Tag: Affordable Care Act

You could label this “what were they thinking” but we’re talking about the Republican Party here. IT seems that in the midst of the latest “crisis,” the failure to launch of the Healthcare.gov web site, the genius Republicans of the House of Representative decided to ask a murder suspect to testify as an computer expert. No, I am not pulling you leg.

House Republicans Asked Murder Suspect John McAfee to Testify on Obamacare Website

by David, Crooks and Liars

According to emails obtained by CNBC, House Republicans asked the founder of McAfee Associates to “guide our oversight and review” of the Affordable Care Act website.

In 2012, McAfee went on the run from Belize authorities after being suspected of the murder of his neighbor. He was later detained in Guatemala and deported to the United States, but has not been charged with a crime.

“This is the Committee of jurisdiction for the Patient Protection and Affordable Care Act (or Obamacare),” House Committee on Energy and Commerce counsel Sean Hayes wrote to McAfee’s lawyer on Oct. 14. “For three years we have been monitoring the implementation of the law and have been trying to dig into what has happened with the Exchange rollout.”

“Given the failures of Healthcare.gov, and Mr. McAfee’s expertise, I was hoping he might be able to discuss his views with staff on the hill,” the email continued. “It would be an informal discussion: we would take notes but these would not be for attribution, it would mainly guide our oversight and review of the program.”

“This would hopefully not be a heavy lift for him: what problems could lead to the compromise of personal identifying information? What could we be doing to prevent data or identify theft? What advice generally does he have?”

The deal fell through when the House wouldn’t pay for Mr. McAfee’s travel expenses. In case you aren’t aware of the hilarity of this invitation, Rachel Maddow gives us the Cliff Note version of Mr. McAfee’s biography

Can you imagine the hilarity of McAfee’s testimony as his mind wanders from the technicalities of launcing a web site to his sexual prowess and drug expertise? C-Span’s ratings would soar.

Over at Esquire’s Politics Blog, resident curmudgeon, Charles Pierce reminds us of his “five minute rule” with this little snippet:

If you listen to Crazy Uncle Liberty (!), Senator Aqua Buddha, or their disciples for five minutes, you find yourself nodding in agreement with almost everything they say. At precisely the 5:01 mark, however, the person to whom you’re listening will say something that detaches the entire conversation from the plane of physical reality and sends it sailing off into the ether.

As an example of the stupid that abounds, he presented a link to this video at a Rand Paul supporter’s web site.

I suppose those who signed the petition didn’t see the tee shirt. Sheesh.

The Affordable Care Act is a very flawed bill that lines the pockets of insurance companies by forcing people to purchase junk insurance that even if the premiums are low, the high out of pocket deductibles and co-pays make care unaffordable. Nor are the insured guaranteed access the treatment and medications they may need, since the bean counters can deny permission and referrals. These are facts that the government and media aren’t telling you

The only reason the right wing is trying to defund/repeal this law, which they can’t, is because they have nothing left to draw attention to themselves and try to scare people into believing that President Barack Obama is a socialist, even though has given the right wing and corporations nearly everything they’ve wanted, including the ACA. The war on the 99% continues from both sides of the aisle.

In the United States, 62% of all bankruptcies in the United States are due to medical bills. It is not among who you would think but most often effects middle aged, middle class, college educated homeowners. 80% of those people had health insurance, so why are they filing for bankruptcy? No other industrial country has this problem.

Our fellow blogger, lambert, writing for naked capitalism, featured this video from Real News Network:

Paul Jay of the Real News Network interviews Dr. Margaret Flowers, a pediatrician from Baltimore who advocates for a national single payer health system, Medicare for all, and Kevin Zeese, co-director of It’s Our Economy, an organization that advocates for democratizing the economy.

At his blog, Corrente, lambert continues to document the atrocities of the Obamacare ClusterFuck.

