Category Archives: Health Care

SCOTUS and Tea Leaves

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The oral arguments over the Affordable Care Act are over, and I’ve been cruising around getting reactions. First, there’s general agreement that it be be a divided decision, and the swing votes will belong to Roberts and Kennedy. No surprise there, I don’t think.

Today the Court heard arguments about “severability,” or whether the entire law has to fall if the individual mandate is struck down. And it appears there may be some awareness on the court that if the mandate goes, and the ACA stays, somebody’s got to pick through the whole beast and revise the thing. The Court doesn’t want that job, but they appeared skeptical that Congress is up to it, either.

David Savage of the Los Angeles Times writes that the justices seem to be leaning toward striking down the whole law, but other writers are not that pessimistic, or optimistic as the case may be.

Lyle Denniston of SCOTUSblog writes,

The Supreme Court spent 91 minutes Wednesday operating on the assumption that it would strike down the key feature of the new health care law, but may have convinced itself in the end not to do that because of just how hard it would be to decide what to do after that. 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 “just couldn’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.” Much of the lively argument focused on just what role the Court would more properly perform in trying to sort out the consequences of nullifying the requirement that virtually every American have health insurance by the year 2014.

There is widespread agreement that the decision could define the Roberts court. This has caused some people to speculate that Roberts may vote to uphold the act just so he can’t be accused of being a right-wing tool. But if he’s the right-wing tool many assume him to be, he won’t care what anyone thinks. You can’t beat being a Supreme Court Chief Justice for job security, after all.

I’m making no predictions. It could go either way.

James Carville argues that if the Supremes flush Obamacare, politically this could work out better for the Dems than for Republicans. Carville says,

“Just as a professional Democrat, there’s nothing better to me than overturning this thing 5-4 and then the Republican Party will own the health care system for the foreseeable future. And I really believe that. That is not spin,” Carville said.

David Frum agrees that a loss for Republicans in the Court would present a bigger political challenge to them than a win. And that’s because Republicans have nothing ready to replace the ACA. After all this time, they’re still hauling out the same loser arguments about tort reform and selling insurance across state lines.

My uninformed guess: the ACA prevails, and probably not by a narrow margin.

What then?

What then is that healthcare comes roaring back as a campaign issue, to which Republicans have failed to provide themselves an answer. Because of the prolonged economic downturn, more Americans than ever have lost—or are at risk of losing—their health coverage. Many of them will be voting in November. What do Republicans have to say to them?

Make no mistake: If Republicans lose in the Supreme Court, they’ll need an answer. “Repeal” may excite a Republican primary electorate that doesn’t need to worry about health insurance because it’s overwhelmingly over 65 and happily enjoying its government-mandated and taxpayer-subsidized single-payer Medicare system. But the general-election electorate doesn’t have the benefit of government medicine. It relies on the collapsing system of employer-directed care. It’s frightened, and it wants answers.

“Unconstitutional” was an answer of a kind. But if the ACA is not rejected as “unconstitutional,” the question will resurface: if you guys don’t want this, want do you want instead?

In that case, Republicans will need a Plan B. Unfortunately, they wasted the past three years that might have developed one. If the Supreme Court doesn’t rescue them from themselves, they’ll be heading into this election season arguing, in effect, Our plan is to take away the government-mandated insurance of millions of people under age 65, and replace it with nothing. And we’re doing this so as to better protect the government-mandated insurance of people over 65—until we begin to phase out that insurance, too, for everybody now under 55.

But if the ACA is struck down, won’t the Republicans still be under the gun to crank out an alternative? Well, maybe not until after the election.

See also The Rock Biter Theory Of Health Care Reform Legislation.

Update: See Steve Kornacki, “The Debate the GOP Can’t Have.”

GOP for Individual Mandate Before They Were Against It

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Awesome segment by Rachel Maddow last nignt —

Visit msnbc.com for breaking news, world news, and news about the economy

Maddow documents that way back when Republicans were battling the evil “Hillarycare” instead of the evil “Obamacare,” Republicans pushed an individual mandate to purchase health insurance as a solution for soaring health care costs. And this includes some of the same Republicans who today declare that the individual mandate is the end of liberty as we know it. If you are short of time you can skip to the 5 minute mark, right before the juicy bits start.

