A data set that looks like America

By Oliver Kim

May marks the annual Asian American and Pacific Islander Heritage Month, which recognizes the history and contributions of this diverse population in the United States. Accounting for that diversity though is one of the challenges facing the Asian American-Pacific Islander (AAPI) community: for example, the Library of Congress commemorative website recognizes that AAPI is a “rather broad term” that can include

all of the Asian continent and the Pacific islands of Melanesia (New Guinea, New Caledonia, Vanuatu, Fiji and the Solomon Islands), Micronesia (Marianas, Guam, Wake Island, Palau, Marshall Islands, Kiribati, Nauru and the Federated States of Micronesia) and Polynesia (New Zealand, Hawaiian Islands, Rotuma, Midway Islands, Samoa, American Samoa, Tonga, Tuvalu, Cook Islands, French Polynesia and Easter Island).

Understanding that diversity has huge policy and political implications, particularly in health policy. Read More

“Ex-Gay” Speaker, Attempted Suicide, and HCSMs

On February 16, Jackie Hill-Perry, an outspoken speaker against homosexuality, delivered a controversial, unapologetically homophobic speech at Harvard’s Emerson Hall. Harvard College Faith and Action, the religious student group that invited Hill-Perry, reserved all the center-front seats for attendees “engaged in protest,” who were “welcomed” to their space of worship. This seemingly beneficent seating arrangement, however, allowed many protestors wearing rainbow flags to experience 30 minutes of worship songs with references to sin and redemption, before having a close-encounter with Hill-Perry. The emphatic speaker then recounted her own journey from initially accepting her same-sex attraction to her eventual embrace of heteronormativity due to her rediscovered Christian faith. A few protestors stormed out of the lecture hall during the height of her speech, when she called same-sex attracted Christians to practice “self-denial,” the same way a Christian would deny lying, stealing, and other grave “sins.”

As undergraduate and graduate students at Harvard, we are fortunate to have access to resources that may help us deal with and recover from the detrimental effects from a hate-filled speech like this. Though far from perfect, we do have at least a limited access to mental health services and other support groups on campus. Intellectually, we have academic resources that could dispute the religious reasoning behind homophobia. In his opening question for Hill-Perry, Professor Jonathan Walton of the Memorial Church quickly challenged the flawed theology Hill-Perry relied on, revealing the parallels between biblically justified racism to biblically justified homophobia. Some students from the audience also pointed out several logical missteps in her reasoning, which led Hill-Perry exclaim how “smart” people at Harvard are. Perhaps, she wasn’t used to speaking to a highly academic audience during her tours. Nonetheless, many non-protesting members of the audience, presumably members of the Harvard Christian group, did nod and clap during her speech. If her remarks could resonate with these Harvard students, how much more persuasive would it be in Christian conferences and churches? Who could stand up for LGBT people, especially the youth, in evangelical communities?

It has long been demonstrated that LGBT youths have a much higher suicide and attempted suicide rate comparing to their heterosexual counterparts in the United States and abroad. They are also significantly more likely to suffer from mental health issues ranging from depression to self-harm. Moreover, those living in evangelical families or communities where homophobia is still prevalent are especially vulnerable. Listening to a speech like the one delivered by Hill-Perry may worsen their daily struggles and increase their risk of suicide. Given these health risks of LGBT youths, we might expect that evangelical leaders who “love the sinner but hate the sin” would at least care about the health and safety of these minors, or simply respect their dignity as human beings. However, the reality could be far gloomier, falling short of these minimum expectations. The rest of the essay will turn the discussion toward how LGBT youths might be treated under the practices of Christian health-sharing ministries (HCSMs).

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Slightly Hazy: An Insurer’s Emergency Room Policy Draws Congressional Scrutiny

By Oliver Kim

Last year, I had the good fortune to present at the Petrie-Flom Center’s conference on transparency and I started with an anecdote about a congressman who decided to wait rather than take his son immediately to the emergency room after he injured himself. The congressman assumed his son only had a sprain, but he had actually broken his arm. So why the wait? Because of a difference in his co-pay. In an interview, the congressman argued for policies to push consumers to understand—and be exposed to— healthcare costs in order to make better decisions about their care: “Way too often, people pull out their insurance card and they say ‘I don’t know the difference or cost between an X-ray or an MRI or CT Scan.’ I might make a little different decision if I did know (what) some of those costs were and those costs came back to me.”