Journalist Steve Brill wrote brilliant cover story for Time magazine, Bitter Pill: Why Medical Bills Are Killing Us, which lays out the reason US health care costs are out of control, just follow the money. He explains how the hospitals and their executives are scamming the system through billing to maximize profits. As an examples of the absurd charges, for a 15 cent Tylenol tablet hospitals charge as much as $1.50, $6 for a marker used to mark the body before surgery and as much as $77 for each of four boxes of gauze used. In hospital a patient can be charges as much as $450 for an electrocardiogram that in a doctor’s office would only cost $150.

This doesn’t happen in other countries where costs are controlled by government set rates for what both private and public plans can charge for various procedures. The problem here in the US isn’t that we don’t have single payer, it’s that the government doesn’t regulate the prices that health-care providers can charge. But in an article at the Washington Post by Sarah Kliff for the Wonkblog writes that we don’t need to look to other countries:

Maryland has succeeded in controlling costs for about four decades now. It is the only state that sets rates for hospitals, with the state government deciding what every Maryland hospital can charge for a given procedure..

That system started in 1976, when Maryland had hospital costs 26 percent higher than the rest of the the country. In 2008, the average cost for a hospital admission in Maryland was down to national levels. “From 1997 through 2008, Maryland hospitals experienced the lowest cumulative growth in cost per adjusted admission of any state in the nation,” the state concluded in a 2010 report (pdf).

Here is a brief summery of the article and what you should know about why health care in this country costs so much (and it isn’t malpractice lawsuits, as some would have you believe):

Hospitals arbitrarily set prices based on a mysterious internal list known as the “chargemaster.” These prices vary from hospital to hospital and are often ten times the actual cost of an item. Insurance companies and Medicare pay discounted prices, but don’t have enough leverage to bring fees down anywhere close to actual costs. While other countries restrain drug prices, in the United States federal law actually restricts the single biggest buyer-Medicare-from even trying to negotiate the price of drugs.

Tax-exempt “nonprofit” hospitals are the most profitable businesses and largest employers in their regions, often presided over by the most richly compensated executives.

Cancer treatment – at some of the most renowned centers such as Sloan-Kettering and M.D. Anderson – has some of the industry’s highest profit margins. Cancer drugs in particular are hugely profitable. For example, Sloan-Kettering charges $4615 for a immune-deficiency drug named Flebogamma. Medicare cuts Sloan-Kettering’s charge to $2123, still way above what the hospital paid for it, an estimated $1400.

Patients can hire medical billing advocates who help people read their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who now works as an advocate in Stamford, CT.

Recently, Mr Brill sat down with Hardball guest host Michael Smerconish  and Neera Tanden from Center for American Progress to discuss how the rising health care costs are killing Americans:

   And it actually that bears on the conversation we’re having, because a chunk of that money is paid by Medicare. Medicare is I point out in the article is very efficient at most things. It buys health care really efficiently, which is a great irony, because it’s supposed to be the big government of bureaucracy.

   Where Medicare is not efficient is where Congress, because of lobbyists have handcuffed Medicare. Medicare can’t negotiate what it pays for any kind of drugs. It can’t negotiate what it pays for wheelchairs, diabetes testing equipment. And if Congress took those handcuffs off of Medicare, you could get about half of the spending cuts that we’re sitting around here talking about.

Raising the eligibility age and/or applying a means test as ways to reduce the cost of Medicare will not fix the rising costs. Only government regulation of the hospitals and the ability of Medicare to negotiate pricing for procedures, equipment and supplies will cut the cost for the patient and the tax payers. Take the profit motive out of saving lives and keeping Americans healthy.

In an a cover story  for Time magazine, journalist Steven Brill spent seven months examining how medical bills are what is really killing us: the extraordinary costs of health care is a “bitter pill”  that nickels and dimes even the insured patient for every pill, band-aid and blanket:

Simple lab work done during a few days in the hospital can cost more than a car. A trip to the emergency room for chest pains that turn out to be indigestion brings a bill that can exceed the price of a semester at college. When we debate health care policy in America, we seem to jump right to the issue of who should pay the bills, blowing past what should be the first question: Why exactly are the bills so high? [..]