Update: Several news stories say that the justice’s questioning today suggests the conservatives on the Court are going to end the mandate. Steve Kornacki says ain’t necessarily so. Ezra Klein is less optimistic.

Wingnutism as an Obsessive-Compulsive Disorder

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Along with not being able to control their fear/loathing of women, wingnuts also are decidedly knee-jerk when it comes to government social programs. So it is that some Republican Senators (Rand Paul, LIndsey Graham, Jim DeMint, and Mike Lee) have trotted out a new plan to “save” Medicare by destroying it.

Dana Milbank writes,

If you’re thinking of answering this in the affirmative, you might want to pause long enough to learn what transpired on the third floor of the Capitol on Thursday. There, four prominent Republican lawmakers announced their proposal to abolish Medicare — “sunset” was their pseudo-verb — even for those currently on the program or nearing retirement. …

… For years, Republicans have insisted that they would not end Medicare as we know it and that any changes to the program would not affect those in or near retirement. In the span of 20 minutes Thursday, they jettisoned both promises.

And in an election year, too, although I don’t know if any of these four is up for re-election this year. Rand Paul isn’t, of course.

DeMint and his colleagues think the time to end Medicare is now — with a cold-turkey conversion to a private program, effective in 2014. “I think if Americans actually find out the truth about what we’re doing, it will be a very big positive for Republicans in the fall,” DeMint forecast.

The plan is to scrap Medicare and enroll seniors in the health care plan for federal workers. Exactly how this would save money is a mystery to me, although Rand Paul says it would save Medicare $1 trillion over ten years, a figure I assume he pulled out of his ass. It’s possible he doesn’t appreciate that adding all those seniors to the federal group insurance plan would drive up the cost of the federal group insurance plan.

At Thursday’s news conference, Jonathan Weisman of the New York Times pointed out that the lawmakers were proposing to do with Medicare almost exactly what President Obama’s reforms do for non-retirees: Direct them into private insurance with a subsidy for those who need it most.

Paul was flummoxed. “Uh, anybody want to comment on that?” he asked, producing laughter in the Senate TV studio.

DeMint gave it a try. “Medicare’s already set up as a government program, so we’re beginning to privatize with this idea,” he said. He said his plan takes Medicare recipients “out from under that manipulative umbrella of the Democratic Party.”

I’ve seen primary exit polling that suggests many seniors vote for Republicans because they believe they will “save” Medicare from the evil President Obama, who wants to “cut” it. Of course, the opposite is actually true. The President is trying to keep the program as it is but keep it solvent by putting tighter controls on payments to providers. On the other hand, all of the GOP candidates, including Mittens, have endorsed some variation of the Paul Ryan Medicare-killing plan. But a big talking point with them is a promise to maintain the current program for people already on it.

Now Rand, DeMint et al. are challenging the candidates to go even further Right on Medicare than they were already, which would be a disaster for whichever one of them is in the general election. That they couldn’t contain themselves and wait until after the November election to make this proposal makes them all look even more like lemmings than they did already.

Related: “The Case for Crazy.” John Avlon argues that the best thing that could happen to the GOP is to nominate Rick Santorum and lose in a historic landslide in November.

If Mitt Romney does finally wrestle the nomination to the ground, and then loses to Obama, conservatives will blame the loss on his alleged moderation. The right wing take-away will be to try to nominate a true ideologue in 2016.

But if someone like Rick Santorum gets the nomination in an upset, the party faithful will get to experience the adrenaline rush of going off a cliff together, like Thelma and Louise—elation followed by an electoral thud.

Part of the delusion that is “movement conservatism” is the belief that a large majority of the American people agree with teabaggery, and that only a fringe of elitist liberals stand against them. A teabag candidate sinking like the Titanic might wake some of them up, and might also be a warning to the small group of gazillionaires underwriting this nonsense that there’s a limit to what their money can buy, even in the age of Citizens United.

The Limits of “Conscience”

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The wingnuts are screeching that we must allow Catholic bishops to dictate the nation’s health insurance policies, because otherwise we are violating their religious conscience. As one non-Catholic explained,

As Americans–Catholics and Baptists alike–we are in absolute agreement on the inviolable freedom of conscience, a right recognized and guaranteed by the First Amendment to the Constitution to every American citizen.

