MONEY Health Care

4 Really Weird Things About the Latest Obamacare Ruling

U.S. President Barack Obama (L) walks out next to Vice President Joseph Biden
Obama's signature health-care law faces a new court challenge. Larry Downing—Reuters

An appeals court says Congress must have meant to make the health care law even more complicated than we thought.

Today two separate appeals courts handed down decisions on challenges to the Affordable Care Act, known popularly as Obamacare. One of those courts, a three-judge panel of the U.S. Court of Appeals for the D.C. Circuit, ruled that the federal government can’t provide insurance premium subsidies to people in states that haven’t set up their own insurance exchanges. The other court rejected that argument.

The D.C. circuit’s opinion, which would invalidate the subsidies paid to about 5 million people, will be a huge, huge deal if it holds up. Much of the early debate and legal wrangling over the ACA focused on the “individual mandate,” the part of law that fines you if you don’t have health coverage. But the subsidies are even more important because they make the required coverage affordable for moderate- to middle-income families. (The subsidies are available to a family of four earning up to $95,400.) The law says you don’t have to pay the fine if insurance isn’t affordable, so without the subsidies the mandate doesn’t apply to so many people.

The ruling could very well be overturned on appeal, and in the meantime the subsidies remain in place. (You can read more on what happens next in this report by Time’s Kate Pickert.) But as a reporter who has covered health care reform closely since the George W. Bush administration, I have to say this ruling just doesn’t make much sense to me. In particular, four very odd things stand out.

1. The court’s interpretation seems implausible.

Quick background: Obamacare subsidies are issued when you buy insurance on an online marketplace called an exchange. Some states set up their own exchanges, but 36 states didn’t, leaving the federal government to do the job instead. The D.C. Circuit ruled that the law authorizes the subsidies to be paid only through state-run exchanges.

This ruling hinges on a close reading of the law, a purported effort to figure out what Congress truly intended. The government, defending Obamacare, argued that because the law can’t work without the premium subsidies, Congress must have meant them to apply regardless of who ran the exchange.

But the court offered another theory: Maybe Congress meant the subsidies to be an incentive for states to set up their own exchanges.

That sounds like a implausibly flexible approach to what was meant to be a sweeping national health care law. After all, it essentially gives any state whose governor or legislature opposes the ACA a chance to opt out of some its biggest provisions—not just the subsidies, but the individual mandate, too.

Cast your mind back to the debate in 2009 and 2010. What I remember was conservatives denying the ACA a single Republican vote and arguing that Democrats would brook no compromise. Democrats, meanwhile, were pointing out that Obamacare looked a lot like the Massachusetts law signed by Republican governor Mitt Romney.

It seems to me that in a long argument over whether Obama and Nancy Pelosi and Max Baucus were tyrants, or just sweetly reasonable splitters-of-the-difference, someone might have said: “Hey, if Republican-led states don’t like the individual mandate, they can always opt out of the exchanges.”

That did not happen.

2. If the ruling stands, this messes up the insurance markets in 36 states.

If there are no subsidies, that doesn’t only mean that many people won’t get help from the government to buy coverage. Even those who didn’t get the subsidies in the first place could face higher prices.

That’s because the law requires the exchanges to sell insurance to everyone who applies, charge them the same rates (based on age) regardless of health, and offer a minimum package of benefits. The problem is that if you don’t have to buy insurance, many people will do so only when they know they need coverage—i.e., when they are sick. And if too few healthy people and too many sick people sign up, insurers have to raise prices to cover the costs. That then means you have to really sick to want to sign up, and that jacks up rates more, and so on. This is known in insurance as adverse selection, or a “death spiral.”

So the federal exchanges could stop working pretty quickly if this ruling stands. In fact, according to the briefs filed by the insurance industry and a group of economists who support the ACA, the adverse selection problem in the exchanges could spill over into the market for private individual plans outside the exchange too, since the law links the two markets in various way. How this would actually play out is unclear, but suffice it say, it’s a major rug-pulling.

