WHAT IS WOMEN HEALTH , HEALTH EDUCATION , INFECTION CONTROL (ICSP) , ENGLISH

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NASAL OBSTRUCTION , HEALTH EDUCATION , INFECTION CONTROL (ICSP) , URDU / HINDI

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4 GOP-appointed justices control health law's fate

WASHINGTON (AP) — Here's a thought that can't comfort President Barack Obama: The fate of his health care overhaul rests with four Republican-appointed Supreme Court justices.

His most sweeping domestic achievement could be struck down if they stand together with Justice Clarence Thomas, another GOP appointee who is the likeliest vote against.

But the good news for Obama is that he probably needs only one of the four to side with him to win approval of the law's crucial centerpiece, the requirement that almost everyone in this country has insurance or pays a penalty.

Lawyers with opposing views of the issue uniformly agree that the four Democratic-appointed justices, including Obama's two picks, Elena Kagan and Sonia Sotomayor, will have no trouble concluding that Congress did not overstep its authority in adopting the insurance requirement that is aimed at sharply reducing the now 50 million people without insurance.

On the other side, Thomas has made clear in several cases that he does not take an expansive view of Congress' powers.

Both the Obama administration and the health care law's challengers believe they can attract the other four Republicans to their side. The group includes Chief Justice John Roberts and Justice Samuel Alito, the two appointees of President George W. Bush who have swung the court to the right in a number of areas; conservative stalwart Antonin Scalia; and the less doctrinaire Anthony Kennedy.

There is no consensus in the legal and academic worlds which way the court will go or even how each of those four justices will vote. The court has set aside six hours over three days, beginning March 26, to hear arguments.

But a legal challenge, once seen as improbable at best, now has everyone's attention, partly because the justices find it weighty enough to devote six hours over three days to hearing the case. That's the most time for any issue in more than 45 years.

"Arguments that once seemed outlandish don't seem quite so outlandish anymore," said University of Michigan law professor Nicholas Bagley, a health law expert who says the law should be upheld.

The fight over the law has played out in starkly partisan terms. It passed Congress without a Republican vote. All the GOP presidential candidates have called for its repeal.

Some supporters of the law worry about the high court's decision because a similar partisan split, with a few important exceptions, has emerged in the lower courts.

"I think as a constitutional matter, this should be an easy case," said Erwin Chemerinsky, a liberal scholar and dean of the law school at the University of California, Irvine. "But every judge appointed by a Republican president, with two exceptions, has voted to strike the law down. And every judge appointed by a Democratic president, with one exception, has voted to uphold the law. Thus, the real issue is whether the Republican-appointed justices will overcome ideology and vote to uphold the law."

Among lawyers who appear regularly before the Supreme Court, Carter Phillips of Sidley Austin LLP offered a fairly typical response in predicting the court is more likely to uphold the law than strike it down. But he was far from certain.

"I have no doubt that if the court strikes down the statute, it will be 5-4," Phillips said. "But if the court upholds the statute, it would not shock me if the decision turned out not to be 5-4. I would be somewhat surprised if Justices Thomas and Scalia both did not vote to strike down the law, but I certainly believe that Justice Alito and the chief" could vote to sustain it.

In the view of Phillips and other lawyers, Kennedy is the most likely Republican to vote in favor of the law. He often provides the decisive vote in cases that divide the court by ideology.

But his record in cases involving Congress' constitutional power to regulate commerce offers both sides some hope. Kennedy was part of the majority that struck down a federal law prohibiting people from carrying guns in or near schools. That 1995 ruling was the first time since the New Deal that the court limited Congress' power under the Commerce Clause.

The 26 states and private parties challenging the health care law peppered their briefs with references to Kennedy's writing in the guns case and another decision, from 2010, in which he took a narrower view than the majority of Congress' power to act in an area not spelled out in the Constitution. The court upheld Congress' authority to continue to hold inmates considered "sexually dangerous" even after they completed their prison terms.

At the same time, however, Kennedy said in a concurring opinion in the guns case that "Congress can regulate in the commercial sphere on the assumption that we have a single market and a unified purpose to build a stable national economy." The Obama administration says Kennedy could have been describing health care, which makes up 17 percent of the U.S. economy.

