Latest word is that there is talk of an excise tax on pharmacy benefit managers (Caremark, Medco, Express Scripts, etc.) to help pay for health care reform ( he said with a smile).
Let’s see, a new tax on a service that provides benefits to millions of Americans and of course there will be no passing of this along to employers and onto the plan participants.
WHAT ARE THEY THINKING?
The American Benefits Council (see link on lower right side of this page) has sent a letter to the Senate leaders expressing again the major concerns large employers have about the current structure of health care reform and its possible implications on the employer based system and on millions of workers who are part of that system.
You may wish to review this letter as part of your assessment of health care reform and its impact on you and your organization.
Beginning with Nixon there has been what appeared to be serious talk to address health care and yet here we are thirty plus years later and still struggling over the issues.
The lessons of the Clinton administration were ignored, the Obama administration started on the wrong foot by putting the design in the hands of the Democratic leadership and today we sit with the likelihood of a half baked piece of legislation that does not reform health care and does not address the fundamental problems that cause our system to be overly expensive and under optimized in terms of the quality of care. Or, there will be failure again and nothing will happen.
I remember sitting in the White House in the 1990s at a small conference table with Ira Magaziner on my right. At the time he was heading up the Clinton health care initiative. The stated purpose of the meeting was to get input from business on health care reform. We listened and I started asking some questions, some question they apparently didn’t want raised and after my third attempt I was effectively excluded from the discussion and not called upon again to speak. That gave me a pretty good clue as to where this was going at the time.
In the 1980s I was a part time consultant for the old Office of HMOs and I saw first hand how they funded plans with inadequate leadership or supported by doctors who saw their participation as a way to preserve business as usual within an HMO. I was on the board of directors of four different HMOs and all went out of businss in a few years becassue of the above and the resistance of the public to “managed care” and the controls, limitations, and oversight that goes with high quality, cost efficient health care.
The Obama effort is not much different. This administration is trying to change virtually every aspect of health care all at once and largely by allowing politicians and their staffs, many with little experience in the real world, to have at it while labeling any counter views as obstructionist. This time something is likely to pass and be implemented simply because there is a “get something, anything done” attitude. The danger is that it is the wrong something and it will take a decade for us to figure that out.
What do they miss in trying to reform healthcare?
In short, each administration tries to make sausage that will be a delight to each individual palate and in the process appeals to no one. History has proven that it is inadequate to simply say there is a problem and to scapegoat this or that group trying to solve that problem.
Hey, everyone loves me, I come in twenty varieties
The reality is that most Americans cannot see a problem, they pay their premiums in many cases somewhat invisibly through payroll deductions and they receive health care with little financial stake along the way. They do not know or apparently care about the quality or appropriateness of that care, they are still fixed in the mindset that they are going to the best doctor in the business and that any questioning of his or her treatment is mere interference driven by a desire to protect some CEOs bonus, perceptions by the way driven by the very politicians who say they want to reform health care in America.
And that is why we may never truly reform health care in America. Even if some legislation passes this time, because it is not the right legislation, we will be far worse off in ten or fifteen years than we are today, and far poorer.
blogsurfer.us
The following is from Politico
Aides tell POLITICO that President Barack Obama will warn Senate Democrats in a White House meeting today that this is the “last chance” to pass comprehensive reform — that if it fails now, no other president will attempt it.
For more information…Politico
Help, I've fallen and I can't get up!
I have a huge balance on my credit cards, my monthly payment is eating me alive with just the interest, and I am going backwards. But, back a few years ago I was just the opposite I was quite prudent and rather than use my credit I cut back and I actually saved a little, so what is the problem now, I’m just catching up for those lean years of spending, it all works out in the end.
So, all of the above is pure fantasy, but as ridicules as the above logic is, it appears to be good enough to justify more and more deficit spending by Congress. The national debt will soon go over the $12.1 trillion dollar mark. I remember back in grammar school (only a million years ago) we used to make fun of that word trillion, who would ever use it?
According to the New York Times, Republicans continued to attack the level of spending, but Democrats said that the measure provided need support for programs such as those serving veterans. The vote for the huge spending bill, which actually totals more than $1 trillion when required spending for social programs is added in, left one spending bill remaining – a $600 billion Pentagon measure that Democrats hope to use to carry along some of the more contentious remaining items
Ah, more spending and a crafty strategy to get it all approved, now that’s the kind of thinking we need. Oh yes, another trillion plus or minus a few billion for health care “reform” should wrap up the year nicely.