Setting up federal exchanges that can’t work seems pretty dumb. Now, as Michael Cannon of the libertarian Cato Institute says, it’s not like lawmakers never make bad laws. States have tried to regulate insurance coverage the way the ACA does, without subsidies, and they’ve run into all these adverse selection problems. The thing is, people in Washington knew this when the ACA was being debated and written. It’s why the subsidies and the individual mandate—a wildly controversial, politically costly provision that many members of Congress wished would go away—were in the law in the first place.

3. This somehow involves the Northern Mariana Islands.

The D.C. Circuit panel notes that the ACA in fact did trigger the “death spiral” problem in this U.S. overseas territory in the Pacific. That’s because the Northern Mariana Islands were subject to the new rules about health coverage but left out of the subsidies. That, says the court, means that maybe Congress really could have meant to regulate the insurance market without subsidizing it too.

I can think of some other reasons why Congress might have klutzed up the part the law that applies to U.S. territories. Like the fact that people in those places have no voting representation in Congress.

4. Congress really isn’t very good at crafting laws

I don’t mean it’s not good at making laws (views may vary on that). I’m talking about the actual writing-it-down part. The court’s lead opinion is devastating in showing how badly written parts of the law are. If these were comments from the professor in a course titled “Lawmaking 101: Making a Bill a Law,” you’d expect to see a big fat red “D” at the bottom of Congress’ term paper. The bill was pushed through hastily after Republican Scott Brown unexpectedly won the late Ted Kennedy’s seat in the Senate, depriving the Democrats of a filibuster-proof majority. The craziness of the legislative process shows in the text.

But its not just a craft problem. The legal vulnerability of the ACA goes hand-in-hand with how politically vulnerable it is. The law makes sense in a basic way and seems to be helping more people get coverage. And polls say people like many of the provisions of the law. But it is also complicated, and hinges on many different players (states, employers, private insurers, Medicare, Medicaid, you and me…) interacting in predictable and not-so-predictable ways. From the beginning, many people have really struggled to get how the law fits together. Turns out that may have included some people in Congress.

MONEY Health Care

Court Ruling Puts a Key Provision of Obamacare in Doubt—For Now

U.S. President Barack Obama (L) walks out next to Vice President Joseph Biden.
Today's D.C. court ruling dealt a blow to Obama's signature legislative achievement, while another set of judges backed the president. Larry Downing—Reuters

A federal appeals court has struck down the premium subsidies offered on the federal insurance exchange, potentially undermining a major provision of the law and raising costs for millions of Americans. With another court upholding the law, more court battles lie ahead.

A three-judge panel at the U.S. Appeals Court for the D.C. Circuit threw the fate of an important part of the Affordable Care Act into doubt Tuesday. In a 2-1 decision in Halbig v. Burwell, the judges ruled that the Internal Revenue Service lacked the authority to allow subsidies to be provided in exchanges not run by the states. That could put at immediate risk the millions of people who bought insurance in the 36 states where these online insurance marketplaces are run by the federal government.

“Because we conclude that the ACA unambiguously restricts the section 36B subsidy to insurance purchased on the Exchanges ‘established by the state,’ we reverse the district court and vacate the IRS’s regulation,” said the decision by Judge Thomas Griffith.

Meanwhile, just an hour later, another three-judge panel on the 4th Circuit Court of Appeals in Richmond, Va., came to the opposite conclusion—upholding the federal subsidies.
“It is therefore clear that widely available tax credits are essential to fulfilling the Act’s primary goals and that Congress was aware of their importance when drafting the bill,” said the decision written by Judge Roger Gregory.

The Obama administration said it will appeal the Halbig decision. The Justice Department will ask the entire appeals court panel to review the decision, and that panel is dominated by judges appointed by Democrats, 7-4. The issue is also in other courts around the country.

White House spokesman Josh Earnest said: “There’s a lot of high-minded case law that’s applied here. There’s also an element of common sense that should be applied as well, which is that you don’t need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace.”