Roberts, on the other hand, joined the majority in the 2010 sex offenders case that broadly endorsed federal power.

As chief justice, Roberts also might feel he has an obligation to try to avoid being in the dissent in a case of such importance.

Ilya Shapiro, a lawyer at the libertarian Cato Institute who opposes the health care law, said that Roberts "as the keeper of institutional integrity, wanting the court to speak with more of one voice" could join with Kennedy and the court's liberal wing, rather than being a dissenter in a 5-4 ruling upholding the law.

Like Roberts, Alito has not had many occasions to weigh in on congressional power. Like Kennedy, he took a narrower view of the 2010 case.

In some ways, Scalia's vote is the most intriguing. He has joined in a series of opinions endorsing limits on Congress' regulatory authority under the Commerce Clause.

Yet the administration is focusing on Scalia's opinion in Raich v. Gonzales, a 2005 case that upheld a federal law banning medical marijuana, even grown and consumed at home, as an appropriate regulation of interstate commerce.

"Congress may regulate even noneconomic local activity if that regulation is a necessary part of a more general economic regulation of interstate commerce," Scalia said in a separate opinion.

Georgetown law professor Randy Barnett, a driving force in the effort to take down the health care law, said he isn't worried about Scalia. "To distinguish his opinion in Raich from this case, Justice Scalia would not even have to break a sweat," Barnett wrote recently.

It's hard to imagine Scalia as the only conservative justice in favor of the law.

If he approved of the law, Scalia would more likely join a significant court majority to ratify it. Administration supporters hope that a larger majority including Scalia would make it harder for Republican politicians to make a partisan case against the law.

___

Online:

Supreme Court: http://www.supremecourt.gov/docket/PPAACA.aspx

EDITOR'S NOTE _ This is part of a weeklong package of stories previewing the Supreme Court's consideration of President Barack Obama's health care overhaul law.

View the original article here

4 Republican justices control fate of health law

WASHINGTON (AP) — Here's a thought that can't comfort President Barack Obama: The fate of his health care overhaul rests with four Republican-appointed Supreme Court justices.

His most sweeping domestic achievement could be struck down if they stand together with Justice Clarence Thomas, another GOP appointee who is the likeliest vote against.

But the good news for Obama is that he probably needs only one of the four to side with him to win approval of the law's crucial centerpiece, the requirement that almost everyone in this country has insurance or pays a penalty.

Lawyers with opposing views of the issue uniformly agree that the four Democratic-appointed justices, including Obama's two picks, Elena Kagan and Sonia Sotomayor, will have no trouble concluding that Congress did not overstep its authority in adopting the insurance requirement that is aimed at sharply reducing the now 50 million people without insurance.

On the other side, Thomas has made clear in several cases that he does not take an expansive view of Congress' powers.

Both the Obama administration and the health care law's challengers believe they can attract the other four Republicans to their side. The group includes Chief Justice John Roberts and Justice Samuel Alito, the two appointees of President George W. Bush who have swung the court to the right in a number of areas; conservative stalwart Antonin Scalia; and the less doctrinaire Anthony Kennedy.

There is no consensus in the legal and academic worlds which way the court will go or even how each of those four justices will vote.

But a legal challenge, once seen as improbable at best, now has everyone's attention, partly because the justices find it weighty enough to devote six hours over three days to hearing the case. That's the most time for any issue in more than 45 years.

"Arguments that once seemed outlandish don't seem quite so outlandish anymore," said University of Michigan law professor Nicholas Bagley, a health law expert who says the law should be upheld.

The fight over the law has played out in starkly partisan terms. It passed Congress without a Republican vote. All the GOP presidential candidates have called for its repeal.

Some supporters of the law worry about the high court's decision because a similar partisan split, with a few important exceptions, has emerged in the lower courts.

"I think as a constitutional matter, this should be an easy case," said Erwin Chemerinsky, a liberal scholar and dean of the law school at the University of California at Riverside. "But every judge appointed by a Republican president, with two exceptions, has voted to strike the law down. And every judge appointed by a Democratic president, with one exception, has voted to uphold the law. Thus, the real issue is whether the Republican-appointed justices will overcome ideology and vote to uphold the law."