Stop complaining, I'm just catching up.
And, from Politico: Democrats will argue that in many cases they are only catching up for what they saw as a lack of public investment in the Bush years. But Republicans counter that agencies like the Environmental Protection Agency are awash in cash given the infusion of billions for clean water projects. And quite apart from the stimulus, total domestic discretionary spending is up about 9 percent since 2008 — growing at double the rate of inflation.
Umm, no doubt your spending and income are up nine percent in the last year, especially with that whopping increase in Social Security benefits in 2010. Oh, wait, inflation is so low there is no increase in Social Security next year. How is it that government agencies need 9% more than? They must be using the same budget and accounting consultants as colleges and health care providers.
Does it really matter what the money is needed for, if you don’t have it you can’t spend it…or so I thoguht, but what do I know. John Maynard, would you go over it one more time?
blogsurfer.us
The Congressional Budget Office (CBO) was asked to estimate the savings in health care if there were tort reform. At the same time they were asked to assess the impact of reform on patient care ( presumably because someone thinks if there is less risk in being sued, there will be less concern about doing something to be sued over).
I will let you come to your own opinion.
I could have sworn there was more here not too long ago
Ok, the title is not a serious question because nobody seems to care what we can and cannot afford. Increase spending, restore programs, give raises, all nice to do to be sure, but at a time when many Americans are not receiving any raise (or don’t have a job) , but are seeing their local and state taxes rise, when many Americans are seeing their 401(k) employer match dissappear along with other benefits, where is the justification for much of this? Where is the prudent spending? Ok, again not serious questions.
The follow is an excerpt from an AP story released December 13.
WASHINGTON (AP) – Senate Democrats overcame a Republican filibuster to clear the way for a vote Sunday on a huge end-of-year $1.1 trillion spending bill that gives budget increases far exceeding inflation to much of the government. The Democratic-controlled Senate voted 60-34 on Saturday to end the GOP filibuster that threatened to hold up the legislation. The final vote would send the measure to President Barack Obama.
The measure pays for Medicare and Medicaid benefits, and boosts spending for the Education Department, the State Department, the Department of Health and Human Services and others.
In the coming week, Congress may try to take a defense spending bill and attach a measure that would raise the $12.1 billion debt ceiling and initiate new spending and tax cut efforts to stimulate jobs.
“We are in a very special kind of economic situation, and frankly, jobs have to be the top priority, and every bill is going to be a jobs bill going forward,” Obama’s top economic adviser, Larry Summers, said on ABC’s “This Week.”
The bill includes $447 billion in operating budgets with about $650 billion in mandatory payments for federal benefit programs such as Medicare and Medicaid as well as an estimated $3.9 billion for more than 5,000 back-home projects sought by individual lawmakers in both parties.
The bill increases spending by an average of about 10 percent to programs under immediate control of Congress, blending increases for veterans’ programs, NASA and the FBI with a pay raise for federal workers and help for car dealers.
The second-ranking Senate Democrat, Dick Durbin of Illinois, said the measure restores money for programs cut under former President George W. Bush such as popular grant programs for local police departments to purchase equipment and put more officers on the beat.
The legislation also:
Renews a federal loan guarantee program for steel companies.
-Calls for federal worker pay increases averaging 2 percent.
Precarious position, what precarious position
The following letter was sent by the CFOs of the companies noted below in hopes of making some changes in the taxation of the Medicare Part D rebate that is provided to employers who retain their prescription coverage in lieu of sending their retired employees into Medicare. A change in the tax status of this payment will, in the long run, cost the federal government money rather than save money and in the process shift more costs to retired workers.
December 11, 2009
Majority Leader
United States Senate
Washington, D.C. 20510
The Honorable Nancy Pelosi
Speaker of the House of Representatives
United States House of Representatives
Washington, D.C. 20515
As Washington contemplates health care reform, we urge Congressional members and the Administration to consider the impact of these efforts upon the broader economy.
Of significant concern to us in both the House and Senate bills are the provisions that would change the tax treatment of the Medicare Part D Retiree Drug Subsidy (RDS) Program to generate revenue to help offset the cost of health care reform.
