1. Woman is tall and abnormally lean

It has a thick, shiny hair without dandruff, perfectly prepared for any weather, the skin is radiant and wrinkle free for women flawlessly with makeup, clean-shaven men
Still burnt off bronzed woman is tall and abnormally lean because the diet pill washed down with cocktails for weight loss, man is drawing a muscular physique
 Because regular exercise is relaxed, happy and full of energy and may be a bright white smile with perfect teeth.
 People spend thousands for products, services and drugs after repeated failed attempts to work equally youthful, attractive and healthy appearance.
The emphasis that is currently placed on good looks outweighs the evaluation of character, personality, productivity and social benefits.
Surrounding us various ways of pushing to personalize its appearance in the company of recognized.
 Consumer industry is booming, people who buckle under the pressure, rise.
It brings with it a number of disorders which are associated with the need to improve their own body and fight his often alleged shortcomings.
His role in the development of psychological damage also plays an escalating fear of failures and the growing frustration of unfulfilled desire for our economic success-oriented society.
Morbid directivity on your own body, exercise, appearance, fear of unwanted differences doubts related to their own appearance and attractiveness to the opposite sex, often behind eating disorders.

Research By:
http://acnenomore2013.blogspot.com/

Stupid Laws Cause Dangerous Hospital Shortages

Despite popular misconception, this is not a pro-choice vs. pro-life situation.

This week, the American Civil Liberties Union (ACLU) filed a federal lawsuit alleging mistreatment of a woman in the days leading up to her miscarriage at a Catholic hospital in Muskegon, Michigan. The ACLU accuses Mercy Health Partners of negligence for, among other things, failing to direct Tamesha Means to a hospital that could have safely terminated her nonviable pregnancy after her water broke at only 18 weeks gestation.

The details of the hospital staff’s conduct can be found in the complaint. According to the ACLU, Means miscarried as Mercy Health staff members were preparing to discharge her—for the third time in two days.

It might be tempting to view the lawsuit as another attempt by pro-choice activists to force pro-lifers to subsidize or participate in conduct inimical to their moral convictions. But the facts of the case may well point to negligence. I make no claim either way. 

Instead, I wish to point out that Tamesha Means could not have easily gone to another hospital, perhaps one offering the full range of women’s health services, because there is no such hospital. Mercy Health is the only hospital in Muskegon County (population 170,000) and the only one within 30 minutes of Means’ home.

Michigan is one of 28 states that artificially caps the number of hospital beds available in a given region. To open or expand a hospital, health providers must first obtain a “certificate of need” (CON) by convincing state health planners that there is a need for more beds. (Another eight states have CON laws, but have rescinded their rules on hospital beds.)

CON proponents argue that providers will fill every bed they build room for, so restrictions on hospital bed inventories are necessary to hold down costs. Planners also want to ensure the number of beds is sufficient to meet a community’s needs. Michigan thus employs a complicated formula purported to arrive at the precise number of beds necessary to supply, but not oversupply, the market.

Using the formula, Michigan’s Department of Community Health has determined that the Muskegon region has too many beds—exactly 203 too many, in fact. Thus, any potential competitor wishing to enter the market would certainly be denied permission. 

Of course, eliminating waste is all to the good. But labeling all health care delivered after a certain point excessive is ham-handed. One wonders what planners think is happening in the 203 extraneous beds—each day all year. Is each patient who makes use of those beds receiving extraneous care? Of course not—some varying portion of the cost of care for every patient who walks through the door is inflated or otherwise inefficient.

Using certificate-of-need laws to combat costs is an attempt to treat the symptom while ignoring the disease. Moreover, it’s a futile attempt. According to the Federal Trade Commission and multiple academics, the preponderance of the evidence suggests CON laws do not actually restrain health costs.

Despite this evidence, CON laws have their defenders. State hospital lobbies, like the Michigan Health & Hospital Association, naturally welcome rules that protect their profits and clobber potential rivals. Other CON proponents are well-intentioned good-government types who do not trust competition to bring about good outcomes for patients.

But perhaps Tamesha Means would have been better served if the state allowed a competing hospital or two to serve Muskegon.

According to the ACLU, many Catholic hospitals will not terminate a pregnancy until the fetus’ heartbeat stops of its own accord—even when the mother’s life is at risk. Maybe that’s wrong. But using the courts to force Catholic providers to violate deeply held beliefs seems a fruitless strategy. Catholic hospitals are unlikely to implement the ACLU’s policy wish list no matter who wins the case.

A truly pro-choice plan of action would focus on repealing laws that circumscribe patients’ ability to choose from a variety of health providers.

FDA food and safety

The Rhode Island Farm Bureau, in its comments, urged the FDA not to adopt the rules, which it says will “drive a lot of farmers out of business.”

The Wisconsin Farmers Union argued that the proposed “rules could potentially have devastating effects on small and medium sized produce farmers.”

Third, members of the public health community should be commended for criticizing the proposed rules.

The comments of Sam Dickman, a third-year medical student at Harvard University, typified some of the public-health community’s welcome opposition to the proposed rules.

“I am very concerned about the ways that the FSMA rules as currently outlined will threaten the viability of small to midsize family farms and new farmers,” writes Dickman.

Dayna Green-Burgeson, a farmer and registered dietician, commented about her concerns over “the impact that FDA’s proposed FSMA rules will have both on my ability to farm and on my patient’s access to locally grown, healthy and tasty fruits and vegetables at a reasonable price.”

Jane Pearson, a Washington State physician, noted in her comments that she’s “concerned that these additional rules will make it more difficult for [local farmers] to continue supplying our community with healthy food and the support they give to creating healthier environments for us locally.”