“Religious exemptions” are being granted to pharmacists who don’t want to fill birth control prescriptions. As Mistermix wrote,

Tebow and his only begotten son Bieber help us if this keeps up, because we’re going to have a medical profession full of delicate conscientious objectors whose heartfelt beliefs keep them from doing their goddam job. Where does this idiocy end? If you’re a Jehovah’s Witness, whose religion forbids blood transfusions, and you want to become a trauma surgeon, will some federal judge support your right to let your patients bleed to death?

We may be closer to that than you realize. Charles Pierce points to the measles epidemic in Indiana and notes a connection to religion:

The state health authorities in Indiana have released a list of possible places where the victims of the outbreak may have contracted the disease. Several of them, including the College Park Church in Indianapolis and a basketball tournament for homeschooled children, are intriguing because of the cross-pollination between fundamentalist Christianity and the anti-vaccination movement. In 2005, a young Indiana woman came home from a mission trip to Romania and kicked off another measles outbreak within the congregation of her church. …

…In 1985, across the border in Illinois, there was a measles outbreak at Principia College, a Christian Science institution. There were 112 confirmed cases and three deaths associated with that outbreak. Between that episode and 1994, there were four large-scale measles outbreaks at Christian Science institutions around St. Louis. By the way, Principia College still maintains a religious exemption from the requirements of Illinois law mandating proof of vaccination.Instead, Principia students can present an “accommodation form” stating their religious objections to vaccination.

And, never fear, a number of states are considering bills that would exempt school children from vaccinations if their parents object for “philosophical” reasons.

I don’t know if anyone has died in the current Indiana outbreak, but all but two of the cases reported have occurred in anti-vaccination families.

A lot of us geezers caught measles when we were kids, and recovered in a few days. But it tends to be harder for adults, and the disease can be fatal. And then there’s German measles, which causes horrific birth defects when a pregnant woman is infected. Are the whackjobs going to start that up again?

I believe a lot of states have allowed Christian Scientists to slide on the vaccination thing, but since there are so few of them it didn’t cause that much of a problem. I’m reading that now about 10 percent of families with small children are refusing or delaying at least some vaccinations, if not all of them, believing the shots are dangerous. Like the diseases they prevent aren’t?

I believe most states hold parents responsible if a child dies from a curable disease and the parents refused to seek medical help on religious grounds. So there’s a limit to “conscience.” You can refuse medical care for yourself, but not for your minor child. But the vaccination issue points to how interdependent we really are, and how a decision made for oneself could impact a lot of other people. And, IMO, where lives are on the line, your “conscience” has to take a back seat to reality.

This is getting ridiculous. So I’m pushing back on the notion that “religious conscience” trumps all other considerations. My modest proposal is that at the very least, anyone who has not received all recommended vaccinations must be required to wear some kind of ID badge or bracelet, so the rest of us know to keep our distance from them. I suspect a lot of folks will quickly decide that maybe vaccines aren’t so bad after all.

What Can One Say But … Santorum

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Meanwhile, Little Rickie thinks that children whose parents can’t afford their medications should just die already. Because “We either believe in markets or we don’t.” From Rawstory:

Republican presidential candidate Rick Santorum told the mother of a child with a rare genetic disorder on Tuesday that she shouldn’t have a problem paying $1 million a year for drugs because Apple’s iPad can cost around $900.

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You might have heard that one of Santorum’s children also has a genetic disorder and recently had to be hospitalized. One assumes he has insurance.

Cost Shifting Is Not Cost Cutting

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You’ve heard that the U.S. spends more on health care than anywhere else on the planet. If you want to see this for yourself, spend some time with this page of charts, graphs and tables compiled by the Kaiser Family Foundation. And what makes the amount we spend even more pathetic is that our overall results do not stand up to that of other nations that spend far less.

Now the Global Health Leadership Institute points out that while we spend much more on health care costs than those other countries, we spend a great deal less on other social services — “rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.”

We studied 10 years’ worth of data and found that if you counted the combined investment in health care and social services, the United States no longer spent the most money — far from it. In 2005, for example, the United States devoted only 29 percent of gross domestic product to health and social services combined, while countries like Sweden, France, the Netherlands, Belgium and Denmark dedicated 33 percent to 38 percent of their G.D.P. to the combination. We came in 10th.