The congressman’s policy prescription is becoming reality: last year, the largest Blue Cross Blue Shield plan Anthem announced a new policy where it would deny coverage for care provided in an emergency room that was later deemed non-emergent (except in certain circumstances). It seems a far cry from simply charging an ER co-pay, but Anthem argues it has seen a rise in non-emergency care being provided in emergency rooms. How are patients supposed to know if the ache or pain they are experiencing is not an emergency? Apparently there is a spreadsheet of over 1,900 ailments that Anthem considers non-emergent.

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Block Grants: Sound Theory or Doomed to Fail?

Block grants are all the rage. Take the latest G.O.P. proposal to repeal and replace the Affordable Care Act: the Graham-Cassidy bill. It proposes to replace the current system and instead give grants to the states, essentially taking the funds the federal government now spends under the ACA for premium subsidies and Medicaid expansion and give those funds to the states as a lump sum with little regulation.

There is a complicated formula by which the bill proposes divvying up this money among the states. Many think the formula is unfair, that it benefits red states over blue states, and that it just flat isn’t enough money. These are incredibly important concerns. But let’s put them to the side for just a moment and consider the theory behind block granting. Is there any world, for instance assuming that the amount and allocation of the funding could be resolved (probably crazy talk), in which switching to block granting may actually improve upon the status quo?

Proponents of block granting health care make two main arguments. First, it will reduce costs. By block granting Medicaid and the ACA subsidies, we end the blank check open entitlement that these programs have become and give states more skin in the game. Second, these cost savings will come from empowering states to innovate. States will become more efficient, improve quality, and solve their own state-specific problems.

These arguments have an understandable appeal. But how will states really react to providing health care coverage on a budget? Read More

How the GOP Misread Public Anger over Obamacare

By David Orentlicher

In today’s New York Times, Kate Zernike reports on the lack of excitement among conservative activists for the Republican health care legislation. As Zernike observes, “President Trump and congressional leaders are getting little support from what were once the loudest anti-Obamacare voices.”

Some observers think that activists are disappointed in the failure of the GOP proposals to go far enough in repealing the Affordable Care Act. But that’s not the real story. In general, the public likes many of Obamacare’s key provisions, such as the protections for people with preexisting medical conditions or the ability of parents to insure their children up to age 26. Even among Republicans, there is majority support for the ban on higher premiums because of preexisting conditions and also for the mandate that insurers cover “essential health benefits.” And by 2014, Obamacare had faded as a campaign issue for Republican candidates for Congress.

So why don’t grassroots Republicans care so much about repealing the Affordable Care Act? Tea Party activists and other voters were genuinely mad about Obamacare, and they fueled the Republican wave in the 2010 House elections that saw Republicans gain 63 seats. But what made them angry was the feeling that President Obama cared more about health care than he did about the economy. In March 2010, when Obama signed the Affordable Care Act into law, the unemployment rate was 9.7 percent. The public cared much more about jobs than about health care insurance, and they saw their President focusing on health care. Remember how many times Obama promised to “pivot” back to the economy?

Voters elected President Trump and gave Republicans majorities in the House and Senate because they wanted more jobs at better pay. If the GOP lets health care distract it from economic stimulus, we may see another wave election in 2018.

RFRA Jumps The Shark: The 8th Circuit Strikes Down the Contraception Accommodation (Part 1)

Flickr/Creative Commons – Bill Ward
Flickr/Creative Commons – Bill Ward

By Gregory M. Lipper

On Thursday, the Eighth Circuit all but assured that major parts of the Affordable Care Act will return to the Supreme Court’s chopping block. This time the issue is whether an accommodation—enabling religious objectors to opt out of offering contraceptive coverage to their employees—itself violates the Religious Freedom Restoration Act (RFRA). The Eighth Circuit ruled for the plaintiffs in Sharpe Holdings, Inc. v. U.S. Department of Health and Human Services, along with a companion case brought by Dordt College. The court concluded that the accommodation substantially burdened plaintiffs’ religious exercise and that the accommodation was not the least-restrictive means of ensuring that the plaintiffs’ employees had contraceptive coverage.

The Eighth Circuit’s substantial-burden ruling is unprecedented. Indeed, the contraception coverage cases appear to be the first time that exempted entities have sued to prevent the government from implementing a religious exemption. Like the other nonprofit organizations challenging the contraception regulations, the plaintiffs in this case are not required to cover contraceptives. All they have to do is provide written notice (to either their plan administrator or the Department of Health and Human Services) that they object to providing contraceptive coverage and wish to opt out. Once they provide that notice, the government arranges for the plan administrator to arrange for contraceptive coverage—at no charge to either the plaintiffs or their employees.

