Hi-Tech Healthcare. Will it give physicians more time with their patients?

President Obama speaks at a rally on health care reform at the University of Maryland Photo: AP

...Senior advisor at the White House Office of Management and Budget (click title to entry - thank you) on health policy Ezekiel Emanuel (brother to Rahm) gave a presentation on Sunday at the Medical Group Management Association's annual conference on the need to restructure how physicians deliver care.
In a speech he titled, "High-Touch Medicine, the Future of the Physician-Patient Relationship," Emanuel, who is also bioethics chair for the National Institutes of Health, said that while the use of information technology is essential for improving healthcare quality, increasing the amount of time physicians spend with patients should be an equally compelling goal....

I have some reservations about the 'character' some of the Senate bill rolls out in the way of touting health care savings based in technology. I don't really buy it. I see a lot of that as a 'spending' bill and not a health care insurance reform bill. The Republican Senate is good at that. Republicans will put together a bill that will spend a lot, but, will it actually reform and revolutionize health care delivery? Maybe.

I believe electronic records, if perfected, can save lives. Absolutely. It will provide immediate information to any physician anywhere in the country to expedite care, especially in emergency rooms.

But, I have reservations about the 'prompts' to physicians delivering care. According to some of the reviews of the Senate bill there will be all this 'data base' availability to physicians when diagnosing a patient. There will be 'prompts' regarding the tests needed and medications to order. There will be prompts to new ideas and new venues of care.

I don't believe physicians that care about their practice need all that and I think it will serve to cause 'excellant' physicians to 'pause' in administering care. It is usually the dedicated and compassionate doctors that seek the most information with a willingness to establish state of the art care for his or her patient.

I don't want my physician to be making decisions regarding my care based upon the latest trend. I want solid diagnosis with proven treatment. One has to wonder what effects this 'automated' format will look like and who has time for it. I would think physicians think new methods and medicine through before using them in their practice and it is why I don't see 'bedside prompts' as an improvement to care. I mean, where is the 'filter' to this information and whom exactly is approving it to be used in a treatment modality.

I believe some of the technologies the Senate has proposed shows short sightedness. There needs to 'trials' of the new high tech bedside doctoring before it is used in general practice. I hope that was part of the bill. Trials of any new idea in the House bill is strongly noted and the venues of change in health care delivery can come swiftly provided there is overwhelming results to the benefits to patients. I also don't see supplying such 'prompts' as a commercial enterprise and/or a 'perk' for the MD. Either it improves patient care or it doesn't.

The next section deals with the Public Helath Service Act (click here) OR here. The Public Health Service Act has been around for decades and has appropriation spending every year. This section simply states it will continue and in a perscribed manner.

The Public Health Service Act has several amendments including Health Insurance Portability, a few issues with Cancer, Muscular Dystrophy and Family Planning. The bill gives the funding a name and states where the monies are found for this provision.

Page 859, lines 1 through 5 and page 860, lines 3 through 5.

SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.
(a) ESTABLISHMENT OF FUNDS.—
(1) IN GENERAL.—There is established a fund to be known as the ‘‘Public Health Investment
Fund’’ (referred to in this section as the ‘‘Fund’’)....

...(B) Amounts deposited into the Fund shall be derived from general revenues of the Treasury.

Below is a list of the 'services' the Public Health Service Act provides. There is no option in replacing it or eliminating it. It was well written decades ago and is fine the way it is:

-coordinating with the States to set (click here) and implement national health policy and pursue effective intergovernmental relations;
-generating and upholding cooperative international health-related agreements, policies, and programs;
-conducting medical and biomedical research;
-sponsoring and administering programs for the development of health resources, prevention and control of diseases, and alcohol and drug abuse;
-providing resources and expertise to the States and other public and private institutions in the planning, direction, and delivery of physical and mental health care services; and
-enforcing laws to assure the safety and efficacy of drugs and protection against impure and unsafe foods, cosmetics, medical devices, and radiation-producing projects.

and

-reducing health care costs, through studies on the interaction of cost, quality, and access; microsimulation modeling, to understand the effect of proposed health care reform; and analyzing health care costs effected by acute, ambulatory, and long-term care and AIDS;
-expanding clinical practice guideline activities by increasing production of important guidelines and evaluating their effect on the cost and quality of health care; and
-enhancing the scientific evidence base for cost-effective clinical practices, by expanding research to improve clinical decisionmaking and strengthening clinical information systems for effectiveness research.

The Public Health Service Act illustrates and sets precedent to the reform the government is working on now. It demands good quality care to Americans at a reasonable cost. One could say, it provides a 'demand' on elected officials to seek reform now that the industry is so out of control and negligent of the priorities of physicans for their patients and providing coverage to everyone. So, when opponents to health care insurance reform refuse to participate they are actually conducting themselves in an Anti-American modality and against 'established' law. Those that oppose this reform bill are sincerely incompetent to understand their role as an elected offical.

In all honesty, The Public Health Services Act is where American Health Care gets 'its tone' and 'impetus.' It wasn't as though one day a House Representative 'thunk it up' and thought it would be a good idea to reform health care. There is a reason why the House bill is so well written and very structured for its implementation. This reform has been on the agenda of the House for some time and it is the Public Health Services Act that is the basis of these reform bills. It is THE LAW, not an option.

This House bill actually is providing another amendment to the Public Health Services Act. Page 862, lines 15 through 23:

(I) appropriated under the heading ‘‘Prevention and Wellness Fund’’ in title VIII of division A of the American Recovery and Reinvestment Act of 2009 (Public Law 111–5); and (II) allocated by the second proviso under such heading for evidence based clinical and community-based prevention and wellness strategies.

Of course, the ARRA (American Recovery and Reinvestment Act) is the stimulus package passed this year once President Obama was in office. This provision takes the monies of the stimulus and impliments it under established law.

Page 863, lines 16 through 24:

(3) BUDGETARY IMPLICATIONS.—Amounts appropriated under this section, and outlays flowing from such appropriations, shall not be taken into account for purposes of any budget enforcement procedures including allocations under section 302(a) and (b) of the Balanced Budget and Emergency Deficit Control Act and budget resolutions for fiscal years during which appropriations are made from the Fund.

The funds allocated for this portion of the bill cannnot be reallocated. They are dedicated funds for the purpose of which they are stated.

Page 864, lines 1 through 5:

TITLE I—COMMUNITY HEALTH CENTERS
SEC. 2101. INCREASED FUNDING.
Section 330 of the Public Health Service Act (42 U.S.C. 254b) is amended—

This is funding for a new provision under the Public Health Service Act to include "Community Health Centers."

"National Association of Community Health Care Centers" (click here)

The Associated Press has a nice artilce about them.

Community clinics have key role in health reform (click here)
By JULIANA BARBASSA (AP) – 3 days ago
SAN JOAQUIN, Calif. — Francisco Lupercio has insurance for his house, his truck and the store he runs with his wife. But he can't afford health insurance, so he joined dozens of other people lining up for exams at a community clinic.
As the recession grinds on, more and more people are relying on taxpayer-supported health centers that offer care on a sliding fee scale. If Congress passes a law giving more Americans access to health insurance, the clinics will also be a critical element to ramping up capacity to care for millions of new patients.
"There is going to be a wave of chronically ill people," said Tanir Ami, executive director of the Community Clinic Consortium for Contra Costa and Solano counties, east of San Francisco. "We're well positioned to care for them."...

Page 865, lines 6 through 14:

TITLE II—WORKFORCE
Subtitle A—Primary Care Workforce
PART 1—NATIONAL HEALTH SERVICE CORPS
SEC. 2201. NATIONAL HEALTH SERVICE CORPS.
(a) FULFILLMENT OF OBLIGATED SERVICE REQUIREMENT THROUGH HALF-TIME SERVICE.—
(1) WAIVERS.—Subsection (i) of section 331
(42 U.S.C. 254d) is amended—

This is establishing the 'status quo' of allowing certain waivers for loan repayment to those that come to work in a 'corp' placement. It provides for scholarships that if accepted by the candidate agree to service in places in the country where they are most needed. It is an 'equity' issue to provide high quality health care workers to all areas of the country, regardless of what is normally preceived as a low earning capacity region.