The Medicare Prescription Drug Improvement and Modernization Act of 2003 added a new prescription drug benefit to the Medicare program for senior citizens. The Act also included a 28 percent subsidy for employers offering retiree prescription drug coverage to encourage them to “stay in the game” (as opposed to dropping coverage, which would have resulted in additional costs for the Medicare program). The strategy was effective, and the subsidy has enabled employers to offer prescription drug coverage to millions of retirees who would have otherwise elected to participate in Medicare Part D. The employer-sponsored plans have resulted in reduced costs to the government and to the retirees.
Health care reform proposals now before the House and Senate include changes to the RDS Program that would negatively impact both retirees and companies. The change would make the 28 percent subsidy taxable to employers, effectively reducing the value of the subsidy. As a result, we would anticipate significant reductions in employer-sponsored retiree prescription drug coverage. Some analysts of the proposal have characterized the non-taxable nature of the subsidy as “double-dipping” because companies receive a tax-deduction for the cost of the coverage and then receive a 28 percent tax-free subsidy. However, the cost of the coverage is considerably more than the combined value of the deduction and the 28 percent. Companies are absorbing more of the total cost than either the retirees or the government. Taxing the subsidy means that more companies will eliminate or reduce the coverage, and more retirees will shift to Medicare Part D, which will create more cost for both the government and the retirees. If more companies than predicted by the Government Accountability Office shift away from coverage, then the provision could result in a net revenue loss rather than the predicted slight revenue gain.
Further, this change would result in large earnings statement reductions due to U.S. GAAP income tax accounting rules, which would require employers to immediately account for the present value of this tax increase.
The impact of the proposed Medicare Part D changes would be felt throughout the overall U.S. economy as corporate entities and investors would be forced to react. We urge our leaders in Washington to carefully consider the far-reaching effects of the health care reform effort and avoid unintended, negative consequences for all stakeholders.
Caterpillar Inc.
Con-way Inc.
Deere & Company
Exelon Corporation
Met Life, Inc.
Public Service Enterprise Group Inc.
Verizon
Xerox Corporation
I hope they get this division of work thing down soon.
John McCain was reportedly shocked that the University of Arizona had received stimulus money to study the division of labor in ant colonies. With over ten thousand earmarks added to spending bills in Congress in the last year, I am not so shocked at all. Stimulus money is being used to pave bike paths, build swimming pools and a whole host of other “necessities”. Hey, I have nothing against ants (unless they are swimming in my new pool), but what is nice to have and what we can afford are two different things, at least they were before the new Congressional math came into vogue.
I find it most curious that as members of Congress conduct a full press against the banks and Wall Street for their financial shenanigans, even dictate their pay and pass laws to hold them in check Congress is putting the American economy at long term risk more than any Citigroup or AIG. Every conceivable rationale is used to justify more and more spending and eventually greater wealth distribution as if the accumulation of wealth is a bad thing. Beyond that, our debt is growing, our lenders are anxious and the accountability that seems so critical for bankers is lacking for Congress whose spending habits are indescribably irresponsible.
Let’s hope the American people do not let this go unnoticed, there are consequences and sooner or later scapegoating Wall Street will not longer hold sway as it now does. The danger of course is that we all like a free ride and as Congress spreads the goodies around without explaining how they will be paid for, the beneficiaries will come to enjoy their largess. After all, the rich are paying for it aren’t they? The same logic is used in the health care reform effort and many people still think that a public option will save money. You can have it all America, we can expand coverage, control costs and improve the quality of health care and nobody has to give up a thing, except a few people via higher taxes.
It doesn’t work that way in health care or in running the Country, sooner or later it all has to be paid for and yet we following the logic of the family who really needs a vacation, a 60″ TV and with such pressures facing them simply charges it. We’ll just pay it off (if you don’t lose your job, get a cut in pay, unless interest rates go up or you suddenly realize you don’t have enough money left for the true necessities like food).
Today the recession is used to justify spending and the recession is blamed on the banks and Wall Street and the financial burden can be absorbed by the rich. Sounds nice and simple doesn’t it? In order to make us feel good, in order to deny responsibility or face hard choices, there is always the handy scapegoat. This is especially true if you are an elected official who can walk away from years of decisions never knowing or caring about the consequences of your actions.
