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Supreme Court greets healthcare mandate with skepticism

Written By anfaku01 on Thursday, April 5, 2012 | 7:10 PM

WASHINGTON — The legal fate of President Obama's embattled healthcare law has always turned on winning over the center of the Supreme Court: JusticeAnthony M. Kennedy.

But as the court considered whether the federal government could require most Americans to get health insurance, Kennedy appeared to deal the president and his allies a heavy blow.


The mandate, he said, "changes the relationship of the federal government to the individual in a very fundamental way." Kennedy called the insurance requirement "concerning" and suggested it might be "unprecedented."


Predicting decisions based on justices' comments during arguments can be risky. And on the second day of oral arguments over the landmark law, Kennedy and Chief JusticeJohn G. Roberts Jr.at times seemed to agree with the government's view that because everyone is likely to need medical care at some time, Congress might have more latitude to require purchase of insurance than of some other product.


But those moments were exceptions. Overall, the clear skepticism about the insurance mandate expressed by Roberts and Kennedy seemed to set the stage for a 5-4 decision, with the court's five Republican appointees pitted against its four Democrats.


Such a ruling would strike out the heart of Obama's healthcare law, his signature domestic achievement, in the middle of the presidential campaign, which could become a significant, and unpredictable, factor in the election. Not since the mid-1930s has the Supreme Court struck down a major regulatory act of Congress.


A ruling against the mandate would not necessarily overturn all of the healthcare law. The question of how much might be left is one the justices will grapple with in Wednesday's arguments, the finale of three days of debate over the law. But on Tuesday, at least, the administration's supporters were dispirited.


"It certainly didn't go as well as I had hoped it would for the government," said Timothy Jost, a law professor at Washington and Lee University and an authority on healthcare law. "It was always fairly certain they had four votes. It's clear now they are going to have a hard time pulling a fifth."


Kennedy and Roberts, along with fellow conservative Justices Antonin Scalia and Samuel A. Alito Jr., repeatedly questioned where the limit on federal power would be if the mandate was upheld. Justice Clarence Thomas was silent, as is his habit, but is expected to vote to strike down the mandate.


"If the government can do this, what else can it … do?" Scalia asked, suggesting Congress might require Americans to buy broccoli or automobiles.


Roberts suggested that the government might require Americans to buy cellphones to be ready for emergencies.


Kennedy, who is often the court's swing vote, seemed to suggest that a mandate directed at individuals could be upheld only if the government offered an extremely powerful justification. And his comments from the bench raised considerable doubt about whether he thought the administration had met that test.


Solicitor Gen. Donald Verrilli Jr., the Obama administration's top lawyer, tried to argue that the insurance mandate would not open the door to other requirements to buy products because healthcare is unique.


"Virtually everybody in society is in this market," said Verrilli, who appeared to struggle to answer conservative justices' probing questions. Justice Ruth Bader Ginsburg and other liberal justices intervened at points to help him along, defending the new law as a reasonable means to cope with the uninsured.


From the start, the mandate to buy insurance has been seen as the central and most controversial provision in the Patient Protection and Affordable Care Act. It is by far the one most Americans say they oppose, according to polls.


Under the law, many of the nearly 20% of individuals in the U.S. who do not have health insurance will have to sign up for a plan starting in 2014 that meets a basic set of standards or pay a tax penalty that will rise from $95 in 2014 to $695 in 2016. Health policy experts warn that without some incentive to buy insurance, people could wait until they got seriously ill to sign up for coverage, pushing up premiums for everyone.


In defense of the mandate, Verrilli said that if a person elected not to get health insurance but then got sick — as nearly everyone will at some point — that person would pass along costs to everyone else.


To prevent that, the Obama administration has argued that Congress can use its authority under the commerce clause of the Constitution to impose the mandate as a way to regulate health insurance. Roberts and Kennedy in the past have supported the federal government's broad authority to regulate commerce.


The Constitution says Congress has the power to "regulate commerce" and to impose taxes to promote the general welfare. The court has upheld federal laws regulating all manner of business, including agriculture, aviation and who can be served at the corner coffee shop.