This provision goes on for awhile about definitions and how a participant has some options to satisfy the service of the contract. The physicians that funded their education through these programs actually have the option of 'servicing the contract' 50% of the time while they spend the rest of their time establishing their own private practice or entering a group practice if they desire. It is a nice option.

These programs also include funding for Dentists and Dental hygienists.

If the 'Loan Repayment Corp Program' has unused monies there is methods to use the monies for recruitment of folks to serve the underserved.

Page 875, lines 4 through 15:

‘‘(d) INSUFFICIENT NUMBER OF APPLICANTS.—If there are an insufficient number of applicants for loan repayments under this section to obligate all appropriated funds, the Secretary shall transfer the unobligated funds to the National Health Service Corps for the purpose of—
‘‘(1) recruitment of sufficient applicants for the National Health Service Corps for the following year; or
‘‘(2) making additional loan repayments under section 338B if there is an excess number of qualified applicants for loan repayments under such section.

There is an emphasis in this section to promote the 'specialty' called "Primary Care." It is also clear in the legislation that these applicants have to demonstrate financial need. There is a lot of legislative support for establishing training in family medicine, general internal medicine, general pediatrics, or geriatrics, including physican assistants including in community-based settings. Other specialties mostly take care of themselves. There is a lot of incentive to practice in high paying specialties and there really is no need to promote those, especially with government monies. There are also aspects of this section to make the public aware of these existing opportunities to those people that need financial assistance. A program is no good if no one knows about it.

Page 892, lines 14 through 25 and page 893, lines 1 through 3:

Subtitle B—Nursing Workforce
SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.
(a) DEFINITIONS.—Section 801 (42 U.S.C. 296 et seq.) is amended—
(1) in paragraph (1), by inserting ‘‘nurse-managed health centers’’ after ‘‘nursing centers,’’; and
(2) by adding at the end the following:
‘‘(16) NURSE-MANAGED HEALTH CENTER.— The term ‘nurse-managed health center’ means a nurse-practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and is associated with an accredited school of nursing, Federally qualified health center, or indpendent nonprofit health or social services agency.’’.

"Institute of Nursing Centers" (click here)

The Institute for Nursing Centers is a network of organizations that focuses on the advancement of nurse managed health centers (NMHCs). The intent of the network is to enhance the work of all partners with an emphasis on developing a national data center for NMHCs. The founding members of the INC are the Michigan Academic Consortium (MAC), the American Association of Colleges of Nursing (AACN), the Nursing Centers Research Network (NCRN), the Michigan Primary Care Association (MPCA), the National Nursing Center Consortium (NNCC), and the National Organization of Nurse Practitioner Faculties (NONPF).

Nurse Health Centers can 'pick up the slack' when emergencies beset the nation. That is not all they do and many Advanced Practice Nurses have speciality areas such as anesthesia, midwives and pediatrics. Example of how a Nurse Health Center can participate:

Eugene schools offering H1N1 vaccine (click here)

Last Update: 10/15 8:07 pm

Eugene (KMTR) - Students in Eugene’s 4J school district started receiving the H1N1 flu vaccine Thursday.
The school health centers at Sheldon, North Eugene and South Eugene High Schools got a larger supply of H1N1 nasal spray vaccine than they expected, and made it available on a first-come, first-served basis.
The first doses were given to students who are in high-priority groups and who can take the nasal form of the vaccine. The live-virus vaccinations are being given to students whose parents bring them to the health centers, according to North Eugene school nurse Debbie Goodman.
“The live vaccine has very specific requirements in order to qualify for that,” Goodman said. “Number one, right now, we are targeting our most vulnerable population, so that's our priority. And with the live virus we can only give the vaccine to healthy individuals with no chronic health conditions, from the age of two years old to 24."...

There is no gender bias or discrimination as nursing is traditionally a woman's field. There are financing programs, loans and grant programs to promote Advanced Practice.

Page 907, lines 18 through 25 and page 908, lines 1 through 3:

SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.
Section 765 (42 U.S.C. 295) is amended to read as follows:
‘‘SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.
‘(a) PROGRAM.—The Secretary, acting through the Administrator of the Health Resources and Services Administration and in consultation with the Director of the Centers for Disease Control and Prevention, shall establish a public health workforce training and enhancement program consisting of awarding grants and contracts under subsection (b).

Page 909, lines 22 through 25 and page 909, lines 1 through 4:

‘‘(4) to provide financial assistance in the form of traineeships and fellowships to public health professionals who are participants in any program described in paragraph (1) and who plan to teach in the field of public health, including nursing; health administration, management, or policy; preventive medicine; laboratory science; veterinary medicine; or dental medicine.

And yes, veterinary medicine is as much a public health concern as human medicine. So, we need veterinarians, too. Examples:

15 Oct 2009: Report
The Spread of New Diseases:The Climate Connection (click here)

by Sonia Shah
As humans increasingly encroach on forested lands and as temperatures rise, the transmission of disease from animals and insects to people is growing. Now a new field, known as “conservation medicine,” is exploring how ecosystem disturbance and changing interactions between wildlife and humans can lead to the spread of new pathogens.

Look up into the tree canopy of the urban tropics in South Asia, Australia, or equatorial Africa and as often as not you will find masses of Pteropos fruit bats, hanging from the branches like so many furry stalactites. Their forests cut down by bulldozers, torched by slash-and-burn farmers, or desiccated from a disrupted climate, fruit bats increasingly intrude upon human communities, adapting to the orchards and cultivated fruit trees of the cities, farms, and suburbs that have subsumed their forests....

It's showdown time over pet licensing (click here)
Houston vows to get tough with vets who defy law for rabies data
By CINDY HORSWELL

HOUSTON CHRONICLE
Oct. 17, 2009, 1:34PM

For more than two decades, many Houston veterinarians have engaged in a quiet mutiny of sorts.
They have refused to follow a law requiring them to essentially name names — to turn over the identities and addresses of pet owners whose dogs and cats received rabies shots.
The city of Houston wants these names to identify some of the hundreds of thousands of pet owners who have failed to obtain the required city license for their dog or cat — and which could result in a citation. Only 4 percent of Houston's estimated 1 million pets are registered today, city officials said....

This section of the House bill goes on for many more pages. It allows for financial assistance to disadvantaged students and sets limits to the extent they can receive those monies. Although this is a large section of the bill, the monies being appropriated are in the millions and not the billions. So, the investment into the workforce is important, but, the bill still has its primary focus on getting good health insurance for the populous of the USA.

This section also gives permission for much more fluidity for change in the health care professions with allowances for 'inter-disciplinary' education and monitoring the need for different specialities for a changing population.

Page 931, lines 14 thorough 19:

TITLE III—PREVENTION AND WELLNESS
SEC. 2301. PREVENTION AND WELLNESS.
(a) IN GENERAL.—The Public Health Service Act (42 U.S.C. 201 et seq.) is amended by adding at the end the following:

It is the next section of the House bill and where I will stop for now. I am almost complete in reading the House bill as the pages number to 1018.

Regards.

Medicare Advantage goes down kicking and screaming. I thought this comparison of 'the truth' against the report from the Insurance Lobby was good.

The report at the title is from The Washington Post and I thought they made a real effort to understand the biased report of the Health Industry.

Below is a report from March of this year which shows graphically that Medicare Advantage is not an advantage to most of the country, YET, it is very expensive for the federal government to subsidize.

High resolution of the Daily Yonder Classification of Counties in the USA (click here)

...Nationally, 23.7 percent of Medicare beneficiaries belong to a Medicare Advantage plan.
Some Medicare Advantage plans do provide more benefits, just as Congress hoped. But most Medicare Advantage plans don’t save any money. In fact, they cost much more than traditional Medicare fee-for-service plans. Each dollar’s worth of enhanced benefits in the private plans costs the Medicare program over three dollars....



“Medicare Advantage” plans (click here) have been touted as a way for elderly rural residents to have a choice in health care plans paid for by Medicare dollars. But few rural Medicare recipients are enrolled in Medicare Advantage plans — and those who have joined are enrolled in Medicare Advantage plans with the highest costs and the fewest benefits....