What’s more, America is one of only three industrialized countries to spend the majority of its health and social services budget on health care itself. For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Our study found that countries with high health care spending relative to social spending had lower life expectancy and higher infant mortality than countries that favored social spending. While the stagnating life expectancy in the United States remains at 78 years, in many European countries it has leapt to well over 80 years, and several countries boast infant mortality rates approximately half of ours. In a national survey conducted by the Robert Wood Johnson Foundation, four out of five physicians agreed that unmet social needs led directly to worse health.

This suggests to me that one of the several factors driving up health care costs is our low rate of “safety net” support for people in need. Here’s an eye-opening statistic:

The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.

In other words, it would almost certainly be less expensive to the rest of us to provide the 119 with basic shelter, food and health care than to just leave them on the streets. And there’s a chance some of them could become self-sufficient with a little help.

The conservative argument is that benefit programs make people lazy and dependent. So what does being chronically sick and cut off from health care (other than emergency rooms when they’re in crisis) make them?

My suspicions are that there is some optimum amount of government social services that gives you the best overall result for the buck, and trying to get by more cheaply just shifts costs somewhere else. So the “saving” is an illusion. In fact, the “saving” may be driving costs even higher.

The other argument a conservative might make (albeit with different framing) is that if the Glorious Free Market isn’t finding a place for some people, then they are surplus population that should just die already. Because, you know, people exist to serve the needs of the Holy Free Market Economy, not the other way around.

That kind of thinking is the only way conservative ideology makes sense.

Stuff to Read About Health Care

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The Los Angeles Times has an op ed by a woman who had been an Obama supporter in 2008 but who turned into an Obama basher later because he betrayed the middle class and all. She even changed her Obama bumper sticker from “hope” to “nope.” But then she changed her mind again.

Why? She was diagnosed with breast cancer, and she has no insurance. But then she found out she could get insurance through the Pre-existing Condition Insurance Plan.

It’s part of President Obama’s healthcare plan, one of the things that has already kicked in, and it guarantees access to insurance for U.S. citizens with preexisting conditions who have been uninsured for at least six months. The application was short, the premiums are affordable, and I have found the people who work in the administration office to be quite compassionate (nothing like the people I have dealt with over the years at other insurance companies.) It’s not perfect, of course, and it still leaves many people in need out in the cold. But it’s a start, and for me it’s been a lifesaver — perhaps literally.

I didn’t even know about the Pre-existing Condition Insurance Plan, which is separate and usually less expensive than the high-risk pool plan, which I did know about. The PCIP will be phased out once the Affordable Care Act goes into total effect in 2014,

The PCIPs can be administered by states, but if the state doesn’t want to mess with it the feds will administer it for them within that state. Interestingly, on the whole “red” states seem more inclined to just let the feds do it than “blue” ones.

Not everyone will be able to afford PCIP insurance, but it will be of help to some people, like the woman who wrote the op ed. In other words, it’s better than nothing. A lot of progressives continue to fail to understand that by holding out for single payer or the public option or whatever else they wanted that had no chance in hell of passing even in 2010, never mind now, they were choosing nothing.

Elsewhere, a Brit visiting New York — to take part in the OWS demonstrations — was bitten by a brown recluse spider and thereby gained firsthand experience with the U.S. healthcare system. Fortunately for her, she had travel insurance that seems to have paid for most of her care. She was treated at Beth Israel Medical Center in New York City, which I understand to be a better than average hospital. But she says, she perceived how “the stranglehold of American private healthcare keeps ordinary people cowed and compliant in the land of the notionally free.”

I do have a quibble with her article. “President Obama’s attempt to reform the system in 2009 roundly failed to remove healthcare as a source of perennial anxiety for most American citizens, or to lighten the dead hand of the market on medical provision in the US.” She doesn’t seem to understand that most of it hasn’t gone into effect yet, although I’d bet money that most OWSers don’t understand what’s in the ACA, either, other than it lacks a public option.