Among lawyers who appear regularly before the Supreme Court, Carter Phillips of Sidley Austin LLP offered a fairly typical response in predicting the court is more likely to uphold the law than strike it down. But he was far from certain.

"I have no doubt that if the court strikes down the statute, it will be 5-4," Phillips said. "But if the court upholds the statute, it would not shock me if the decision turned out not to be 5-4. I would be somewhat surprised if Justices Thomas and Scalia both did not vote to strike down the law, but I certainly believe that Justice Alito and the chief" could vote to sustain it.

In the view of Phillips and other lawyers, Kennedy is the most likely Republican to vote in favor of the law. He often provides the decisive vote in cases that divide the court by ideology.

But his record in cases involving Congress' constitutional power to regulate commerce offers both sides some hope. Kennedy was part of the majority that struck down a federal law prohibiting people from carrying guns in or near schools. That 1995 ruling was the first time since the New Deal that the court limited Congress' power under the Commerce Clause.

The 26 states and private parties challenging the health care law peppered their briefs with references to Kennedy's writing in the guns case and another decision, from 2010, in which he took a narrower view than the majority of Congress' power to act in an area not spelled out in the Constitution. The court upheld Congress' authority to continue to hold inmates considered "sexually dangerous" even after they completed their prison terms.

At the same time, however, Kennedy said in a concurring opinion in the guns case that "Congress can regulate in the commercial sphere on the assumption that we have a single market and a unified purpose to build a stable national economy." The Obama administration says Kennedy could have been describing health care, which makes up 17 percent of the U.S. economy.

Roberts, on the other hand, joined the majority in the 2010 sex offenders case that broadly endorsed federal power.

As chief justice, Roberts also might feel he has an obligation to try to avoid being in the dissent in a case of such importance.

Ilya Shapiro, a lawyer at the libertarian Cato Institute who opposes the health care law, said that Roberts "as the keeper of institutional integrity, wanting the court to speak with more of one voice" could join with Kennedy and the court's liberal wing, rather than being a dissenter in a 5-4 ruling upholding the law.

Like Roberts, Alito has not had many occasions to weigh in on congressional power. Like Kennedy, he took a narrower view of the 2010 case.

In some ways, Scalia's vote is the most intriguing. He has joined in a series of opinions endorsing limits on Congress' regulatory authority under the Commerce Clause.

Yet the administration is focusing on Scalia's opinion in Raich v. Gonzales, a 2005 case that upheld a federal law banning medical marijuana, even grown and consumed at home, as an appropriate regulation of interstate commerce.

"Congress may regulate even noneconomic local activity if that regulation is a necessary part of a more general economic regulation of interstate commerce," Scalia said in a separate opinion.

Georgetown law professor Randy Barnett, a driving force in the effort to take down the health care law, said he isn't worried about Scalia. "To distinguish his opinion in Raich from this case, Justice Scalia would not even have to break a sweat," Barnett wrote recently.

It's hard to imagine Scalia as the only conservative justice in favor of the law.

If he approved of the law, Scalia would more likely join a significant court majority to ratify it. Administration supporters hope that a larger majority including Scalia would make it harder for Republican politicians to make a partisan case against the law.

___

Online:

Supreme Court: http://www.supremecourt.gov/docket/PPAACA.aspx

EDITOR'S NOTE _ This is part of a weeklong package of stories previewing the Supreme Court's consideration of President Barack Obama's health care overhaul law.

View the original article here

Health Care In Massachusetts Turns To Cost Control

Voters are hearing a lot about health care this year. Republicans want to make the 2012 elections a referendum on the health care law that President Obama signed two years ago.

That law was largely based on one that then-Gov. Mitt Romney signed into law nearly six years ago in Massachusetts.

Romney is now a GOP presidential contender, and that has made the Massachusetts universal health care law a political football. Romney's rival Rick Santorum recently called it "an abject failure."

But "Romneycare," as Santorum and others call it, isn't controversial in its home state. And a lot of people there don't call it Romneycare because it took the support of a lot of other people — Democratic legislators, business leaders, insurers, hospitals and doctors, consumer groups — to get it passed.

But it's true that Romney got the ball rolling. When I interviewed him in 2006, Romney said he got the idea from talking to Massachusetts business leaders.