The other issue with Medicare Advantage is fraud. There has been some wide spread issues in the country regarding fraud.

As noted in the financial sector in October or 2008, when the private sector of our society is provided with vast sizes of money, they can't handle it. The monies are poorly recorded and basically there is waste and greed. So, anytime the private sector of the country states they have a better idea that won't cost the public as much as government, be aware.

The problem and it is a profound problem is that when government monies make its way into the private sector there are problems and although the private provider looks good on paper, the waste and cost only shows up when the 'entire' dynamics of what it costs to monitor them and litigate them is realized. It is not worth it and people suffer due to the fraud and greed. Ultimately, people get better services and overall costs of any government program is less than private providers.

The American people need to find confidence in the decisions of their government and seek to be very skeptical of the arguments that want to demonize it, especially when people of integrity are at the top of its leadership. We have witnessed what eight years of the worst Republican administration in history has brought us. Yeah, even worse than Nixon. So, while it is true most years with Republicans 'demonstrating' poor quality government is real, it is 'loaded' to be that way. "W" was incompetent. "Right, Brownie?" I can't believe he was actually in office for eight years. His administration was such a joke. They were corrupt to the core.

The Washington Post has validated my most profound point through this entire debate. When the youngest of our citizens have health care, the 'cost' levels out and we as a nation are 'balanced' and 'healthy' both fiscally and through the deepest understanding of 'habeous corpus.'

Analysis: (click title to entry - thank you) There is a lively debate about whether the penalty would goad healthier people to get coverage. But the reports are probably too pessimistic. Massachusetts has gotten all but 3 percent of residents into coverage with a penalty of roughly the same size. The reports also do not take into account the draw of the low-cost "young invincibles" policy included in the bill. And the Congressional Budget Office estimates coverage levels would rise to 94 percent of Americans, from 83 percent.

A lot of this is common sense. Trust your instincts, they are usually right and OUR government is effective when the right people are in charge. The Obama Administration is just about the most sincere administration short of FDR.

You can put the Kennedy administration in that category as well. But, it was very short lived, wasn't it? JFK never wanted to go into Vietnam and he was doggedly pursuing corruption and organized crime in this country, civil rights was paramont to his 'idea' of just and fair. The country is better off in the hands of 'the working class' and that is primarily the Democratic Party. Sorry, it is just the way it is. The USA Constitution wasn't conceived for the rich and powerful to ignore the well being of citizens. It wasn't !!!! It also was written with the 'idea' that citizens could 'opt' to be greedy over reasonable.

I'm going to take a look at the rest of the House Bill. I don't think the Senate Bill is worth shit. Senator Chris Dodd is the only one that really cares about it, so I hope he is successful on the Senate floor. I'll read the Senate bill, too.

Page 820, lines 1 through 18:

TITLE VIII—REVENUE-RELATED PROVISIONS
SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE LOW-INCOME ASSISTANCE UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM TO ASSIST SOCIAL SECURITY ADMINIS8
TRATION’S OUTREACH TO ELIGIBLE INDIVIDUALS.
(a) IN GENERAL.—Paragraph (19) of section 6103(l) of the Internal Revenue Code of 1986 is amended to read as follows:
‘‘(19) DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR LOW-INCOME SUBSIDIES UNDER MEDICARE PRESCRIPTION DRUG PROGRAM TO ASSIST SOCIAL SECURITY ADMINISTRATION’S OUTREACH TO ELIGIBLE INDIVIDUALS.—

The States are 'qualifying' people into the areas of subsidy to the new 'Public Option.' But, it is the brevity of the Federal government that will allow this new commission to monitor that eligibility through examination of records. Those records are fairly invasive. The Federal government wants the truth and nothing short of it. It is the way it should be. It is easier and less costly to prevent fraud than to litigate it. It is easier to stop the flow of monies to the wrong hands than to attempt to recoup those monies.

Everything goes into figuring out eligibility for folks. Example: Page 821, lines 9 through 17:

‘‘(ii) unearned income information and income information of the taxpayer from partnerships, trusts, estates, and subchapter S corporations for the applicable year,
‘‘(iii) if the individual filed an income tax return for the applicable year, the filing status, number of dependents, income from farming, and income from self-employment, on such return,

And don't believe for one minute those folks making all the noise about Health Care Insurance Reform don't object to this as well. They won't be able to hide. When government works to benefit the people it is economically prudent, especially over a long period of time. It took Former President Clinton nearly eight years to turn a National Debt into a National Surplus. It took "W" less than a year to squander it. Republican administrations 'specialize' in 'immediate gratificiation' to reinforce their popularity. Democratic administrations believe in good government for ALL.

The flow of information between agencies of the government to administer a domestic program is widely criticized by Right Wing Bozos, but, it is necessary to provide a better venue of government control. And yes, it is control. Absolutely. I would think that would be reassuring to folks. That the government has control over information. This isn't a 'free flow' of information to the public or identity thieves, but, it is a way for one agency to speak to another to insure the best outcome for the 'PUBLIC TRUST.' There is nothing threatening about it unless one has gotten used to living outside the law and conducting themselves in a corrupt 'fashion' much of which is the venue of 'The South.' I shouldn't get started on this, but, the impoverishment of the Southern USA is based in lack of good government and the corruption of the public because average folks have to survive, so 'they play by the rules.' Things have to change and it will.

Page 821, lines 24 and 25 and Page 822, lines 1 thorugh 5:

‘‘(v) if the individual files a joint return for the applicable year, the social security number, unearned income information, and income information from partnerships, trusts, estates, and subchapter S corporations of the individual’s spouse on such return, and

S Corporations (click here)
S corporations are corporations that elect to pass corporate income, losses, deductions and credit through to their shareholders for federal tax purposes. Shareholders of S corporations report the flow-through of income and losses on their personal tax returns and are assessed tax at their individual income tax rates. This allows S corporations to avoid double taxation on the corporate income. S corporations are responsible for tax on certain built-in gains and passive income....

Page 823, lines 9 through 18:

‘‘(D) RESTRICTION ON USE OF DISCLOSED INFORMATION.—Return information disclosed under this paragraph may be used only by officers and employees of the Social Security Administration solely for purposes of identifying individuals likely to be ineligible for a low-income prescription drug subsidy under section 1860D–14 of the Social Security Act for use in outreach efforts under section 1144 of the Social Security Act.’’.

There is a lot 'going on' about the way this reform initiative is paid for. It closes down long lived programs in order to CONSOLIDATE efforts and streamline the system. That scares people. Folks become 'used to' thinking about 'their security' in a particular venue and particular dynamic and they are 'shaken up' when change occurs. Change is a nice word, but, the 'actuality' of carrying it out is another story. That is a good deal of what is occuring in the USA regarding this issue. Page 824 sets up a new Trust Fund. Lines 8 through 25 and Page 825, lines 20 through 25 and Page 826, lines 1 through 4:

SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; FINANCING FOR TRUST FUND.
(a) ESTABLISHMENT OF TRUST FUND.—
(1) IN GENERAL.—Subchapter A of chapter 98 of the Internal Revenue Code of 1986 (relating to trust fund code) is amended by adding at the end the following new section:
‘‘SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND.
‘‘(a) CREATION OF TRUST FUND.—There is established in the Treasury of the United States a trust fund to be known as the ‘Health Care Comparative Effectiveness Research Trust Fund’ (hereinafter in this section referred to as the ‘CERTF’), consisting of such amounts as may be appropriated or credited to such Trust Fund as provided in this section and section 9602(b).
‘‘(b) TRANSFERS TO FUND.—There are hereby appropriated to the Trust Fund the following:...
...The amounts appropriated under paragraphs (1), (2), (3), and (4)(B) shall be transferred from the Federal Hospital Insurance Trust Fund and from the Federal Supplementary Medical Insurance Trust Fund (established under section 1841 of such Act), and from the Medicare Prescription Drug Account within such Trust Fund, in proportion (as estimated by the Secretary) to the total expenditures during such fiscal year that are made under title XVIII of such Act from the respective trust fund or account.