· Hospitals arbitrarily set prices based on a mysterious internal list known as the “chargemaster.” These prices vary from hospital to hospital and are often ten times the actual cost of an item. Insurance companies and Medicare pay discounted prices, but don’t have enough leverage to bring fees down anywhere close to actual costs. While other countries restrain drug prices, in the United States federal law actually restricts the single biggest buyer-Medicare-from even trying to negotiate the price of drugs.

· Tax-exempt “nonprofit” hospitals are the most profitable businesses and largest employers in their regions, often presided over by the most richly compensated executives.

· Cancer treatment-at some of the most renowned centers such as Sloan-Kettering and M.D. Anderson-has some of the industry’s highest profit margins. Cancer drugs in particular are hugely profitable. For example, Sloan-Kettering charges $4615 for a immune-deficiency drug named Flebogamma. Medicare cuts Sloan-Kettering’s charge to $2123, still way above what the hospital paid for it, an estimated $1400.

· Patients can hire medical billing advocates who help people read their bills and try to reduce them. “The hospitals all know the bills are fiction, or at least only a place to start the discussion, so you bargain with them,” says Katalin Goencz, a former appeals coordinator in a hospital billing department who now works as an advocate in Stamford, CT.

Mr. Brill was a guest on MSNBC’s “The Last Word“, he discussed with guest host Ezra Klein the costs of health care, who’s to blame and how we can fix the US broken health care system:

In a recent on air essay on his PBS program, Moyers & Company and an opinion piece at Huffington Post, Bill Moyers took a look at the revolving door of special interest groups and their lobbyists, how they win and the rest of us lose.

We’ve seen how Washington insiders write the rules of politics and the economy to protect powerful special interests but now, as we enter the holiday season, and a month or so after the election, we’re getting a refresher course in just how that inside game is played, gifts and all. In this round, Santa doesn’t come down the chimney — he simply squeezes his jolly old self through the revolving door. [..]

The last time we looked, 34 former staff members of Senator Baucus, whose finance committee has life and death power over the industry’s wish list, were registered lobbyists, more than a third of them working on health care issues in the private sector. And the revolving door spins ever faster after a big election like the one we had last month, as score of officials, elected representatives and their staffs vacate their offices after the ballots are counted. Many of them head for K Street and the highest bidder. [..]

Reforms were passed that are supposed to slow down the revolving door, increase transparency and limit the contact ex-officials and officeholders can have with their former colleagues. But those rules and regulations have loopholes big enough for Santa and his sleigh to drive through, reindeer included. The market keeps growing for insiders poised to make a killing when they leave government to help their new bosses get what they want from government. That’s the great thing about the revolving door: one good turn deserves another.

The door continues to spin with the latest exodus from Commodity Futures Trading Commission (CFTC). DSWright at FDL‘s News Desk has the latest:

Step right up and Spin the Revolving Door – and what is your prize? Why, a nice job on Wall Street working for the people you used to regulate – you wrote in the loopholes, now you get the cash for exploiting them! [..]

Many Americans understood that the Dodd-Frank “reforms” were mostly worthless. They will not prevent another crisis or another massive TARP type bailout as the law did absolutely nothing about Too Big To Fail banks (which have actually gotten bigger).

This should not have been a surprise given one of the law’s namesakes, Senator Chris Dodd, was caught red handed getting special loans from perhaps the worst offender in irresponsible mortgage origination – Countrywide. Senator Dodd barely survived an ethics investigation from his similarly compromised colleagues.

But what critics may not have understood was that Dodd-Frank was apparently a jobs program for politically connected staffers.

The last count of lobbyists, as of October, directly involved in advising the president, a member of his cabinet or campaign staff is 55.