 

"The key insight was this: People who don't have insurance nonetheless receive health care — and it's expensive," Romney said.

Romney saw a state fund set up to provide free care — paid for by a growing surcharge on private insurance premiums — was spending a billion dollars a year.

"My question was, could we take that billion dollars and help the poor purchase health insurance — let them pay what they could afford? We'd subsidize what they can't," Romney said.

The percentage of uninsured people has gone down. Nearly everybody in Massachusetts has health coverage, while the rate of uninsured nationally has gone up to one in six.

The proportion of employers offering health plans has gone up in Massachusetts, despite fears that availability of government-subsidized insurance would "crowd out" employer-sponsored coverage. Nationally the rate is believed to be static.

*This figure may be a statistical anomaly. The rates in 2009 and 2011 were close to 60 percent, the same as in 2005.

Access to health care has improved in Massachusetts, while emergency room visits have gone down — possibly a sign that people with insurance are more likely to have a regular source of care. Self-rated health is improving.

And he proposed a requirement that people buy private health insurance if they're able. That's the "individual mandate" that has become a curse word in Republican politics these days.

"We're going to say, 'Folks, if you can afford health care, then, gosh, you'd better go get it,' " Romney said back in 2006. " 'Otherwise you're just passing on your expenses to someone else.' That's not Republican, that's not Democratic, that's not Libertarian — that's just wrong."

Flash forward to 2012. Romney's successor, Democrat Deval Patrick, says the health plan Romney launched is no abject failure — it's working.

"I think it's just been a terrific success," Patrick said in an interview. "And [it's] a statement of value — about our values here, about how people aren't all on their own, that we are in this together."

Patrick says no state can match Massachusetts' record of getting more than 98 percent of its citizens insured for health care — and virtually every last child. And, he boasts, "It has cost the state about 1 percent in additional new state spending."

The Massachusetts law has had strong and steady support — and little opposition. Last year, an attempt to repeal the "individual mandate" — the part that requires most people to have insurance — couldn't get enough signatures. Last week, only 39 people had "liked" its Facebook page.

To get an idea of how it's working at the ground level, I stopped by the office of Dieufort Fleurissaint, a self-employed Haitian-American businessman. He has a tax prep and insurance business. He's also an evangelical minister who worked with the group Greater Boston Interfaith Organization, which helped get the health law passed.

"Close to 500,000 people didn't have health insurance," Fleurissaint says. "Now, because of the passing of the law, they have health insurance."

And one of them, it turns out, is Fleurissaint. He used to be a mortgage broker, but his business crashed in 2008. He couldn't pay his health insurance premiums.

But under the new law, Fleurissaint qualified for state-subsidized insurance.

"My premium ... dropped from $1,200 on a monthly basis [to] $770 for the same coverage for the same family of four," he says. And when his income dropped again during the recession, so did his health insurance costs.

"The law has been extremely good for me," he says, but he admits that not all his business colleagues like the law.

"They complained that they were forced, basically obligated to purchase health insurance," Fluerissaint says. "So I explained to them that it's much better to have health insurance than not having it."

In fact, despite some initial grumbling, more Massachusetts businesses of all sizes have begun offering insurance.

When I called the Massachusetts Restaurant Association, it said it didn't know of any members that don't offer coverage. That was surprising, since restaurant owners have been among the most opposed to health laws like this one.

Similarly, Bill Vernon, who heads the Massachusetts office of the National Federation of Independent Businesses, says the law "works for Massachusetts." The NFIB is a plaintiff in one of the lawsuits challenging the constitutionality of the Obama health plan that will be argued later this month before the U.S. Supreme Court.

But in Massachusetts, Vernon says, "my guess is that we would probably be pretty much split on the issue of whether to repeal the law or not. That suggests repeal is not something we would favor. And I don't think it's politically realistic, either."

Likewise, the individual mandate has not met with nearly the resistance that many predicted.

"The sky did not fall," says Andrew Dreyfus, president of Blue Cross Blue Shield of Massachusetts, the state's largest insurer. "And by the way, we have much stronger penalties around the individual mandate than the national law has, and despite that, the sky did not fall."

