Senate's Charade of Repealing Obamacare Continues With Another Doomed Bill; Bill Also Would Block Federal Funds for Planned Parenthood

On February 3rd of this year, the House voted to repeal the Affordable Care Act (Obamacare), getting Republicans on record in favor of overturning the law for the first time since the party took control of Congress. The bill passed on a 239-186 vote. President Obama already has threatened to veto the legislation — and like past bills to repeal ObamaCare, it is unlikely to go far under the current administration, despite Republicans now controlling the Senate and having a bigger majority in the House. But the vote serves as an opening shot in the 114th Congress’ efforts to chip away at the law. Several lawmakers have introduced bills to change or undo parts of the Affordable Care Act, and some could garner bipartisan support. [Source]

Senate GOP health law repeal delivers wins to party's wings

December 3, 2015

AP - Republicans ignored a White House promise of a veto Wednesday and pushed toward Senate passage of legislation demolishing President Barack Obama's health care overhaul and blocking Planned Parenthood's federal funds.

After weeks of strategizing, GOP leaders began rolling out a measure they said would attract the votes needed for approval by week's end. To achieve that, they balanced victories for some of the most conservative GOP senators with concessions for more moderate Republicans facing competitive 2016 re-elections.

The White House accused Republicans of "refighting old political battles," a reference to unanimous GOP opposition to the measure ever since Obama began pushing it through Congress and dozens of votes lawmakers have staged to undo the statute.

Repeal would "roll back coverage gains and would cost millions of hard-working families the security of affordable health coverage they deserve," the White House wrote in its letter pledging a veto.

Senate Majority Leader Mitch McConnell, R-Ky., tauntingly suggested that Democrats reconsider their defense of the health care law.

"This is their chance, and President Obama's chance, to begin to make amends for the pain and hurt they've caused" by the statute, which Republicans blame for rising health care costs.

On Wednesday, a Department of Health and Human Services report said that health care spending grew last year at 5.3 percent, in part because over his law's coverage expansion and the steepest climb since Obama took office.

The GOP said a veto would only help its presidential and congressional candidates by underscoring that Republican control of the White House and Congress could spell the end of the law they derisively label "Obamacare" and of Planned Parenthood's federal dollars.

Pleasing conservatives, the measure would all but kill the 2010 Affordable Care Act, effectively ending its requirements that individuals obtain health insurance and that large companies offer coverage to workers by erasing the financial penalties enforcing those obligations.

The bill would repeal the law's expanded Medicaid coverage for lower-income people and its federal subsidies for those buying policies in insurance marketplaces. It would also annul a slew of tax increases the law imposed to cover its costs, including levies on medical devices, costly insurance policies, investment income of higher-earning people and indoor tanning salons, according to documents obtained by The Associated Press.

Healthcare Reform Law and 2009 Stimulus Bill Mandate Biometric Screening and Electronic Health Records by 2014

There would be profound changes in the practice of medicine. Overall, medicine would be much more tightly controlled. The observation that was made in 1969 that, "It is now abundantly evident that Congress is not going to go along with national health insurance. But it's not necessary — we have other ways to control health care". These would come about more gradually, but all health care delivery would come under tight control. Medical care would be closely connected to work. If you don't work or can't work, you won't have access to medical care. The days of hospitals giving away free care would gradually wind down, to where it was virtually non-existent. Costs would be forced up so that people won't be able to afford to go without insurance. People pay for it, you're entitled to it. Your medical care would be paid for by others. Therefore, you would gratefully accept, on bended knee, what was offered to you as a privilege. Your role being responsible for your own care would be diminished. Here's the way this works: everybody has made dependent on insurance, and if you don't have insurance then you pay directly; the cost of your care is enormous. Access to hospitals would be tightly controlled and identification would be needed to get into the building. Anybody moving about the hospital would be required to wear an identification badge with a photograph and telling why he was there, employee or lab technician or visitor or whatever. This is to be brought in gradually, getting everybody used to the idea of identifying themselves - until it was just accepted. This need for ID to move about would start in small ways: hospitals, some businesses, but gradually expand to include everybody in all places! [The New Order of the Barbarians: Planning the Control Over Medicine, Dr. Lawrence Dunegan, 1988]

Emanuel Requires City Workers Enrollment in Wellness Program or Pay Higher Premiums

September 16, 2011

NBC - Chicago Mayor Rahm Emanuel is giving city workers an important health choice: enroll in a new wellness plan, expected to be unveiled Friday, or pay a higher premium. The price if they don't enroll: $50 a month.

The program includes an initial screening that focuses on preventative care for asthma, heart disease and diabetes. City employees would then receive wellness training to achieve long-term health goals, including weight loss.

Smokers wouldn't be penalized, but they would be encouraged to quit. Advisers overseeing the program will monitor progress on a bimonthly basis, and those who reach their goals could see their health care premiums reduced.

"We will help you be a good steward for your health," Emanuel said Friday, "but if you choose not to, you'll pay that price and that is the price you'll have to pay."

The mayor believes the program will help cut the annual $500 million bill for health care for city employees.

"We are going to implement a citywide wellness plan for city employees," Emanuel confirmed at a recent press conference, "because health care costs for the city are being driven by 10 percent a year, and we're not seeing revenue grow that way."

Most city unions have signed on to the agreement, according to the Chicago Sun-Times, except the Fraternal Order of Police, which represents more than 10,000 city employees.

The FOP says its members have different health concerns and it doesn't want members to pay higher premiums if they decide not to enroll in the program.

But Emanuel says the program is a necessary step to getting healthcare costs under control.

"You can't ask the taxpayers to pay for a healthcare problem that you can manage and do a good job," Emanuel said. "You can do that with cholesterol, you can do that through diabetes, you can do that through smoking, through heart, blood pressure. Every one of those is manageable."

Can Your Company Require a Biometric Health Screening in Order to Continue Insurance Coverage?

March 2, 2011

Yahoo Answers - My spouse has worked for the same company for the past 15 years. The company seems to be forcing the issue of a biometric health screening. Under the heading of “Is this mandatory?” it says..

"For salaried employees, in order to participate in the 2010 Medical Plans you are required to go through the on-site biometric screen process, and the online Health Risk Assessment. If a salaried employee chooses not to participate in either the Biometric Screen, or the online Health Risk Assessment, they will not be eligible for 2010 Medical Insurance, and you will receive COBRA notification to your home if you were previously participating in the medical plans."

Is this crap legal? Can a company terminate your insurance for not completing this so called health assessment?

tonalc2

Yes. Welcome to the wonderful world of risk-based, profit-driven health coverage.

