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Monday, March 2, 2015

Health Care Reform Articles - March 2, 2015


How to Equitably Finance a Universal Healthcare System
Vermont Workers' Center
https://www.facebook.com/video.php?v=10152687274592592

The Phony Legal Attack on Health Care 

By 

On Wednesday, the Supreme Court will hear oral arguments in one of the most anticipated cases of the term: King v. Burwell, a marvel of reverse-engineered legal absurdity that, if successful, will tear a huge hole in the Affordable Care Actand eliminate health insurance for millions of lower-income Americans — exactly the opposite of what the law was passed to do.
The central claim of the lawsuit, which was filed on behalf of four Virginians by a small group of conservative activists who have long sought to destroy Obamacare, is that the law does not allow tax-credit subsidies to be made available to anyone living in the 34 states whose health care exchanges are operated by the federal government, which stepped in when those states declined to set up their own.
This is, to put it mildly, baloney.
In the long, tangled history of the debate over the Affordable Care Act, no member of Congress ever indicated a belief that the law would work this way. To the contrary, the law explicitly provides for “quality, affordable health care for all Americans.”
And it has accomplished a good deal of this goal: More than 11 million people now have coverage under the law, and more than eight in 10 of them qualify for subsidies. In other words, broad availability of the subsidies is central to the functioning of the act. Without them, it collapses.
But because of the opponents’ purposefully blinkered reading of four words in the 900-page law the case is now before the Supreme Court.
The four words — “established by the State” — appear in a subsection of the law dealing with the calculation of tax credits. The law’s challengers say this means that credits are available only in the 16 states that have set up their own exchanges.
The challengers did not innocently happen upon these words; they went all out in search of anything that might be used to gut the law they had failed to kill off once before, on constitutional grounds, in 2012. Soon after the law passed in 2010, Michael Greve, then chairman of the Competitive Enterprise Institute, which is helping to finance the current suit, said, “This bastard has to be killed as a matter of political hygiene. I do not care how this is done, whether it’s dismembered, whether we drive a stake through its heart, whether we tar and feather it and drive it out of town, whether we strangle it.”
After the challengers found the four-word “glitch,” as they initially called it, they worked backward to fabricate a story that would make it sound intentional. Congress, they claimed, sought to induce states to establish exchanges by threatening a loss of subsidies if they did not. (Not coincidentally, the challengers also traveled state to state urging officials not to set up exchanges, thus helping to create the very “crisis” they now decry.) Of course, if Congress intended to introduce a suicide clause into a major piece of federal legislation, it would have shouted it from the mountaintops and not hidden it in a short phrase deep inside a sub-sub-subsection of the law. So it is no surprise that no one involved in passing or interpreting the law — not state or federal lawmakers, not health care journalists covering it at the time, not even the four justices who dissented in the 2012 decision that upheld the Affordable Care Act — thought that the subsidies would not be available on federal exchanges.
Many legal observers were surprised that the court agreed to hear the case at all. But despite several justices’ clear dislike for the health care law, it is hard to imagine how they could disregard their longstanding approach to interpreting statutes, which, as Justice Clarence Thomas wrote in a 1997 case, requires them to consider “the language itself, the specific context in which that language is used, and the broader context of the statute as a whole.”
Reading the Affordable Care Act as a whole, it’s clear that Congress meant to provide subsidies on both federal and state exchanges. For one thing, why establish a federal exchange that doesn’t actually work? As an amicus brief submitted by a group of legal scholars put it, “Congress does not write statutes to fail.”
And yet the challengers insist that their bizarre, noncontextual reading of the law is the only possible one. A majority of federal judges who have reviewed the case have thrown out this argument. So should the Supreme Court. Even if the court were to consider the law ambiguous, under its own precedent it must defer to an agency’s reasonable interpretation of the statute’s wording. Here, that agency is the I.R.S., which has issued a rule affirming that subsidies are available no matter who establishes the exchange.
The challengers disingenuously say that Congress can go back and change the wording, knowing full well that Republicans on Capitol Hill hate the law almost as much as they do. The states that currently rely on federally operated exchanges could set up their own, but many — egged on by the challengers — have already refused to do that.
Whatever legal games the challengers play, this case has never been more than a ginned-up, baseless attack on one of the most important pieces of social legislation of the last generation. The health of millions of Americans hangs in the balance. And now it is not even clear that the four plaintiffs have legal standing to bring the lawsuit.