And Joseph Kohn, a doctor and farmer, commented that he’s “deeply concerned about the impact that FDA’s proposed rules under FSMA would have on my food business and the farms that I buy food from.”

Finally, I’d be remiss if I didn’t note that opposition to the proposed rules is not universal.

Some commenters view the proposed rules quite differently than I do. Take, for example, a group called the Center for Progressive Reform.

“Not only will it substantially prevent many of the wide-ranging harms associated with contaminated produce,” writes the CPR, commenting in support of the proposed produce rule, “but it will do so at a reasonable cost[.]”

I suppose that’s true, if by “substantially prevent[ing]” harms at a “reasonable cost” the CPR means spending hundreds millions of dollars in order to decrease foodborne illness by somewhere between zero and two percentage points.

So will the FDA adopt these costly rules and crush small farmers? Only time will tell.

Commenters Blast Proposed FDA Food Safety Rules

The comment period for two controversial proposed FDA food safety regulations, part of the Food Safety Modernization Act, closed yesterday. What did commenters have to say?

Earlier this week Keep Food Legal, the nonprofit I lead, submitted formal comments to the FDA in opposition to two proposed food safety rules the agency is currently considering. The comment period closed yesterday.

The proposed rules, mandated thanks to passage of the Food Safety Modernization Act (“FSMA”) in 2011, would increase the regulatory burden faced by fruit and vegetable farmers and other food handlers, packers, and sellers and require many to adopt procedural standards the FDA claims would prevent a small percentage of foodborne illness (between 3.7% and 5.7%, according to Keep Food Legal’s research).

Keep Food Legal also joined with the Farm and Ranch Freedom Alliance and others to submit joint comments authored by FARFA pertaining to an existing amendment to the FSMA, commonly referred to as the Tester Amendment, which requires the FDA to exempt small farmers from many FSMA requirements.

As of noon yesterday, the FDA had received about 12,000 comments on the proposed produce rule and more than 5,000 on the procedural standards rule.

In our independent comments, we urged the FDA to reject the proposed rules for three reasons—1) the proposed rules would hurt small farmers, other small food entrepreneurs, and their customers; 2) the proposed rules, despite their great cost, are unlikely to make food any safer; and 3) the proposed rules violate the U.S. Constitution.

Rather than rehash Keep Food Legal’s comments here, I urge you to read them at our website—and to check out my previous columns (like this one and this one) and my 2012 law journal article on the FSMA and food safety.

Instead, I’d like to highlight a few of those comments I’ve read that were made by others around the country.

In doing so, I won’t pretend to have read (nor to have any intent to read) the thousands of comments submitted to the FDA as part of the rulemakings. But in reading several dozen comments, I’ve noticed some common themes coursing through the comments.

First, small farmers appear to be united in their opposition to the proposed rules.

Tellingly, I did not come across a single commenter who both identified herself or himself as a small farmer and who also supported the proposed rules.

Small farmer Kyle Young’s comments typified those of small farmers opposing the proposed rules. Young referred to himself as “a small farmer utilizing farming techniques that have been safely providing food for humans for the past 10,000 years[.]”

Western Pennsylvania farmers Donald and Rebecca Kretschmann, who grow fruits and vegetables on fifteen acres and sell their produce via a burgeoning CSA program, also commented in opposition to the proposed rules.

“The FSMA has the real potential to make it impossible for small produce growers to make a living by requiring costly and we feel unnecessary alterations to the way produce is handled,” wrote the Kretschmanns.

And small farmer Erica Gruebler commented that she is “deeply concerned about the impact that FDA’s proposed rules under FSMA would have on my farm and business as well as my family.”

The FDA Wants to Ban Berger Cookies, the World's Most Delicious Dessert

The FDA may soon kill off the world’s most delicious dessert—Baltimore’s own Berger Cookies. Please believe I make this claim as one who is not otherwise overly enamored of sweets.

For those who haven’t had the pleasure, we’re talking fudge slathered over a shortbread cookie to rapturous effect.

If you are one who feels another dessert has a better claim to distinction, know that it doesn’t matter. Whatever you’re into will be banned too if it contains artificial trans fats, which the FDA may decide to outlaw as soon as January.

Berger Cookies, whose recipe has been only slightly modified since the 1830s, are obviously not healthy. But they are one of life’s little pleasures, and the law that criminalizes them is an ass. A tremendous, giant donkey and/or posterior. Of evil.

Via Capital News Service:

    In the past two weeks, the Berger Cookie bakery has made two attempts to produce the cookies without trans fat, said owner and president Charles DeBaufre, Jr. The result was discouraging, he said.

“We’ve tried it and trust me, it is nasty. It doesn’t taste right,” DeBaufre said. “The texture’s not there. It’s an entirely different product.”

Trans fats are essential to the taste and flavor of the cookie, DeBaufre said. If the ban goes into effect, he said he would apply for an exception. If the bakery is denied an exception, he said he would continue to test out new recipes or “go out of business, one of the two.”

As Baylen Linneken noted earlier this month, the FDA claims a ban may prevent between 3,000 and 7,000 deaths from heart disease each year. But evidence for this proposition is equivocal at best. New York City banned trans fats in 2006, and the heart disease mortality rate fell. But, says Linneken, it fell faster in the rest of the country—where trans fats are still freely available—over the same period.

The FDA further claims the benefits of prohibiting trans fats would dwarf the costs. But there is no way they could know that. As they acknowledge (PDF), their estimates do not include losses to consumers who find themselves unable to obtain foods they once enjoyed.