DAR

A company has no legal duty to give insurance at all, generally. In states where it does it MAY be illegal (for companies of a certain size) but I’m pretty sure you would have to take it to court, and the government wants EVERYONE’s private records online, 4th amendment or not (look at Obamacare); so I think you’d have a hard time with it. Is there an implication you won’t be covered if you have preexisting conditions? Because if that is the case, it may not satisfy legal standards IF there are legal standards. Note that there often are not, particularly for small companies.

Does Obamacare Require BMI Screening and Electronic Health Record by 2014?

July 19, 2010

Examiner.com - One of the latest rumors to circulate on the internet about the Obamacare nightmare is that it will require all Americans to undergo BMI (Body Mass Index) screening by 2014. Presumably, the BMI results will be used to ration health care in some manner as finite numbers of doctors, nurses, and hospitals struggle to cope with unlimited demand for their services.

To find the truth, I examined the full text of HR 3590, The Patient Protection and Affordable Care Act, as well as its companion bill HR 4872, the Health Care and Education Reconciliation Act. This takes some time, even scanning with the search function on a browser, since the HR 3590 contains a whopping 906 pages and HR 4872 adds an additional 55 pages. That is quite a number of dead trees for a law that is supposed to simplify and lower the cost of health care.

I conducted my examination by searching both documents for “bmi.” This resulted in a large number of hits, but only two referred to “Body Mass Index.” The majority were some form the word “submit,” which says a lot about Obamacare in itself.

1. The first reference is in section 2703 State Option to Provide Health Homes for Enrollees with Chronic Conditions on page 203. BMI is mentioned here as one of the medical conditions that defines the term “chronic condition” (specifically a BMI over 25). There is no mention of mandatory screening for BMI.


2. The second reference to BMI was in section 4004 Education Outreach Campaign Regarding Preventive Benefits on page 428. In this section, BMI is mentioned as one of the factors that people will use to determine their disease risk on a website. Again, there is no mention of mandatory BMI screening.

The second bill, HR 4872, contained several references to “submit,” but no references to Body Mass Index.

At this point, I was ready to declare the mandatory BMI screening a hoax.

Just before I published this article, however, someone pointed me in the direction of a document called HIT (Health Information Technology) Standards 170.302. This document purports to show Secretary Kathleen Sebelius’ new certification standards for electronic health records (EHRs). Further, a CNS News report (http://cnsnews.com/news/article/69436) refers to section 3001 Office of the National Coordinator for Health Information Technology of the American Recovery and Reinvestment Act of 2009, the stimulus bill, rather than the Obamacare law itself. 

Section 3001 in Part C Duties of the National Coordinator Subpart 3 paragraph (a) (ii) states that the National Coordinator shall “update the Federal Health IT Strategic Plan” with “utilization of an electronic health record for each person in the United States by 2014.” This constituted the basis for Sebelius’ new EHR standard.

On page 61 (of 228) in The Code of Federal Regulations Part 170 (http://www.ofr.gov/OFRUpload/OFRData/2010-17210_PI.pdf) it states that EHRs will calculate BMIs. An additional document (http://healthcare.nist.gov/docs/170.302.e.2_BMI_v0.2_fulldoc.pdf) refers to certification criteria for EHRs and specifically shows that BMI will be part of the vital signs included in EHRs. 

Therefore, it appears that the rumor is true as far as the claims that Obamacare will require an EHR for all Americans and that the EHR will be required to include a calculation for BMI. The speculative claim that the BMI will be used to ration health care is so far unsubstantiated. I will leave it up to the reader to decide whether and how much to be alarmed by the BMI requirement.

I will say that it is extremely likely that Obamacare will result in health care rationing. Massachusetts enacted what President Obama called an “essentially identical” plan in 2006 and the result has been skyrocketing costs (http://bit.ly/dvTxyU). Rapidly increasing demand with a static level of supply led to sharply increasing costs. To deal with these increasing costs, Governor Deval Patrick enacted price controls in the form of denying insurance companies to increase rates.

Jon Kingsdale, who directed in Massachusetts’ version of Obama’s health insurance exchanges, said recently,

"If you're going to do health-care cost containment, it has to be stealth. It has to be unsuspected by any of the key players to actually have an effect."

He further stated that:

The solution to the problem was finding a “significant systematic way of pushing back on the health-care system and saying, 'No, you have to do with less'” (http://bit.ly/dvTxyU).

In other words, the government will have to quietly ration care.

This shows the ultimate importance of efforts to defeat Obamacare. If you value your health care, vote for candidates who will repeal and defund the new law. Also support state and local candidates who will support efforts such as the lawsuit by Georgia and several other states against the law.

Reform the reform!

Onsite Employee Health Screening and Biometric Testing

October 26, 2008

CorporateWellnessIncentive.com - Onsite Employee Health Screening and Biometric Testing means better heath risk assessment baselines and better security.

“Onsite Employee Health Screening and Biometric Testing” is a hot phrase these days, but it can help your workers with health management, too. When the pundits talk about Onsite Employee Health Screening and Biometric Testing, they’re usually referring to retinal scanners, fingerprint readers, and other high-tech security measures. However, if you trace the phrase “Onsite Employee Health Screening and Biometric Testing” back to its roots, it refers to the measurement of unique human physical and behavioral characteristics.

Corporate Health Promotion Programs are of critical importance to the modern business. As a result, Onsite Employee Health Screening and Biometric Testing should be one of the tools in the arsenal of a forward-thinking organization. 

Onsite Health Screening and Biometric Testings aren’t just a “feel-good” measure for your employees. Assessments of employee health help your workers to prioritize their well-being, which results in happier, more productive employees.

Health risk assessments also build your database of employee biometric data.

Onsite Employee Health Screening and Biometric Testing, when handled worksite by our experienced professionals, is hassle-free and smoothly organized. The biometric data we collect then can be stored digitally for years or even decades, helping you and your workers build better health risk assessment baselines that you can use to analyze workers fitness and the efficacy of your corporation’s Health and Productivity Programs. Collected biometric data can even allow an employee’s doctor to assess that individual’s health over many years, helping him or her spot trends and diagnose disease.

Onsite Employee Health Screening and Biometric Testing extends to a wide variety of health risk tests, including measurements of blood pressure, blood type, body fat, substance abuse, and susceptibility to cardiovascular disease. Collecting biometric data for security purposes – like fingerprints, facial recognition imprints, or hand geometry – can be dovetailed with our health tests to minimize workflow disruption.

What Is a Biometric Screening?

March 28, 2011

eHow.com - A biometric screening is a short health examination that determines the risk level of a person for certain diseases and medical conditions. Many employers and universities encourage staff or students to complete this type of health screening so they can start thinking about their health and pursue treatment if needed.