First, this morning House Majority Leader Eric Cantor (R-VA) made the rounds of talk shows spouting how the Affordable Health Care bill can be repealed with a simple majority in the House and Senate since the bill was passed under reconciliation. Without a filibuster proof majority in the Senate, Ryan Lizza at The New Yorker points out the obstacles for that to happen:

Many Republicans, especially in the blog and talk-radio swamps, would cry, “Use reconciliation!” Readers familiar with the congressional debates of 2009-2010 will remember that this procedure allows certain budgetary measures to pass through the Senate with a simple majority. [..]

But reconciliation wouldn’t work here-the process can only be used for policies that have budgetary effects and a C.B.O. score. Much of the A.C.A., such as the insurance exchanges and subsidies, would fall under these categories. But a lot of it, including the hated individual mandate, does not. Repealing the exchanges and subsides without repealing the mandate and the other regulations and cost controls in the law would create a health-care Frankenstein that a President Romney would be rather nuts to support.

That said, the SCOTUS ruling has some rather complex ramifications and Chief Justice Robert’s ruling was rather sly. First was there are the three bit from SCOTUSblog that Lambert Strether pointed out at Corrente:

First, here’s the reasoning:

   Essentially, a majority of the Court has accepted the Administration’s backup argument that, as Roberts put it, “the mandate can be regarded as establishing a condition — not owning health insurance — that triggers a tax — the required payment to IRS.” Actually, this was the Administration’s second backup argument: first argument was Commerce Clause, second was Necessary and Proper Clause, and third was as a tax. The third argument won.

Second, here are the implications for the role of the State as we have understood it from the New Deal onward; what Phillip Bobbitt would call a change a Constitutional Order:

   The rejection of the Commerce Clause and Nec. and Proper Clause should be understood as a major blow to Congress’s authority to pass social welfare laws.

Third, here is the new Constitutional Order:

   Using the tax code — especially in the current political environment — to promote social welfare is going to be a very chancy proposition.

Chancy or not — and it will be the precariat that suffers mischance, and not the elite, in any case — that’s what they’re going to do.

Next from Scarecrow at FDL News Desk who argues that Chief Justice Robert’s “incoherent decision” will “shackle congress” and “screw millions of uninsured:

In the process, he did violence to constitutional law and logic.  Consider, for example, Robert’s logic on the “mandate.”  In saving the “mandate,” Roberts essentially defined it as not a mandate.  You are not really required to purchase insurance, he noted; instead, you may choose not to purchase insurance and instead pay a minor tax.  As we know, taxing is just a way to collect revenues, a contribution to the common, aggregate costs of public programs.  In this case, the program is paying for many people’s health care through a system of risk/cost sharing.

But if the so-called mandate is not really a mandate but rather an option that can be avoided by paying a tax, and if a legitimate purpose of this tax, as government and amicus briefs argued, is to help cover aggregate costs across a pool of many insured and uninsured people, then what does that do to Robert’s argument about the Commerce Clause?  When arguing about the Commerce Clause, Roberts insists it’s a requirement to purchase a “product,” which forces you to take an action, and thus to engage in commerce when you would not otherwise have done that.  Regulating “inaction” is not permissible, Roberts argues.

But if, as Roberts concludes, the “mandate” is not a mandate, and the tax’s purpose is to help cover pooled costs, and not to buy a “product,” then there is no “mandate” to purchase a “product.”  So no one is forced to engage in commerce as Roberts framed it.  Indeed the “commerce” is already there in the risk sharing system across millions of people, all engaged in commerce by paying premiums into a pooled risk scheme.  Robert’s entire premise for striking down the Commerce Clause rationale is thus contradicted by his argument about how it’s permissible for Congress to enact a tax to support funding of collective health care costs.  That’s what the tax does; but it’s also what paying insurance premiums does.