This loss will be particularly acute for those who live near or hail from Baltimore, where Berger Cookies are a revered commodity. But the ban will also affect frozen pizzas, microwave popcorn, donuts, and no doubt other local amuse-bouches.    

The nation already has an ample supply of actual, terrifying public health crises like antibiotic-resistant bacteria and critical drug shortages. It would be nice if the agency that professes to protect us from such perils would leave. The cookies. Alone. People can decide what to eat for themselves.

ATF Agents Befriended, Arrested Mentally Disabled People in Stings

Aaron Key wasn't sure he wanted a tattoo on his neck. Especially one of a giant squid smoking a joint.

But the guys running Squid's Smoke Shop in Portland, Ore., convinced him: It would be a perfect way to promote their store.

They would even pay him and a friend $150 apiece if they agreed to turn their bodies into walking billboards.

Key, who is mentally disabled, was swayed.

He and his friend, Marquis Glover, liked Squid's. It was their hangout. The 19-year-olds spent many afternoons there playing Xbox and chatting with the owner, "Squid," and the store clerks.

So they took the money and got the ink etched on their necks, tentacles creeping down to their collarbones.

The vaccination process

In rich countries, few children die of rotavirus diarrheal disease, but it does kill some 500,000 kids living in poor countries annually. Prior to 2006, when vaccines against rotavirus became available, about one in five kids under the age of five in the United States annually came down with it, of which 57,000 were hospitalized. Subsequent to widespread vaccination, hospitalization rates have dropped by 90 percent. Interestingly, rotavirus hospitalizations among older children and young adults who are not immunized have also fallen by around 10,000 annually. Why? Because they are no longer are exposed to the disease in infants who would otherwise have infected them.

Vaccines do not produce immunity in some people, so a percentage of those who took the responsibility to be vaccinated remain vulnerable. This brings us to the important issue of herd immunity. Herd immunity works when most people are immunized against an illness, greatly reducing the chances that an infected person can pass his microbes along to other susceptible people, such as infants who cannot yet be vaccinated, immunocompromised individuals, or folks who have refused the protection of vaccination.

People who refuse vaccination for themselves and their children are free-riding off herd immunity. Anti-vaccination folks are taking advantage of the fact that most people around them have chosen the minimal risk of vaccination, thus acting as a firewall protecting them from disease. But if enough refuse, the firewall comes down and other people get hurt.

Oliver Wendell Holmes articulated a good libertarian principle when he said, "The right to swing my fist ends where the other man's nose begins." Holmes’ observation is particularly salient in the case of whooping cough shots.

Infants cannot be vaccinated against whooping cough, so their protection against this dangerous disease depends upon the fact that most of the rest of us are immunized against it. Unfortunately, whooping cough incidence rates have been increasing along with the number of people refusing immunization for their kids. The annual number of pertussis cases fell to a low of 1,010 in 1976. Last year, the number of reported cases rose to 48,277, the highest number since 1955. Eighteen infants died of the disease in 2012, and half of the infants who got it were hospitalized.

In 2005, an intentionally unvaccinated 17-year-old girl brought measles back with her from a visit to Romania and ended up infecting 34 people. Most of them were also intentionally unvaccinated, but a medical technician who had been vaccinated caught the disease as well and was hospitalized. Despite the medical technician’s bad luck, the good news is that the measles vaccine is thought to protect 99.8 percent of who get the shot. Similarly, in 2008 an intentionally unvaccinated seven-year-old boy sparked an outbreak of measles in San Diego. The boy, who caught the disease in Switzerland, ended up spreading his illness to 11 other children, all of whom were also unvaccinated, putting one infant in the hospital. Forty-eight other kids who were too young to be vaccinated were quarantined.

To borrow Holmes’ metaphor, people who refuse vaccination are asserting that they have a right to “swing” their microbes at other people. There is no principled libertarian case for their free-riding refusal to take responsibility for their own microbes.

Refusing Vaccination Puts Others At Risk

A pragmatic argument for coercive vaccination
Vaccination Candy box Images: dreamstimeA significant proportion of Americans believe it is perfectly all right to put other people at risk of the costs and misery of preventable infectious diseases. These people are your friends, neighbors, and fellow citizens who refuse to have themselves or their children vaccinated against contagious diseases.

There would be no argument against allowing people to refuse vaccination if they and their families would suffer alone the consequences of their foolhardiness. It would be their right to forego misery-reducing and life-preserving treatments. But that is not the case in the real world.

The University of Pittsburgh’s Project Tycho database, launched last week, quantifies the prevalence of infectious disease since 1888 in the United States. Drawing on Project Tycho data, a November 28 New England Journal of Medicine article concluded that vaccinations since 1924 until now prevented 103 million cases of polio, measles, rubella, mumps, hepatitis A, diphtheria, and pertussis. While the NEJM article did not calculate the number of deaths avoided as a result of vaccination, one of the study’s authors estimates that number is between three and four million.

People who don’t wish to take responsibility for their contagious microbes will often try to justify their position by noting the fact that the mortality rates of many infectious diseases had declined significantly before vaccines came along. And it is certainly true that a lot of that decline in infectious disease mortality occurred as a result of improved sanitation and water chlorination. A 2004 study by the Harvard University economist David Cutler and the National Bureau of Economic Research economist Grant Miller estimated that the provision of clean water “was responsible for nearly half of the total mortality reduction in major cities, three-quarters of the infant mortality reduction, and nearly two-thirds of the child mortality reduction.” Improved nutrition also reduced mortality rates, enabling infants, children, and adults to fight off diseases that would have more likely killed their malnourished ancestors.