I'll have the lobster with a side of caviare
Lobster sales are down in restaurants because no one wants to be seen as wealthy. That’s a shame because wealthy is a good thing, as we strive to redistribute wealth in America we should be mindful of gifts the wealthy have provided; libraries, hospitals, museums, institutions for the arts, research centers and countless more socially beneficial giving, not to mention millions of jobs and new industries in the process of becoming wealthy.
Wealth is a good thing and so is the opportunity for anyone to accumulate wealth. Sadly that opportunity is declining because it appears today that we are more interested is holding back than encouraging achievement, we would rather see a nation of mediocrity than one of unbridled opportunity. There are people in this society who have not gotten out of life what they wished, some unfairly so but far more because they simply did not strive to achieve all they could, they made poor decisions or they concluded that they were happy with what they had. That will always be so, but dragging down the achievers to become a nation of average certainly should not be our goal.
The only thing I have against wealth is that I was never clever enough to achieve it. I’ll take six Powerball and two Mega Million tickets please.
blogsurfer.us
I have had a few words to say on this topic before but it just keeps getting better. A December 10, 2009 article in the Wall Street Journal tells of a town in California where it has become fashionable to walk away from a mortgage because the mortgage is higher than the current value of the home. I suspect the fact that you allow your name and picture on the front page of a national newspaper relating your low moral values and outright stupidity is some insight into why these people got into this fix in the first place. Here is a hint of how indirectly your tax dollars are used:
Thanks to a rare confluence of factors — mortgages that far exceed home values and bargain-basement rents — a growing number of families are concluding that the new American dream home is a rental.
Some are leaving behind their homes and mortgages right away, while others are simply halting payments until the bank kicks them out. That’s freeing up cash to use in other ways.
Ms. Richey’s family of five used some of the money to buy season tickets to Disneyland, and plans to take a Carnival cruise to Mexico in March. Mr. Fernandez takes his girlfriend out to dinner more frequently. “We’re saving lots of money,” Ms. Richey says
You want to see my putting green, let me move the beamer
You have heard of spin, here is a sample of the ultimate, walk away from your mortgage obligations and it’s a good thing for the economy because while you left the bank, its shareholders and most likely taxpayers with your unpaid debt you have free cash to help boost the economy. Even Ripley would not believe this.
The flip side of those losses, though, is massive debt relief that can help offset the pain of rising unemployment and put cash in consumers’ pockets.
For the 4.8 million U.S. households that data provider LPS Applied Analytics estimates haven’t paid their mortgages in at least three months, the added cash flow could amount to about $5 billion a month — an injection that in the long term could be worth more than the tax breaks in the Obama administration’s economic-stimulus package.
“It’s a stealth stimulus,” says Christopher Thornberg of Beacon Economics, a consulting firm specializing in real estate and the California economy. “The quicker these people shed their debts, the faster the economy is going to heal and move forward again.”
Even before they decided to walk away from their mortgage, this family had no trouble spending, but they had no money for a down payment or thought it unnecessary.
Ms. Richey, the teacher, arrived in Palmdale in 1999. In 2004, she and her husband, Timothy, bought a two-story home on Caspian Drive, near Avenue O-8, with a no-down-payment loan. They took pride in the amenities they installed: a powder room with granite countertops, a backyard pool and play area, and the purple-and-turquoise fantasy playroom upstairs for their three daughters.
But the value of the house plunged to less than $200,000 in 2009. Their $430,000 mortgage, with its $3,700 monthly payment, began to look more like an unwanted burden.
Yeah, I have an unwanted mortgage payment too.
This guy had a mortgage payment of $4,800 on a salary of $8,300 and he still had the money to install a custom putting green in is back yard. It’s nice of him to sell the home though and stick the banks with a loss of only $123,000. Oh, now that he is renting and his payments a lower he is keeping his BMW coupe, fire engine red no doubt.
Mr. Fernandez says he made four attempts to modify the larger of the two mortgages on his home, which add up to $423,000. Ultimately, he was offered a monthly payment that, together with back taxes, was higher than what he had been paying. Today he’s working to partially reimburse his lenders, IndyMac Bank (now OneWest Bank) and American First Credit Union, by selling the home, which he expects to fetch about $300,000.
With an income of about $8,300 a month and a rent of $2,200, Mr. Fernandez says he now has the wherewithal to do things he couldn’t when he was stretching to pay the mortgage. He recently went to concerts by Rob Thomas and Mat Kearney. He also kept his black BMW 6 Series coupe, which has payments of about $700 a month.