Don't underestimate the importance of the competency of The Secretary of Health and Human Services. She has to know how to do math. She has to have folks that work for her that understands how to do math and then they have to coordinate their figures and efforts with the US Treasury to insure all the monies are where they should be when they should be. There is a lot of responsibility on her shoulders when this bill passes and her department is responsible for the health of this nation. She is very important.

Page 827, lines 21 thorugh 24 and Page 828, lines 1 and 2:

"(1) IN GENERAL.—Subject to paragraph (2), amounts in the CERTF are available, without the need for further appropriations and without fiscal year limitation, to the Secretary of Health and Human Services for carrying out section 1181 of the Social Security Act.

Page 829, starts language about 'the insured' and 'self-insured health plans.' It is a change in direction of the relationship between government and insurance companies. In this case, there is a fee (it is an administration fee) placed on these plans to be sure they are registered with the government and to be sure their 'insured' are actually well cared for under the provisions of this bill. Here again, it is easier to prevent issues than litigate them afterwards and that is what this provision is about primarily.

Lines 9 through 18:

‘‘Subchapter B—Insured and Self-Insured Health Plans
‘‘Sec. 4375. Health insurance.
‘‘Sec. 4376. Self-insured health plans.
‘‘Sec. 4377. Definitions and special rules.
‘‘SEC. 4375. HEALTH INSURANCE.
‘‘(a) IMPOSITION OF FEE.—There is hereby imposed on each specified health insurance policy for each policy year a fee equal to the fair share per capita amount determined under section 9511(c)(1) multiplied by the average number of lives covered under the policy.
‘‘(b) LIABILITY FOR FEE.—The fee imposed by subsection (a) shall be paid by the issuer of the policy.

This provision goes on to define terms and words. There isn't anything 'tricky' about the language.

Just as a point of interest, there was a meeting recently where some of the best professionals in the health care industry met to 'talk about' the movement of change for the USA's health care. It was called, "The Aspen Institute/Time Aspen Health Forum." This forum is not new. It is mostly an annual event and has been looking at health care in the USA as well as globally, including disease trends and treatment such as the avian and swine flu. There are several video forums published on this website. They are all interesting, but, take some time to listen to their content. The last video features Former Senator Tom Daschle. He makes a concerted effort to put the debate into perspective:

President Obama’s Prospects for Health Reform, Insurance Reform (click here) featuring:
- The Honorable Tom Daschle, Former Senate Majority Leader
- David B. Snow Jr., Chairman and CEO, Medco
- Peter Long, Senior Vice President for Executive Operations, Kaiser Family Foundation (Moderator)

The former Senator eloquently addressed the enormity of the issues we face as a nation regarding health care. Not to alienate anyone interested in this debate, Former Senator Daschle refers to an acronym called CER. Another name for CER is 'being careful we are making the change the nation needs.' This forum took place only a few days ago so it is very relevant.

Comparative Effectiveness Research Funding (click here)
The Recovery Act (ARRA) contains $1.1 billion for comparative effectiveness research. Comparative effectiveness research (CER) compares treatments and strategies to improve health. This information is essential for clinicians and patients to decide on the best treatment. It also enables our nation to improve the health of communities and the performance of the health system.

Back to the House Bill.

The bill includes all forms of health delivery, including these small incidental policies we occassional subscribe to for travel, school activities, etc. Page 833, lines 14 through 18:

‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The term ‘accident and health coverage’ means any coverage which, if provided by an insurance policy, would cause such policy to be a specified health insurance policy (as defined in section 4375(c)).

There are 'except entities' to any fee rendered, page 834, lines 22 through 24 and page 835, lines 1 though 10:

‘‘(C) any program established by Federal law for providing medical care (other than through insurance policies) to individuals (or the spouses and dependents thereof) by reason of such individuals being—
‘‘(i) members of the Armed Forces of the United States, or
‘‘(ii) veterans, and
‘‘(D) any program established by Federal law for providing medical care (other than through insurance policies) to members of Indian tribes (as defined in section 4(d) of the Indian Health Care Improvement Act).

Page 835, lines 22 and 23 and page 836, lines 1 though 9:

‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES
‘‘SUBCHAPTER A. POLICIES ISSUED BY FOREIGN INSURERS
‘‘SUBCHAPTER B. INSURED AND SELF-INSURED HEALTH PLANS
‘‘Subchapter A—Policies Issued By Foreign Insurers’’.
(B) The table of chapters for subtitle D of such Code is amended by striking the item relating to chapter 34 and inserting the following new item:
‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES’’.
(3) EFFECTIVE DATE.—The amendments made by this subsection shall apply with respect to policies and plans for portions of policy or plan years beginning on or after October 1, 2012.

I don't approve of American funds for health care to go to foreign entities or any entity in countries that practice 'tax shelter' banking opportunities. Every USA dollar that leaves the country, leaves the economy. There are specific protests I have regarding government and the use of USA monies to foreign entities. It is WRONG to send American dollars anywhere outside the USA boundaries and its possessions in regard to the military and health care dollars. They are areas of national security and YES, the issue of the health of the people of this nation is one of security. It is my opinion all issues of national security should be 'housed' within the definition of the sovereignty of the USA kept within its borders.

There are going to be repeal of some existing laws. And here again, some people will be screaming, "I never bargained for this." Hogwash. The government needs to be fluid and efficient. There cannot be conflicting language or focus to laws if they are to be effective and efficient. Page 836, lines 11 though 24:

TITLE IX—MISCELLANEOUS PROVISIONS
SEC. 1901. REPEAL OF TRIGGER PROVISION.
Subtitle A of title VIII of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173) is repealed and the provisions of law amended by such subtitle are restored as if such subtitle had never been enacted.
SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) PROGRAM.
Section 1860C–1 of the Social Security Act (42 U.S.C. 1395w–29), as added by section 241(a) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Public Law 108–173), is repealed.

This is a new focus for 'delivering' health care in the USA. Page 838, lines 8 through 17:

‘‘Subpart 3—Support for Quality Home Visitation Programs
‘‘SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING CHILDREN.
‘‘(a) PURPOSE.—The purpose of this section is to improve the well-being, health, and development of children by enabling the establishment and expansion of high quality programs providing voluntary home visitation for families with young children and families expecting children.

This is very important. Every child being born in the USA will be addressed with a program that will start them on the best path. The reasons for such a program are more than can be discussed in a short paragraph, however, put it into context this way; "If every child and their parents are given information and guidance to prevent obesity in children we would be a healthier America." It is my opinion a program like this is not only necessary, but, vital. Why? Because it brings children closer to a relationship with health care professionals, including their pediatrician.

A personal story.

I raised two sons. I love them dearly and they are good sons. They love me and we have an open and honest relationship. I am a resource to them and they are a joy to me. When they needed a pediatrician, they had one from birth and had the same pediatrician for all their growing up years, to the age of 18 years old.

Regardless of where we lived on the East Coast of the USA, they were always returned at least once a year for their annual physicals. Dr. Wilson was well known to them, they knew they saw him at least once a year and as they became young adults they had their physical exams in complete privacy with their pediatrician while I was seated in the Waiting Room should there be an issue to discuss. It was our choice to allow that privacy and it worked to give them a sense of autonomy in a very important aspect of growing up.

The result? I rarely experienced illness with my children. The physician visits outside of their wellness visits were very limited over the entire 18 years of their lives. No lie. I did not have enormous costs to their wellness. They were cared for by a man well versed in his profession and I had complete faith in any and all of his recommendations. Today, at the ages of 30 and 28, my sons are healthy without complications. They are substance free and happy in relationships.

I might have been lucky, but, I could put all my worries to rest at the doorstep of Dr. Wilson and the result was incredible. My sons aren't afraid of health of their bodies and seek physicians when needed and have physical exams on a regular basis. My youngest son has two children and they receive regular check ups and those kids are healthy. They enjoy their healthy little lives to date.

Healthy bodies begin at tender ages with good habits. This provision is very important.