So how did the suit get so far? That is an excellent question, and only the Supreme Court can answer it.

By NICHOLAS BAGLEY


ANN ARBOR, Mich. — THE Supreme Court will hear arguments on Wednesday in King v. Burwell, the latest high-stakes litigation over the future of the Affordable Care Act. The question at hand is whether the law permits the federal government to help pay insurance premiums for people anywhere in the United States — or, as the plaintiffs argue, only in states that have established their own health care exchanges.
Just 16 states have established such exchanges. If the court rules in favor of the plaintiffs, an estimated 9.6 million people who bought insurance through HealthCare.gov will lose their coverage.
Tough luck, say the plaintiffs: The harsh consequences of a ruling in their favor should be irrelevant to the justices, whose only job is to interpret the statutory text. In any event, the plaintiffs contend, those harsh consequences are perfectly consistent with what Congress meant the law to accomplish.
But the plaintiffs are mistaken. It’s not irrelevant that a ruling in their favor would inflict such damage. To the contrary, that fact helps us correctly interpret the statute’s text. Indeed, it shows that the plaintiffs’ understanding of that text is wrong.
As the Supreme Court has said time and again, no provision of a statute should be read in isolation. Laws must be read as a whole, with an eye to harmonizing their interdependent parts. That means the court is reluctant to read a stray passage here or there in a way that would destabilize an entire statutory scheme.

We have a plan for fixing health care

by Orrin Hatch, Lamar Alexander, and John Barrasso

 Lamar Alexander (R-Tenn.) chairs the Senate Health, Education, Labor and Pensions Committee. Orrin Hatch (R-Utah) chairs the Senate Finance Committee. John Barrasso (R-Wyo.) chairs the Senate Republican Policy Committee. 
Wednesday, the Supreme Court will hear oral arguments about whether the Obama administration used the IRS to deliver health insurance subsidies to Americans in violation of the law. Millions of Americans may lose these subsidies if the court finds that the administration acted illegally. If that occurs, Republicans have a plan to protect Americans harmed by the administration’s actions.
When the court rules in King v. Burwell, we anticipate that it will hold the administration to the laws Congress passed, rather than the laws the administration wishes Congress had passed, and prohibit subsidies in states that opted not to set up their own exchanges, as the language in the law clearly states. Such a ruling could cause 6 million Americans to lose a subsidy they counted on, and for many the resulting insurance premiums would be unaffordable. 
Republicans have a plan to create a bridge away from Obamacare. 
First and most important: We would provide financial assistance to help Americans keep the coverage they picked for a transitional period. It would be unfair to allow families to lose their coverage, particularly in the middle of the year. 
Most of these people have gone through the wringer to get this insurance. Millions lost their previous health-care plans because those plans didn’t meet Obamacare’s requirements; others no longer have access to the doctors or hospitals they were accustomed to; millions spent weeks trying to purchase insurance on the flawed Web site rolled out by the administration; and many have seen their out-of-pocket health costs or premiums skyrocket.
People do not deserve further disruption from this law.
Second, we will give states the freedom and flexibility to create better, more competitive health insurance markets offering more options and different choices. Republicans understand that what works in Utah is different from what works in Tennessee or Wyoming. We want to give states the time and flexibility to design health-care systems that work for them, not for the bureaucrats in Washington.
People who live in states that have state exchanges will continue to be subject to Obamacare’s costly mandates and rules, along with the subsidies. But their states could also have the benefit of our solution. Every state would have the ability to create better markets suited to the needs of their citizens.
We have had many discussions with our Senate and House Republican colleagues on this issue, and there is a great deal of consensus on how to proceed. Many of our colleagues have good ideas, and we look forward to working together.
We all agree Obamacare is a mess. But Wednesday, Obamacare will not be the key issue before the court. The key issue is whether the administration can unilaterally rewrite laws passed by Congress to meet its political objectives. We hope the court will protect the delicate balance of powers between the three branches of government. 
Such a ruling would also give Congress an opportunity — to stop Obamacare’s damage and create a pathway to reforms that move our health-care system in the direction of freedom, choice and lower costs.