Purpose

• A biometric screening is a general health check that can identify any significant cardiovascular or nervous system problems. This health check provides several biometric measures including: cholesterol levels for full lipid panel and glucose; blood pressure; blood glucose levels and also includes a measurement of height, weight and body mass index (BMI). Results are typically available within a few days after the screening, and are kept confidential.

Significance

• The biometric screening can be one of several components of a complete health and wellness check. Most doctors and clinics perform a biometric screening as part of a wellness program that includes the completion of a health risk assessment (HRA) questionnaire, and a consultation. Results of the biometric screening can help to identify various diseases or health problems, and allow the patient to work with their physician to lower their health risks for certain conditions.

Components

• The typical biometric screening test can take up to 15 minutes, and is performed at a physician's clinic, or on site at an employment facility or college campus. It can consist of all or some of the following screening tests: carotid artery ultrasound screening; blood pressure check; blood draw; diabetes screening; and cholesterol screening.

Types

• The blood pressure screening is completed with a standard blood pressure check. The blood test is conducted by drawing a vial of blood; patients are required to fast for a short period of time before having blood drawn. The diabetes screening is performed by measuring glucose levels in the blood from the blood test. The cholesterol screening is performed with a "finger-stick" test that measures full lipid and glucose levels. The carotid artery ultrasound test determines the risk factor of having a stroke. This test measures how much plaque has accumulated in the arteries.

Benefits

• Biometric screenings allow the patient to learn about her current health status, and determine her risk for common diseases including diabetes, heart disease, asthma and other medical conditions. The physician or nurse conducting the tests can review the results of the screening with patients and follow up to do further tests, or recommend a treatment plan or wellness program based on immediate needs.

Read More...

Rand Paul’s Hilarious Explanation of Obamacare

Rand Paul’s Hilarious — Yet Revealing — Obamacare Explanation: Guess What New Injury Codes Are Included

May 28, 2013

The Blaze - Obamacare will require doctors to use roughly 122,000 new medical diagnostic codes to inform the federal government of injuries sustained by Americans, so says Kentucky Senator Rand Paul.

The new codes, Sen. Paul explained, include classifications for "injuries sustained from a turtle," "walking into a lamppost" and "injuries sustained from burning water skis."

"Your government just wants to take care of you," he added, criticizing the new law's 9,000-plus pages of new regulations. "They don't think you're smart enough to make these decisions."

Physicians currently have about 18,000 medical diagnostic codes to choose from to help them inform insurers of their patients' ailments. However, as Paul (himself a physician) notes, Obamacare includes a mandate for 140,000 of those codes -- and some of them sound downright ridiculous.

"Included among these codes," the senator continued, "will be 312 new codes for injuries from animals; 72 new codes for injuries just from birds; 9 new codes for 'injuries from the macaw."'

"The macaw?" he asked. "I've asked physicians all over the country, 'Have you ever seen an injury from a macaw?"'

He continued, adding that he had found "two new injury codes under Obamacare for 'injuries sustained from a turtle."'

"Now, you might say, 'Well, turtles are dangerous' -- but why do you have to have two codes?" he asked.  "Your doctor has to inform the government whether you've been struck by a turtle or bitten by a turtle."

He added:  "There is a new code for ... walking into a lamppost. There's also a code for 'walking into a lamppost, subsequent encounter.'"

"I guess that's if you don't learn," he added. "[T]here is [also] a code ... for 'injuries sustained from burning water skis."'

Though the Republican senator delivered his speech earlier this month to the Iowa Republican Party, his Obamacare remarks have only recently gained traction online: see video by clicking on the headline link.

IRS Scandal Suddenly Became About Obamacare

Why the IRS Scandal Suddenly Became About Obamacare

May 15, 2013

The Atlantic Wire - It seems as if the battle over the IRS' improper focus on Tea Party groups has splintered into an attack on the Affordable Care Act, better known as Obamacare. But it's more accurate to say that the new scandal is simply the latest reason being used to attack the president's health-care legislation.

Here's how the two are linked. When the Supreme Court upheld the ACA last June, it did so on what could be described as a four-to-four-to-one vote. The Court's four liberal justices supported the policy; four of the five conservatives opposed it. Chief Justice John Roberts's majority opinion upheld the policy for an unexpected reason: Congress has the ability to regulate health care as part of its power to tax. Since the policy was administered through the IRS, the law was Constitutional.

According to CNBC, there are 47 different provisions of the ACA that the IRS is supposed to administer. (An overview of some of the Act's provisions is provided at the IRS website.) That's 47 new things for the IRS to track — meaning a substantial increase in the amount of work the IRS needs to do. According to reporting from the Fiscal Times, the IRS will add over 2,000 new employees to do that work, an addition that also requires a substantial increase in the amount of money the IRS needs.

Attacks on the ACA are not new. Today, the House is expected to vote for the 37th time to repeal the policy entirely. Nor are attempts to inhibit the IRS' ability to administer the policy by curtailing funding new; in March, the House passed a funding resolution that aimed at scrapping that money.

What's new is the leverage provided by the still-brewing IRS scandal. It didn't take ACA opponents long to imply that the IRS' errors and failures in the administration of non-profit status implied that it couldn't be trusted to properly administer Obamacare. Michele Bachmann presented the most extreme argument to that end, but she wasn't alone in suggesting that there was a problem. On Monday's Morning Joe, Newt Gingrich argued that the agency was fundamentally untrustworthy, asking, "Why would you trust the bureaucracy with your health if you can’t trust the bureaucracy with your politics?"

Senator Dean Heller of Nevada was more direct. Yesterday, Heller wrote a letter to Health and Human Services Secretary Kathleen Sibelius indicating that both Congress and her agency must "look closely at the money given to the IRS through the health care law" in light of "recent events" involving the IRS. Heller announced that he planned to introduce a bill that would block the $440 million the agency needs for implementation, though, as the Las Vegas Sun points out, that legislation would be unlikely to get past Senate Majority Leader Harry Reid. 

Given the narrow scope of malfeasance outlined in the Inspector General's report about the IRS, it's not yet clear if critiques of the agency as a whole will stick. The president yesterday called for harsh consequences for those involved, albeit not as harsh as demanded by the Speaker of the House.

Boehner on IRS: My question isn't who's going to resign, it's who's going to jail.
— Michael McAuliff (@mmcauliff) May 15, 2013

Should accountability for the mistakes happen quickly, the damage the agency faces would likely be contained. (One thing that probably isn't worrying the IRS is the prospect of a sharp decline in its popularity. A 2009 Gallup poll identified the agency as the third-least popular in the government.)

The calls for Obamacare to be separated from the IRS will continue no matter what happens, as evidenced today in a harsh editorial in the Wall Street Journal. The most striking aspect of that editorial, though, is what isn't prominently featured: the argument that the IRS non-profit mistakes make the case for taking ACA administration away from the IRS. It's mentioned, but it's not needed for the argument. It's almost as if the Journal would have made the case against the ACA regardless of the scandal.