There is a mandate for spending on this program and while 5% is a healthy allowance it is also a limit on the spending of the program. Page 840, lines 6 through 9;

‘‘(B) the State will reserve 5 percent of the grant funds for training and technical assistance to the home visitation programs using such funds;

To help contain costs, the bill spells out clearly the lack of waste in duplication. Page 840, lines 10 through 29:

‘‘(C) in supporting home visitation programs using funds provided under this section, the State will promote coordination and collaboration with other home visitation programs (including programs funded under title XIX) and with other child and family services, health services, income supports, and other related assistance;
‘‘(D) home visitation programs supported using such funds will, when appropriate, pro20
vide referrals to other programs serving children and families; and

I like the attention given to Indian tribes. They have been viewed as a nation within a nation with 'hands off' of spending federal monies to improve their quality of life. There aren't even police forces that deal with the crime found among American Indian tribal grounds, it is the FBI that responds to issues. Regardless, to extend the Health Care Reform initiative to our American Indian Tribes is right and best. These folks have suffered from a long time when it comes to quality health care and it time we realize how they struggle as a small nation to provide for their people and extend health care to them no different than a citizen of the USA born outside of a tribal area. And, yes, the USA has tribal areas !

Page 841, lines 3 through 14:

‘‘(1) INDIAN TRIBES.—From the amount reserved under subsection (l)(2) for a fiscal year, the Secretary shall allot to each Indian tribe that meets the requirement of subsection (d), if applicable, for the fiscal year the amount that bears the same ratio to the amount so reserved as the number of children in the Indian tribe whose families have income that does not exceed 200 percent of the poverty line bears to the total number of children in such Indian tribes whose families have income that does not exceed 200 percent of the poverty line.

Here again is the stipulation of the 200% poverty line (approximiately $35,000 annually), page 841, lines 15 through 25 and page 842, lines 1 and 2;

‘‘(2) STATES AND TERRITORIES.—From the amount appropriated under subsection (m) for a fiscal year that remains after making the reservations required by subsection (l), the Secretary shall allot to each State that is not an Indian tribe and that meets the requirement of subsection (d), if applicable, for the fiscal year the amount that bears the same ratio to the remainder of the amount so appropriated as the number of children in the State whose families have income that does not exceed 200 percent of the poverty line bears to the total number of children in such States whose families have income that does not exceed 200 percent of the poverty line.

One of the criticisms I ALWAYS hear about Democratic programs is that it is an attempt to 'control' parenting and tell a parent how to raise a child.

That isn't the case.

The word isn't 'control' it is 'empowerment.'

There are specific 'interventions and outcomes' expected of this provision of the bill and I want to list them here, although I think it is a little silly, simply because the critics will take issue of every aspect of the program. By defining the 'interventions and outcomes' there is an understanding that the bill will provide 'AT LEAST' this much and has a limit to 'THE MAXIMUM' it provides in 'authority' of government and licensed personnel that will provide the program.

Page 844, lines 17 through 25, page 845, lines 1 thourgh 25 and page 846, lines 1 and 2:

‘‘(iv) monitor fidelity of program implementation to ensure that services are delivered according to the specified model; and
‘‘(v) provide parents with—
‘‘(I) knowledge of age-appropriate child development in cognitive, language, social, emotional, and motor domains (including knowledge of second language acquisition, in the case of English language learners);
‘‘(II) knowledge of realistic expectations of age-appropriate child be5
haviors;
‘‘(III) knowledge of health and wellness issues for children and parents;
‘‘(IV) modeling, consulting, and coaching on parenting practices;
‘‘(V) skills to interact with their child to enhance age-appropriate development;
‘‘(VI) skills to recognize and seek help for issues related to health, developmental delays, and social, emotional, and behavioral skills; and
‘‘(VII) activities designed to help parents become full partners in the education of their children;
‘‘(B) includes expenditures for training, technical assistance, and evaluations related to the programs; and
‘‘(C) does not include any expenditure with respect to which a State has submitted a claim for payment under any other provision of Federal law.

The bill goes on to describe quality assurance issues for the monies spent. Page 846, lines 5 through 15:

‘‘(A) IN GENERAL.—The expenditures, described in paragraph (1), of a State for a fiscal year that are attributable to the cost of programs that do not adhere to a model of home visitation with the strongest evidence of effectiveness shall not be considered eligible expendtures for the fiscal year to the extent that the total of the expenditures exceeds the applicable percentage for the fiscal year of the allotment of the State under subsection (c) for the fiscal 15 year.

The bill recognizes the Federal legisation cannot 'impose' this provision by the terms of the States. Page 847, lines 6 through 11:

‘‘(h) WAIVER AUTHORITY.—
‘‘(1) IN GENERAL.—The Secretary may waive or modify the application of any provision of this section, other than subsection (b) or (f), to an Indian tribe if the failure to do so would impose an undue burden on the Indian tribe.

It is important to recognize the special circumstances of American Indians. They do have very different dynamics within the authority of their tribes, but, they are also a part of the USA and we want them healthy and contributing productively to their own nation as well as the greater of the people of the USA.

The bill goes on to discuss issues of quality assurance and economy. The program will be monitored for effectiveness, cost and efficiency of delivery. The program will be modified to deliver 'over time' as the 'best' strategies emerge. The bill has the best interest of the 'USA budget' at heart while still delivering high quality of care to citizens.

Page 853, lines17 through 25:

‘‘IMPROVED COORDINATION AND PROTECTION FOR DUAL ELIGIBLES
‘‘SEC. 1150A. (a) IN GENERAL.—The Secretary shall provide, through an identifiable office or program within the Centers for Medicare & Medicaid Services, for a focused effort to provide for improved coordination between Medicare and Medicaid and protection in the case of dual eligibles (as defined in subsection (e)). The office or program shall—

Here again, it cannot be stated enough that we have duplicity in legislations over the years, which happens in a democracy of people numbering more than 300 million. The bill actively seeks to reduce 'dual status' of participants. It streamlines the administration of the government's responsibility and it controls cost.

There is provision in the bill to allow appeals to any of the decsions of the Secretary. Different from the legislation of the Republicans that block litigation. I was astounded to realize there was no recordkeeping demanded of the investment banks given the bailout funds. The Bush adminisration did that sort of thing on a regular basis. The monies sent to Iraq's government and Halliburton were literally 'give aways' without accountability. The bailout was the same way. I don't believe in that. If the American people provide money for anything there should be an accounting. I am still waiting to hear where Rumsfeld put his 'offshore account.' Its got to be somewhere.

And yes, I am stating the Republicans in the Bush years STOLE money from the government and it was just too bad for the taxpayers of the nation. Absolutely and if anyone doesn't believe Paulson and Goldman Sachs didn't loot the USA Treasury, then they need to think again.

The next section of the bill deals with 'work force' development. It is a quality assurance statute. It is lengthy from what the outline looks like, but, seems standard and straight forward. Health care needs a workforce and for the first time in history the government is going to be sure that workforce is important enough to monitor and facilitate.

Page 856, lines 1 through 4.

DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT
4 SEC. 2001. TABLE OF CONTENTS; REFERENCES.

The table of contents alone comprises three pages. I am not going to go over every aspect of the outline. I didn't see the provision for unions, through.

I am going to take a break and I'll be back.

...about 200 pages to go...it just seems so obvious something 'public' has to be done...

Baucas stated, "My job is to write a bill that the Senate will pass." No, sir, that is not your job. You job as majority leader is to have the Republicans on the committee understand you have to write a bill the country desperately needs and the President will sign !!!!

...I'm just scanning what I've read to date to be sure I didn't miss something, like the provision allows for free health care for Dick Cheney...Oh, that's right, Cheney gets his health care free anyway.

WASHINGTON — Supporters of President Barack Obama's drive to remake health care are pushing back against a dire report from the insurance industry warning of hefty new costs for consumers from the latest legislation.
AARP Executive Vice President John Rother told reporters Monday that he doesn't think the report is "worth the paper it's written on." He said if anyone believes it, that's a problem....

Here it is. I knew there was something about 200% of the poverty level, which works out to be about $35,000, I forgot to mention.