‘’We believe that this decision is incorrect, inconsistent with Congressional intent, different from previous rulings, and at odds with the goal of the law: to make health care affordable no matter where people live. The government will therefore immediately seek further review of the court’s decision,” said a statement from the Justice Department.

Meanwhile, Elizabeth Wydra, chief counsel for the Constitutional Accountability Center, said the ruling wouldn’t take effect right away. “The court’s rules are that it doesn’t happen for 45 days,” to give the government time to ask for a full en banc hearing, “or 7 days after the en banc hearing has been denied.”

Should the decision eventually stand, however, it could mean at least five million Americans would face an average premium increase of 76%, according to a projection done by the consulting firm Avalere Health.

The court said that the wording of the health law “plainly makes subsidies available only on Exchanges established by states,” and that the legislative history of the bill “provides little indication one way or the other of congressional intent.”

But Judge A. Raymond Randolph offered a strong dissent. “It makes little sense to think that Congress would have imposed so substantial a condition in such an oblique and circuitous manner.”

The case could end up in the Supreme Court.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

TIME Health Care

What the New Obamacare Court Decisions Mean for You

U.S. President Barack Obama speaks before signing the H.R. 803, the Workforce Innovation and Opportunity Act. during an event in the Eisonhower Executive Building, July 22, 2014 in Washington, DC.
U.S. President Barack Obama speaks before signing the H.R. 803, the Workforce Innovation and Opportunity Act. during an event in the Eisonhower Executive Building, July 22, 2014 in Washington, DC. Mark Wilson—Getty Images

Two federal courts, two conflicted rulings. What does it all mean?

On Tuesday, two federal courts issued rulings on President Obama’s healthcare law. Here’s what you need to know about how the rulings affect you:

What did the courts say?

A panel in the D.C. Circuit Court of Appeals ruled that the Affordable Care Act (ACA) does not allow the federal government to distribute insurance subsidies through a federal exchange being used in 36 states. Many states declined to set up their own insurance exchanges, forcing the federal government to set up its own central exchange where subsidized plans are sold. The D.C. court said that only people living in those states with their own exchanges are eligible for federal subsidies, due to ambiguities in the language of the ACA.

But in the Fourth Circuit Court of Appeals, judges reached the opposite conclusion. That panel ruled that the federal government does have the authority to hand out insurance subsidies through the federal exchange, and always intended subsidies to be available to any eligible individual in the U.S., regardless of who is running the exchange.

What happens next?

The federal government will appeal the D.C. court ruling and plaintiffs in the identical case in the Fourth Circuit will also likely appeal. The issue is likely to remain unsettled for many months.

What does this mean for Americans currently getting insurance through the ACA?

Nothing yet. With conflicting rulings on the same day and appeals certain, the status quo will remain in place — for now.

But if the D.C. ruling ends up being upheld and the Fourth Circuit overturned, the consequences would be immense. By 2016, more than 7 million people are set to receive ACA insurance subsidies through the federal exchange at the center of each of Tuesday’s rulings. These subsidies are now under threat, and could disappear in those 36 states if the D.C. ruling is upheld on appeal.

Without subsidies, millions in those states could see their insurance premiums go up dramatically. The ACA requires most Americans to have health insurance but only if they can afford it. Without subsidies, coverage for millions would become unaffordable. Removing these people from the health insurance pool could destabilize premiums for everyone else.

What would that mean for Obamacare?

It would be a hammer blow, if the D.C. ruling stands. The government would no longer be able to distribute insurance subsidies in those 36 states, unless those states opted to set up their own exchanges. That would be unlikely, since many of the states that declined to set up exchanges did so in protest at the ACA. The subsidy system is a central feature of Obamacare and Democrats’ plan to expand insurance coverage to low- and middle-income Americans.

Opponents of the law have sued over the ACA before. What makes this case different?