Obamacare Gives the Federal Government License to Micromanage Every Facet of Our Lives; Tax Penalty Under Obamacare Violates the Constitution

Obamacare faces new legal challenge: Its 'tax' still violates the Constitution

April 30, 2013

Timothy Sandefur | Christian Science Monitor - The Supreme Court saved Obamacare by deeming the law's individual mandate a 'tax.' But in that case, the law violates the Constitution's Origination Clause, which says all tax bills must originate in the House, not the Senate. Letting the law stand sets a dangerous precedent. 

With tax day and IRS forms fresh in their minds, most Americans might think the US tax system couldn’t get any more daunting. But next year, some new complexity kicks in.

One of the hotly debated features of the Patient Protection and Affordable Care Act (or “Obamacare”) takes effect in 2014. Under the law’s “individual mandate,” nearly everyone who isn’t covered by an employer will have to buy health insurance or pay a penalty. This penalty was officially labeled a “tax” by the Supreme Court, or at least by five of the justices, in its decision on Obamacare last June.

The Obama administration, however, never argued that the individual mandate is an exercise of Congress’s taxing authority. And as recently as October, in an interview with Rolling Stone magazine, President Obama avoided the “tax” justification, and still insisted that the individual mandate is a regulatory action authorized by the Commerce Clause.

Just what Americans need: more confusion and ambiguity in their tax law.

By calling the mandate to buy insurance a “tax,” the court did more than trigger new debates about semantics. It created a potentially fatal constitutional glitch in the law.

Article I, Section 7 of the Constitution says that tax bills – “all bills for raising revenue” – must “originate in the House of Representatives.” The framers wrote this “Origination Clause” because they recognized the potential danger in the taxing power, and they wanted to keep it as close as possible to voters. So they entrusted it to members of the House, who are elected every two years and have smaller constituencies than senators, who represent whole states and serve staggered six-year terms.

But Obamacare didn’t follow the constitutional script. Instead of originating in the lower chamber, it started in the Senate, when Majority Leader Harry Reid took an old bill the House had passed that would have given veterans tax credits to buy homes, struck out all of that bill’s language, and inserted instead the confusing web of provisions that became the Affordable Care Act.

Was this “gut and amend” ploy valid?

That question is now in front of US District Judge Beryl Howell in Washington, D.C., in a challenge to Obamacare filed on behalf of Matt Sissel, an Iowa small business owner who was decorated for service as a medic in the Iraq war.

Obamacare was passed hastily, by lawmakers who admitted they had not read the bill. The legislation was passed during the holiday season, through questionable procedural tricks. It was never popular, and a recent Kaiser Family Foundation poll found that only 36 percent of Americans currently support the law. Even the Supreme Court’s liberal wing agreed that large parts of it were unconstitutional. In part of last June’s decision, Justices Stephen Breyer and Elena Kagan joined the conservatives to hold that Congress had illegally tried to force states to expand their Medicaid rolls.

These are all good reasons not to give a reflexive pass to the law’s most controversial aspects – including the way it was enacted.

The Supreme Court has never addressed whether the Senate can evade the Origination Clause by hollowing out a House bill and substituting its own tax.  

“If any act violates the Origination Clause, it would seem to be the Affordable Care Act,” Randy Barnett, a Georgetown University Law School professor and leading constitutional critic of Obamacare, has written.

The Constitution’s procedural guidelines might seem like dry formalities. But such procedures were designed to safeguard the rights of the American people. And if last June’s Supreme Court decision is not to become a precedent for Congress to impose any variety of mandates on Americans under the taxing power, courts should take care to enforce democratic controls over that power.

Obamacare gives Congress license to micromanage every facet of our lives

March 27, 2012

Timothy Sandefur | Christian Science Monitor - The Obama administration has never offered a principled explanation of how to square the health-care law's individual mandate with the Constitution. If Congress can force us to buy health insurance, what can’t it order us to buy?

The US Supreme Court today heard arguments today on what may be the most important constitutional case in a generation. Some of the nation’s top attorneys are debating the Patient Protection and Affordable Care Act, often known as Obamacare.

The eventual ruling could chart the boundaries of federal power for generations to come – not only for health care, but across the policy spectrum.

A major focus of the Supreme Court hearings is the individual mandate – the law’s requirement that almost all Americans who aren’t covered by employers must purchase a health-care plan, whether they want to or not.

The plaintiffs – including 26 states as well as individuals and businesses – argue that Congress has no authority to force people to buy insurance. Most Americans agree: A recent Gallup poll found that 72 percent – including 56 percent of Democrats – consider the mandate unconstitutional.

Obama administration attorneys counter that Article I, Section 8 of the Constitution, known as “the commerce clause” – giving Congress power to “regulate commerce among the several states” – is more than expansive enough to validate the mandate.

They rely on a list of Supreme Court precedents that stretch the definition of “interstate commerce” pretty far.

In the 1940s, the court allowed Congress to punish a farmer for growing wheat on his own land for his own use, on the theory that wheat prices would be affected if everyone did that. In the 1960s, the court classified civil rights laws as “regulations of commerce” even when they involved businesses that did practically no interstate business. And in 2005, the court ruled that Congress could prohibit someone from growing marijuana in her yard for her personal medical use, because federal laws against drugs are a kind of economic regulation.

Still, the court has never held that the federal government may compel people to participate in commerce. And this is what makes the individual mandate unprecedented: Never before has Congress presumed to order average Americans to purchase a good or a service in the marketplace.

Simply from the standpoint of semantics, the law’s defenders face a challenge. As ordinarily understood, the word, “regulate,” implies rules for activity that people have freely chosen to engage in (running a business, for instance). The word doesn’t imply forcing people, say, to start a business in the first place.

Likewise, “commerce” implies economic activity – but someone who fails to buy health insurance is not engaged in economic activity.

Beyond these disputes over definitions lies a fundamental question about the extent of federal power: If Congress can force us to buy health insurance, what can’t it order us to buy?

Timothy Sandefur is a principal attorney with Pacific Legal Foundation, a public-interest legal organization that litigates for limited government, individual rights, and free enterprise. He represents small business owner Matt Sissel in challenging the constitutionality of the Affordable Care Act’s individual mandate “tax.”

SmartPhone Physical Booth at TedMed 2013

Can a Smartphone Do What Your Doctor Does?

April 28, 2013

ABC News - During our medical training, we're taught to gather and use information from three sources: a patient history, a physical exam and lab tests. By far the most difficult to master is the physical exam. A good exam requires knowledge of anatomy and physiology, and awareness of normal variations that allow a doctor to recognize abnormalities.