Morning Plum: Republicans won’t have any contingency plan if Court guts subsidies for millions

By Greg Sargent March 2 

With the Supreme Court set to hear oral arguments this week in the lawsuit that could do severe damage to the Affordable Care Act, some Republican lawmakers are working hard to convey the impression that they have a contingency plan for the millions who will likely lose subsidies — and coverage — if the Court rules with the challengers. Senators Orrin Hatch, Lamar Alexander, and John Barrasso have published a Washington Post op edwith an oh-so-reassuring title: “We have a plan for fixing health care.”
The good Senators, amusingly, cast their “plan” as something that will protect people from “the administration’s” actions and from Obamacare itself, not from the consequences of the legal challenge or a Court decision siding with it. The plan vows to “provide financial assistance” for a “transitional period” to those who lose subsidies, while Republicans create a “bridge away from Obamacare.” Of course, anyone who watched last week’s chaos in the House knows Congressional Republicans are unlikely to coalesce around any “transitional” relief for those who lose subsidies (that would require spending federal money to cover people) or any permanent long-term alternative. This chatter appears transparently designed to make it easier for conservative Justices to side with the challengers.
Yet even if this game works on the Justices in the short term, any eventual failure to come through with any  contingency plan could saddle Republicans with a political problem, perhaps even among GOP voters.
A poll taken by Independent Women’s Voice — a group that favors repealing Obamacare in the name of individual liberty — found that in the nearly three dozen states on the federal exchange, 75 percent of respondents think it’s very (54) or somewhat (21) important to restore subsidies to those who lose them. In the dozen main presidential swing states, 75 percent of respondents say the same.

Undermining Children’s Insurance

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Senior Republicans in Congress are seeking major changes to the Children’s Health Insurance Program when the program’s money runs out in September.
Their proposal, labeled a “discussion draft” for legislation yet to be written, could deprive more than a million children of insurance or force their families to pay higher out-of-pocket costs for their coverage. It also would shift costs to states, which would be left holding the bag to pay for the children’s insurance or for the care of the children as uninsured patients.
The draft is being circulated by Senator Orrin Hatch of Utah, chairman of the Senate Finance Committee; Representative Fred Upton of Michigan, chairman of the House Energy and Commerce Committee; and Representative Joe Pitts of Pennsylvania, chairman of the health subcommittee. It threatens to undermine the progress made in reducing the number of uninsured children, gains that came from enrolling more children in Medicaid and in CHIP, which covers children whose families earn too much to qualify for Medicaid.

Minnesota's nonprofit health care: Can you heal me now?