If you want to know what is wrong with America, it is a growing number of people who can rationalize this type of behavior.
blogsurfer.us
Here is what Paul Krugman says in his column on the New York Times online:
December 9, 2009, 8:48 am
The health care compromise
Here’s what’s being reported. No public option, but a trigger which is unlikely to be pulled. But some good stuff in exchange: nonprofit plans available through the exchanges, plus Medicare buy-ins for the 55-65 set (me! me! me!).
If this is the final plan, it’s better than most of us were expecting — and definitely good enough to go with.
Good enough for what? Does it make health care more affordable (affordable does not mean you can now buy it because the government is subsidizing your premium by the way), is the quality of your health care raised or will it be raised because of “good enough?” Is there any benefit for the millions of Americans with health insurance today? Does it take steps to solve the financial woes of Medicare (cutting payments and gutting Part C are not the answer).
If “good enough” is expanding coverage for some into a flawed system and creating more demand thereby setting the stage for further uncontrolled health care spending, then yes, it is good enough.
blogsurfer.us
Like many Americans, the scary economy has caused me to pause a bit before I spend. As someone who is mostly retired, I think long term (relatively speaking of course). My income is fixed and given my property taxes just went up by 50%; I cannot help but wonder what lies ahead for other increases in my expenses. I take no comfort in the fact that the greatest risk for retirees is longevity, not money woes or is that the same thing. Frankly, I find it curious to consider longevity a bad thing. I say bring it on.
As many Americans and I try to trim spending and boost savings, I ask myself are we making any progress. Does it really do any good if we save while the folks in Washington spend what amounts to our money like sand through a kid’s beach sifter? Isn’t it all coming from the same pot in the final analysis? You bet your bippy it is. Someday all the saving we are doing will go out the window in higher taxes and higher inflation. Someday our ability to spend even if we want to will be curtailed because what we get to keep from what we earn will leave little beyond the necessities. Welcome to a new American standard of living.
Look, I’m no economist, just an average guy who has been around for 66 years, is basically cheap and worries about the future. Sure, we are going through some rough times, some are having it rougher than others, but is the way out of this to keep propping things up or is it better to take our medicine, get it over with and move on with a few coins left in our pockets instead of the pockets of half of Asia? Hey, I’m just asking.
When I wake up I expect a job, a house, a new car, free health insurance and a new credit card with zero interest
We’re sick, need to barf over the bowel, climb into bed for a day and sweat it off. On second thought, a more apt analogy may be that we have a whopping hangover from a ten-year binge and someone is trying to convince us that more of the same is good for us only now we are not the ones on the binge.
We fix our roads just to spend money, reform health care, but really do nothing, my savings account earned $0.22 last month and it cost me $1.50 to take $20.00 from an ATM, we pay people to buy a car from companies that are owned by the government, now we are going to pay people to caulk their homes which they bought because the government gave them $8,000 toward the down payment. The President of the United States is telling banks to loan money, but worst of all, the one person who came closest to me ever having a sports idol turns out to be a sleazebag, which on the plus side may qualify him to go into politics, who knows a governor or even president.
Please don’t put one of those damn 80 foot windmills in my backyard, I already have a headache.
Tom Jefferson and the boys who started all this must be spinning in their graves, have we ever screwed things up.
blogsurfer.us
Amendment 3002, Amendment 4212, Amendment 5436, Amendment 5685
Let us fast forward a few weeks and assume health care reform passes the Congress and is signed into law, then what? Well, you have a massive piece of legislation as the starting point. In other words, you have a giant wad of play dough for Congress to manipulate in the future.
As one legislative aid told me recently, “once this passes we can start making changes.”
And changes they will make of that you can be sure.
It has been estimated that the mandates applied to health insurance add between 20 and 25% to the cost of insurance. Thus, the high premiums charged by much maligned insurance companies are driven in large part by our state politicians who cannot resist tinkering with health care in favor of this or that cause or constituency. Not only do these mandates add to the cost of health insurance, they continuously reinforce the idea that all health care should be “free” to the patient. But hey, nobody blames the politicians; it is far more convenient to blame the guy who tells you your premium is going up.
