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Posts Tagged ‘Medicaid’

H-Hour by Christine Doyle

I was going to title this post D-Day but decided that was too harsh since it refers to the day a military attack is unfurled.  Too many people, on both sides of the aisle, view Obamacare in military terms. In fact, the whole fight mentality is part of the problem. It has caused a lot of Americans to tune out exactly when they need to dial in and be informed. We need to be realistic and reasonable in how we approach healthcare reform because everyone agrees costs have spiraled out of control at exactly the time when government resources are strapped. Since we’re talking about healthcare, it seems H-Hour is a more appropriate term for this post.  The hour has arrived when Americans are confronting healthcare reform. Today is the deadline when those without insurance have to sign up or face penalties of either 95 dollars or 1% of their incomes, whichever is greater. I signed up last week, paid my first premium and am now feeling relief that I am protected in a catastrophic event. Having said that, I am far from satisfied with the outcome.

I don’t qualify for assistance (nor would I ask for it) and don’t mind paying a little more for coverage, as long as doing so opens the umbrella to those who have never been able to get it. I was willing to pay a little more but didn’t want to have to give up what was working. I did choose to go through a private insurer who knew me and my health history.

What I got is very different from what I wanted. I am happy that 100 percent of preventive care is covered (yoga isn’t but chiropractic care is) and wanted continuity of care by still having access to my same doctors.  Like many Americans, I have always chosen my doctors based on a variety of factors, including experience, referrals, professional credentials and history. Imagine my concern that I am now paying about the same in premiums but none of my doctors will be participating in my plan. And guess what? I don’t blame them. Why should an excellent doctor accept brokered payments that reduce their compensation while adding additional costs to their practices and mandates over what tests doctors should or should not be ordering? There is a reason we have the best healthcare in the world. Traditionally, we have valued good doctors.

A friend whose husband is an undeniable do-gooder (he works to promote green energy, for goodness sake!) is now paying 15,000 dollars a year to get her family of four covered. Wow. That was unexpected. A young relative, who is a gifted artist and was uninsured, is having to apply for a full-time job to get benefits after his parents got a bill for 60,000 dollars after he was treated for appendicitis.  Here in Missouri, a prominent Republican, formerly an outspoken foe of Obamacare, is now advocating for this state to expand Medicaid. That’s because hospitals, who have no where to turn when dealing with patients who have fallen between the cracks, are overwhelmed by these new costs. Personally, I recognize that the Affordable Care Act means someone like me won’t be denied coverage for run of the mill problems like high blood pressure and the occasional stiff neck and shoulder. But, states should be concerned about taking money to expand Medicaid when funding could run out, when only a 1/4 of the enrollees are young and healthy, when so many Americans, especially Latinos, seem uncomfortable trusting the Federal Government with such personal concerns as their medical histories. And so many small businesses simply can’t afford to comply with the mandate to provide health insurance.

The latest polls show only a 1/4 of Americans are happy with the Affordable Care Act as it stands. The thing that irritates them the most is the mandate or penalty if they don’t sign up. It motivated me because I didn’t want to pay 1% of my income. Most polls show most Americans like that those with pre-existing conditions can no longer be barred from coverage. Americans did soften in their opposition to Obamacare over the last couple of months but only incrementally. And fewer are in favor of an outright appeal. It’s time for Republicans to promote a reasonable response that includes an acknowledgement that something needs to be done. I don’t have the answers but I do hope we can stop short of trying to fix what isn’t broken and just fix what is.

 

 

 

States Experimenting to Lower Health Care Costs / Associated Press

 

As states work on implementing the complex federal health care reforms, some have begun tackling an issue that has vexed employers, individuals and governments at all levels for years — the rapidly rising costs of health care. The success of models that are beginning to emerge across the country will ultimately determine whether the Affordable Care Act can make good on its name.

It’s too early to tell what will work and what won’t, but states, insurers and medical groups are experimenting with a variety of programs to contain costs without undermining care. These test runs come as millions of new patients will gain eligibility for health insurance under the federal law, putting additional pressure on the system.

“Look at any of the long-term projections for the federal budget or for state budgets,” said Alan Weil, executive director of the National Academy for State Health Policy. “If we don’t bring down health care costs, we’re either going to be paying a whole lot more in taxes or we’re going to stop spending money on other things we care about.”

The Affordable Care Act is expected to extend coverage to many of the roughly 50 million Americans who lack insurance by expanding Medicaid, the state-federal health care program for low-income people, and requiring most others to purchase insurance or pay a fine.