Technology can help, and at TedMed 2013, the SmartPhone Physical exhibit by MedGadget/Nurture showcased some of the latest advances. The goal was to bring complex tests that are pricey to perform with traditional equipment into primary care clinics.

The result: accessible, affordable $200 phone accessories, most of them approved by the U.S. Food and Drug Administration as "equivalency standards," meaning they're equal to the industry standard. This technology could improve access to these tests, cut down on referrals, and provide overall better care.

"It's great for primary care physicians, new doctors with less experience, teaching and even some patients," said Shiv Gaglani, a medical student at Johns Hopkins and curator of the exhibit. "Some physicians can go through their entire training without really learning to look into an eye."

But I was skeptical. In medicine, we learn to question everything. If my own mother came to me saying hugs were good for a cold, I would take the hug, then ask to see the evidence. So I decided to try it out. Gaglani would be my "doctor" for this 10-minute exam using the following gadgets:

Blood Pressure Monitor by Withings and Blood Oxygen Monitor by iSp02
 

We started off, like in all physical exams, by taking the vital signs: blood pressure, heart rate, and oxygenation. The screen buzzed with colorful readings and real-time measurements, and then uploaded my information into an iPad, where I could get it through an app. It was a start, but I wasn't that impressed. The technology for "automated vital signs" had been around for a while, and a few years ago I taught my 7-year-old cousin how to use the machine on my grandmother.

ECG Cellphone Case by AliveCor

 

By squeezing my thumbs onto the metal plates of this iPhone cover, I was able to get a partial ECG that was uploaded and emailed to me. Interesting! One of the problems physicians have is that patients with heart symptoms often improve and the ECG normalizes by the time they see the doctor. This device was simple enough that patients with symptoms could get this cell phone case and be taught how to use it. So the next time symptoms occurred, we could get an ECG from during the cardiac event. One of the women who tried it earlier had palpitations during her exam and was diagnosed with a rhythm abnormality.

iExaminer by Welch Allyn
 

The eye exam, or "fundoscopy," is the only way we can look directly at blood vessels inside the body without having to cut anything open. It can tell us a lot about diseases such as high blood pressure and diabetes. Unfortunately, it takes a lot of practice, so many of us end up referred to an ophthalmologist. The iExaminer was able to take an impressive visual photo of the inside of my eye and turn it into a .pdf.

SpiroSmart
 
This smartphone looked at lung function, which usually is tested at a special lab during an uncomfortable exam. Guidelines for chronic lung diseases such as asthma, cystic fibrosis and chronic obstructive pulmonary disease suggest these tests should be done regularly, but because it is often inconvenient to make a separate trip, they're underused. It would be great if these tests were more accessible.

"Unlike the lab machine, which uses pressure, this device uses sound and has been shown to be almost as accurate," said SpiroSmart co-creator Mayank Goel. "This opens up so many doors; imagine even being able to do this test over the phone!"

Other devices included ThinkLabs' ds32A digital stethoscope that records body sounds (like heart murmurs), the MobiUS SP1 handheld ultrasound machine that looked at the carotid arteries in the neck and was surprisingly accurate compared to the full ultrasound machines, and an otoscope that looked at my eardrum and took a picture.

Overall, I was grudgingly impressed. The devices seemed to combine the best parts of human experience and technology, using technology to gather reliable information, especially for those with less experience, and the physician to interpret the results.

Studies looking at "inter-rater reliability," the concept of how likely is it that different people interpreting the same physical exam sign will get the same diagnosis, show that technology is often better for gathering consistently objective information.

The long lineup at the SmartPhone Physical Booth at TedMed included the surgeon general and Dr. Daniel Kraft, faculty chair of medicine at Singularity University in San Diego, who was impressed by the potential for improving access to care, whether in remote areas or overseas.

"It can enable primary care anywhere. And even though we need to do more testing to ensure accuracy, the potential is great," Kraft said.

One of the problems, however, is that each device has to be attached to the phone in a separate way, and data is uploaded to different apps, creating a huge amount of information to sift through.

"Our ability to gather data is overtaking our ability to pare it down and use it to improve our health," said TedMed editor-in-chief John Benditt.

And it's true. The creation of complex devices and technology is surpassing our ability to learn it and use it to its full potential before the "next big thing" comes out. What I'd really like to see is an ECG machine and BP machine that combines data with the lung machine and uploads it to the same profile. Arguably, the next big challenge in medicine may not be the creation of new technology but finding a way to integrate existing ones.

Obamacare Pushes U.S. Over the Cliff

Bureaucrats want to cut Medicare and Social Security, which are directly funded by payroll taxes (FICA)... the Feds will use our tax dollars to subsidize expansion at the state level of Medicaid to all Americans. Where is the money coming from to fund this? If we are on a 'fiscal cliff', then Obamacare should be the first thing to go. Obamacare is not about extending affordable heath care coverage to every American: it's about the government controlling and rationing our healthcare and forcing every American to have an electronic health care record (which bureaucrats will have access to) in order to receive coverage. It's also about collecting additional taxes from small businesses and individuals by forcing people without insurance to pay a fee to the IRS unless they meet federal poverty levels (currently $11,170 for individuals, $23,050 for a family of four). Obamacare could lead to the government having real-time access to individuals' finances and bank accounts and a 'National ID Card'—the mark of the beast (source).

"That information will be irrevocably integrated into a cradle-to-grave medical record to which insurers, employers, government and law enforcement will have access is, to me, exactly what privacy is not. People are not going to feel comfortable going to the doctor, because now you are going to have a permanent record that will follow you around for the rest of your life that says you had syphilis, or depression, or an abortion or whatever else." - A.G. Breitenstein, director of the Health Law Institute

Counting down to ObamaCare: What's coming in 2013?

November 29, 2012

The Week - Most Americans still don't know what to expect from President Obama's health care overhaul, and the big changes are yet to come

When House Speaker John Boehner (R-Ohio) said after the 2012 election that "ObamaCare is the law of the land," he was more stating the facts than waving a white flag. Republicans haven't entirely given up on neutering, or at least undermining, President Obama's signature domestic achievement, but the Patient Protection and Affordable Care Act has survived several legislative attempts at repeal, a harrowing Supreme Court challenge, and now a presidential election that promised critics their last best chance of killing ObamaCare before it takes full effect in 2014. Still, a lot of the nuts and bolts of the law are still loose (or still in their packaging), making 2013 a very big year for the health care overhaul.