A ruling that threatens to strip insurance subsidies from millions of Americans is the most significant threat to Obamacare since it overcame the challenge to its constitutionality in the U.S. Supreme Court in 2012 — though that same ruling made its Medicaid expansion optional and not mandatory, blocking millions of low-income Americans from coverage. Legal arguments made against Obamacare since have not struck at the heart of the law’s goal of expanding coverage. The recent Hobby Lobby lawsuit, for example, only affected contraception coverage for some employer health plans.

TIME Health Care

GOP Lawsuit Over Obamacare ‘Loophole’ for Congress Dismissed

Permanent Subcommittee On Investigations Hearing On High Speed Trading
Senator Ronald Johnson, a Republican from Wisconsin, questions witnesses during a Senate Permanent Subcommittee on Investigations hearing in Washington, D.C. on June 17, 2014. Andrew Harrer—Bloomberg/Getty Images

Sen. Ron Johnson's claim related to the law's stipulations for members of Congress and their staffs was tossed out by a federal judge Monday

A Republican senator’s challenge to the part of President Barack Obama’s healthcare law involving members of Congress and their staffs was dismissed Monday by a federal judge.

Sen. Ron Johnson (R—Wisc.) filed the suit related to the Affordable Care Act (ACA) provision that members of Congress and their staff may only receive health plans created under the healthcare law, or offered through a online exchange established under the law. The lawsuit claimed that the federal Office of Personnel Management “created a loophole that allowed congressional staff an exemption from the ACA’s provisions,” according to the decision.

The so-called loophole allowed some junior staffers not considered part of the official office of a member of Congress to continue receiving employee benefits, rather than having to buy insurance under the law.

“The Obama administration violated its own signature health care law by giving special treatment to members of Congress and their staffs,” Johnson said in a statement Monday.

U.S. District Judge William Griesbach dismissed the lawsuit on Monday. Griesbach said Senator Johnson failed to show he’d been harmed by the healthcare law, Reuters reports.

The U.S. Supreme Court affirmed in 2012 the law’s “individual mandate” that requires most Americans to buy health insurance or pay a tax penalty.

MONEY Health Care

Why Your Spouse Could Start Costing You More At Work

Wedding rings with health cross on them
Burazin—Getty Images

As health care costs climb, firms are rethinking how much they should spend on coverage for their workers’ husbands and wives.

Q. I hear my company will start charging even more for my spouse to sign up for my health insurance. Why is that?

A. This summer, companies are busy choosing health plans for 2015. And the discussions in the boardrooms are about as heated as the air outside the office, according to Randall Abbott, a senior consultant with Towers Watson. Abbott has been in nearly a dozen meetings in the past three weeks that have addressed one particularly fraught topic: how much companies shell out for health care for their workers’ spouses.

Struggling to rein in health care spending and worried about having exceptionally rich benefits that trigger Obamacare’s so-called Cadillac tax in a few years, businesses are looking for ways to pare back insurance costs. And spousal coverage is often floated as a possible cutback, Abbott says. Many firms have figured out that they spend at least as much—and often more—on coverage for spouses than they do on the workers themselves, so they are rethinking the approach to coverage.

That could mean a higher health insurance premium next year. Just how much higher won’t be clear until this fall, when you sign up for next year’s plan.

“It is a very charged topic,” says Abbott. “Many organizations have prided themselves on being family friendly, and they talk about their employees and family as part of the corporate family, but actions like this are starting to restate the deal between employers, employees, and family members.”

Businesses are not required to offer coverage to spouses—though most large firms do.

Many companies have already been passing on higher costs, hoping spouses will think twice before jumping onto the employee’s plan. This year, half of firms with more than 1,000 workers had spouses pay more for their health premium than workers do, according to Towers Watson’s research.

One-quarter of large firms charge spouses more for coverage when they have access to employer-sponsored coverage at their own job but turn it down. Another 15% plan to go that route in 2015. How much more? On average, couples pay an extra $1,200 a year.

“We think the surcharge will grow not necessarily because all employers think it is a great idea, but it almost becomes a defensive measure to make sure your plan doesn’t become a dumping ground for spouses,” says Abbott.