Page 789, lines 1 through 18:

SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER CERTAIN CHIP PROGRAMS.
(a) IN GENERAL.—Section 2102(b) of the Social Security Act (42 U.S.C. 1397bb(b)) is amended by adding at the end the following new paragraph:
‘‘(6) REQUIREMENT FOR 12-MONTH CONTINUOUS ELIGIBILITY.—In the case of a State child health plan that provides child health assistance under this title through a means other than described in section 2101(a)(2), the plan shall provide for implementation under this title of the 12-month continuous eligibility option described in section 1902(e)(12) for targeted low-income children whose family income is below 200 percent of the poverty line.’’.
(b) EFFECTIVE DATE.—The amendment made by subsection (a) shall apply to determinations (and redeterminations) of eligibility made on or after January 1, 2010.

Page 801, lines 4 and 5 start a new section:

Subtitle F—Waste, Fraud, and Abuse

There is a lot of 'standard legislative' language here. As Senator Snow says, "Langauge that means what we want it to mean."

There are provisions to drop individual providers or entities if they are found in fraudulent status. Then it goes on to be specific that 'any' entity found to be eliminated from participation cannot receive monies through another entity, such as a health care clinic someone might own.

Page 807, lines 9 through 25 and page 808, lines 1 through 3:

SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION RELATING TO CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.
(a) STATE PLAN REQUIREMENT.—Section 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), as amended by sections 1631(b)(1), 1703, and 1753, is fur15
ther amended—
(1) in paragraph (75), by striking at the end ‘‘and’’;
(2) in paragraph (76), by striking at the end the period and inserting ‘‘; and’’; and
(3) by inserting after paragraph (76) the following new paragraph:
‘‘(77) provide that the State agency described in paragraph (9) exclude, with respect to a period, any individual or entity from participation in the program under the State plan if such individual or entity owns, controls, or manages an entity that (or if such entity is owned, controlled, or managed by an individual or entity that)—

Those handling government payments and monies must be registered, Page 810, lines 11 through 13:

SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES REQUIRED TO REGISTER UNDER MEDICAID.

There will be denial to payment if they are not registered, Page 811, lines 4 through 5 and 12 through 15:

(b) DENIAL OF PAYMENT.—Section 1903(i) of such Act (42 U.S.C. 1396b(i)), as amended by section 1753, is amended—
‘‘(26) with respect to any amount paid to a billing agent, clearinghouse, or other alternate payee that is not registered with the State and the Secretary as required under section 1902(a)(78).’’.

This is in regard to judicial review, page 812, lines 16 and 17 and page 813, lines 7 through 12:

SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED MISCONDUCT.

...‘‘(B) to reimburse (or otherwise compensate) a managed care entity for payment of legal expenses associated with any action in which a court imposes sanctions on the managed care entity for litigation-related misconduct.’’.

What is a "Litigation Related Misconduct?" This is my take on it. Let's say the insured needs a kidney transplant. The insurance policy makes allowances for such procedures and practices provided the patient has a good chance of surviving the operation and meets any requirements the insurance company sees fit.

The obvious objection is that who is anyone in an insurance company to know what requirements should be to qualify as a kidney transplant patient. No one. The fact is the only person(s) qualified to order a transplant for a patient is an MD/Surgeon that has examined the patient and all necessary tests.

Also.

Who is to say whom will survive an operation? What is the sense in performing an operation if the patient is expected to die? Either way, if the patient has a better chance at living without the surgery, even a few days, no one is going to 'play God' and state that a transplant wouldn't save their life. Now, if a patient has multiple system involvement with an 'ejection fraction of 15% of his left heart ventrical' there might be a better candidate for the kidney because the patient probably won't make it to the operating table, yet alone survive the stress of organ transplant. As a matter of fact, someone with that poor a heart would probably never be a candidate for a kidney, however, they might be a candidate for a heart.

So, when push comes to shove and the insurance company is willing to litigate the payment for any reason and surgery or a procedure is not performed or a new medication isn't given that is called 'Delaying Patient Care.' For physicians and health care professionals that is an ethics issue and one taken seriously. Patients are supposed to be given relief from their symptoms in reasonable manner that benefits the patient.

But.

For insurance companies that provide coverage for health care they may see it as 'good prudent decision making' and not an ethics issue at all. So, if they decide there is no payment to be made and the patient 'seems' to meet all requirements according to their physician/surgeon, the insurance company is guilty of 'delaying patient care' and quite possibly cause the patient's death while the litigation is taking place.

That won't be allowed under this provision. Insurance companies will not be allowed to play with patient's lives and well being by delaying payment or approval through any litigation process.

Page 813, lines 16 and 19 and page 814, lines 4 through 14;

Subtitle G—Puerto Rico and the Territories

SEC. 1771. PUERTO RICO AND TERRITORIES.
(a) INCREASE IN CAP.—

‘‘(6) FISCAL YEARS 2011 THROUGH 2019.—The amounts otherwise determined under this subsection for Puerto Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa for fiscal year 2011 and each succeeding fiscal year through fiscal year 2019 shall be increased by the percentage specified under section 1771(c) of the America’s Affordable Health Choices Act of 2009 for purposes of this paragraph of the amounts otherwise determined under this section (without regard to this paragraph).

So, USA territories are going to receive an increase in their payments as well. I guess everyone is going to be treated the same across the spectrum of the USA Health Care Insurance Reform Bill. Sounds right.

The next section is called "Technical Corrections". Page 917, lines 24 and 25 and page 918, lines 1 through 3:

(d) TECHNICAL CORRECTION TO SECTION 605 OF CHIPRA.—Section 605 of the Children’s Health Insurance Program Reauthorization Act of 2009 (Public Law 111–3) is amended by striking ‘‘legal residents’’ and inserting ‘‘lawfully residing in the United States’’.

I believe the 'operative word' is "lawfully."

I believe the word, 'residing' is a bit questionable.

Legally residing does not necessarily mean a resident. Or does it? Let's see, if Tony Blair buys a house in Palm Beach, Florida and resides there, he is lawfully residing, right? Or is he simply 'at' his home in a non-resident country and therefore is 'occupying' the house and not truly residing?

Hm?

I think that word, depending on the court, would be ambiguous. The language needs to be cleaned up a bit, and the words that should be used is "Resident" as noted by the Immigration Service.

John Lennon had that frustration. He owned property in New York and I believe from time to time he was made to go back to Great Britain to renew the 'Visa.' I think that would be the 'operative' issue in any court decision. Whether or not a person was residing would be overridden by their 'Visa/Immigration Status.' I think the language should be cleaned up a bit. Then again this is exclusively about children and we even bring Iraqi children here for treatment, so, the language would stand. We'll be getting kids from other places though to receive treatment in the USA. I think this language needs a separate provision with more specifics as to what child qualifies as 'legally residing.' I believe that is inappropriate.

The USA isn't going to be the children's haven for every country on the planet. We can easily be a 'resource' for children needing care they cannot receive elsewhere and perhaps without cost. But. That is a State Department provision. Yep. Any children not a 'legal resident' that requires care needs to be qualified by the State Department and they can have their own provision. I think that is the best way to do it, regardless the country of origin.

This Health Insurance Reform Bill is for the people of the USA. Granted we are a compassionate people that like to extend our ability to help to all people, especially children, however there is a limit to the monies that can be appropriated for children from other countries that come here for treatment. It isn't right and adds undo fiscal burden to the USA Treasury.

First, we take care of our own. I am sorry, but, there has to be a limit and a deterrent. A 'wide open' provision such as that would cause undo fiscal burden on the cost of this legislation and a victim for scrutiny. I don't want this bill to be viewed as a poorly conceived document and allowed to be trashed in the future.

The bill and its programs have to stand as examples of the ability of Democrats and the President to legislate in a 'balanced' measure. I think there needs to be care in how compassionate this legislation is to extend benefits to those that might be here legally but not residents of the USA. There is nothing saying anyone that comes to the USA can't receive care or treatment, but, to the extent this bill provides for them should be clear and concise and limited.

Page 819, lines 22 through 25:

SEC. 1782. EXTENSION OF QI PROGRAM.
(a) IN GENERAL.—Section 1902(a)(10)(E)(iv) of the Social Security Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended—

Section 1902 of the SSI Act addresses subsidized health care. So any of the provisions within this section reflect changes to that subsidy.