The penalty for not buying insurance can be on the order of $1,200 a year for a 37-year-old single person in Boston. But only about 1 percent of taxpayers end up paying any penalty.

Meanwhile, a new study in the journal Health Affairs shows that more Massachusetts citizens are seeing a doctor regularly, fewer are going to emergency rooms for care, and the percentage who rate their own health as "good" or "excellent" is going up.

But that doesn't mean everything about Massachusetts health care is wonderful.

The 2006 law didn't do anything about controlling the state's health costs, which were already among the nation's highest.

So now the conversation in Massachusetts has turned to cost control. And some very interesting things are beginning to happen.

They didn't happen overnight. When Patrick took over the governor's office in 2007, he called together top insurers, hospital executives and doctors to talk about controlling costs. He says it was an exercise in frustration.

"I finally lost my patience," Patrick says. "Because they'd sit around the table and everyone would start their response the same way — 'Well, governor,' they'd say, 'it's complicated.' "

Patrick says the insurers would point to the hospitals, the hospitals would point to the doctors, the doctors would say it's malpractice suits or red tape or the imaging center down the street.

Patrick says he got fed up. "I understand it is complicated," he says. "But the point is, we have to stop being defeated by that complexity."

So, two years ago, the governor directed his insurance commissioner to exercise a little-used power to turn down a requested rate increase because it was excessive. Not every state has this power.

Insurance companies were outraged. But Dreyfus of Blue Cross Blue Shield now says it was a pivotal point.

"It sent a message to the entire health care community and the business community that we had to change," Dreyfus says.

And change seems to be happening. Insurers have torn up their contracts with hospitals calling for annual reimbursement increases of 8 percent and 10 percent, and negotiated agreements providing for 3 percent, 2 percent and even zero percent increases.

Blue Cross Blue Shield has persuaded some of the state's biggest hospitals, and thousands of doctors, to accept a new kind of payment. Instead of getting paid every time they do something — a venerable system called fee-for-service that encourages them to provide more and more services — they're paid a fixed amount each month for each patient.

That was tried in the 1990s, and it failed, largely because of backlash over its incentive to stint on care. The new wrinkle is that this time hospitals and doctors have to meet 60-some different quality measures to show they're not cutting back on care.

Dreyfus says a third of his company's 2.8 million subscribers are now on these so-called "global payment" plans, and he's hopeful that most of the state will be on this kind of reimbursement within the next two to three years.

The various steps seem to be working to moderate Massachusetts' historically high health care inflation rates. "We've got some more work to do here," the governor says, "but average premium increases were almost 17 percent two years ago. They are less than 2 percent right now."

But he doesn't trust that it will automatically go on that way. Patrick and many others, inside and out of government, say Massachusetts now needs some legislation to lock in these changes and go further — cut down on administrative costs, reform the malpractice system and other innovations.

The big idea you often hear these days is to hold total Massachusetts health spending to a target tied to the state's overall economic growth.

"I want to assure ... that it's sustainable," Patrick says, "that we don't continue to have increases above the rate of growth in the economy." Otherwise, he says, health care will "eat up everything else."

Legislators, who are wary of tampering with a health sector that accounts for 20 percent of the state's economy, are expected to come up with their own proposals this spring.

But significantly, no one is talking about repealing the 2006 law. Not even businessmen like Fred Difinis, who runs a small business selling parts for playground equipment. He's unhappy with the Massachusetts health plan because it requires him to buy coverage for prescription drugs, which he says he doesn't need.

"I'm not sure I necessarily want to see the law repealed," he says. "What I want to see is some balance on the cost side of the equation."

If Massachusetts can do that, it might become a national model — again.

View the original article here

Health insurers question Obama birth control plan

(Reuters) - Health insurers said on Friday they feared President Barack Obama had set a new precedent by making them responsible for providing free birth control to employees of religious groups as he sought to defuse an election-year landmine.

Obama on Friday announced the policy shift in an effort to accommodate religious organizations, such as Catholic hospitals and universities, whose leaders are outraged by a new rule that would have required them to offer free contraceptive coverage to employees.

Instead, the Obama administration ordered insurers to provide workers at religious-affiliated institutions with free family planning if they request it, without involving their employer at all. Insurance industry officials said the abrupt shift raised questions over how that requirement would be implemented.