The plaintiffs insist that by opting out of providing contraceptive coverage, they “indirectly provide, trigger, and facilitate that objectionable coverage through the … accommodation process.” Every other federal appeals court to have addressed these challenges—even courts as conservative as the Fifth Circuit—has rejected this argument. Indeed, the plaintiffs are being asked to do what they have already done voluntarily: state, in writing, that they object to providing contraceptive coverage to their employees. And it is the HHS regulations, not the plaintiffs’ written notice, that facilitates the provision of contraceptive coverage to plaintiffs’ employees.

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Hell Hath No Fury Like An ACA Opponent Scorned

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Flickr Creative Commons/Tabitha Kaylee Hawk

By Gregory M. Lipper

Over the weekend, Ted Cruz again lamented the role played by John Roberts in rejecting the plaintiffs’ arguments in King v. Burwell, the recent attempts to undermine the Affordable Care Act in the Supreme Court. After Chief Justice Roberts wrote the Supreme Court’s 6–3 opinion in the case, the emerging narrative in some conservative circles is that Roberts and his (apparently illegitimate) judicial restraint is to blame. Cruz said that “if [Edith] Jones and [Michael] Luttig had been on the court instead of Souter and Roberts, then the marriage laws in every state would still be on the books and Obamacare would not been law.” Apparently, the same Chief Justice who invalidated a key provision of the Voting Rights Act, went out of his way to reach the First Amendment question in Citizens United, and joined aggressive decisions targeting contraceptive coverage and labor unions is actually a passive Obama apologist who should never have been nominated.

That, I suppose, is one lesson to be learned. Another is that the King lawsuit was so obviously frivolous and nakedly political that even arch-conservative and Affordable Care Act skeptic John Roberts felt constrained to reject it.

Let’s review: in King v. Burwell, the plaintiffs argued that four words in the Affordable Care Act should be read in isolation to prevent the federal government from offering subsidies to those who lived in states that refused to create their own healthcare exchanges. They pressed this argument even though such a reading would have rendered the federal exchanges entirely illusory, stripped millions of Americans of health insurance, and produced the very death spiral the Act was supposed to prevent.

Commentators noted that the plaintiffs’ argument was reminiscent of “an old Amelia Bedelia story” and that it depended on the “Moops doctrine.” And those were the nice reviews. Others described the case as “cynically manufactured,” “mean-spirited,” and a “political challenge … dressed up in legal garb.” The plaintiffs’ counsel didn’t help matters by speaking about the companion case in rather political terms.

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(Final) Reply to Author of Cato Brief in Little Sisters Contraception Case

kangaroos
Flickr Creative Commons/Charlie Marshall

By Gregory M. Lipper

This is the third and (I promise) final installment in my skirmish with Josh Blackman over a brief that he and Cato Institute filed in support of Little Sisters of the Poor’s quixotic challenge to regulations requiring them to fill out a form to obtain an exemption from providing contraceptive coverage to its employees. If you haven’t read the previous posts, you can do so here (my first post), here (Josh’s response to me), here (my first reply to Josh), and here (Josh’s second response to me). The basic gist is that, contrary to Cato’s brief, (1) HHS had the authority to implement the nonprofit accommodation, and (2) if HHS didn’t have the authority to issue the accommodation, then Hobby Lobby no longer controls whether the original contraceptive coverage requirement satisfies RFRA, because the Court in Hobby Lobby pointed to the HHS accommodation as the basis for concluding that a less-restrictive alternative exists.

Now, on to Josh’s most recent response.

First, Josh suggests that he’s not actually assuming away the basis of Hobby Lobby, because the HHS nonprofit accommodation could still in theory be enacted by Congress; even if HHS lacked the authority to issue the nonprofit accommodation, he says, it would still constitute a less-restrictive means and thus lead to the same result in Hobby Lobby (such that the Supreme Court can dodge the question in Little Sisters).

But that’s not right either. The premise of Hobby Lobby was that the less-restrictive alternative was existing and on the books; the accommodation was one that “HHS has already devised and implemented.” The Court added: “[W]e need not rely on the option of a new, government-funded program in order to conclude that the HHS regulations fail the least-restrictive-means test. HHS itself has demonstrated that it has at its disposal an approach that is less restrictive than requiring employers to fund contraceptive methods that violate their religious beliefs.” Justice Kennedy, the decisive vote, added that “the mechanism for [accommodating the plaintiffs] is already in place.” (All emphases added by me.)