Roberts’ reasoning on Medicaid is equally illogical. His premise is that Congress cannot expand an existing program administered by states that depends on shared state/federal funding by conditioning funding for the whole program on the states actually implementing the expansion.  As Brad DeLong observes, if Congress were just now creating a fully expanded Medicaid, to be implemented by states but mostly paid for by the feds, there would be no question that Congress could condition federal funding on the states actually carrying out the programs.  But if the program already exists for half the needy population, Congress cannot complete the program for the other half and use the same leverage to achieve the same degree of state cooperation.

As per the CBO, if the states actually implement the expansion and make an effort to get those eligible to sign up, 16 to 17 million more people will have health care coverage. But without that leverage to get the states to accept Medicaid expansion it leaves the poor between around 50% and 133% of the poverty line in a real no man’s land, because they would both be ineligible for Medicaid AND the coverage subsidies in the exchanges.

As for the states voluntarily opting in for the Medicaid expansion, David Dayen doesn’t think that will happen either, even though the cost for the states would only be responsible for less than 10% of the costs.

And being on the hook for even a small amount of funds isn’t going to make any of these governors happy. Heck, here’s a Democrat, former West Virginia Governor and current Senator Joe Manchin, making the argument for them:

   We should all recognize that the health care challenges that many West Virginians and Americans face are not going to go away unless Congress takes additional action to repair this bill. Now that the Court has ruled, we can move forward with fixing what is wrong with this bill and saving what is right. I have always been determined to reduce the burden on states from the Medicaid expansion, and this ruling affirms my position – and makes clear that states must have the flexibility to live within their means by determining Medicaid eligibility as each state sees fit. I have always said one size doesn’t fit all.

That’s going to be a compelling set of logic for a non-trivial number of governors. They’ll also distort how much the expansion would put their states “on the hook.” 26 states sued to eliminate the Affordable Care Act entirely, and they almost got there. Why wouldn’t they jump at the chance to eliminate the portion that creates half of the coverage benefits?

This isn’t going to be universal. New Mexico’s Republican Governor Susanna Martinez, for example, certainly sounds like she’ll take the money. But Southern states in particular, who paradoxically house the citizens most in need of the Medicaid expansion coverage, will be likely resisters at the outset. And it’s not like a lot of success in modern America comes from rallying at the grassroots level for poor and disenfranchised people.

As was noted by Ezra Klein of the Washington Post, opponents of the ACA see this as a win:

“We won,” said Georgetown law professor Randy Barnett, who was perhaps the most influential legal opponent of the Affordable Care Act. “All the arguments that the law professors said were frivolous were affirmed by a majority of the court today. A majority of the court endorsed our constitutional argument about the Commerce Clause and the Necessary and Proper Clause. Yet we end up with the opposite outcome. It’s just weird.”

Yes, it’s weird but so was the whole ACA bill from the very start.

Up Date: SCOTUS has ruled the individual mandate unconstitutional constitutional but redefined as a tax.

Up Date: As per MSNBC, the mandate was upheld but redefined as a tax. There is some confusion as to whether that means it is unconstitutional or not.

Up Date: Roberts votes with the four “liberal” justices.

Quotes from SCOTUS Blog:

The money quote from the section on the mandate: Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.

On the Medicaid issue, a majority of the Court holds that the Medicaid expansion is constitutional but that it w/b unconstitutional for the federal government to withhold Medicaid funds for non-compliance with the expansion provisions.

Another way to think about Medicaid: the Constitution requires that states have a choice about whether to participate in the expansion of eligibility; if they decide not to, they can continue to receive funds for the rest of the program.

In other words, states can opt out of ACA without losing federal funding for Medicaid.

Rejection of mandatory Medicaid expansion –at time of slashing of safety nets–could be devastating to most vulnerable.

— Katrina vandenHeuvel (@KatrinaNation) June 28, 2012

Up Date: More from SCOTUSBlog:

In Plain English: The Affordable Care Act, including its individual mandate that virtually all Americans buy health insurance, is constitutional. There were not five votes to uphold it on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power. That is all that matters. Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose new funds if they didn’t comply with the new requirements, rather than all of their funding.