But vaccines have played a substantial role in reducing death rates too. An article in the Journal of the American Medical Association compared the annual average number of cases and resulting deaths of various diseases before the advent of vaccines to those occurring in 2006. Before an effective diphtheria vaccine was developed, for example, there were about 21,000 cases of the disease each year, 1,800 of them leading to death. No cases or deaths from the disease were recorded in 2006. Measles averaged 530,000 cases and 440 deaths per year before the vaccine. In 2006, there were 55 cases and no deaths. Whooping cough saw around 200,000 cases and 4,000 deaths annually. In 2006, there were nearly 16,000 cases and 27 deaths. Polio once averaged around 16,000 cases and 1,900 deaths. No cases were recorded in 2006. The number of Rubella cases dropped from 48,000 to 17, and the number of deaths dropped from 17 to zero.

With the latter disease, the more important measure is the number of babies, born to rubella-infected mothers, who suffered from disease-induced birth defects, such as deafness, cloudy corneas, damaged hearts, and stunted intellects. Some 2,160 infants were afflicted with congenital rubella syndrome as late as 1965. In 2006 it was one.

The risk that infectious diseases will kill innocent bystanders is not the only issue. Sheer misery counts too. The fevers, the sweats, the incessant coughs, the runny noses, the itchy rashes, and the lost days at work must be taken into account, too. And, of course, many people end up in the hospital as a result of infectious disease.

Before a chicken pox vaccine became available, upwards of four million kids got the disease every year, of which 11,000 were hospitalized and 105 died. In 2004, the estimated number cases had dropped to 600,000, resulting in 1,276 hospitalizations and 19 deaths. Before the measles vaccine was introduced in 1962, some 48,000 were hospitalized and 450 died of that infection each year. So far this year there have been 175 cases and three hospitalizations. A 1985 study by Centers for Disease Control and Prevention epidemiologist in the journal Pediatrics estimated that the first 20 years of measles vaccination in the U.S. had prevented 52 million cases, 5,200 deaths, and 17,400 cases of mental retardation.

Obamacare's Hidden Tax on Your Health Insurance

U.S. GovernmentOn November 29, as most Americans staggered through a tryptophan-induced haze, the federal government published final rules (PDF) for the Health Insurance Providers Fee—or Health Insurance Tax, to be more honest. It's a strange fee; one for which the amount to be collected is predetermined, and then parceled out among each "covered entity" that charges premiums for health coverage, proportionate to the insurer’s share of net premiums. Which is to say, it's a tax that hits individuals, and small-to-medium-sized businesses that have to pool risks, but explicitly excludes the sort of "self-insured plan" offered by large employers. Unless you work for a large company that self-insures, you can expect the fee to be passed on and to add a couple of percent to the cost of your health coverage.

Health Insurance TaxU.S. GovernmentHow much the tax will add to your bill is a bit of a guessing game, since the government has already decided how much it will collect, but the size of the market is a bit up in the air in the age of crashing government Websites and legally required policy cancellations. Buried on page 832 (yes, really) of the Patient Protection and Affordable Care Act (PDF) is Section 9010(e), which announces, bluntly, that the IRS will collect:

    $8 billion in 2014
    $11.3 billion in 2015
    $11.3 billion in 2016
    $13.9 billion in 2017
    $14.3 billion in 2018

After that, "the applicable amount shall be the applicable amount for the preceding calendar year increased by the rate of premium growth."

It's good to have confidence in how much revenue you'll collect, isn't it? I'll bet the health insurance providers who will be passing this tax on to their customers wish they had the same confidence.

In fact, the new tax is enough of a concern that insurers, like Aetna, are distributing brochures (PDF) explaining why premiums are subject to a somewhat unpredictable new levy. "Because the new federal fee will impact the cost of plans going forward," cautions Aetna, "we feel it’s important for you to understand this fee. By doing so, you can better anticipate and plan for the expected impacts."

How much will the new tax add to the average health coverage bill? The Heritage Foundation's David R. Burton says it "will increase individual and small group health insurance premiums by an additional 2–3 percent."

Douglas Holtz-Eakin, president of the American Action Forum and former director of the Congressional Budget Office, performed detailed calculations of the costs Obamacare is likely to inflict on health care, and predicts the "anticipated impact is as much as 3 percent or nearly $5,000 per family over a decade."

When the Obama administration promised us cost control on health care, we should have realized that meant upwards.

Canada to Cop: It's OK to Smoke Pot, Just Not In Uniform

Canada to Cop: It's OK to Smoke Pot, Just Not In Uniform

As marijuana grows more socially and legally acceptable, the political issues around it evolve:

Dude, I'm so high right now.Cpl Ronald Francis, an officer with more than 20 years' service in the eastern province of New Brunswick, has a medical prescription that allows him to take up to 3g of the drug daily to treat symptoms of post-traumatic stress disorder, Canadian broadcaster CBC reports. While senior officers have said that his marijuana use is fine under Canadian medical and human rights laws, they have drawn the line over smoking in public while wearing the [Royal Canadian Mounted Police]'s famous red serge uniform. Assistant commissioner Gilles Moreau told CBC that "it would not portray the right message to the general public, it's definitely not something we would support or condone."

If only all our drug debates were like this one.