Often overlooked are the law’s efforts to stabilize constantly rising costs.

U.S. health care spending reached $2.7 trillion in 2011, or $8,700 per person, according to the Centers for Medicare and Medicaid Services. The agency says those numbers are climbing and predicts spending will reach $14,000 per person by 2021.

The higher costs mean higher premiums for businesses, which are passing on more of those expenses to their employees, and for individuals, who are seeing a rise in out-of-pocket costs.

In the Portland area, spiking costs have forced Steve Ferree to reduce the benefits he offers his 32 employees at the Mr. Rooter Plumbing franchise he owns.

“We feel bad about it,” he said. “We do provide good insurance, and we want to make sure we take care of folks, so that’s a tough decision to make.”

Premiums for employee-only coverage have spiked 65 percent since 2006, Ferree said, and employee and spouse plans rose 90 percent. Workers cover a quarter of the premium.

The struggles of business owners such as Ferree illustrate the difficulty of finding solutions, even in a state that has been held out as a potential national model for savings.

The recession provided what is expected to be a temporary reprieve, with health care costs slowing to 3.9 percent annually between 2009 and 2011, the slowest growth rate since the government began keeping track in 1960, according to data from the Centers for Medicare and Medicaid Services. Over the preceding 18 years, per capita health care costs grew an average of 6.5 percent a year.

Yet despite the recent slowdown, health care costs continue growing faster than both wages and the economy as a whole, accounting for an ever-larger share of spending for employers and workers alike. It now accounts for nearly 18 percent of U.S. economic activity, up from 5 percent in 1960.

Annual premiums for employer-sponsored family coverage jumped nearly 4 percent this year, and single coverage rose almost 5 percent, according to a report released last week by the nonprofit Kaiser Family Foundation. The foundation expects prices will begin rising faster as the economy improves.

many FACTORS

Economists say soaring health care costs are driven primarily by industry consolidation and expensive new medical technologies and prescription drugs.

The Affordable Care Act’s cost-containment section reduces Medicare reimbursements to providers and requires commercial insurance companies to issue refunds if more than 20 percent of their revenue goes to profits, salaries and overhead. Hospitals will face penalties when patients develop conditions while in their care.

The federal law also promotes “accountable care organizations” within Medicare, which are charged with improving coordination to reduce wasteful spending.

But much of the experimentation on reducing costs is driven by state governments and private businesses.

Oregon has tried to tackle rising costs by focusing on Medicaid, which serves 550,000 people in the state and is expected to grow by 200,000 under the Affordable Care Act’s Medicaid expansion that starts next year.

Gov. John Kitzhaber spearheaded last year a new model of delivering services under Medicaid. His initiative led to a state law that set up “coordinated care organizations,” which attempt to integrate mental, physical and dental care as they improve the way chronic conditions are managed. These organizations are required to manage their costs within a fixed rate of growth.

Some coordinated care groups are hiring staff to work intensely with Medicaid patients who frequently visit the emergency room.

“We try to deal with the medical part. But everything they go through, we have to take into account, because if you don’t have money to pay your bills, you’re going to have stress” that complicates medical problems, said Ruby Ibarra, a community health specialist for Multnomah County, which is part of a coordinated care organization in the Portland area.

Elsewhere in the state, Trillium Community Health Plan in Eugene has a program starting this month that gives up to $200 in prepaid debit cards to pregnant mothers who quit smoking.

Oregon’s law also has led to the rapid expansion of “health homes,” supporting a system of primary care that calls for clinics to stay open longer and offer same-day appointments.

The health home model has been successful at improving preventive care in Enterprise, Ore., a town of 2,000 in the remote northeastern corner of the state.

“You don’t feel like you’re just pushing papers around here. You really feel like you have an important part to play in improving people’s health,” said Dr. Elizabeth Powers, one of four physicians at Winding Waters Clinic in Enterprise, an early adopter of the health home model.

The clinic serves all patients, including those with Medicaid, Medicare and private insurance. The federal Affordable Care Act also encourages wider adoption of the health home model.

‘GAINSHARING’

In New Jersey, hospitals have reported success with a Medicare program that paid doctors who saved money for hospitals. Officials said it contributed to lower costs and shorter hospital stays without increasing mortality or readmission rates because doctors began considering the costs of their orders.

The experiment, known as “gainsharing,” is expanding this year to more hospitals, including some outside New Jersey.