"We are concerned about the precedent this proposed rule would set," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, the industry's trade group. "As we learn more about how this rule would be operationalized, we will provide comments through the regulatory process."

Zirkelbach said insurers "have long offered contraceptive coverage to employers as part of comprehensive, preventive benefits that aim to improve patient health and reduce health care cost growth."

Employers who have signed on for such health plans in the past paid part of the cost of birth control prescriptions, while their employees also bore some of the expense through co-payments.

Aetna, the third-largest U.S. health insurer, said that it would comply with the policy but needed "to study the mechanics of this unprecedented decision before we can understand how it will be implemented and how it will impact our customers."

An Aetna spokeswoman said the company "did not have any direct input into the actual policy decisions that were made."

When asked about the insurer concerns, the White House cited a report from the U.S. Health and Human Services Department that estimates the costs of providing free birth control can be offset by reducing expenses associated with unintended pregnancies.

(Reporting by Lewis Krauskopf in New York, Additional reporting by Caren Bohan in Washington, Editing by Michele Gershberg, John Wallace and Matthew Lewis)

View the original article here

Health mandate to include birth control

This is a great step forward for the health of all women

The Obama administration recently ruled that health insurance plans must include contraception among the preventive services available to women without deductibles or co-pays under the new health-care law [“Contraception mandate outrages religious groups,” Health, seattletimes.com, Feb. 3].

This decision does not force doctors to prescribe contraception, or a woman to use it. Instead, it makes contraception affordable for many women who otherwise would not be able to afford it. As a nurse, I know this is a great step forward for the health of all women.

Despite the fact that 98 percent of Catholic women use contraception, some in the religious community are demanding that the current exemption for churches and religious organizations be expanded to include colleges, hospitals and social service agencies. This would be a disastrous decision for women’s health.

This issue goes to the heart of the personal-health decisions a woman makes with her doctor and care team, not her employer. As a Catholic, my grandmother died giving birth to her eighth child in so many years, and my mother had 10 pregnancies within less than 12 years. With birth control, their pregnancies could have been spaced so as to minimize the extreme physical, emotional, financial and psychological toll placed upon our family.

As a nurse, I know the decision not to expand the exception was the right one — as a matter of public health, respect for individual conscience and simple fairness to Washington women and their families.

This politicalizing from the pulpit, however, is one of the reasons why I struggle with my Catholic faith.

— Mary McNaughton, registered nurse, Everett

This is a threat to our fundamental freedoms

The recent news about the Health and Human Services mandate gives one something to, shall we say, pause over. I find this move very interesting. For those of us who are disturbed by this mandate, the issue is not simply abortion; it is that our government, while arguing that it is defending a woman’s right to choose, this mandate is going to deny that same right of conscience to those of us, men and women, who believe that all life is sacred, from conception to natural death..

The government, according to our founding documents, lacks the legitimacy, or the power to do what is being threatened by the Health and Human Services Mandate. It does not have the competency to do so.

The disagreement between us in this matter is about much more than just the life issues. We disagree on fundamental Constitutional, democratic principles. The right of conscience applies to all moral, political and social justice issues, not just the life issues. That is why this is, and will continue to be, a legitimate debate, not a forgone conclusion.

This is not just a mandate, it is a mortal threat to fundamental freedoms. You give government this kind of power and you no longer live in a democracy.

— Daniel J. Doyle, Edmonds

View the original article here

Is U.S. Health Spending Finally Under Control?

9:36 a.m. | Updated to correct reference to lines in Chart 3.

Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.

“Growth in U.S. health spending remains slow in 2010” was the headline of a news release on Jan. 9 by the Centers for Medicare and Medicaid Services, part of the Department of Health and Human Services. At an increase of 3.9 percent over national health spending in 2009, “the rates of health spending growth in 2009 and 2010 marked the lowest rate in the 51-year history of the National Health Expenditure Accounts,” the release said.

Perspectives from expert contributors.

The news was quickly picked up and disseminated by news organizations, including The New York Times.

What is one to make of this development? Is it evidence that we have finally “broken the back of the health care inflation monster,” as former Secretary of Health and Human Services Margaret Heckler famously put it in 1984. That was just after the Reagan administration had introduced the current prospective case-based payments for hospital inpatient care but two years before the health care inflation monster returned with a vengeance.