  • Article by: STEVE CALVIN and THEODORE J PATTON 
  • Minnesotans live in a state that consistently ranks near the top in health care measures. The percentage of Minnesotans who are insured is among the highest in the nation; clinical measures of health are above average; Minnesota’s per-capita costs have never been high compared with national averages. Nonetheless, it is unsustainable for an increasingly large percentage of our resources to be devoted to health care.
    Minnesota’s enviable health rankings arise from a number of causes. Our state has a relatively strong economy with high levels of employment. Employers have provided comprehensive health coverage, and taxpayers provide generous public programs. We are also home to world-renowned medical education and research institutions, such as the Mayo Clinic and the University of Minnesota.
    Many might also point to the fact that much of the health care in Minnesota is provided by hospitals and insurers that are classified as nonprofit.
    This leads to two questions. The first is whether a high-performing health care system should be exclusively composed of nonprofit organizations. The second is whether Minnesota hospitals and insurers actually fulfill the kind of mission that would justify nonprofit status.
    We believe the answer to both questions is no. When carefully examined, Minnesota’s largest health care entities are hiding behind some very small nonprofit fig leaves.
    Minnesota has always had a small number of insurers, with five covering more than 90 percent of the local market. The number of hospitals is also shrinking. Changes to payment systems and a transition to seeing more care provided at outpatient locations have put financial pressure on many Minnesota hospitals. This has led to significant consolidation. Minnesotans now receive care from hospitals that have morphed into a dwindling number of complex health systems, as in the acquisition of Park Nicollet by HealthPartners.
    These health systems are big business in Minnesota. After subtracting government-run facilities, 72 percent of Minnesota hospitals are classified as nonprofit. According to the Star Tribune’s 19th Annual Nonprofit 100, nonprofit health systems, hospitals and insurers comprise 19 of the 20 largest nonprofit organizations in Minnesota and take in 92 percent of the overall revenue among the top 100.
    The top 15 among these organizations generated enough revenue in 2013 to rank them among the 50 largest publicly held companies headquartered in Minnesota. State taxpayers are generously subsidizing entities that, in certain cases, generate more revenue than Fortune 500 companies.
    Meanwhile, the excess of revenue over expenses at these nonprofits is eye-popping. In 2013, Mayo Clinic had a margin of revenue over expenses of $612 million. While Mayo is a global brand, HealthPartners, Allina Health and Fairview Health Services also had margins totaling $848 million.
    How can this be true? It largely stems from tradition.
    Favorable tax treatment for nonprofit hospitals is deeply rooted in American public policy. Nonprofit hospitals became exempt from taxation as early as 1894, based on the rationale that they advanced the general welfare by providing charity care for the poor. It was not until 1954, however, that Congress enacted Section 501 of the Internal Revenue Code. Section 501 provided federal tax exemption to various types of “charitable” organizations.
    For a hospital to be recognized as a charitable organization, it must satisfy something called the community benefits standard. Until 1969, the IRS required hospitals to provide charity care — that is, without expectation of payment — in order to meet this standard and qualify for nonprofit status. Unfortunately, today the current community benefits standard has no such requirement. The current standard is vague and overly broad. It takes into account as community benefits worthy but unrelated activities ranging from round-the-clock emergency rooms to providing bikes for children.
    So, how profitable are “nonprofit” hospitals in the United States? McKinsey and Co. recently found that the 2,900 nonprofit hospitals in the U.S. had higher profit margins than their 1,000 for-profit counterparts.
    Nonprofit health care executives appropriately argue that without a financial margin there is no mission. But it appears that too often the margin has become the mission.
    Nonprofit hospitals supposedly operate for the benefit of their communities and are required to reinvest any profits back into the organization. In exchange for their charitable mission, nonprofit hospitals 1) are exempt from local, state and federal taxation, and 2) can receive tax-deductible donations.
    According to the New England Journal of Medicine, tax exemptions saved nonprofit hospitals $13 billion nationwide in 2013. In 2005, according to the Minnesota Department of Health, the tax exemptions received by Minnesota nonprofit hospitals totaled $443.6 million, or $540.3 million in 2014 dollars. These numbers rival the controversial public subsidies for the new Vikings stadium. What do Minnesotans receive in exchange?