Some employers require spouses with other coverage options to sign up for that employer plan. Ten percent of firms used that strategy this year, and 13% plan to add the rule next year.

Of course it isn’t always possible for a firm to know if a spouse has access to an employer-sponsored plan through his or her own job. “It is generally done on the honor system,” says Abbott. But if your spouse submits a claim, that may offer clues. For example, a work-related accident might reveal that he or she works at a large firm, where benefits are typically offered.

Only 2% of large companies have stopped paying any of the premium for spousal coverage.

While most of the attention so far has been on partners and spouses, employers are also eyeing what they spend on coverage for workers’ children. Previously most large firms had two rates: individual and family. Now the lineup at most companies includes an individual, couple, and family rate. A few even go as far as to base your premium on the number of children in your family. “This has become one more plan feature that is enormously important for employees and their spouses to understand,” Abbott says.

TIME Health Care

Johns Hopkins to Pay $190 Million to Victims of Secretly Recorded Exams

A sign stands in front of part of the Johns Hopkins Hospital complex on July 8, 2014, in Baltimore.
A sign stands in front of part of the Johns Hopkins Hospital complex on July 8, 2014, in Baltimore. Patrick Semansky—AP

A male gynecologist secretly filmed and took pictures during exams with female patients

Johns Hopkins Hospital announced on Monday that it reached a $190 million settlement with patients whose exams were secretly recorded by a gynecologist.

The class-action lawsuit involved more than 8,000 former patients of Dr. Nikita Levy, the Associated Press reports, and the deal marks one of the largest involving sexual misconduct by a doctor. Most of the discovered videos and photographs—about 1,200 videos and 140 photos—did not include the women’s faces and were taken with a pen-like camera he wore around his neck.

The case never led to criminal charges but essentially argued that Johns Hopkins should have been aware of what the doctor was doing. Levy committed suicide 10 days after he was fired in February 2013, which occurred after an employee came forward with suspicions.

Johns Hopkins released a statement in October on the discovery of Levy’s “misconduct and breach of trust,” writing: “We have redoubled our efforts to ensure that all of us in the Johns Hopkins community understand our responsibility, and we want to encourage you to speak up if you have any concerns about patient care or privacy.”

In a statement sent to reporters, Jonathan Schochor, the lawsuit’s lead attorney, said: “When learning of Dr. Levy’s behavior, our clients were extremely distraught. They felt a great breach of faith and trust. They felt betrayed. Now, with this proposed settlement, we can begin the process of healing our community.”

The settlement still needs final approval by a judge, the AP reports.

“We assure you that one individual does not define Johns Hopkins,” the hospital system said on Monday, acknowledging the settlement. “Johns Hopkins is defined by the tens of thousands of employees who come to work determined to provide world-class care for our patients and their families.”

MONEY Health Care

Why Does an MRI Cost So Darn Much?

Blood vessel with human brain MRI
This is a very expensive picture to take. Yuji Sakai—Getty Images

A single scan runs $2,600 on average (before your insurance kicks in). Here's what makes this common diagnostic procedure so expensive.

When it comes to pricey hospital procedures, MRIs come to mind. Sure enough, according to recently released Medicare pricing data analyzed by NerdWallet Health, the average cost of an MRI in the U.S. is $2,611. Here’s what’s behind that number.

Make Room for a Big Machine

Magnetic resonance imaging machines use magnets and radio waves to produce black-and-white images of bones and organs, usually to help with a diagnosis. Only five companies make MRI machines, and each specializes in a few magnet strengths, so there is relatively little competition when it comes time for a hospital or medical center to buy one.

Machines come in a variety of sizes and powers. Their imaging power is measured in magnetic field strength units called Teslas; low-field or open MRI machines measure 0.2 to 0.3, while the strongest currently on the market are 3 Teslas. Used low-field MRI machines can be as cheap as $150,000 or as expensive as $1.2 million. For a state-of-the-art 3 Tesla MRI machine, the price tag to buy one new can reach $3 million.