Essentially, the individual mandate of the ACA was upheld under the right of the government to tax individuals. Chief Justice Roberts agreed with that and voted with Ginzburg, Breyer, Kagan, Sotomayor.

The court also ruled if individual states opt out of the ACA, they cannot lose current Medicaid funding. They will only lose new funding.

Up Date: From Lyle Denniston at SCOTUSBlog:

The rejection of the Commerce Clause and Nec. and Proper Clause should be understood as a major blow to Congress’s authority to pass social welfare laws. Using the tax code – especially in the current political environment – to promote social welfare is going to be a very chancy proposition.” This is a big deal. Congress in the future may have to use far more of the taxing power than they are comfortable with. This is still a conservative ruling in many respects.

National Federation of Independent Business v. Sebelius (pdf)

It would seem that there really are rational Republicans in elective office. Thank you to Louisiana Attorney General Buddy Caldwell who recognized that the Patient Protection and Affordable Care Act neither protects the patient or makes health care affordable. The only thing that will do that is single payer and that isn’t in the bill. Single payer health care spreads the cost of health care across the spectrum, covering everyone, and insures access to care from birth to death. So, AG Caldwell is suing the Obama Administration because he trusts the government more than the greedy, profit driven insurance companies.

ThinkProgress spoke with Louisiana Attorney General Buddy Caldwell outside the Supreme Court on Wednesday. Caldwell opposes Obamacare and the individual mandate, but for a different reason than most of his fellow litigants: it props up the private health insurance industry. “Insurance companies are the absolute worst people to handle this kind of business,” he declared. “I trust the government more than insurance companies.” Caldwell went on to endorse the idea of a single-payer health care system, saying it’d “be a whole lot better” than Obamacare:

   KEYES: You don’t think the subsidies for low-income people are going to be helpful?

   CALDWELL: No, no. The worst thing you can do is give it to an insurance company. I want to make my point. All insurance companies are controlled in their particular state. If you have a hurricane come up the east coast, the first one that’s going to leave you when they gotta pay too many claims is an insurance company. Insurance companies are the absolute worst people to handle this kind of business. I trust the government more than insurance companies. If the government wants to put forth a policy where they will pay for everything and you won’t have to go through an insurance policy, that’d be a whole lot better.

I don’t know about the rest of Mr. Caldwell’s politics but I wish there was a Democrat in the White House that agreed with him on this.

Today the Supreme Court heard arguments about the severability of the individual mandate in the Affordable Health Care bill  and the expansion of Medicaid.

The day after the Supreme Court suggested that President Obama’s health care law might be in danger of being held unconstitutional, the justices on Wednesday turned their attention to the practical consequences and political realities of such a ruling.

The justices seemed divided on both questions before them: What should happen to the rest of the law if the court strikes down its core provision? And was the law’s expansion of the Medicaid program constitutional?

The two arguments, over almost three hours, were by turns grave and giddy. They were also relentlessly pragmatic. The justices considered what sort of tasks it makes sense to assign to Congress, what kinds of interaction between federal and state officials are permissible and even the political character of the lawsuits challenging the law. One justice dipped into Senate vote counting.

The court had in other words, on the third and final day of a historic set of arguments, moved from the high theory of constitutional interpretation to the real-world consequences of what various rulings would entail.

The arguments on severability, which hinged totally on whether the mandated stays or goes, boiled down to three points:

1. sever only the mandate, allow the rest of the law to stand and let Congress sort it out;

2. sever the mandate along with insurance regulations like guaranteed issue and community rating, to prevent what the government argues would be an insurance death spiral;

3. or throw out the whole law, which did not include a standard severability clause.

The Justices seemed divided over point #2 and #3 rather than #1. For the most part, the discussions and comments were reflective of the consequences of overturning the entire law or any part of it:

[..] A common reaction, across the bench, was that the Justices themselves did not want the onerous task of going through the remainder of the entire 2,700 pages of the law and deciding what to keep and what to throw out, and most seemed to think that should be left to Congress.  They could not come together, however, on just what task they would send across the street for the lawmakers to perform.  The net effect may well have shored up support for the individual insurance mandate itself.