    A reasonable person might conclude that Minnesotans should receive, at the very least, charitable services equal to the value of the tax exemptions provided. In reality, Minnesotans receive a jumbled assortment of services that stray far afield from the original theory behind supporting tax-exempt hospitals. Services counted under the current community benefits standard include 1) charity care, 2) the “unreimbursed costs” of care for Medicaid and Medicare patients, 3) cash and in-kind contributions, 4) bad debt, 5) educational programs, 6) medical research and 7) “community-building activities.”
    Minnesota law neither specifies a minimum level of community benefits necessary to retain tax exemption nor requires the provision of any charity care.
    We need a state standard that separates actual charitable activities from those that more closely resemble business promotion. Recent efforts by legislators to redefine community benefits stalled. People can reasonably disagree as to whether the current hodgepodge of “community benefits” provides appropriate flexibility or constitutes no standard at all. But Minnesota’s nonprofit hospitals should be held accountable for the subsidies they receive.
    Accountability starts with requiring nonprofit hospitals to provide charity care equal to at least half the value of the tax exemptions received. Hospitals that fail to meet this basic threshold should lose their nonprofit classification.
    In addition, the boards of directors of Minnesota’s nonprofit health systems ought to reflect the diversity of the communities they serve. A review of the composition of two of Minnesota’s largest health system boards found them to be predominantly composed of white, male business executives. There is no question that business acumen is important, but governing boards should be more representative of the community and strive to provide culturally competent care. Hospitals and insurers should appoint appropriately diverse boards to maintain their nonprofit status.
    If operating revenue is not expended in the provision of charity care or other charitable services, then it is important to explore how it is being utilized. One way revenue is being spent is through an increase in executive compensation.
    In 2013, the average compensation for the four highest paid nonprofit CEOs in Minnesota — all leaders of health care systems — was $2.18 million. This trend is not limited to the C-suite. IRS 990 forms show that many lower-level executives are making more than $1 million a year.
    Another way revenue is being spent is through a medical arms race for the latest technology and facilities, as a smaller number of health systems compete for customers and to provide the most profitable services.
    Last, mounting financial pressure is driving acquisitions of physician groups and hospitals. Despite these pressures, some have maintained their independence.
    Our concern is not that some hospitals and insurers are successful in terms of profitability. Rather, the problem concerns how profits are spent when Minnesota taxpayers are providing generous subsidies. We are not advocating for the dismantling of Minnesota’s nonprofit hospital and insurer infrastructure. The provision of charity care, education and research are true community benefits. But other activities deserve heightened scrutiny.
    Everyone sees the need for improvement in our health care system. Minnesota’s nonprofit health care entities should be enthusiastic about innovations designed to improve care, satisfy patients and lower costs. Unfortunately, ostensibly nonprofit health care systems are often blind and deaf to alternatives, particularly when offered from the outside or when innovation threatens to decrease revenue. Examples of organizational ossification are not hard to find.
    The fee-for-service payment system is a major force behind expensive care, and it is clear that bundled payments for an episode of care is one way to restrain costs and encourage collaboration. Pregnancy is the perfect episode of care to test bundled payments. Regrettably, when the idea was first proposed to various Minnesota health care executives, responses ranged from “what would it take for you to give this idea up?” to “you are talking about a for-profit entity.” Fortunately, such attitudes are changing.
    Two future health care scenarios appear plausible. One is further system consolidation until only two or three large systems remain. Some see this as desirable and inevitable, but we know how consolidation has worked out in other industries, such as airlines and cable television. This would result in health care entities that are “too big to fail.”
    The preferable course is a health care landscape built on reformed nonprofit organizations existing for reasons beyond boundless growth. Nonprofit health care systems and insurers should serve as platforms for innovation — even in collaboration with for-profit partners. Partnerships focusing on innovation will result in higher value care for all Minnesotans. That would be a real community benefit.
    Steve Calvin is medical director of the Minnesota Birth Center. Theodore J Patton is an investigator for the Minnesota Department of Commerce. The views expressed here by Patton do not necessarily represent those of the Minnesota Department of Commerce.
    http://www.startribune.com/opinion/commentaries/287380091.html