NYC Health Commissioner Says E-Cigarettes Must Be Banned Because They Look Like the Real Thing

FIN e-cigarette adFIN e-cigarette adYesterday the New York City Council held what The New York Times describes as "one of the most scientifically vague and emotionally charged health committee hearings in recent memory." The scientifically vague part was the justification offered by supporters of a ban on the use of electronic cigarettes in "public places" such as bars and restaurants. The main sponsor of the proposed ban, Councilman James Gennaro, has said it is aimed at protecting children who might mistake e-cigarettes for the real thing, conclude that smoking must be cool again, and proceed directly to a pack-a-day habit that will endanger their health and shorten their lives. Perhaps recognizing that some people might deem this scenario implausible, ban backers offered a few more arguments at yesterday's hearing:

The health commissioner, Dr. Thomas A. Farley, said electronic cigarettes were such a recent invention that he could not say whether they were hazardous to the health of those smoking them or those who might breathe in secondhand vapor. He said that they do put out fine particles and chemicals, and "I certainly can't guarantee that that is safe."

He said the problem with e-cigarettes was that they made smoking socially acceptable, and that they were a "bridge" for people who went back to smoking regular cigarettes.

"Does it help people quit, or does it help people not quit?" Dr. Farley asked, rhetorically.

Then Dr. Farley indulged in a bit of theater himself, fishing around in his shirt pocket, saying, "Just to give you an idea, I've got one here somewhere," before pulling out an electronic cigarette that he pronounced "indistinguishable" from a real one. He and other supporters of the ban say e-cigarettes confuse people like bartenders and restaurant owners who have to enforce the existing smoking ban, making that ban harder to enforce.

The rationale for the smoking ban was protection of bystanders, and Farley concedes there is no evidence that e-cigarette vapor—which consists almost entirely of propylene glycol (an FDA-approved food additive) and water, plus nicotine and flavoring agents—poses a risk to vapers, let alone the people around them. Still, he "can't guarantee" it is safe, since  e-cigarettes "do put out fine particles and chemicals." So do cooking, perfume, and diner flatulence. Can Farley guarantee those are safe? If not, shouldn't he be demanding a ban on these emissons as well?

Farley supplements Gennaro's concern about confused children with sympathy for confused bartenders and restaurateurs, who might tell a patron "you can't smoke in here," only to discover that he is in fact vaping. To spare them the embarrassment of such a faux pas, Farley proposes making it illegal to impersonate a smoker. That is one approach. Another would be for the managers of bars and restaurants to instruct their employees in the differences between a burning stick of dried vegetable matter and an e-cigarette, which contains no tobacco and produces no smoke. It is even possible that waiters and bartenders have begun to figure this out on their own. But if bar and restaurant owners do not want to deal with this hassle, they can always ban vaping in their establishments, keeping in mind that they might lose some customers to vaper-friendly competitors.

Farley's third argument is that e-cigarettes are a "bridge" that leads former smokers back to conventional cigarettes. As with secondhand vapor, there is no evidence whatsoever to support this hypothesis, and the hearing room was full of former smokers who had the opposite experience: E-cigarettes helped them stop smoking, thereby dramatically reducing the health risks they face. That was what made the hearing "emotionally charged": A bunch of self-righteous, know-it-all politicians and bureaucrats want to legally ostracize people who have found a much less dangerous way to get their nicotine fix. By lumping vaping in with smoking, an e-cigarette ban will discourage other smokers from trying a product that could literally save their lives. All in the name of health.

Obamacare’s Website Is Working

Obamacare’s Website Is Working (Somewhat) Better—But It’s Still Going To Have a Tough Time Hitting Its Sign-Up Goals

Funny how quickly Obamacare data leaks when it’s reasonably good news. During the initial days of Obamacare’s launch, federal officials repeatedly refused to provide enrollment data. Health and Human Services Secretary Kathleen Sebelius and Press Secretary Jay Carney even claimed they didn’t have.

Leaked notes from the administration’s Obamacare “war room” later revealed that just six people made it all the way through the federal exchange system, which covers 36 states, on day one. And despite the denials from administration officials, the low number was known and discussed inside parts of the administration by the second morning the exchanges were online. Eventually we found out that during the entire month of October, just 27,000 people signed up for health insurance plans through HealthCare.gov—a figure that the administration waited until the middle of November to release.

But now that the consumer end of the federally run insurance portal is working somewhat better, sign-up data is leaking on a daily basis. In the last three days alone, some 56,000 people have picked plans through the site, including about 27,000 on Tuesday alone, according to a report in The Washington Post citing sources familiar with the numbers.

Working "better" is, of course, a pretty low bar, since the federal insurance portal was barely working at all for the month of October. But there’s no question that this represents a meaningful improvement in site performance, at least on the consumer side.

Yet these numbers don’t necessarily point to success for the law. For one thing, it’s not certain that all of the people being counted in these tallies will actually be enrolled. As The Hill noted yesterday when the first two days of sign-up numbers leaked, these enrollees are “people who chose plans but had not necessarily paid their first premium.” The (likely administration-connected) sources tipping reporters to these numbers say the administration is counting these individuals as having enrolled. But as a CNN story today points out, no one is actually enrolled without paying the first month’s premium. According that story, one insurer in Indiana has recieved payment from just 20 percent of applicants. So these numbers may be overstating the true enrollment levels within the federal exchange system.

Nor does this take into account the ongoing problems with transmitting accurate enrollment information to insurers. Sources told The Washington Post earlier this week that roughly a third of enrollments were affected by these errors. Insurers say that in some cases, enrollment data isn’t being transmitted at all.

Even if you assume that everyone ends up enrolled, the current trajectory probably doesn’t put the administration on track to hitting its goal of enrolling seven million people in private coverage through the law by the end of March.

At an average of about 19,000 sign-ups per day, the result would be about 2.3 million enrollments in the federal system. State-run exchanges will add to that total, but not enough to get it close to the goal: California, the biggest of the states running its own exchange, is only aiming to get 500,000-700,000 individuals signed up by the end of March, and most of the other states are relatively small.