The few positive moments for the administration came when the law's opponents got their turn to argue. Kennedy and Roberts pressed them to address the unique dynamics of the healthcare market, in which people who do not get health coverage affect everyone's costs.


"That is not true in other industries," Kennedy said at one point. "That's my concern in the case."


In his closing comments, Verrilli shifted gears and tried to convince the conservative justices of the virtues of judicial restraint.


"The Constitution leaves the democratically accountable branches of government" the choice of how best to regulate business and commerce, he said. "That is exactly the kind of thing that ought to be left to the judgment of Congress."


After Wednesday's third day of arguments, the justices will meet behind closed doors Friday to cast their votes and begin working on opinions.

7:10 PM | 0 comments

Is healthcare a privilege or a right?

AppId is over the quota AppId is over the quota One of the most striking take-aways from this week's U.S. Supreme Court hearings on the healthcare reform law was the steadfast insistence on the part of Republicans to deny affordable and accessible medical treatment to as many people as possible.

The party is determined to maintain the status quo of healthcare being a privilege and not a right — putting us at odds with just about every other developed nation on the planet and, not coincidentally, resulting in about 50 million people being uninsured.

The bulk of attention this week was on Tuesday's hearing on the so-called mandate, the reform law's requirement that most people sign up for health insurance or face a modest tax penalty. Judging from some of the questions posed by conservative justices, this is where the law may fall apart.

But some of the most telling remarks came a day later when the attorney representing 26 Republican-led states argued that the law's expansion of Medicaid violates states' rights and represents an act of coercion by the federal government, even though the federal government, and not the states, will foot the bill for nearly all of that additional coverage.


This is a key piece of the reform puzzle. As it stands, the law won't provide coverage to all 50 million now left to fend for themselves (and thus pass along the cost of their care to other taxpayers and ratepayers). It will instead bring about 30 million into the insurance fold.


More than half of that number — about 17 million — will receive insurance through Medicaid. Mostly we're talking about low-income people who are not currently eligible for the program in most states.


Paul Clement, the lawyer for the states, argued that the federal government is twisting the arms of state officials by putting current Medicaid funds on the line. In other words, if states don't agree to expand coverage, they could lose the billions they now receive for the program.


This is a breathtaking assertion on a number of levels. First, no one forces a state to participate in Medicaid. If it doesn't like the federal government's terms, it can walk away from the program.


Second, if a state participates in Medicaid so it can insure some people, why wouldn't it be in favor of any move that allows it to insure more people?


Then there's the core belief among Republicans that the public sector has virtually no role to play in extending health coverage to as many people as possible, even when the private sector has failed miserably in meeting this responsibility.


As I wrote earlier this month, Republican attacks on the mandate as a threat to freedom and liberty ignore the real-world realities of the insurance business.


By allowing people to avoid buying insurance until they need it, and then requiring insurers to cover anyone who comes knocking at their door regardless of medical condition, you create a risk pool of exclusively sick people.


This is a recipe for financial catastrophe, all but ensuring that premiums rocket skyward and thus making health insurance less affordable and accessible for everyone. That's not political ideology talking; it's simple economics.


Opposing an expansion of Medicaid is no less reckless. As things stand, family insurance rates are now as much as $1,500 higher annually because of the cost of treating the uninsured, according to a study by the advocacy group Families USA.


If we can all agree that having tens of millions of people uninsured is not just a national disgrace but also an unfair financial burden for people who do have insurance, then one of our priorities must be to extend coverage to as many people as we can.


This has been accomplished in part by the reform law's provision that young adults can stay on their parents' plans to age 26. According to census figures, young adults are the age group least likely to have health insurance.


In terms of income, nearly two-thirds of the uninsured are in households making less than $50,000 a year. Expanding Medicaid eligibility would thus be the most effective and efficient means of bringing coverage to this segment of the population.


