Obama's re-election bid.

Moving beyond the conspiracy theorists, others questioned the vitality of the economy when many of the new jobs were part-time.

The Washington Post cited published data by Paul Dales of Capital Economics indicating that the number of Americans working 30 hours or less per week actually has retreated to pre-recession levels. Many of the new part-timers are working between 30 and 34 hours per week. That may not be ideal, Dales admits, but it is has a more notable economic effect than if they were working only 20 hours per week.

Still, the personal tales of part-time workers are unsettling. Displaced workers and recent college graduates describe a job market that is unforgiving and jobless benefits that get exhausted. There are almost 4 million Americans who have been out of work for a year or more and their prospects for landing a job are even grimmer.

CNN broadcast a piece tracking the fortunes of part-time workers — a college graduate manning a movie theater concession stand, a displaced telecommunications executive who reads to young children and a long-time radio station employee who works three jobs, including at his own Internet radio startup.

The part-time workers CNN interviewed aren't particularly upset or bitter. They recognize their plight is tied to the sluggish national economic recovery. One woman said getting laid off from her previous well-paying corporate job gave her a chance to re-evaluate her life priorities. The Internet radio entrepreneur said his layoff gave him the freedom, at age 50, to try something he had always wanted to try.

The larger concern voiced by these workers and many others is the waste of talent. The movie-theater employee is selling popcorn instead of pursuing a career in photography after taking her college degree in fine arts. A 27-year-old data entry clerk at a bank wants to go to law school, but cannot pay off her undergraduate student loans, let alone take on the debt required to earn a law degree.

Wyden Walks Medicare Policy Tight Rope

His Medicare reform white paper co-authored with GOP presidential running mate Paul Ryan has Democratic Oregon Senator Ron Wyden in the political crosshairs of just about everybody.Democratic Oregon Senator Ron Wyden, who isn't even on the ballot this fall, nevertheless finds himself in the middle of a hard-fought, negative presidential campaign. And he isn't happy about it.

Wyden co-authored a provocative white paper on Medicare reform options earlier this year along with House Budget Chair and now GOP presidential running mate Paul Ryan. The Mitt Romney-Ryan campaign seized on the white paper — and Wyden — as evidence of bipartisan support for their approach to Medicare reform.

Wyden has gone to great pains, including a speech this week to the Portland Rotary, to say ‘no dice.’

Defending the white paper and his collaboration with Ryan, Wyden says what Romney has endorsed and House Republicans have passed is not consistent with the white paper's approach to "preserve the Medicare guarantee."

In an interview with Ezra Klein of The Washington Post, Wyden said the major differences between his views and those of Romney involve the Affordable Care Act and Medicaid. Romney and Ryan favor repeal of the Affordable Care Act and Wyden doesn't. The Ryan-inspired House budget would give states more freedom to run their Medicaid programs for low-income citizens, but also provide less money. Wyden says that will harm lower-income seniors who qualify for both Medicare and Medicaid.

The Commerce Clause Yellow Brick Road

The Commerce Clause has been used over time by the Supreme Court to enable and block economic regulation. Now a new watershed case involving an individual health care mandate is sitting on the high court's docket.The Commerce Clause in the U.S. Constitution has been a source of strong disagreement since the time of Thomas Jefferson. Arguments over this clause, which on its face controls what economic activity Congress can and cannot regulate, has intertwined with New Deal legislation, the ability to ship wine directly to consumers and, now, the Affordable Care Act.

Nina Totenberg, the encyclopedic NPR reporter who covers the U.S. Supreme Court, delivered a brief history lesson on the Commerce Clause this week, as anticipation builds for the high court's decision on what detractors sneeringly call ObamaCare.

Thomas Jefferson was one of the first to question how far the Commerce Clause could be stretched after the Supreme Court, led by Jefferson nemesis John Marshall, ruled in 1824 that the Constitution gave Congress broad powers.

Totenberg says the argument picked up with intensity 70 years later when the federal government tried to limit the antitrust actions of emerging large corporations. Federal officials suffered a setback in an 1895 ruling involving a sugar company when the court said the government lacked jurisdiction to regulate its activities because most refining was conducted within a state. 

Health Care System in Limbo

Supreme Court justices may have more to weigh than just the constitutionality of the Affordable Care Act.If the U.S. Supreme Court finds the federal health care reform act unconstitutional later this year, experts say it could unravel more of the nation's health care system than anticipated, including Medicare.

Judy Feder, a former Clinton administration official, tells NPR's Julie Rovner that the push toward more integrated and coordinated health care delivery would be disrupted.

Gail Wilensky, who ran Medicare and Medicaid programs for President H.W. Bush, says voiding federal health care reform would erase the most recent benchmarks for doctor and hospital payment rates. 

"Hospitals might not get paid. Nursing homes might not get paid. Doctors might not get paid," Wilensky says. "Changes in coverage that have begun to take effect for the elderly, such as closing the donut hole, might not happen." The effects, she adds, would undoubtedly spill over to everyone in the health care system.

Sara Rosenbaum, a professor of health law, likens it a train wreck. "We could find ourselves at a grand stopping point for the entire health care system." One problem she cites is the possibility of thousands of Medicare policies being suddenly null and void.