QI is the Qualifying Individuals (QI) Program.

Page 819, lines 5 through 18:

(b) ELIMINATION OF FUNDING LIMITATION.—
(1) IN GENERAL.—Section 1933 of such Act (42 U.S.C. 1396u–3) is amended—
(A) in subsection (a), by striking ‘‘who are selected to receive such assistance under sub10
section (b)’’;
(B) by striking subsections (b), (c), (e), and (g);
(C) in subsection (d), by striking ‘‘furnished in a State’’ and all that follows and inserting ‘‘the Federal medical assistance percent age shall be equal to 100 percent.’’; and
(D) by redesignating subsections (d) and
(f) as subsections (b) and (c), respectively.

This particular 'section' of the Medicare Act has to do with Part B and the amount of reimbursement the States receive from the federal government to help pay for their programs to 'qualifying individuals.' This provision makes it easier on the States to pay for those individuals, because, the Federal government is going to provide total reimbursement.

Page 820 starts a very important section and will be read tomorrow. Lines 1 through 9:

TITLE VIII—REVENUE-RELATED PROVISIONS
SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE LOW-INCOME ASSISTANCE UNDER THE MEDICARE PRESCRIPTION DRUG PROGRAM TO ASSIST SOCIAL SECURITY ADMINISTRATION’S OUTREACH TO ELIGIBLE INDIVIDUALS.

...until then.

I do not believe the Pakistan authorities are so stressed for direction they are showing any signs of defeat...

...as the installations and targets of the criminals are unprotected.

These attacks aren't expected and there are no barriers to prevent these attacks.

It speaks loudly to the fact there isn't so much a since war within Pakistan so much as a 'police action' to bring regions of the country away from the oppressive influence of the Taliban. These acts of violence are more akin to the 'sectarian' attacks we witnessed in Iraq for so long.

...The FIA building was attacked on March 11 last year and Manawan Training School on March 30 this year. Thirty-six people had lost their lives in the two attacks.

In the end, all the 10 terrorists were dead (click here)— either killed by law enforcers or blowing themselves up after having been cornered — but they kept the city on tenterhooks for more than three hours. The entire security paraphernalia was mobilised and police, elite force, Rangers and the army were all roped in as the scale and magnitude of the attack became evident....

Obama signs Kerry-Lugar bill into law (click title to entry - thank you)
By Anwar Iqbal Friday, 16 Oct, 2009

The US president signed the Enhanced Partnership with Pakistan Act of 2009, also known as the Kerry-Lugar-Berman bill, without fanfare before leaving on a trip to New Orleans.
The bill has come under fierce criticism in Pakistan, which dampened the US desire to showcase the bill as a major milestone towards establishing long-term partnership with Pakistan.
Although Foreign Minister Shah Mehmood Qureshi told a news briefing in Washington on Wednesday that Obama would also attach a signing statement to the new law, the White House said that the president did not and had no intention to do so.
A signing statement underscores the way the executive intends to implement a law, which may differ from the text of the law itself. ‘This law is the tangible manifestation of broad support for Pakistan in the US, as evidenced by its bipartisan, bicameral, unanimous passage in Congress,’ White House spokesman Robert Gates said....

Two injured in grenade attack in Quetta (click here)
DawnNews Report Thursday, 15 Oct, 2009

The injured security personnel were shifted to the Combined Military Hospital for medical treatment, according to the police.

Earlier in the day, militants launched attacks in Lahore, and carried out bombings in Peshawar and Kohat.

Target Killings

Unknown gunmen also killed one person inside a shop and injured another, in what police are describing as a target killing.

The assailants shot the shopkeeper when Quetta’s Jinnah road was at its busiest. The attackers then abandoned the body of the victim and fled from the scene.

Quetta has been hit by four target killings in as many days, highlighting the precarious security situation in the city.

A poll in the "Dawn" Newspaper (click here)

Should western coalition forces negotiate with the Afghan Taliban?
Yes(46%)
No(49%)
Don’t know(5%)

It is very similar to the sectarian violence that spawned in Iraq. It is a matter of the local police to come to terms with how best to handle the mess. They know it is coming, they can identify the criminals when they enter the city. It is a matter of how do they control this? To confront the criminals is to spawn violence.

I don't believe a private security force is the answer. That will confuse the issue.

Huge blast strikes Peshawar, several injured (click here)
Thursday, 15 Oct, 2009

Preliminary reports suggest the attack was carried out by a car bomb, Peshawar’s CCPO Liaquat Ali told DawnNews.
The CCPO said that a car packed with explosives was parked at the scene, and that it was later detonated by remote control
Police cordoned off the area and the injured were being shifted to the Lady Reading hospital.
People trapped under the rubble were still being dug out, and sources told DawnNews that eight injured survivors and the body of a dead child were shifted to the Lady Reading Hospital.
Earlier, the city of Peshawar had been placed on high alert, after reports that terrorists had entered the city.
Residents interviewed by DawnNews said that they were unhappy with the security which had been provided by the government, and that they had been trying to arrange for private protection for some time.
Initial reports suggest that the bomb exploded outside the NWFP chief minister’s driver’s house.— DawnNews

Large explosive operations such as this are usually the work of al Qaeda. Here again it isn't the military that is in a quandry to respond to unexpected local attacks, it is the police trying to deal with these thugs. It sounds as though there is a considerable bit of confusion in regard to containing and responding to this issue.

TTP claims killing 11 in Kohat blast (click here)
By Abdul Sami Paracha Friday, 16 Oct, 2009

...The police station is in a high-security zone where official residences of Kohat region’s DIG, district police officer and district coordination officer, PAF officers’ mess and flats and a security checkpost are located.
According to officials, the light green double-cabin pick-up driven by a young man slammed into the main gate of the Saddar police station. The van carried about 100kg of explosives.
The powerful blast created a six-foot deep and 10-foot wide crater. Nearly half of the police station’s building and a boundary wall of the nearby officers’ mess collapsed. Eight vehicles were destroyed and a school building and several houses were damaged.
The place was strewn with parts of victims’ bodies and some parts were found even on roofs of nearby houses. The blast was heard in places as far as Darra Adamkhel.
A student who was going to school was among the dead. Hospital sources confirmed to have received 11 bodies. The three slain policemen who died were identified as constables Fayyazul Hassan, Mohammad Noor and Khursheed. The civilian victims are Javed, Tariq, Haji Baseer
Khan, Abdul Wali, Tahir-ur-Rehman and Arshad Ali. Two bodies were mutilated beyond recognition.
The injured, two policemen and a prisoner among them, were taken to the Combined Military Hospital....

The current government in Pakistan is far from imploding. They are building alliances in the region to assist in stability. The more stability in the region, the less the criminals of the Taliban and al Qaeda can operate their killing campaigns.

Whoever expected Putin to show up on the scene? It is a good thing. There is more and more consolidation of effort between all the parties including The West. They will be contained. If there is anything Russia is BEST at, it is establishing 'stable government states' and containing chaos. If anyone can assist this to a peaceful end between India and Pakistan it will Putin. Absolutely.

It would be good if Kashmir was settled as well. I think a Saudi Price was asking Obama to intercede in Kashmir. I don't believe Obama will take up an active role with Kashmir, but, might include the issue with State Department initiatives. He and Secretary Clinton might seek to bring Kashmir to the talks.

Gilani, Putin agree to strengthen ties (click here)
By Shamim-ur-Rahman Thursday, 15 Oct, 2009

BEIJING: Pakistan and Russia agreed on Wednesday to re-launch their inter-governmental commission by the end of this year to revatalise bilateral relations, with focus on infrastructure development, energy, rail link, heavy industry and upgradation of Pakistan Steel.
The agreement was reached at a meeting between Prime Minister Yousuf Raza Gilani and his Russian counterpart Vladimir Putin held here on the sidelines of the Shanghai Cooperation Organisation.
During the meeting which lasted about an hour and fifteen minutes, they agreed on the need for re-engaging relations, according to Pakistan’s Ambassador Masood Khan who briefed the media on the talks between the two leaders.
Mr Putin said his country would support Pakistan’s request for full membership of the SCO and indicated that he would back resumption of composite dialogue between India and Pakistan because reduction of tension between the two countries would facilitate improvement of Moscow’s relations with Islamabad....