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A Reply to the Author of Cato’s Brief in the Little Sisters Contraception Case

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Flickr Creative Commons/WEBN-TV

By Gregory M. Lipper

Josh Blackman has replied to my post criticizing the Cato Institute’s amicus brief (which Josh coauthored) in support of the cert petition in the Little Sisters contraception case. My original post made two arguments: (1) if you take away the nonprofit accommodation, Hobby Lobby no longer supplies a rule of decision, because the presence of the nonprofit accommodation was what led the Court to conclude that RFRA barred the coverage requirement, and (2) if you prevent regulatory agencies from offering reasonable, tailored accommodations to their regulations, the result is bad for religious liberty.

Two brief comment on Josh’s reply.

First, on the question of agency authority to issue religious accommodations, Josh incorrectly suggests that I miss a subtelty in his argument. Josh/Cato say that the Department of Health and Human Services (HHS) has authority to issue religious accommodations, but that it may not decide “which organizations were worthy of the exemption, and which would be burdened by the accommodation.” I address this argument in my original post: the Cato brief assumes that religious accommodations are all-or-nothing, but that is not how the Religious Freedom Restoration Act (RFRA) works. RFRA details when accommodations are available and when they are not (and the Establishment Clause limits accommodations that unduly harm third parties). So an agency (HHS, or otherwise) cannot, as a practical matter, offer accommodations without determining who is eligible for that accommodation and who is not. As I said in my original post, Cato “would force agencies to choose between a bludgeon and no tools at all, even when the agency would need a scalpel to craft religious accommodations consistent with RFRA.”

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Some Thoughts from a Health Lawyer on King v. Burwell

By Joan H. Krause

[Cross-posted from Hamilton and Griffin on Rights]

The long-awaited and much-debated opinion in King v. Burwell is here. In an opinion written by Chief Justice Roberts – who almost single-handedly saved the ACA with his 2012 opinion in N.F.I.B. v. Sebelius – and newly joined by N.F.I.B. dissenter Justice Kennedy as well as the more liberal Justices, the Court agreed with the Fourth Circuit that the ACA’s tax credits (or “subsidies”) are available to individuals who purchase insurance through both State and Federal health insurance Exchanges. The Petitioners, four Virginia residents who did not wish to purchase health insurance, had argued that Virginia’s Federally-run Exchange did not constitute “an Exchange established by the State” under the ACA tax credit provision; because unsubsidized coverage would cost more than 8% of the Petitioners’ incomes, they would be exempt from the Act’s individual mandate and would not be required to purchase health insurance. While acknowledging that the Petitioners’ arguments regarding the “plain meaning” of the phrase were strong, the majority nonetheless sided with the Government, holding that the context and structure of the overall statute led to the conclusion that the statute permitted tax credits for insurance purchased on “any Exchange created under the Act,” whether State or Federal (slip op. at 21). Justice Scalia penned a scathing yet witty dissent (“We should start calling this law SCOTUScare,” slip op., Scalia, J. dissenting, at 21), arguing that the plain meaning of the language made clear that tax credits were available only on State exchanges, and that any flaws in the Act’s design should be left to Congress to fix.

Despite the attention it received, King was something of a stealth ACA case. Lacking the Constitutional controversies of N.F.I.B., it was in many ways a run-of-the mill statutory interpretation case focusing on four words in a massive document containing, in the words of the Chief Justice, “more than a few examples of inartful drafting” (slip op. at 14).   And yet the potential effects of the decision were perhaps even more far-reaching, in large part because of the timing. N.F.I.B.’s Commerce Clause analysis may have more precedential value in the long-run, but far fewer of the Act’s provisions had gone into effect in June of 2012. With approximately 7 million individuals now receiving insurance through the Federal Exchange, and the majority of them (an estimated 87%) receiving subsidies, the decision in King could have led to the devastating loss of insurance for millions of Americans.

While commentators will no doubt parse every sentence of the opinion (including the Court’s refusal to defer to the IRS’s interpretation of the statute under Chevron), as a health lawyer I found two aspects of the opinion notable. First, the Chief Justice drafted a very nuanced (and mercifully succinct) description of the health insurance market flaws the ACA was designed to address. The Chief Justice understood the ACA’s “three key reforms” – guaranteed issue and community rating of insurance policies, the individual mandate, and tax credits – as well as the ways in which the three were “closely intertwined” (slip op. at 3-4). The first few pages cite multiple horror stories from states where some, but not all, of these reforms were enacted; for data, the opinion cites liberally to the Brief for Bipartisan Economic Scholars as Amici.   In its depth (not to mention brevity), the analysis is completely different from the tortured description of health insurance found just a few years ago in N.F.I.B., evincing a far more sophisticated understanding of both the legal issues and the legislation itself.

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