Needless to say, all these problems would be moot if the United States followed the example of its economic peers in Europe and Asia and adopted some sort of Medicare-for-all system guaranteeing universal coverage.


But since that's not going to happen any time soon, our sole alternative is to work within the existing system. And that means some sort of requirement that everyone have health coverage — a proposal originally championed by the conservative Heritage Foundation and embraced by leading Republican politicians (until they realized it was actually a Marxist plot to destroy the healthcare system).


It also means opening the door wider to lower-income folk through the Medicaid program, which, subsidized almost entirely by the federal government, is hardly an abrogation of states' rights and is instead more akin to a gift from Washington.


Republican presidential candidate Rick Santorum showed up outside the Supreme Court earlier this week to say that only "our creator" can bestow rights on people. The inference was that lawmakers have no business fostering a right to healthcare, or even the expectation of such a right, among Americans.


Santorum's 3-year-old daughter has a severe genetic disorder called Trisomy 18. According to the U.S. National Library of Medicine, half of all infants with the ailment do not survive beyond the first week of life. "Some children have survived to the teenage years, but with serious medical and developmental problems," it says.


Luckily for this little girl, her father has reported earning more than $3.6 million since he left Congress in 2007, so she'll probably never want for insurance coverage.


But do Santorum and his Republican allies truly think that others who lack such good fortune deserve less, or perhaps no, medical care? Do they believe that other children with preexisting conditions have less of a right to treatment?


Or is there perhaps room to acknowledge that simple standards of human decency make clear that society has certain obligations, and in the United States, as of this moment, those obligations are not being met?


 

2:38 PM | 0 comments

Dr. Paul H. Crandall dies at 89; invented techniques for diagnosing, treating epilepsy

Dr. Paul H. Crandall, un neurochirurgo UCLA pioniere ora ampiamente utilizzato tecniche per diagnosticare la fonte di zollbeschlagnahmungen epilettica nel cervello e rimuovendo le cellule incriminate, morte il 15 marzo dalle complicazioni di polmonite a Santa Monica-UCLA Medical Center. Egli era 89.

Crandall, che ha fondato il dipartimento di neurochirurgia UCLA, "era il padre del programma di epilessia di UCLA," Dr. Neil Martin, l'attuale Presidente di neurochirurgia presso Geffen School della UCLA of medicine, ha detto in un comunicato. "Il suo lavoro clinico pose le basi per le nostre attuali strategie trattare epilettica zollbeschlagnahmungen e la sua ricerca scientifica informa trattamento dei neurochirurghi dell'epilessia oggi."


Epilessia può essere trattato con farmaci in circa il 60% dei casi. Chirurghi abbiano tentato di curare altri zollbeschlagnahmungen con chirurgia cerebrale dal presso almeno tardo XIX secolo, ma i medici spesso rimosso enormi quantità di tessuto senza avere alcuna comprensione di dove nel cervello il zollbeschlagnahmungen erano in realtà originarie.


I ricercatori in Francia avevano tentato l'impianto di elettrodi nel cervello per registrare l'attività cerebrale durante la zollbeschlagnahmungen, ma gli elettrodi sono stati lasciò nel solo durante l'operazione stessa e forniti solo le informazioni minime.


Crandall e Dr. Richard Walter, poi capo della neurologia presso la UCLA, perfezionato la capacità dell'impianto di elettrodi nel cervello dei pazienti epilettici e lasciarli per lunghi periodi. All'inizio negli anni sessanta, i pazienti sono stati portati in laboratorio ogni giorno e collegati ad una macchina di EEG che ha registrato un impulso elettrico su strisce di carta, producendo cumuli di carta. Ma i ricercatori non riuscì a catturare qualsiasi zollbeschlagnahmungen.


Crandall, è capitato di essere a guardare una delle prime Gemini orbitale missioni della NASA in televisione quando ha sentito il controllo missione annunciare la frequenza cardiaca dell'astronauta. Incuriosito, ha chiamato la NASA e ha chiesto come hanno fatto egli è ciò che ha detto che l'agenzia usato recentemente inaugurato radio banda FM, mettendo i diversi canali di informazioni su una frequenza FM che cosa poi con travi torna alla terra. Ha immediatamente chiesto per uno dei dispositivi.