The dilemma could be captured perfectly in two separate comments by Justice Antonin Scalia – first, that it “can’t be right” that all of the myriad provisions of the law unrelated to the mandate had to fall with it, but, later, that if the Court were to strike out the mandate, “then the statute’s gone.”  [..]

Justice Anthony Kennedy, who is considered the swing vote on the individual mandate, expressed concern “possible unintended consequences in the form of huge costs to insurance companies if the mandate – which would bring millions of healthy young people into the healthcare system and spread out costs – was invalidated alone”:

“We would be exercising the judicial power if one … provision was stricken and the others remained to impose a risk on insurance companies that Congress had never intended,” Kennedy said. “By reason of this court, we would have a new regime that Congress did not provide for, did not consider.”

The four liberal justices expressed deep reservations about tossing out the sweeping law that has hundreds of other provisions, some of them already in effect.

Justice Sonia Sotomayor, one of the four and an Obama appointee to the court, asked whether the court should allow Congress to decide what to do next. “What’s wrong with leaving it in the hands of people who should be fixing this, not us?”

Justice Ruth Bader Ginsburg went further. She said many parts of the law had not been challenged in court. “Why make Congress redo those?”

On the matter of Medicaid expansion a majority of the justices were inclined to support the government’s role in prodding states to expand the state-federal Medicaid healthcare program for the poor, providing coverage for an estimated 17 million Americans:

The court’s more liberal justices all expressed puzzlement about why there should be a problem with the expansion in light of the fact that it is almost entirely to be paid for by the federal government. The states say they are being coerced into participating because a decision not to may cause them to lose not only the new money but also existing funds.

Justice Elena Kagan described a hypothetical program only slightly different from the real one. “It’s just a boatload of federal money for you to take and spend on poor people’s health care,” she said to a lawyer for the states, Paul D. Clement. “It doesn’t sound coercive to me, I have to tell you.” [..]

He (Chief Justice John G. Roberts Jr) said the court’s decision on the Medicaid expansion should be informed by the reality that the states have “since the New Deal” cheerfully accepted federal money.

“It seems to me that they have compromised their status as independent sovereigns because they are so dependent on what the federal government has done,” the chief justice said.

Justice (Antonin) Scalia addressed the political realities of the litigation itself, asking Mr. Clement whether there was “any chance that all 26 states opposing it have Republican governors, and all of the states supporting it have Democratic governors?”

Mr. Clement responded, “There’s a correlation, Justice Scalia.”

In her last article on Wednesday’s sessions, Slate‘s Dahlia Litwick gives her assessment of the last three days:

Amid all the three-day psychodrama, it’s easy to get confused about what’s happened and what hasn’t. Court watchers seem to generally agree that the individual mandate is in real peril and will rise or fall with Chief Justice Roberts and Justice Kennedy. Court watchers also agree that 19th-century tax law-while generally adorable-will not prevent the justices from deciding the case by July. And they also agree that they may have counted five justices who appear willing to take the whole law down, along with the mandate, and the Medicaid expansion as well.

But the longer they talked, the harder it was to say. A lot of today’s discussion started to sound like justices just free-associating about things in the law they didn’t like. That doesn’t reveal all that much about the interplay between the four separate challenges-what happens when they all have to be looked at together-or anything at all about what will happen at conference or in the drafting of opinions. Could the five conservative justices strike down the entire health care law, and take us into what Kagan described this morning as a “revolution”? They could. Will they? I honestly have no idea anymore. As silent retreats go, this one was a lot less enlightening than I’d hoped.

Constitutional law professor Jonathan Turley discussed the hearings with Keith Olbermann on Countdown, calling this case a “game of chicken” that “can be deadly.”