Here's a chronological rundown of what benefits and rules kick in over the next year, what has yet to be finalized, and what the GOP is doing to keep up the fight:

What has already taken effect

As Obama noted repeatedly in the presidential campaign, ObamaCare already allows parents to keep their children on their health insurance plans until age 26, makes it so children cannot be denied coverage due to pre-existing conditions, offers some preventative services at no out-of-pocket cost, and prohibits insurers from setting lifetime limits on benefits. On Nov. 20, the Department of Health and Human Services (HHS) published a whole ream of (largely technical) rules guiding how ObamaCare will be implemented.

December 14, 2012

This is the HHS deadline for states to decide whether they will set up their own health insurance exchanges, partner with the federal government, or let the feds set one up for them.

"Basically, these will be health insurance stores," says Peter Grier at The Christian Science Monitor, "markets intended to provide a more organized and competitive way for people to buy a product that's often complicated and confusing." 

Eligible shoppers will include workers whose employers don't provide affordable health care, the self-employed, and early (pre-Medicare-age) retirees.

As of Nov. 29, 18 states have said they will set up their own exchanges, six have signed on for state-federal partnerships, 17 said they will leave the work to the federal government, and 10 are still undecided. Massachusetts and Utah already have exchanges, although Utah's is "relatively barebones" and only serves employers, not individuals, says Sarah Kliff at The Washington Post.

This is one of the major ways Republicans hope to hobble ObamaCare. Setting up the exchanges will be a huge undertaking for the states, and the federal government will have an even harder time setting up 17 to 30 different systems for opt-out states. If the Obama team can't create those exchanges, ObamaCare loses its conduit for providing insurance to millions of Americans. It would serve Democrats right, says The Wall Street Journal in an editorial. There's no way HHS can pull off the exchanges in a year, and "when it turns out that ObamaCare's costs are underestimated and its benefits exaggerated," why should GOP governors who opposed it be left holding the bag?

January 1, 2013

Regardless of what happens with the "fiscal cliff," a few ObamaCare-specific taxes will kick in at the New Year. People earning more than $200,000 a year (for couples, $250,000), the Medicare Part A (hospital coverage) payroll tax will go up less than 1 percent, to 2.35 percent of wages. Medical device makers face a new 2.3 percent tax, although the IRS has not yet defined what counts as a taxable "medical device."

July 1, 2013

This is the scheduled date for a group of new Consumer Operated and Oriented Plan (CO-OP) nonprofit, member-run health insurance companies to open their doors for business.

October 2013

At this point, the states' health insurance exchanges are supposed to go live, letting residents browse through the approved options and sign up for plans. As envisioned, shopping for health insurance should be as easy as shopping for plane tickets or rental cars online.

Of course, "Buying health insurance is a lot more difficult than purchasing a plane ticket on Expedia," says The Washington Post's Kliff. 

So this is also the informal deadline for "setting up large-scale customer support operations" at the state and/or federal level.

Late 2013

In the GOP's other big shot at striking a blow against ObamaCare, the Supreme Court recently opened the door to a second high-court challenge to the law. In this case, the challenge involves the employer mandate — companies with 50 or more employees will have to provide health coverage or pay a $2,000 fine for every worker past No. 30 — and the requirement that all non-church employers provide free contraception. If the lower court makes its ruling by spring 2013, as expected, says Kilff, "that could lay the foundation for a repeat performance in front of the Supreme Court late next year — just before the major parts of the health care law are expected to kick into gear."

January 1, 2014

The major parts of the law are scheduled to kick into gear: The individual mandate and employer mandate, the health insurance exchanges, and the ban on insurers excluding people based on pre-existing medical conditions. This is also when Medicaid coverage expands to everyone in participating states who earns up to 133 percent of the federal poverty level. Under the individual mandate, everyone will be required to have health insurance, with federal subsidies for everyone earning up to 400 percent of the federal poverty level (currently $11,170 for individuals, $23,050 for a family of four).

Find out how ObamaCare affects you, or watch this video primer from the Kaiser Family Foundation:

Obamacare Countdown: What is Slated to Happen Over the Next Year?

Obamacare countdown: What is slated to happen over next year?

The health-care reform law, aka Obamacare, is poised to enter a crucial 12 months that includes setting up state exchanges, levying taxes on the wealthy, and preparing for the individual mandate.

November 28, 2012
 
Christian Science Monitor - Obamacare lives. That may be one of the most sweeping consequences of the 2012 presidential election. By winning a second term, President Obama has essentially ended Republican hopes of rolling back his signature Affordable Care Act before it takes full effect. Even adamant opponents of the health-care reform law in the GOP-controlled House recognize that it's pointless to continue pushing repeal legislation, at least for now.

"Obamacare is the law of the land," said House Speaker John Boehner (R) of Ohio on Nov. 8.

With its immediate future secure, the health-care law now enters a crucial 12 months. Federal and state officials must race to prepare for Jan. 1, 2014, which is opening day for some of the Affordable Care Act's most far-reaching provisions. As Health and Human Services Secretary Kathleen Sebelius noted in congressional testimony this past spring,

"2013 will be a critical year for building the infrastructure and business operations" needed to expand health insurance coverage to millions of low-income Americans.

It's possible that some aspects of Obamacare (as many people, including the president, now call it) could be scaled back in budget negotiations intended to avert the "fiscal cliff" crisis. But here's a primer on top upcoming milestones as the law currently stands.

State insurance stores. By 2014, each state (and the District of Columbia) is supposed to have a health insurance exchange up and running. Basically, these will be health insurance stores – markets intended to provide a more organized and competitive way for people to buy a product that's often complicated and confusing.

Those eligible to shop at the exchanges will include people whose employers don't offer affordable health coverage, and others who need to buy insurance on their own for some reason (such as, they're self-employed, or they're retired and not yet eligible for Medicare).

States are supposed to tell Washington by Dec. 14 whether they'll run their own exchanges, partner with the federal government, or not get involved, in which case Uncle Sam will set up and run insurance stores for them.

Whoever controls them, there's a lot of work to get ready for October 2013. That's when exchanges are supposed to open their (presumably online) doors and allow potential customers to check out their products and begin the selection process. Between now and then, exchange officials will have to sort and certify offerings from insurance providers, while building the information systems and electronic customer interfaces they'll need to conduct business.

Coverage purchased through exchanges is slated to take effect at the beginning of 2014.

Tax hikes. Whatever the outcome of current budget negotiations, taxes on the wealthy are certain to rise in at least one area. To help pay for the Affordable Care Act's expansion of coverage, the tax on wages for Medicare Part A (hospital insurance) will rise by just under 1 percent for individuals who make more than $200,000 and for married couples who earn more than $250,000.

The increase will put this payroll tax at 2.35 percent for folks in those income levels. It's scheduled to take effect on Jan. 1, 2013.

The Affordable Care Act also mandates a new 2.3 percent tax on "medical devices," set to begin on the same date. The Internal Revenue Service hasn't yet issued final regulations setting the boundaries for what this levy will hit, however. Among the issues here is whether things often sold to consumers as well as health-care professionals, such as latex gloves, will be subject to the new tax.