Iraq is flying on its own. Hope for Afghanistan to do the same.

Iraq Prime Minister's Office, ho/AP Photo
In this image released by the Iraqi Prime Minister's Office, Iraq's Prime Minister Nouri al-Maliki, right, shakes hands with his Turkish counterpart Receb Tayyip Erdogan, during a meeting in Baghdad, Iraq, Thursday, Oct. 15, 2009.

...Turkish-Iraqi ties have been warming since the 2003 (click here) U.S.-led invasion toppled dictator Saddam Hussein, but raids by Turkish forces pursuing Kurdish rebels who use northern Iraq as a stronghold have been a consistent sore point in relations.
Nouri al-Maliki delivered the message to Turkish Prime Minister Recep Tayyip Erdogan during a meeting in Baghdad, the Iraqi government spokesman said.
"Iraq's prime minister reiterated that the government will not allow any forces to cross Iraqi borders," said Ali al-Dabbagh.
In a statement delivered later Tuesday by Erdogan as he stood next to al-Maliki at the end of the visit, the Turkish leader said Turkey respects Iraqi sovereignty but emphasized that the Kurdish rebels are a threat to its security and that it will continue to combat them in the future....

85,000 people are a lot of people. Some would say that is an underestimate. I probably is. In 2003, Fallujah was a city of 600,000 people in 2003. 85,000 seems like an underestimate. There are still those in refugee camps and the Iraqi government can't say for sure all their citizens are accounted for within all the dispersals over the years since March 2003.

Iraq says 85,000 violently killed (click here)
Page last updated at 17:24 GMT, Wednesday, 14 October 2009 18:24 UK
Just over 85,000 Iraqis were killed in Iraq between 2004 and 2008, according to the first estimate from the Iraqi government since the war began.
The figure is based on death certificates issued by the ministry of health and included 15,000 unidentified bodies.
It counts violent deaths of military, police and civilians, but does not include foreigners or insurgents.
Previous attempts to calculate the number of dead have been controversial.
Past reports have used a number of different methods to produce estimates ranging from more than 100,000 to well over half a million deaths since 2003.
The Ministry of Human Rights included the figure in a larger report into human rights in the country....

It would seem the Iraqi army and police are being loyal to their leadership. They are fighting and dying to secure their country.

FACTBOX-Security developments in Iraq, Oct 15 (click here)
Thu Oct 15, 2009 8:43am EDT
Oct 15 (Reuters) - Following are security developments in Iraq at 1230 GMT on Thursday.* denotes a new or updated item*
MOSUL - A roadside bomb killed one policeman and wounded another officer and three civilians in western Mosul, 390 km (240 miles) north of Baghdad, police said.*
MOSUL - A roadside bomb targeting an Iraqi army patrol wounded one civilian in eastern Mosul, police said.*
BAGHDAD - A roadside bomb killed an Iraqi soldier and wounded two others and one civilian in north Baghdad's Adhamiya district, police said.
KIRKUK - A roadside bomb wounded four Iraqi policemen in southern Kirkuk, 250 km (155 miles) north of Baghdad, a police source said.
TUZ KHURMATO - A roadside bomb wounded a member of the Kurdish security forces on Wednesday in Tuz Khurmato, 170 km (105 miles) north of Baghdad, police said.
RAMADI - An assailant attacked and wounded a local journalist on Wednesday in Ramadi, 100 km (60 miles) west of Baghdad, police said.


Returning to Iraq: Oregon Army National Guard soldiers on leave reenter the war zone (click here)
By Mike Francis, The Oregonian
October 15, 2009, 5:25PM
KUWAIT CITY – It feels like any commercial flight, this Ryan Air 767 out of Dallas. "Get Smart" plays on the movie screens in each cabin, and flight attendants walk the aisles, collecting napkins and plastic cups. And then the pilot turns on the intercom and delivers an ambivalent welcome. "We're sorry to have to bring you back, but hopefully we'll see you on another one of our flights real soon, when you're coming home for good."...



Exclusive: Army Brigade Will Not Go to Iraq in January as Scheduled (click here)
Move Frees Up an Additional Combat Unit That Could Be Sent to Afghanistan
By LUIS MARTINEZ
Oct. 15, 2009
In perhaps another sign of the improving security situation in Iraq, an Army brigade slated to replace a departing unit this January has received orders not to deploy, defense officials told ABC News....

And this time when we leave a war behind we are doing it the right way. We aren't leaving enough munitions in the country for them to start and conduct still another war. The USA is leaving and taking everything home. I would think the USA and its allies need most of it in Afghanistan.

Leaving Iraq Is a Feat That Requires an Army (click title to entry - thank you)
By MARC SANTORA
Published: October 8, 2009
JOINT BASE BALAD, Iraq — There is no more visible sign that America is putting the Iraq war behind it than the colossal operation to get its stuff out: 20,000 soldiers, nearly a sixth of the force here, assigned to a logistical effort aimed at dismantling some 300 bases and shipping out 1.5 million pieces of equipment, from tanks to coffee makers.
It is the largest movement of soldiers and matériel in more than four decades, the military said.
By itself, such a withdrawal would be daunting, but it is further complicated by attacks from an insurgency that remains active; the sensitivities of the Iraqi government about a visible American presence; disagreements with the Iraqis about what will be left for them; and consideration for what equipment is urgently needed in Afghanistan....

California comes out of the closet and Ahnold is no Girly Man. Will the USA follow?

...The highly contentious piece of legislation (click here) drew strong support from the gay community and ire from conservative groups. After vetoing a similar bill last year, and recently implying that he would veto all of the bills on his desk if the legislature did not agree on a water bill, Schwarzenegger surprised many with his decision to honor Milk....



Governor OKs Harvey Milk Day, marriage bill (click title to entry - thank you)
Wyatt Buchanan, Chronicle Sacramento Bureau
Tuesday, October 13, 2009

...The governor signed the measure late Sunday along with new laws to help gay and lesbian people in the state, including a measure giving same-sex couples legally married in other states all the rights of marriage in California.
While the governor vetoed the bill honoring Milk last year, President Obama's awarding Milk the Presidential Medal of Freedom and an Academy Award-winning film about Milk's life moved Schwarzenegger to sign the bill, spokesman Aaron McLear said.
"The bill is symbolic of the importance of the gay community to California, which is why he signed it," McLear said, adding that Schwarzenegger wanted to "honor that community." It is the only such day of recognition for a gay or lesbian person in the United States.
The measure was among 478 bills signed by Schwarzenegger on Sunday, the deadline for him to act on legislation passed by the Legislature before its session ended Sept. 11. The governor vetoed 229 bills....

Obama: "I will end Don't Ask, Don't Tell"

As noted in The NYTimes - "It is what the Afghan Constitution call for and there are two qualified candidates."

Musadeq Sadeq/Associated Press
A billboard for the candidate Abdullah Abdullah towering over a broom seller in Kabul, where many voters said they were leery of a presidential runoff.

Democracy is not always perfect. I am confident in the early years of the USA's thirteen original colonies there was a lot of 'stumbling' when elections were held.

Democracy and the Afghan Constitution is not the enemy to the people, it is corruption that is the enemy to freedom. They cannot abandon the document that brings them qualified candidates to their democracy. They must seek to 'perfect' the process and root out the corruption.

No matter whom wins the 'runoff election' Afghanistan will be in good hands. I believe there will be less corruption than the first election. There are only two candidates, there is less opportunity for dishonest results.

Corruption is fought when there is loyalty to the 'idea' of law and not the current threat of warlords. It is very important the elections go forward and democracy under the Afghan Constitution is 'honored.'

Either candidate is more than qualified. The Afghan people have been well served to date by having two qualified candidates resulting from the first election. They should have fun with their political loyalties and seek to perfect their election process. This is a second chance to practice perfection. It should get easier and easier to master 'the task' each time. Loyalty to the Constitution is the demonstration of the bravery of people deserving of a good life.

The Afghans are very intelligent people. I couldn't make a broom like that.