Most Doctors Give In to Requests by Parents to Alter Vaccine Schedules

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A wide majority of pediatricians and family physicians acquiesce to parents who wish to delay vaccinating their children, even though the doctors feel these decisions put children at risk for measles, whooping cough and other ailments, a new survey has found.
Physicians who reluctantly agreed said they did so to build trust with families and to avoid losing them as patients.
The survey, published Monday in the journal Pediatrics, asked a nationally representative sample of 534 primary care physicians in 2012 how often parents in their practices postponed one or more vaccinations for children younger than age 2.
The Centers for Disease Control and Prevention advises that children be vaccinated for 14 diseases before age 6 on a schedule, which entails roughly 29 shots, sometimes several at once.
Ninety-three percent of doctors reported that in any given month, they had been asked at least once to delay vaccines. A fifth said more than 10 percent of parents in their practices had asked them to delay vaccines.
One-third of doctors said they acquiesced “often” or “always”; another third gave in only “sometimes.”
Such deference is in keeping with today’s doctoring style, which values patients as partners, said Dr. Paul A. Offit, a pediatrician specializing in infectious diseases at the Children’s Hospital of Philadelphia, who was not involved in the study.

Psychiatric Drug Overuse Is Cited by Federal Study

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WASHINGTON — Federal investigators say they have found evidence of widespread overuse of psychiatric drugs by older Americans with Alzheimer’s disease, and are recommending that Medicare officials take immediate action to reduce unnecessary prescriptions.
The findings will be released Monday by the Government Accountability Office, an arm of Congress, and come as the Obama administration has already been working with nursing homes to reduce the inappropriate use of antipsychotic medications like Abilify, Risperdal, Zyprexa and clozapine. But in the study, investigators said officials also needed to focus on overuse of such drugs by people with dementia who live at home or in assisted living facilities.
The Department of Health and Human Services “has taken little action” to reduce the use of antipsychotic drugs by older adults living outside nursing homes, the report said. Doctors sometimes prescribe antipsychotic drugs to calm patients with dementia who display disruptive behavior like hitting, yelling or screaming, the report said. Researchers said this was often the case in nursing homes that had inadequate numbers of employees.
Dementia is most commonly associated with a decline in memory, but doctors say it can also cause changes in mood or personality and, at times, agitation or aggression. Experts have raised concern about the use of antipsychotic drugs to address behavioral symptoms of Alzheimer’s and other forms of dementia. The Food and Drug Administration says antipsychotic drugs are often associated with an increased risk of death when used to treat older adults with dementia who also have psychosis.

Medicating Women’s Feelings

By JULIE HOLLAND
WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.
These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.
The pharmaceutical industry plays on that fear, targeting women in a barrage of advertising on daytime talk shows and in magazines. More Americans are on psychiatric medications than ever before, and in my experience they are staying on them far longer than was ever intended. Sales of antidepressants and antianxiety meds have been booming in the past two decades, and they’ve recently been outpaced by an antipsychotic, Abilify, that is the No. 1 seller among all drugs in the United States, not just psychiatric ones.
As a psychiatrist practicing for 20 years, I must tell you, this is insane.
At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism.



If Patients Only Knew: When More Information Means Less Treatment


If we knew more, would we opt for different kinds and amounts of health care? Despite the existence of metrics to help patients appreciate benefits and harms, a new systematic review suggests that our expectations are not consistent with the facts. Most patients overestimate the benefits of medical treatments, and underestimate the harms; because of that, they use more care.
The study, published in JAMA Internal Medicine and written by Tammy Hoffmann and Chris Del Mar, is the first to systematically review the literature on the accuracy of patients’ expectations of benefits and harms of treatment. They examined over 30 studies that assessed whether patients understood the upsides or downsides of certain treatments. To a great extent, patients didn’t.
In the 34 studies that assessed understanding of benefits, patients overestimated their potential gain in 22 of them, or 65 percent. For instance, a 2002 study published in the Journal of the National Cancer Institute asked women who had undergone prophylactic bilateral (double) mastectomy to estimate how much the procedure reduced their risk of breast cancer. On average, the women thought they had reduced that risk from 76 percent to 11 percent, an absolute risk reduction of 65 percentage points.
For the more than 80 percent of the women in the study who did not have a BRCA genetic mutation — which drastically increases the risk of breast cancer — the real risk before surgery of developing breast cancer was 17 percent, meaning they greatly overestimated their risk reduction. Even the women with a BRCA mutation overestimated their risk reduction, but to a lesser extent.
Another 2012 study published in the Annals of Family Medicine asked patients to estimate the benefits of screening for bowel and breast cancer, and the use of medications to prevent hip fracture and cardiovascular disease. More than two-thirds of patients overestimated the benefits of medications to prevent cardiovascular disease, and more than 80 percent overestimated the benefits of medications to prevent hip fractures.
Further, 90 percent of patients overestimated the benefits of breast cancer screening, and 94 percent overestimated the benefits of bowel cancer screening. The researchers also asked the patients to estimate the minimum reduction in bad outcomes (like fractures or deaths) they would need to achieve to find the treatment worthwhile. For three of the four studied interventions, the minimum benefit patients would accept was higher than the actual benefit.