Finally — a few days ago some of you were commenting on Rick Ungar’s article in Forbes about how the ACA’s hitherto little-known regulations of insurance companies’ medical loss ratio would drive insurance companies out of business and usher in the dawn of a national single payer system. Unfortunately, as Sarah Kliff explains, the regulations will not drive insurance companies out of business. It might shave a little off their profits, but they’ll still make profits.

The Supremes Will Decide

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This morning the Supreme Court agreed to hear an appeal of one of the health care reform challenges. Adam Liptak writes for the New York Times:

The Supreme Court agreed to hear appeals from just one decision, from the United States Court of Appeals for the 11th Circuit, in Atlanta, the only one so far striking down the mandate. The decision, from a divided three-judge panel, said the mandate overstepped Congressional authority and could not be justified by the constitutional power “to regulate commerce” or “to lay and collect taxes.”

The appeals court went no further, though, severing the mandate from the rest of the law.

On Monday, the justices agreed to decide not only whether the mandate is constitutional but also whether, if it is not, how much of the balance of the law, the Patient Protection and Affordable Care Act, must fall along with it.

SCOTUS will hear arguments in March and will probably hand down a decision in June, smack in the middle of the general election campaigns.

Ezra Klein has a backgrounder on the legal issues in the case.

Fudging Facts to Fit the Fallacies

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You know the pattern. A news story comes out that makes conservative ideology look bad. Then, like a swarm of angry bees, rightie bloggers go to work on the story, knock out the most damaging parts and fudge the rest, then post the revised version on their blogs with the conclusion “Democrats [or the poor, or liberals, or anybody else they don’t like] are stupid [or corrupt, or just evil].”

Example, the original story: A 24-year-old man in Cincinnati has an infected wisdom tooth. A dentist tells him the tooth needs to be pulled, but the man has no insurance and cannot afford it. The dentist gives him a prescription for an antibiotic and a painkiller. The young man decides he can’t afford both, and he just gets the painkiller. The infection spreads to his brain, and he dies from a treatable tooth infection. The moral is that if he had had health insurance he almost certainly would not have died.

Granted, deciding to fill the pain killer prescription but not the antibiotic, instead of the other way around, was not smart, but it’s not unusual these days for people to not realize that infections really can kill you. Young men in particular tend to think they are invincible.

As for the tooth, the article doesn’t say what the dentist planned to charge to extract the tooth, but a bit of googling revealed that the cost of extracting one impacted wisdom tooth (the tooth was almost certainly impacted if it was infected) runs between $350 -$650, depending on how badly the tooth is impacted, and that does not include the cost of anesthesia, x-rays, or post-operative care, which is sometimes needed.

The cost of antibiotics range widely from almost free to “holy bleep,” and the type of antibiotic prescribed depends on the type and severity of the infection. The cheap ones don’t always work on whatever infection you might have. So without more information we don’t know what the guy might have had to spend on the antibiotic, but it could have been anywhere from $20 (possibly less) to more than $100.

And probably any dentist will tell you that even if that infection had been brought under control the guy would still need the surgery to keep it from returning.

Example, wingnut version: According to Donald Douglas (to whom I do not link, after past experience with DD’s relentless and aggressive hostility to whomever disagrees with him), the infected wisdom tooth could have been pulled for a mere $80. He knows this because the original story also mentioned a 12-year-old Maryland boy who died for want of a tooth extraction that would have cost $80. But that would not have been a wisdom tooth, which cost a lot more to extract. Scared Monkeys repeats the misinformation about the tooth extraction cost.

Then, they all decide the guy could have gotten a $4 antibiotic from Wal-Mart. Again, maybe, maybe not. It depends on what antibiotic was prescribed, and we don’t know that. The doctor might have thought the common and cheap ones like amoxicillin wouldn’t have done the job. This is possible, since the antibiotic was prescribed by an emergency room doctor who saw the young man after his face had swollen and he was getting headaches.

[Update: Add James Joyner to the list of bloggers who assume the young man could have gotten a $4 supply of pills at Wal-Mart.]

Having decided that the young man died because he was too cheap to fork over $84, or ask his family for the money, the bloggers go on to attack his character for wanting government handouts. Well, enough of that.