Of course, enrollment almost certainly won’t proceed on an evenly distributed basis. The experience of Massachusetts with Romneycare suggests that there will probably be a significant spike in enrollment right before the individual mandate kicks in, although the enrollment numbers there are so low, relatively speaking—just over 8,000 people enrolled in the final month before the mandate kicked in—that it’s hard to draw a strong conclusion about how much the Bay State’s enrollment patterns will be replicated on the much larger national scale.

I would also expect that there’s a (smaller) surge of activity during the early part of this month. The website is finally performing well enough to be usable for many people; December 23 is the (revised) deadline to get coverage that kicks in on January 1; and Medicare private exchanges typically experience a spike in enrollment during the week after Thanksgiving. My best guess, then, is that we’ll see somewhat higher sign-up activity this month, slightly lower numbers in January and February, and a big jump in March. But since nothing on this scale has ever been tried before in the U.S., no one really knows. But the point is that the administration will need to significantly boost the average number of sign-ups in order to meet their enrollment target.

Finally, it’s worth remembering that the headline enrollment total, whatever it turns out to be, isn’t the only number that matters. As the administration has indicated repeatedly, it’s also important that health plans manage to sign up the right demographic mix, with enough young and healthy individuals to balance out the older and sicker beneficiaries. Already, there are signs that young adults are may spurn the law and its coverage scheme, with more than half of young adults aged 18-29 disapproving of the law, believing it will make their care more expensive, and saying they are unlikely to enroll in coverage.

The administration, meanwhile, hasn’t released demographic breakdowns of people who have signed up so far, which is telling enough. Since enrollees have to provide their age and other personal information, we know that the data on the demographic composition of sign-ups so far exists. And since we also know that good news leaks, and bad news doesn’t, it’s probably safe to assume that whatever information the administration has isn’t particularly good.

Obamacare's buggy implementation

The fact that these critical systems haven't been built—months after the launch of the exchanges and with just weeks to go until insurers need to start being paid—makes it clear that the implementation effort still lags far behind. And if the rollout of portions that remain incomplete resembles the rollout so far, that means there are lots of new problems still to come.

But it’s not just that there’s a lot of work still to do. The insurer payment workaround also highlights how much of Obamacare's buggy implementation is still being managed on a temporary, ad hoc basis. The administration is flying a broken vessel without a flight plan.

Significant delays started early this year, when the administration decided to hold off on implementing the single most critical part of the small-business exchange system. Then, in mid-summer, reporting requirements for employers, along with the employer mandate and income verification requirements, were delayed too. Since the launch of the law, we've seen further delays in the Spanish language website, Medicaid data transfer systems that are necessary to facilitate coverage, and the federal small-business exchange, which has now been completely delayed by a year. Last month, the White House proposed an administrative tweak in response to public anger over a wave of plan cancellations, one that, if it has a significant effect, could further undermine the health law's enrollment scheme.

The legal authority to implement many of these changes is dubious, but the administration seems more concerned with charging ahead than with accounting for legal niceties. As with the insurer payment tweak, if need be, they'll sort it all out later.

These aren’t the signs of an administration that is prepared to effectively handle the rollout of the largest and most complicated domestic policy in a generation; quite the opposite. They’re the signs of an administration that is struggling keep its signature initiative afloat, somehow. They’re just making it as they go along, and hoping that eventually it all works out.

Will this latest workaround buy the administration some time? Perhaps. Insurers seem to prefer it to the alternative of not getting paid. But buying time is about all it will do.

It's also worth remembering what happened the last time Obama pointed people frustrated with the online system toward a manual alternative: It turned out that the call centers and the pen-and-paper enrollments he said could help move people through the enrollment process were dependent on the same broken web system that was causing all the problems in the first. It was a workaround that didn't work. Ultimately, what the long list of tweaks, delays, and temporary patches to the law suggest is that, as passed, written, and envisioned by its Democratic authors, the law itself doesn’t work either.

Obamacare Insurance Workaround

Obamacare Insurance Workaround Reveals Law that Remains Unfinished, Unaccountable, and Unworkable
The latest tweak reveals how much of the health law's basic architecture is still incomplete.

October, when it became clear that Obamacare's online enrollment system wasn't functioning, President Obama gave a speech in which he told people who wanted to sign up to contact call centers instead, or fill out pen and paper applications.
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 This week, the administration announced that it would be employing another manual workaround, this time for critical insurer payment systems. In this case, it's not because the payment system is broken. Instead, it’s because the part of the system that is supposed to both calculate how much money the government owes insurers in premium subsidy and cost-sharing payments and make the appropriate payments simply hasn't been built yet.

What hasn't been built can’t be used, but insurers need to be paid in order for the system to function. So the administration has decided to require insurers to estimate how much they are owed and submit payment requests manually. Later, after the systems are built, the plan is to sort out the details and figure out the exact amounts that should have been billed, then reconcile any differences.

Because it deals with the insurance industry side of the system, this temporary, technical tweak will probably garner far less attention than the ongoing problems with the consumer side of the federal exchange system. But the on-the-fly patch offers a revealing moment for the law all the same, one that highlights how unfinished, unaccountable, and unworkable the health law continues to be.

On the most basic level, the newly proposed patch suggests how much work remains on simply constructing the essential technical infrastructure necessary to make Obamacare's exchange-based insurance scheme work. Some 30 to 40 percent of the functionality remains incomplete, according to Henry Chao, the Medicare technology official who oversaw the development of the exchanges. And the features that remain to be built are vital to the system’s functionality.