The room that houses the machine, called an MRI suite, can cost hundreds of thousands more. Safety features must be built in to protect those right outside from the magnetic field. Add in patient support areas and installation costs, and a suite with just one machine can cost anywhere from $3 million to $5 million. Recouping these costs factors into your bill, but that alone does not tell the entire story.

Add in the Doctors and Hospitals

Charges for a single MRI scan vary widely across the country for reasons beyond startup costs. According to the recently released Medicare data, MRIs charges are as little as $474 or as high as $13,259, depending on where you go. (Another recent study of medical claims by Change Healthcare found that in-network prices for certain MRIs can run from $511 to $2,815.) That’s because hospitals and medical centers can charge whatever they want, and in most cases they don’t have to justify prices or even disclose them ahead of time.

Doctors can also charge whatever they want, and though the MRI facility probably sets the rates of their staff doctors, you’ll be charged separately for a radiologist to read the MRI. Additionally, your ordering physician may ask for the MRI to be done with or without contrast dye, or both. This “dye” is actually a paramagnetic liquid that responds to the machine’s magnet and helps enhance certain abnormalities on the scan that would not have otherwise been visible, common in neurological MRIs.

This means that in addition to cost of the scan, your total bill for the MRI will include the radiologist fee, the contrast dyes, and the cost of the procedure itself. Depending on the medical center, these charges may be bundled together into one charge. Bundling is one type of common error on medical bills, so always check over an itemized statement before paying for any costly medical procedure.

Read more from NerdWallet Health, a website that empowers consumers to find high quality, affordable health care, and insurance.

 

 

 

 

 

 

 

 

 

 

 

 

MONEY Health Care

How to Get the Same Health Care at a Quarter of the Cost

Bandaids with different pricing
Even within your insurer's network, prices for the same service often vary by 300%. Sarina Finkelstein—Ales Veluscek/Getty Images

The prices for getting tested and treated are all over the map. To save on your medical bills, learn to shop smarter.

You know that visiting doctors and hospitals outside your insurer’s network is pricey. What might surprise you is how big a bill you could face even when you stay in network. In a recent analysis of 93 types of services and procedures, Change Healthcare, a company that tracks medical claims, found that in-network prices for the same service often vary by 300% and can differ by as much as 750%.

Picking the higher-price option can cost you: You’ll typically owe full fare until you meet your ­deductible, and then usually a percentage of the bill. “Most people assume if you go in-network everyone is paid the same, so the financial implication for you will be the same,” says Douglas Ghertner, CEO at Change Healthcare. “But that is absolutely not the case.”

Your insurer or employer probably has a web tool that lists what you’ll pay for certain services at local providers, factoring in your deductible and co-insurance. Use it. For these types of care in particular, the swings in insurers’ negotiated in-network rates are wide—and you may have time to shop around.

Imaging: $511 to $2,815 for an MRI; $307 to $2,747 for CT scan

Imaging bills typically run two to three times higher at hospitals than at freestanding radiology centers, according to health insurer Cigna. At hospitals, says Brian Keigley, founder of price-comparison firm New Choice Health, “radiology is often subsidizing other service lines.” Ask your doctor for options other than the hospital (or the MRI machine his practice owns). When comparing costs, confirm that the price includes a pro to read the scan. Check that the facility is ACR-accredited, says Keigley, and make sure your doctor will accept the results.

Specialists: $67 to $207 per visit

When you need a specialist such as a cardiologist or neurologist, you frequently end up seeing whomever your primary-care doctor recommends. But you ought to know what’s behind the suggestion. Often he or she will refer you within the same health system, says Christine Riedl of health insurer Aetna. Ask your doctor how crucial it is to see this specialist vs. another MD, and get a few additional names. For common specialties, your plans’ pricing tool most likely factors in quality metrics by practice, so you can see if the one charging less meets those standards.