L.B.J. and Truman: The Bond That Helped Forge Medicare


Lyndon B. Johnson was often derided for being egocentric, but when it came time to sign his landmark bill creating Medicare, 50 years ago this July, he graciously insisted on sharing the credit with the 81-year-old Harry Truman. At almost the last moment, Johnson decided to change the location from Washington to Truman’s presidential library in Independence, Mo.
During the ceremony, Johnson noted that in 1945, the newly installed President Truman had called for national health insurance, planting “the seeds of compassion and duty which have today flowered into care for the sick, and serenity for the fearful.” Johnson then presented his host with the nation’s first Medicare card. Deeply moved, Truman later wrote in a letter to Johnson that the ceremony was “the highlight of my post-White House days.”
On Wednesday, the Supreme Court will hear arguments in King v. Burwell, a case that, if resolved against the Obama administration, could endanger some of the fundamentals of President Obama’s health care program.
Just as Mr. Obama’s Affordable Care Act was based on elements of Johnson’s Medicare, some of the most important domestic achievements by presidents throughout history have been based on the pathbreaking efforts of a predecessor. Acknowledging his debts to Truman in health care, education and civil rights, Johnson privately told him that his presidential record was unequaled, adding, “It makes all of us look like pygmies.”

Healthy in a Falling Apart Sort of Way

By 
 

When asked on a medical form to evaluate my overall health, I invariably check “healthy.” But I sometimes wonder how accurate that is.
After all, I do have arthritis that necessitated a double-knee replacement 10 years ago, and I find it increasingly difficult to open containers designed to thwart a 2-year-old. My spine is a mess, and my back hurts from time to time. I have tinnitus and some hearing loss in one ear. I was treated for breast cancer 16 years ago. I take a statin to lower a cholesterol level that defied conservative measures of diet and exercise. And I constantly have to practice remembering people’s names.
So, at nearly 74, how healthy am I? Well, I also walk three miles and swim three-quarters of a mile nearly every day. I’ve taken over most of the chores my late husband once did. I shovel and sweep my walk, cook most of my meals, and care for an active Havanese puppywho’s walked four times a day and runs free in the park every morning.
I have yet to retire and still work part time writing a weekly column, though I’ve resisted the temptation to write another book, choosing instead to enjoy more theater, opera, concerts and grandchildren, and to train the puppy to be a therapy dog.
All of which invites the question of how one defines health.
In 1948, the World Health Organization described health as “a stage of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” By that definition, I and millions of Americans like me across the age spectrum would flunk, leaving “most of us unhealthy most of the time,” as Richard Smith noted in theBMJ blog in 2008.
But disease patterns have changed since 1948. Most people, like me, are aging with chronic ailments and disabilities, yet they continue to function independently. The old definition of health “minimizes the role of the human capacity to cope autonomously with life’s ever changing physical, emotional, and social challenges,” wrote Machteld Huber and her colleagues wrote in BMJ in 2011. And the definition fails to recognize that people are able to “to function with fulfillment and a feeling of well-being” even when they have a chronic disease or disability, they wrote.


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