The core service that health insurers provide is paying for eligible claims by beneficiaries. But if insurers don't get paid themselves, they can’t cut checks for those claims. Some of the larger insurers could finance delays, at least for a little while, but as former Medicare official Kevin Lucia tells Reuters, smaller insurance plans, which are heavily represented in the health law’s exchanges, aren't well equipped to do so. Plan providers need that money, and they need it soon if they're going to be able to actually provide insurance to their plan members.

Religious Freedom Restoration Act and contreseption

Such a requirement, the Greens and the Hahns argue, violates the Religious Freedom Restoration Act (RFRA), which says "government may substantially burden a person’s exercise of religion" only if it is "the least restrictive means" of serving a "compelling governmental interest." Congress passed RFRA almost unanimously in response to a 1990 Supreme Court decision that loosened the restraints on laws that limit religious freedom.

Last June the U.S. Court of Appeals for the 10th Circuit ruled that the contraceptive mandate probably fails RFRA's test, opening the way to a preliminary injunction barring the government from enforcing the rule against the Greens. A month later the U.S. Court of Appeals for the 3rd Circuit rejected the Hahns' RFRA claim, declaring that "a for-profit, secular corporation cannot engage in the exercise of religion."

Money changes everything, I guess. As the 10th Circuit pointed out, it is well established that nonprofit corporations such as churches can "engage in the exercise of religion." The Obama administration conceded as much when it exempted houses of worship from the contraceptive mandate.

Furthermore, the Supreme Court has heard religious freedom claims by Jewish merchants who challenged a Sunday closing law and by an Amish employer who objected to paying Social Security taxes. If people do not lose their religious liberty when they create nonprofit corporations or when they start businesses, why should they sacrifice this right when they combine the corporate form with a monetary motive?

The Supreme Court has repeatedly held that for-profit corporations (such as the New York Times Company) are protected by the First Amendment, recognizing that such organizations are one way individuals exercise their rights to freedom of speech and freedom of the press. The same is true of religious freedom.

To insist otherwise requires a kind of compartmentalization that is anathema to people whose faith infuses the way they do business. "Since Conestoga is distinct from the Hahns," the 3rd Circuit averred, "the Mandate does not actually require the Hahns to do anything." Maybe the court could explain that to God.

Obamacare and Contraception Exceptions

How mandatory birth control coverage violates religious liberty.

For many Americans, religion is something you do on weekends and holidays. For others, it is the central organizing principle of life. That split helps explain the dispute over Obamacare's requirement that businesses pay for their employees' contraceptives, which is the focus of two cases the Supreme Court agreed to hear last week.

President Obama says forcing employers to provide 100 percent coverage for 20 kinds of contraception is a straightforward matter of "public health and gender equality." He nevertheless recognizes that the rule runs afoul of certain religious doctrines, which is why he exempted churches and offered to accommodate church-affiliated organizations such as hospitals and universities by routing contraceptive coverage through a middleman.

But the idea that a profit-making enterprise could raise an equally valid religious objection to the mandate seems beyond the president's ken. After all, business is business, and religion is religion.

That is not how David and Barbara Green see it. The Greens, who together with their three children own the Oklahoma-based craft store chain Hobby Lobby, are dedicated to "honoring the Lord in all we do by operating the company in a manner consistent with Biblical principles."

Norman and Elizabeth Hahn, Mennonites who together with their three sons own Conestoga Wood Specialties, a Pennsylvania cabinet manufacturer, likewise do not leave their religious scruples at the threshold of their business. Conestoga declares, for example, that "human life begins at conception," adding that "it is against our moral conviction to be involved in the termination of human life through abortion, suicide, euthanasia, murder, or any other acts that involve the taking of human life."

Both the Greens and the Hahns believe certain forms of contraception (IUDs and pills taken after intercourse) fall into that category because they can prevent implantation of a fertilized ovum. They therefore believe that forcing them to pay for those contraceptives makes them complicit in the taking of human life.

One Third of Obamacare's Federal Exchange Enrollments Are Buggy

Since shortly after the October 1 launch of Obamacare's exchanges, we've been hearing complaints from health insurers about the transmission of enrollment data through the federally run insurance portal, HealthCare.gov. It's not coming through correctly, industry officials have said. In some cases, it's not coming through at all.

But until now, there's been little indication of how many people were affected by the problems. According to The Washington Post, the errors are pervasive.

 The errors cumulatively have affected roughly one-third of the people who have signed up for health plans since Oct. 1, according to two government and health-care industry officials. The White House disputed the figure but declined to provide its own.

The mistakes include failure to notify insurers about new customers, duplicate enrollments or cancellation notices for the same person, incorrect information about family members, and mistakes involving federal subsidies. The errors have been accumulating since Health Care opened two months ago, even as the Obama administration has been working to make it easier for consumers to sign up for coverage, the government and industry officials said.

Government sources tell the Post that so far about 149,000 people have signed up for plans within the federal exchange system, which covers 36 states. More have picked plans within the state-run exchanges. But two months after launch, enrollment totals still lag far behind the administration's goal of 500,000 private insurance sign-ups for just the month of October.

And in part because of the transmission errors, many of the people who have signed up are still not fully enrolled, according to the Post:


The errors, if not corrected, mean that tens of thousands of consumers are at risk of not having coverage when the insurance goes into effect Jan. 1, because the health plans they picked do not yet have accurate information needed to send them a bill. Under the 2010 law designed to reshape the health-care system, consumers are not considered to have coverage unless they have paid at least the first monthly insurance premium.

In theory, discrepancies between federal enrollment records and data received by insurers is supposed to be run through a monthly comparison process. But that can't happen yet. As the Post notes, "The part of the online system that is supposed to perform this comparison, known as 'reconciliation,' is not yet built, according to government officials."