Insurance mandate. The US government doesn't require you to have health insurance – yet. But that day is coming. That day is Jan. 1, 2014, to be precise, when the Affordable Care Act's individual mandate takes effect.

Starting then, adults who don't have health coverage will have to pay a fine (or tax, as the US Supreme Court ruled) of $95 per year, or as much as 1 percent of income – whichever is greater. This is scheduled to rise year by year, topping out in 2016 at $695 per adult or 2.5 percent of income.

For families, the fine goes from a maximum of $285 or 1 percent of household income to $2,085 or 2.5 percent of income, over the same period.

The fine can be waived for a limited number of reasons, including financial hardship. And it goes hand in hand with government subsidies intended to help make coverage affordable.

For instance, Obamacare calls for an expansion of Medicaid, the big federal-state health insurance program for poor and disadvantaged people. The Affordable Care Act provides a big influx of federal dollars to try to cajole states to expand Medicaid so that it includes everybody who makes less than 133 percent of the poverty level.

The US Supreme Court has said states don't have to participate in this, though, and some Republican governors have said they'll decline the expansion.

For Americans who earn a bit more, Obama­care also has provisions. Uncle Sam will provide subsidies on a sliding scale for people making up to 400 percent of the poverty level.

Related:

• How much do you know about health-care reform? Take our quiz!
• Is Obamacare on table for 'fiscal cliff' talks?
• 'Obamacare' tackles health care costs. Will Congress?

Obamacare Is Here To Stay

Obamacare Is Here To Stay -- But Big Challenges Remain

November 8, 2012

The Ticket - Now that President Obama has secured re-election, allies and foes alike agree that his health care reform law is here to stay. The legislature, the executive, the judiciary and now the electorate, in its own way, have ratified it. And as more popular provisions of the law take effect in the coming months, rolling them back will be an increasingly dicey political proposition.

But that doesn't mean it's smooth sailing for the ACA from this point forward. The law is vast and complicated and sure to encounter implementation problems -- and many of those problems won't be fixable unless Republicans agree to participate constructively.

The key elements that have already taken effect include the guarantee of free preventive care, a ban on insurers from denying coverage to sick children, a partial closing of the Medicare prescription drug coverage gap and letting people under 26 remain on a parent's policy.

Over the course of the coming months and years, the law will introduce payment reforms and other programs intended to hold the growth of health care costs down at sustainable levels.

But the vast bulk of the law takes effect in 2014, just over a year from now. And that's when some of the biggest challenges will manifest.

Starting that year, no insurance company will be able to turn away customers or charge them higher prices because of their health status. Most Americans within 133 percent of the poverty line will be able to enroll in Medicaid, and those between 133 percent and 400 percent of the poverty line will be entitled to federal subsidies to purchase private insurance. Nearly all will be required to buy insurance on a regulated exchange in their state or pay a tax penalty.

Implementation of the law still faces obstacles -- mostly because Republicans will oppose, or have a difficult time, engaging it constructively. So far, the GOP has been single-minded in its quest to repeal the law entirely, which means that as problems with the law arise, fixing those glitches and guarding against failures will be a heavy legislative lift.

One key challenge is that many Republican-led states have vowed not to implement their own insurance exchanges (though some were likely holding out until the election results came in). If a state doesn't build its own exchange, the law empowers the federal government to step in and build one unilaterally. But it's unclear how easy that will be for the federal government, and some GOP governors believe it's too politically toxic to be perceived as abetting the law -- however irrational it may be, as a policy matter, to cede control to Washington.

Another obstacle is that the Supreme Court made the law's Medicaid expansion optional for states. Even the reddest states have a huge incentive to accept it, because the federal government will initially cover the entire cost of the expansion, and then provide matching funds at an extraordinarily high rate of 90 percent. But some Republican governors like Rick Perry of Texas insist they won't play ball. If those sorts of promises hold, the number of people the law is meant to insure will be reduced by millions.

The Supreme Court validated the individual mandate, but separate lawsuits challenging the requirement that insurance policies cover contraception without copays are making their way through the courts. Again, the Supreme Court is expected to have the final say.

The law also calls for the creation of a Medicare cost-cutting panel -- the 15-member Independent Payment Advisory Board -- which will target provider reimbursements if and when Medicare costs grow faster than a sustainable threshold level. However, IPAB commissioners will require Senate confirmation, and Republicans will easily be able to block all of them, unless President Obama resorts to recess appointments, or Senate Democrats reform the filibuster rules to fast-track presidential nominees.

Apart from that, the Affordable Care Act will also lower Medicare reimbursement rates to hospitals and private insurers by some $716 billion over the next 10 years. In return, Medicare will be fully solvent for an additional eight years -- until 2024.

IRS Set to Police You on Health Care

The Tax Man Cometh to Police You on Health Care

July 7, 2012

AP - The Supreme Court's decision to uphold most of President Barack Obama's health care law will come home to roost for most taxpayers in about 2½ years, when they'll have to start providing proof on their tax returns that they have health insurance.

That scenario puts the Internal Revenue Service at the center of the debate, renewing questions about whether the agency is capable of policing the health care decisions of millions of people in the United States while also collecting the taxes needed to run the federal government.

Under the law, the IRS will provide tax breaks and incentives to help pay for health insurance and impose penalties on some people who don't buy coverage and on some businesses that don't offer it to employees.

The changes will require new regulations, forms and publications, new computer programs and a big new outreach program to explain it all to taxpayers and tax professionals. Businesses that don't claim an exemption will have to prove they offer health insurance to employees.

The health care law "includes the largest set of tax law changes in more than 20 years," according to the Treasury inspector general who oversees the IRS. The agency will have to hire thousands of workers to manage it, requiring significant budget increases that already are being targeted by congressional Republicans determined to dismantle the president's signature initiative.

"Knowing the complexity of the health law, there's no question that the IRS is going to struggle with this," said Rep. Charles Boustany Jr., R-La., chairman of the House Ways and Means oversight subcommittee. "The IRS wants more resources. Well, we need to start digging down into what are they doing with the resources and personnel."

Treasury spokeswoman Sabrina Siddiqui said,

"The overwhelming majority of funds used by the agency to implement the Affordable Care Act go to administer the premium tax credits, which will be a tax cut averaging about $4,000 for more than 20 million middle-class people and families."

The Supreme Court, in its 5-4 ruling, upheld the mandate that most Americans get health insurance. The majority said Congress has the power to enforce the mandate under its taxing authority. The decision labeled the penalties a tax, noting that they will be collected by the IRS.