The charts below provide a longer-run perspective on health spending in the United States. They are all based on the rich data tables released annually by the Office of the Actuary of the Centers for Medicare and Medicare Services.

Charts 1 and 2 show the growth of health spending from 1965 to 2010, broken down by source of payment. Chart 1 exhibits the time path of actual health spending, not adjusted for inflation. Chart 2 exhibits the percentage of total national health spending contributed by the various sources in the chart.

In the charts the green area denotes out-of-pocket spending at the time health care is consumed, the red private health insurance, the gray Medicare, the yellow Medicaid and the blue “other third-party payments.”

The latter category is a grab bag of mainly public programs like spending by the Department of Defense, the Veterans Administration health system, the Indian Health Service, Workers’ Compensation, school health, general federal and state public-health activities and so on. Although each item in the list is relatively small, together these programs now add up to slightly over 20 percent of total national health spending.

Charts 1 and 2 illustrate the growing role of the Medicare and Medicaid programs in total health spending. They also show that out-of-pocket spending as a percentage of total national health spending has steadily decreased over time, even though the average American family probably feels that quite the opposite has occurred.

This is so because out-of-pocket spending for health care in dollars in the United States can rise even though as a percentage of total health spending it falls, because per-capita health spending in the United States is so large – typically twice as large as the corresponding figures in other nations.

Charts 3 and 4 tell an interesting story. The blue line in Chart 3 represents inflation-adjusted, real national health spending per capita in constant 2005 dollars. The red line represents real, inflation-adjusted gross domestic product per capita. The G.D.P. deflator was used to adjust the two-time series for inflation (see Table B-7).

As the charts show, both real national health spending per capita and real G.D.P. per capita fluctuate considerably from year to year. On average, the growth rate of health spending has exceeded the growth rate of G.D.P., although in a few years the opposite occurred.

I am certainly not the first to notice this. Charts like these are old hat in the Office of the Actuary of the Centers for Medicare and Medicaid Services, and they have been remarked on in the literature for some time, as this example shows.

Charts 3 and 4 illustrate two additional points.

First, depending on the beginning and end points one chooses for calculation, the average percentage points by which the annual growth in health spending has exceeded the average annual growth in G.D.P. over the chosen period – a difference known among health policy analysts simply as “excess cost growth” – can vary quite a bit. One really needs charts like these to study the phenomenon, not point-to-point averages.

Second, the annual growth in real health spending per capita appears to have fluctuated around a long-run trend that has declined ever so gently over the longer period (see the blue line in Chart 3). That trend reflects in part that the annual growth in real G.D.P. per capita has also fluctuated around a gently declining trend line. As is shown in Chart 4, the trend line around which excess growth fluctuates is virtually flat.

The $64,000 question is how soon the excess growth of health spending will descend from its historical average of 1.5 to 2.5 percent first to, say, 1 percent or so, and eventually to 0 percent.

It is tempting to view the relatively lower cost growth in recent years as a first step in that direction. But nothing in the history of health spending in the United States suggests that this is the time to break out the Champagne to celebrate that victory.

After all, low rates of spending increases in 2009-10 could just be the lagged effect of the deep recession in 2008-9. There is evidence in the literature that health spending does not completely march to its own drummer, regardless of what happens in the rest of the economy, but instead tends to rise and fall somewhat with the rest of the G.D.P., albeit with a lag of one to two years. The safest bet is that on the long road to eventual zero excess growth in health spending, we will ride up and down quite a few more times on the health-spending roller coaster.

Now why is it reasonable to assume that excess cost growth will just have to decline to zero in the long run – that is, to assume that health spending will not eventually growth faster than G.D.P. and perhaps even more slowly?

Economists would explain such a trend as flows: as the fraction of G.D.P. devoted to health care increases, the added satisfaction, or utility, that people derive from added health care is likely to diminish relative to the added satisfaction derived from consuming more of other things. It could explain a gradual decline in the excess growth of health care spending.

Finally, economists retreat here to the one law on which they all agree, namely, Stein’s Law, named for the late economist Herbert Stein: “If something cannot go on forever, it will stop.” Trust us. It will, in the long run.