Back to the example of the boy who might have been saved by a $80 tooth extraction — the original story said,

The Maryland boy underwent two operations and six weeks of hospital care, totaling $250,000. Doctors said a routine $80 tooth extraction could have saved his life. His family was uninsured and had recently lost its Medicaid benefits, keeping Deamonte from having dental surgery.

The family may well have faced a choice of either paying for the tooth extraction or for groceries, and they chose groceries. But the larger point is that the $250,000 no doubt was paid by taxpayers, or else the hospital padded other patients’ bills to cover the loss. It would have been more cost effective for all of us to have paid for the $80 extraction. If righties actually care about the cost of health care and federal budget deficits and such, they might want to ponder that.

When Righties Love Government Spending

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Most of you probably remember how the Medicare prescription drug benefit, Medicare Part D, was passed in 2004. The Bush Administration rammed the bill through Congress without allowing the Congress critters to see the CBO estimates of what it would cost.

A big reason Medicare Part D added billions of dollars to the federal deficit is that the law that created Part D forbids the government for negotiating for drug prices. Part D works a lot like Medicare Advantage, which is that it pays private insurance companies to offer prescription drug benefits to seniors. The prices of drugs are negotiated between the insurance companies and the pharmaceutical companies.

By 2007, reports were coming out that Medicare Part D was paying 58 percent more, on average, than the Veterans Administration paid for the same drugs. Part D was a huge giveaway to Big Pharma, which was financed through deficit spending, since the Bushies refused to raise taxes to pay for it.

Further, when the law went into effect in January 2006, 6.5 million seniors and disabled people in the Medicaid program were transferred to Medicare Part D for their prescription drug benefits. This group was called “dual eligibles,” since they got most of their health care through Medicaid but prescription drugs through Medicare Part D. The New York Times reported in 2006 that this shifting of programs was a windfall for the pharmaceutical industry:

The pharmaceutical industry is beginning to reap a windfall from a surprisingly lucrative niche market: drugs for poor people.

And analysts expect the benefits to show up in many of the quarterly financial results that drug makers will begin posting this week.

The windfall, which by some estimates could be $2 billion or more this year, is a result of the transfer of millions of low-income people into the new Medicare Part D drug program that went into effect in January. Under that program, as it turns out, the prices paid by insurers, and eventually the taxpayer, for the medications given to those transferred are likely to be higher than what was paid under the federal-state Medicaid programs for the poor.

Under Medicaid, the federal government and state agencies purchase drugs from pharmaceutical companies at the “best price,” meaning the lowest price negotiated by private insurance companies or any other purchaser. These prices are watched closely, and the drug companies sometimes are required to rebate money back to the government if it is discovered somebody else got a better deal.

Needless to say, Medicaid pays a lot less for the same drugs than Medicare Part D pays. This year the CBO estimated that if the “dual eligible” beneficiaries were receiving drug benefits under the Medicaid pricing system, over ten years the federal government would save up to $112 billion dollars (see chart on page 54).

Now, for all the hollering Republicans do about how Medicare is going broke, a sensible person would assume they’d jump at the chance to save $112 billion without cutting benefits. However, “sensible” and “Republican” haven’t lived in the same zip code for some time.

A proposal to make this very change was made in the House recently, and for a time many Republicans supported it. Jonathan Cohn describes how House Majority Leader Eric Cantor led a charge against the bill, however. Note that Big Pharma donated $168,000 to Cantor’s re-election campaign in the last cycle.

Cantor is getting his talking points from the usual sources — think tanks like the Heritage Foundation and the American Enterprise Institute. The Heritage argument is classic think-tank rhetoric — much alarm is expressed, and buzzwords like “price controls” and the superiority of “market based structures” are drizzled throughout.

But taken as a whole, the argument makes no sense. It’s not exactly word salad, but something like ideological bullet list salad. Changing Medicare Part D would cost too much! (Saving $112 billion costs too much?) Seniors would have to pay higher drug prices! (Actually, pharma raised drug prices after Medicare Part D went into effect; see the New York Times article linked above.) Quality of care would suffer! (That only makes sense if you think Lipitor works better if you pay more for it.)

Jonathan Cohn links to more rebuttals of the rightie arguments. See also this 2008 article from Health Affairs, which pretty much demolishes all of the Heritage arguments, including the argument that the “rebate system” stifles innovation.