Those who don't get qualified health insurance will be required to pay the penalty — or tax — starting for the 2014 tax year, unless they are exempt because of low income, religious beliefs, or because they are members of American Indian tribes.

The penalty will be fully phased in by 2016, when it will be $695 for each uninsured adult or 2.5 percent of family income, whichever is greater, up to $12,500. The nonpartisan Congressional Budget Office estimates that 4 million people will pay the penalty that year.

The law, however, severely limits the ability of the IRS to collect the penalties. There are no civil or criminal penalties for refusing to pay it and the IRS cannot seize bank accounts or dock wages to collect it. No interest accumulates for unpaid penalties.

So how can the IRS enforce the mandate? Scary letters and threats to withhold tax refunds.

The law allows the IRS to withhold tax refunds to collect the penalty, and most filers get refunds. This year, 77 percent of the 135 million individual income tax returns processed by the IRS qualified for a refund. The average refund: $2,707.

For those who don't qualify for a refund, a stern letter from the IRS can be effective, even if it doesn't come with the threat of civil or criminal penalties, said Elizabeth Maresca, a former IRS trial attorney who supervises the Tax & Consumer Litigation Clinic at the Fordham University law school.

"Most people pay because they're scared, and I don't think that's going to change," Maresca said.

The IRS has not yet issued procedures for taxpayers to prove they have insurance. But IRS Commissioner Douglas Shulman, in a 2010 speech, said he envisioned a process similar to the one used by taxpayers to report interest or investment income.

Under this scenario, an insurance company would send the taxpayer and the IRS forms each year verifying that the taxpayer has qualified insurance. Taxpayers would file the forms with the IRS along with their returns, and the IRS would check them to make sure they match the information supplied by the insurance companies.

The IRS says it is well on its way to gearing up for the new law but has offered little information about its long-term budget and staffing needs, generating complaints from Republican lawmakers and concern from government watchdogs.

The IRS is expected to spend $881 million on the law from 2010 through 2013, hiring more than 2,700 new workers and upgrading its computer systems. But the IRS has not made public information about its spending plans in the following years, when the bulk of the health care law takes effect.

The lack of information makes it impossible to determine whether the IRS will have adequate workers to enforce the health care law, the Treasury inspector general for tax administration said in a report three weeks ago. The report, however, concluded that "appropriate plans had been developed to implement tax-related provisions" of the law.

In 2010, House Ways and Means Committee Republicans issued a report saying the IRS may need as many as 16,500 additional auditors, agents and other employees "to investigate and collect billions in new taxes from Americans."

That assessment has been widely cited by opponents of the law. The IRS disputes the jobs number but hasn't offered another one.

"That is a made-up number with no basis in fact," IRS spokesman Dean Patterson said in an email. "The 2012 budget calls for about 1,200 employees for the IRS to implement the (Affordable Care Act), and the vast majority of those employees are needed to build technology infrastructure to support payments like the new tax credits for individuals and small businesses."

Republicans on the House committee have accused the IRS of obscuring its cost of putting in place the health care law by absorbing it into in other parts of the agency's budget. They cite a June report by the Government Accountability Office that said the IRS has not always accurately identified spending related to the new health care law.

"The agency's repeated lack of transparency to Congress and its failure to provide accountability to the American taxpayers raises fundamental concerns about implementation authorities vested to the IRS," the top four Republicans on the Ways and Means Committee wrote in a June 27 letter to the IRS commissioner.

The committee chairman, Rep. Dave Camp, R-Mich., has scheduled a hearing on the tax implications of the Supreme Court's ruling for Tuesday.

Obama Makes 'No Apologies' for Health Care Law

In First Election Bus Tour, Defiant Obama Touts His Health Care Law

July 7, 2012

The Ticket - President Barack Obama promised cheering supporters in Ohio that he would "make no apologies" for his overhaul of health care and mocked rival Mitt Romney's apparent change of heart on his own approach in Massachusetts.

"When you hear all these folks saying, 'Oh, no, no, this is a tax, this is a burden on middle-class families,' let me tell you, we know because the guy I'm running against tried this in Massachusetts and it's working just fine--even though now he denies it," Obama told about 300 supporters at Dobbins Elementary School in the village of Poland.

The president brought up health care often on this week's two day bus tour--the first of this election cycle. On Friday, the president's reelection campaign promoted an interview with an NBC affiliate in Cincinnati in which he hit Romney for changing his tune on whether the individual mandate—the requirement that people have health insurance—is a penalty or a tax. Romney says it's a tax in Obamacare but a penalty in his own plan.

"One of the things that you learn as president is that what you say matters and your principles matter," Obama scolded in the interview. "And sometimes, you've got to fight for things that you believe in and you can't just switch on a dime."

The debate has flared because the Supreme Court upheld Obama's signature domestic policy achievement under Congress's taxing power. Republicans have seized on that to accuse the president of breaking a pledge not to raise taxes on middle-class families. The White House insists that the fine imposed is a penalty, not a tax.

"We're going to charge you a penalty to make sure that you're not unloading those costs on everybody else," Obama said in Poland. "It will affect less than 1 percent of the population, because most Americans are responsible and do the right thing. I make no apologies for it."

"We're going to keep it moving forward. It was the right thing to do two years ago, it's the right thing to do now, and we're going to keep moving," he said.

Obama's argument highlighted an interesting aspect of Campaign 2012: While pundits confidently predicted that he would not run on the health care law, which remains unpopular, the president rarely misses a chance to highlight it on the stump.

There is no doubt that the economy remains both the top issue on voters' minds and Obama's greatest vulnerability. But the president has shown no hesitation about making health care an integral part of this appeal to supporters.

Here he is, again, in Poland:

"I'm running because I continue to be convinced that in a country like ours, the greatest country on Earth, nobody should go bankrupt just because they get sick. I am proud of the work we did."

Here he is in Sandusky, Ohio, on Thursday:

"I'm running because the health care law that we passed was the right thing to do … we fought so hard to make that happen, and now the Supreme Court has ruled. It is time for us to move forward. We don't need to reargue the last two years. I'm willing to work with anybody who wants to make it work, who wants to improve health care in this country and lower costs for individual families. But I don't want to just keep on having political arguments that are based on politics and not on facts."

Here is part of what he said is in Maumee, Ohio, on Thursday:

"I'm running because I believe that in America, nobody should go bankrupt because they get sick. I'll work with anybody who wants to work with me to continue to improve our health care system and our health care laws. But the law I passed is here to stay.

And here is a very small sample of what he said in in Parma, Ohio on Thursday: "I couldn't be prouder of the work that we have done in getting this health care law passed."

In Parma, the president met—and embraced—Natoma Canfield, a cancer survivor whose letter about health care inspired him to fight for his overhaul. The letter reportedly hangs in the Oval Office.