A look into the future of health care is available today in the mammogram debate. The revised guidelines were quickly dismissed by the administration and members of the Senate just as quickly amended their pending health care legislation to assure that there would be full coverage for this screening no questions asked. There was no time for debate and nobody really cared if the suggested rethinking was right or wrong it was politically incorrect…and it was emotional. These two factors are the primary drivers for health care spending decisions in the future.
No questions asked and nobody between you and your doctor is what has gotten Medicare into trouble, expand that approach throughout the health care system and you have the makings of out of control costs. There are smart people in government who know this does not work, but that is of little consequence because we are in the process of turning over those decisions to several hundred people who respond to….you got it…political correctness and emotion (with a modicum of self interest in the mix).
As we politicize health care decision making at the federal level we leave in place the ability for the states to continue their micromanagement and we also create pilot programs to research how health care can be more efficient and cost effective, we fund comparative effectiveness studies in the hope of filtering throughout the system best practices for providing care…you know, like new guidelines for mammograms …
Representative Wizard
Mr. Speaker, I rise to introduce the “Freedom from Oversight, Control and Interference between Patient and Doctor in Healthcare Decision Making Act of 2011.”
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For all the forty-eight years I worked in the corporate world I was paid a salary. My salary was based on 40 hours of work each week although many (too many) weeks it was far more than 40 hours. Yes, I have to admit there were times it was less than 40 as well.
What I was paid was designed to be competitive with my peers and also based on my performance, what value I added and how I did that. I was not paid by the number of PowerPoint presentations I prepared or the number of Excel spreadsheets created or even the number of meetings I attended. Admittedly if I received my pay that way I might have prepared even more presentations and scheduled more meetings. Add on payment for each e-mail and a villa in Monaco is mine.
By now you may know where I am going with this.
Seven hundred thousand physicians more or less in the US and virtually all who are in private practice are compensated on a fee-for-service basis. Not only that, they generate their own demand for services and often are financially involved with facilities providing additional services on a fee-for-service basis where demand is generated by the physician. In fact, through the services they order physicians control about 70% of all health care spending.
Even if you accept the premise that most physicians are motivated only to serve their patient in the best way possible, there remain strong incentives to spend money on health care. Fear of being sued is one, but patient demand is another and that demand is driven by advertising and the mistaken belief that more is better and the more sophisticated the technology the better.
While I readily admit the practical task of changing from fee for service to a salaried cadre of physicians is daunting, it is difficult to see how real reform of the health care system can occur within the current structure.
Being compensated on a fee for service basis may be fine if the goal is to increase income by the services you render or where the customer is not only price sensitive but more importantly able to be objective in the purchase. After all, unless you drive a 1954 Mercedes gull wing roaster you probably don’t care who changes your oil.
Capitation payment, that is a set monthly fee for each patient regardless of the patients use of a physicians services, has been tried in the past and is now the “in thing” in Massachusetts where they struggle with increased health care costs after expanding the number of insured and encouraged adverse selection. Critics of capitation say it encourages the physician to avoid providing care, proponents say it encourages use of routine services so that more costly care is avoided and thus both the physician and patient benefit. However, under this model for a physician to increase income he or she must negotiate a higher capitation rate or increase the patient base. There is also the issue of patient mix, that is, does the physician have a capitation rate that accurately reflects the health risks of his patients? Clearly, the use of capitation does not remove all the negative incentives.
No claims to file, no malpractice to pay, no justification for each procedure I want to order, no referrals…I like it!
So the question remains can the health care system ever deliver consistently high quality health care (or even measure it) in the most efficient manner across the country with several hundred thousand physician entrepreneurs operating in individual offices?
Would the strongest incentives for high quality, efficient health care be possible with networks of employed, salaried physicians focused not on running a business, but on caring for patients with their salaries based in part on the quality of the care provided?
Now, that would be health care reform.
As regular readers know I am a big fan of the idea of unintended consequences because I believe politicians are incapable of thinking beyond the moment.
One aspect of health care reform is an expansion of Medicaid which is largely run by the states. While there is some additional federal money going toward this expansion it is not sufficient to cover all the added cost and hence, cash strapped states are being saddled with more costs. Hopefully, this new bill will not be paid by cutting school funding or other essential services but who knows.
A report on the I Love Benefits Blog speculates that some states may merely drop Medicaid and push people into more generous federally subsidized benefits created via health care reform.
Now that would truly be an unintended consequence.
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