Physical therapy: $620 or $2,280 for 10 sessions

Hospital facilities often negotiate higher prices with insurers than standalone PT practices do, says Justin Moore of the American Physical Therapy Association. If your doctor suggests a therapist, find out if he or she specializes in your condition. Check on how many visits you’ll need, the cost per visit (some pricing tools do not include PT), and what you’ll owe (confirm that with your insurer). Ask what signs will indicate progress, such as being able to walk down a hallway in X amount of time. Says Moore: “Being able to spell that out is an indication of the quality of care.”

TIME Budget

Lower Health Care Costs Brighten America’s Debt Outlook

Senate Deal on U.S. Debt Limit Emerging as Time Runs Short
A police officer rides a motorcycle past the United States Capitol building at sunrise in Washington, D.C., U.S., on Tuesday, Oct. 15, 2013. Pete Marovich—Bloomberg/Getty Images

Fiscal doom will be delayed thanks to lower health care inflation in recent years. But will Congress take notice?

For years, America’s health care costs grew at an unsustainable rate. That was the main reason America’s long-term fiscal position looked unsustainable as well; Medicare, Medicaid, and other health programs were spiraling out of control. But our health care cost inflation is no longer unsustainable. That’s huge news, because it means our long-term deficits should be manageable, too.

Louise Sheiner and Brendan Mochoruck of the Brookings Institution compared the Congressional Budget Office’s latest fiscal outlook with its projections from five years ago, and the shift is striking. In 2009, the CBO expected Medicare spending to skyrocket from 3% to 6% of GDP by 2030; it now expects much more modest growth to less than 4% of GDP. Overall, former CBO director Peter Orszag, President Obama’s first budget director, calculated the projected savings in federal health spending since the 2009 report at $7.9 trillion.

Those numbers, like all long-term budget estimates, could change radically. And while Obamacare’s cost controls contributed to the cost slowdown, it’s not clear how much they contributed. Policy wonks and political hacks will have plenty of time to argue about why the cost curve is bending. But the trend itself, as Orszag argues, is the most important trend in fiscal policy in decades. It’s the difference between a deficit crisis and a phantom deficit crisis. In 2009, graphs of projected federal health spending looked like ski slopes; graphs of all other spending looked like sidewalks. The long-term deficit problem was basically a medical problem.

Now it’s not such a problem. The question is whether Washington will notice.

Republicans have spent the last five-and-a-half years griping about the budget deficit, and most of their gripes have been absurd. They were wrong to accuse President Obama of creating a record trillion-dollar deficit, which he actually inherited from President Bush. They were wrong to criticize Obama for increasing the deficit with his 2009 stimulus bill, which was an amazingly effective Keynesian response to an economic crisis; the budget-balancing austerity approach the GOP was advocating led to much slower recoveries and double-dip recessions in Europe. And they were wrong to accuse Obama of turning the U.S. into Greece; the deficit has shrunk by more than half during his presidency, dropping from 10 percent of GDP to less than 4 percent as the recovery has progressed.

We still have a big national debt, and the CBO expects it to grow from 74% of GDP today to 106% in 25 years. We’ll spend trillions of dollars servicing that debt, and we should remember how Bush squandered President Clinton’s surpluses with unpaid-for tax cuts and unpaid-for wars every time we cut the check. But we are not Greece. Our finances are looking better in every way.

TIME Civil Rights

New Guidelines Could Help Many Pregnant Workers

Jacqueline Berrien
Chair of the Equal Employment Opportunity Commission Jacqueline Berrien speaks at a Middle Class Task Force event in the Eisenhower Executive Office Building across from the White House in Washington, in this Tuesday, July 20, 2010 file photo. Charles Dharapak—AP

Any form of workplace discrimination or harassment against pregnant workers by employers is now a form of illegal sex discrimination

(WASHINGTON) — New federal guidelines on job discrimination against pregnant workers could have a big impact on the workplace and in the courtroom.

The expanded rules adopted by the bipartisan Equal Employment Opportunity Commission make clear that any form of workplace discrimination or harassment against pregnant workers by employers is a form of sex discrimination — and illegal.