Nurse Practitioners Can Make Health Care Cheaper

 And Doctors Want to Stop Them.
"The major motivation in this opposition is kind of a turf war," says Dale Ann Dorsey, a nurse practitioner (NP) who runs her own women's health clinic in Scottsdale, Arizona.

A nurse practitioner is a registered nurse (RN) who has pursued extra clinical training and a master's degree and is able to practice medicine beyond the scope of what a regular RN can. How far beyond that scope NPs should be allowed to go is a question facing legislators across the country.

Arizona is one of 18 states that allow nurse practitioners to run independent primary care practices, with full prescribing privileges, and without the oversight of a licensed physician. Earlier this year, nurse practitioners in California pushed to liberalize scope-of-practice rules in the Golden State, only to be stopped dead in their tracks by the powerful California Medical Association (CMA), which poured more than $1 million into lobbying efforts in the first half of 2013 to defeat the legislation.

"[Nurse practitioners'] training is very limited compared to physicians," says Paul Phinney, a California pediatrician and former CMA president. "They lack a certain kind of experience that I believe is very important to the safety of patients and the quality of medical care that they're providing."

He has a point. Physicians are required to obtain far more education and clinical experience than are nurse practitioners. But there's little to no evidence showing that, when it comes to primary care, all of that extra education makes any difference in the health outcomes of patients. A 2012 Health Affairs survey of the medical literature found no difference in patient health between groups treated by doctors and by nurse practitioners. The survey did find a slightly higher satisfaction rate among patients of nurse practitioners.

So if outcomes are similar, and patients are satisfied, why are states such as California hesitant to let more nurses open their own practices? The question is especially pressing since groups such as the Association of American Medical Colleges are expecting a severe doctor shortage in the near future due to the aging population. Reason Foundation analyst Adam Summers says that concern for the public good is a secondary consideration at best in this case.

"Licensing laws are almost always sold as being in the public interest," says Summers. "But in reality all they do is drive up prices and reduce competition, which reduces the incentive to provide good services to the consumer."

Leaked U.N. Document Highlights Drug War Dissent

 An internal U.N. document leaked to The Guardian offers a rare glimpse of disagreement about drug policy among member states, several of which are advocating a less violent approach. The document, a draft of a policy statement scheduled to be released next spring, suggests a breakdown in the international consensus supporting the forcible suppression of politically disfavored pharmacological tastes:

Ecuador is pushing the UN to include a statement that recognises that the world needs to look beyond prohibition. Its submission claims there is "a need for more effective results in addressing the world drug problem" that will encourage "deliberations on different approaches that could be more efficient and effective."

Venezuela is pushing for the draft to include a new understanding of "the economic implications of the current dominating health and law enforcement approach in tackling the world drug problem", arguing that the current policy fails to recognise the "dynamics of the drug criminal market."...

Norway wants the draft to pose "questions related to decriminalisation and a critical assessment of the approach represented by the so-called war on drugs." Switzerland wants the draft to recognise the consequences of the current policy on public health issues. It wants it to include the observation that member states "note with concern that consumption prevalence has not been reduced significantly and that the consumption of new psychoactive substances has increased in most regions of the world." It also wants the draft to "express concern that according to UNAids, the UN programme on HIV/Aids, the global goal of reducing HIV infections among people who inject drugs by 50% by 2015 will not be reached, and that drug-related transmission is driving the expansion of the epidemic in many countries."

 The EU is also pushing hard for the draft to emphasise the need for drug-dependence treatment and care options for offenders as an alternative to incarceration.

"Drug users should be entitled to access to treatment, essential medicines, care and related support services," the EU's submission suggests. "Programmes related to recovery and social reintegration should also be encouraged."

With the exception of Ecuador, this is pretty mild stuff, especially at a time when former presidents of Latin American countries have publicly called for an end to the war on drugs and two U.S. states, along with Uruguay, have taken a big step in that direction by legalizing marijuana. But in the context of U.N. policy statements, which are usually organized around mindless mantras like "A Drug-Free World by 2000," these deviations from prohibitionist orthodoxy seem almost radical.

"The idea that there is a global consensus on drugs policy is fake," Damon Barrett, deputy director of Harm Reduction International, tells The Guardian. "The differences have been there for a long time, but you rarely get to see them. It all gets whittled down to the lowest common denominator, when all you see is agreement. But it's interesting to see now what they are arguing about."

Jacob Sullum is a senior editor at Reason magazine

High-cost government-run health program

If other high-cost government-run health programs are any indication, there's a significant risk of large-scale fraud, abuse, and waste.

Medicare's payment system is rife with bad payments, some of which are billing errors and some of which are outright fraud. A 2011 review by the Government Accountability Office (GAO), for example, estimated that the system made some $48 billion in improper payments each year. That's about 10 percent of Medicare's budget. The problem has always been that there are very few checks on who can bill the system. As I noted in a 2011 story on fraud in government health systems, a 2008 GAO report found that it's possible to set up shop billing Medicare with little more than a few forged documents and a dummy phone number—one that went to an empty desk at GAO's office. Medicaid, the health program for the low-income and disabled, has been similarly plagued by abuse and outright fraud.

This has been going on for years, and yet relatively little has been done to stop it. Under the Obama administraiton, Medicare's managers have taken some steps to address fraud and abuse in the system, but at best these efforts have succeeded only at marginally reducing the problem, cutting out a few billion dollars in wasteful or fraudulent spending each year. The magnitude of the problem is still pretty enormous, and what the IRS IG report suggests is that it may soon grow to encompass Obamacare as well.