This post has been revised to reflect the following correction:

Correction: January 20, 2012

An earlier version of this post reversed a reference to the lines in Chart 3. The blue line (not red) represents health spending; the red line (not blue) represents gross domestic product per capita.

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Celebrity Workouts and <b>Diets</b> for Women | Weight Loss and Control <b>...</b>

Celebrity Workouts ?nd Diets f?r Women

Article b? Richard Rowsons

Wh?l? ??? m?? b? fascinated w?th celebrity workouts ?nd diets f?r women, r??k?n ?b??t th? people wh? h?l??d such w?ll-kn?wn ladies t? reach th??r fitness goals ?nd th?? ?r? none ?th?r th?n th??r professional personal trainers ?nd experts. More ?ft?n th?n n?t, such professionals m?? h??? b??n th? ones reliable ?n devising those fitness programs customized f?r each female star. Th?? ?? ???t one reason wh? ??? ?h??ld ?l?? hire ???r ?wn personal teacher ?nd n?t ???t rely ?n generic fitness programs. Look ?t h?w those personal trainers h?l??d such female celebrities lose weight ?r stay ?n tiptop shape. Th?t?s h?w fitness professionals work.

If ??? want t? follow one ?f those celebrity workouts ?nd diets f?r women, ??? w?ll eventually need a h?l? ?f a professional personal teacher. Th?t person w?ll determine whether th? celebrity diet ?r workout th?t ??? ?r? tiresome t? follow ?? recommended f?r ??? ?r n?t. Y?? need t? consider th? fact th?t w? ?ll h??? various fitness needs ?nd ?t doesn?t mean th?t a fitness program th?t worked f?r Jennifer Lopez w?ll ?l?? work ?n ???. In th? event th?t ??? ??n pursue th? same workout ?nd diet ?f a female celebrity, ??? Fergie ?r Kim Kardashian, ??? w?ll still need th? guidance ?f a fitness expert.

S?m? examples ?f workouts ?nd diets ?f female celebrities th?t h??? b??n shared over th? Internet ?nd ?n fitness magazines, include Shakira?s workout routine, Lady Gaga?s concert tour diet, Chelsea Handler?s ab workout ?nd diet, LeAnn Rimes? n?w diet, Jordin Sparks? healthy weight loss routine, Jessica Simpson?s exercise program, Cheryl Cole?s ?n?r?d?bl? weight loss secret, Anne Hathaway?s butt exercises, th? Britney Spears workout, Naya Rivera?s fitness tips ?nd more. A? a fan, ??? ??n?t h?l? b?t check out details regarding diets ?nd workouts ?f famed personalities. B?t b? wise ?nd m?k? sure th?t those details ?r? r?ght ?nd ???r sources ??n b? trusted.

Celebrity workouts ?nd diets f?r women m?? vary b?t th?? usually h??? ??m? common grounds. F?r instance, wh?n ?t comes t? diet, ?t?s mostly low carbohydrates ?nd more proteins. Fruit juices ?? natural antioxidants ??n b? ??rt ?f ?n? celebrity diet f?r women. Wh?n ?t comes t? exercises, ?t?s mostly more cardio ?nd more stretching exercises w?th occasional weight lifting f?r female celebrities. Once ??? hire a professional personal teacher, ??? w?ll know more ?b??t th? similarities ?nd differences ?f celebrity fitness.

Y??r hired personal teacher ??n ?l?? inform ??? ?b??t particular components present ?n those celebrity workouts ?nd diets f?r women. One component ??n b? those ??-called sports-inspired workouts. Th??? ?r? usually included t? achieve a lean ?nd well-toned body. Such workouts ??n b? paired w?th cardiovascular exercises. A further possible component ?f celebrity fitness th?t ??? ??n include ?n ???r ?wn ?? dancing workouts; th?? ?? n?t a surprise ??n?? dancing itself ?? b? now a form ?f exercise. F?r th? diet component, ??? ??n learn h?w celebrity women eat five ?r six meals a day w?th particular restrictions ?f course. Th?r? m?? b? ?th?r details ?b??t celebrity fitness th?t ???r select personal teacher ??n share w?th ???.

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