Updating its pregnancy discrimination guidelines for the first time in more than 30 years, the agency cited a “persistence of overt pregnancy discrimination, as well as the emergence of more subtle discriminatory practices.”

The guidelines spell out for the first time how the Americans With Disabilities Act applies to pregnant workers. And they emphasize that any discrimination against female workers based on past or prospective future pregnancies is also illegal.

Joan C. Williams, a law professor at the University of California’s Hastings School of Law in San Francisco, said the new guidelines issued this week can have two major impacts: steering EEOC investigators to be more sensitive to the sometimes special needs of pregnant workers and giving employment lawyers more ammunition in defending clients who were victims of such discrimination.

Williams, an expert in the field whose work is cited three times in the EEOC’s new 60-page “enforcement guidance” on pregnancy discrimination, called the toughened stance of the EEOC “a significant victory.”

Williams, who co-authored a 2011 study called “Pregnant, Poor and Fired,” said the main impact may by erecting “very, very, simple and very, very commonsense” guideposts for EEOC investigators, as well as providing strong ammunition for employment lawyers whose clients are victims of such discrimination.

“I think it will make a really big difference,” she said in an interview. “This is also the direction the courts have begun to go in, and that’s why the EEOC said, ‘Yeah, that makes sense.'”

The guidelines were last updated in 1983. EEOC Chairwoman Jacqueline A. Berrien suggested the update was needed and timely. “Despite much progress, we continue to see a significant number of charges alleging pregnancy discrimination, and our investigations have revealed the persistence of overt pregnancy discrimination, as well as the emergence of more subtle discriminatory practices,” she said in a statement.

The new guidelines prohibit employers from forcing pregnant workers to take leave and acknowledge that “employers may have to provide light duty for pregnant workers.” After childbirth, lactation is now covered as a pregnancy-related medical condition.

It’s not just women who will benefit.

The guidelines say that when it comes to parental leave, “similarly situated” men and women must be treated on the same terms.

The update comes two weeks after the Supreme Court agreed to consider a case involving the EEOC’s duty to try to settle charges of job discrimination before filing lawsuits against employers.

The issue has gained increasing attention — and vexed business groups — as the Obama administration ratchets up its enforcement of the nation’s anti-discrimination laws.

The latest EEOC data shows a 46 percent increase in pregnancy-related complaints to the EEOC from 1997 to 2011.

In its report, the agency cites specific, real-life examples of what it considers illegal discrimination. It used only first names and did not reveal locations, occupations or employers. Among them:

— Three months after “Maria” told her supervisor that she was pregnant, she was absent a few days due to an illness unrelated to her pregnancy. When she returned to work, “her supervisor said her body was trying to tell her something” and she was let go.

— Shortly after Teresa informed her supervisor of her pregnancy, “he met with her to discuss alleged performance problems.” Even though Teresa had consistently received outstanding performance reviews during her eight years of employment with the company, she was discharged.

— Birah, a woman from Nigeria, claimed that when she was visibly pregnant with her second child, “her supervisors increased her workload and shortened her deadlines so she could not complete her assignments, ostracized her, repeatedly excluded her from meetings to which she should have been invited, reprimanded her for failing to show up for work due to snow when others were not reprimanded, and subjected her to profanity.”

Protections for pregnant women vary widely around the globe — as does enforcement. Sweden bans discrimination because of pregnancy and requires companies employing more than 25 people to help both men and women combine work and parenting. Egyptian laws give pregnant women the right to work fewer hours and three months’ paid leave after birth — requirements women’s rights groups say prompt employers to hire men. And in Mexico, laws prohibit discrimination against pregnant women, but there is little enforcement by the government.

The American Civil Liberties Union welcomed the updated U.S. guidelines, which were approved Monday on a 3-2 partisan-line vote by the Democratic-led commission.

“Pregnancy is not a justification for excluding women from jobs that they are qualified to perform, and it cannot be a basis for denying employment or treating women less favorably than co-workers,” said Laura W. Murphy, director of the ACLU’s Washington Legislative Office.

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