Dopo quasi due anni di negoziati, NASA, lo inviò a dispositivo di telemetria FM, che gli ha permesso di collegare gli elettrodi del cervello del paziente per un piccolo trasmettitore. Il segnale che viene poi registrato su un registratore a nastro bobina a bobina, consentendo il monitoraggio 24 ore su 24. Crandall conquistò il suo primo sequestro nel 1968. Più tardi, il team ha aggiunto registrazione video di correlare il comportamento paziente con attività cerebrale.


Incorporando gli elettrodi presso i siti stessi in ogni paziente, squadra di Crandall, che è in grado di gradualmente a concentrarsi su gruppi di cellule dove attività anomale che si verificano, che consente la rimozione delle cellule e attenuanti zollbeschlagnahmungen. E rimuovendo i ciuffi di cellule intatte, i ricercatori sono riusciti a studiare in laboratorio come le interazioni delle cellule di prodotti zollbeschlagnahmungen.


Il team ha sviluppato il protocollo e la nomenclatura che è ancora utilizzata da neurochirurghi per trattare l'epilessia: fase 1, un EEG normale con elettrodi di superficie per la diagnosi di epilessia; Fase 2, uso di elettrodi impiantati per localizzare le cellule colpite; e la fase 3, la rimozione chirurgica delle cellule.


"Il suo contributo non è solo quello che ha trovato, ma così l'approccio di come fare per fare questo," ha detto Dr. Gary Mathern, UCLA professore di neurochirurgia.


Paul Herbert Crandall nacque Feb. 15, 1923, bambini in Essex Junction, VT, il più giovane di sette. Ha ricevuto la laurea dall'Università del Vermont, nel 1943, poi si arruolò nell'esercito degli Stati Uniti, dove lui cosa scelti per frequentare la scuola medica, ricevendo la laurea in medicina dal Vermont nel 1946. Dopo la residenza presso l'Università di Chicago, si riunì la Army Medical Corps nel 1952, che servono due anni come capo di neurochirurgia presso un ospedale militare a Francoforte, Germania.


Nel 1954, è arrivato alla UCLA, dove egli come uno dei tre soci fondatori della divisione di neurochirurgia, che è stato aggiornato a un reparto nel 2008. Si ritirò nel 1988 ma continuò le sue ricerche.


Crandall servito su Commissione della US Department of Health nazionale per l'epilessia dal 1976 al 1977. perché il suo lavoro aveva dimostrato il valore di monitoraggio a lungo termine della zollbeschlagnahmungen e delle sue procedure per la gestione dei casi difficili, la Commissione ha raccomandato l'istituzione di centri specializzati epilessia nelle grandi aree urbane, una raccomandazione che successivamente è stata implementata.


Il suo lavoro anche contribuito a estendere la chirurgia ai bambini per il controllo zollbeschlagnahmungen.


Nel 1977, Crandall ha suonato chirurgia 18 anni Alfonsina "Nina" Davies cui genitori avevano cercato inutilmente per una cura per il suo grave epilessia. L'intervento chirurgico fermato il zollbeschlagnahmungen e Nina completato college di guadagnare il dottorato nel campo dell'istruzione e diventando a sovrintendente assistente per il Santa Ana Unified School District. Purtroppo, morì nel 2011 di una condizione nota come improvvisa morte inspiegabile, l'epilessia, risultato di un raro della malattia.


Nel ottobre 2011, i suoi genitori, Thomas e Nadia Davies, ha donato $2 milioni alla UCLA per la ricerca di epilessia, dotandola di una sedia in onore di Crandall.


Crandall è sopravvissuto dalla moglie, Barbara, UCLA professore emerito di pediatria e genetica; quattro figli; e tre nipoti.


Maugh è un ex scrittore medico del Los Angeles Times.


News.obits@latimes.com

11:37 AM | 0 comments

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