In Massachusetts, the first state to enact comprehensive health care reforms, lawmakers supported last year a goal of restraining the rise in health care costs to a level no greater than the state’s overall growth rate. To accomplish this, legislators passed a multi-tiered state law that expands the role of physician assistants and nurse practitioners to act as primary care providers, making it easier for patients to access care outside the emergency room.

The law also requires providers to disclose more information to consumers about costs and quality and allows the state to review proposed consolidations to assess the effect on those factors.

The Massachusetts regulations provide money to accelerate electronic record-keeping and create tax credits for businesses that adopt wellness programs to combat preventable chronic diseases.

Cost-containment efforts are not confined to states that have embraced President Barack Obama’s health care reforms.

Many Southern states are transitioning their Medicaid patients into managed-care programs, which receive a fixed amount of money for each patient, regardless of their costs. Some insurance companies are thinning their networks of doctors to funnel patients to lower-cost options.

South Carolina, for example, is targeting elective early births, trying to keep newborn babies out of the expensive neonatal intensive care unit. The state also trained 18 community health workers who are in clinics that see a large number of Medicaid patients.

There are substantial challenges to copying these experiments nationally. Adopting a technology system to keep medical records electronically, for example, entails substantial upfront costs, as does hiring staff to coordinate patient care. At the same time, providers have to be careful to avoid skimping on needed care to save money.

Most of the experiments are too new to produce reliable data about their success, but health policy experts warn that the rapid rise in costs is unsustainable.

“It has to end eventually,” said Larry Levitt, senior vice president of the Kaiser Family Foundation, “because we can’t have an economy driven entirely by health care.”

A Season of Conciliation

If you look at the headlines out of Washington, DC right now, it isn’t hard to see why Sen. Harry Reid is saying that Washington is broken. After all, Congress is even fighting over how to fight (that’s what the question of filibuster reform is about) and for the first time in two terms, Americans are saying they do not believe President Barack Obama is honest. I disagree with a lot of this administration’s policies, particularly around Obamacare, but the person? That’s a little harsh. No wonder so many reasonable people are either getting out of Congress or opting not to run. 

In story after story, we can see how this moment is being shaped, not by what Americans want or need from their government but from the iron triangle of Congress, Special Interests and the Media. 

Except in one story. Whose significance should not be undervalued. President George H.W. Bush and President Barack Obama held a press conference at the White House to present an award to an Iowa couple who created a non-profit that feeds hungry children in 15 countries. President Obama paid tribute to the elder Bush for “how bright a light you shine” and marveled at the fact that the elder Bush parachuted out of a plane at 85.   There is no mistaking that these two Presidents are rising above the partisanship that is turning so many voters off to politics altogether. And that is leadership. 

The senior Bush said it clearly when he went on ABC’s “This Week” recently, “I think it’s very important to fix a broken system and to treat people with respect and to have confidence in our ability to assimilate people.” 

The middle, that reasonable ground in the center, where we parse through legislation and compromise, is missing in action. And when 90% of Americans say they want a federal ban on assault weapons only to watch it get shot down by the NRA, no wonder they’re losing faith in their government. What about the rollout right now on Obamacare and how hard it is to find objective information? This article http://well.blogs.nytimes.com/2013/07/15/health-insurance-within-reach/ is one writer’s attempt to explain the program but even this article, while well-intentioned, claims Medicaid will be “free.”  And just a couple of paragraphs later says it’s going to cost the government a lot of money. We are our government. And that disconnect is not only expensive in a financial sense; it’s bankrupting us spiritually. That’s why we need both sides to start working together with an eye to what the American people want from them. Because the cost of all this partisan gridlock and spin is about more than dollars and cents. 

 

 

What Medicaid does and doesn’t fix according to Harvard

Medicaid has mixed record on improving health for poor, study says

By Noam N. Levey

4:00 p.m. CDT, May 1, 2013

 WASHINGTON — As state leaders debate whether to expand their Medicaid programs next year under President Obama’s healthcare law, new research suggests the government insurance plan for the poor has only a mixed record of improving health.

Medicaid beneficiaries are less likely than the uninsured to have catastrophic medical expenses and significantly less likely to suffer from depression, researchers at the Harvard School of Public Health and the Massachusetts Institute of Technology found.

But those on Medicaid did no better controlling their blood pressure or cholesterol levels, raising questions about the program’s ability by itself to help low-income Americans become healthier.

The lack of health gains came even though Medicaid beneficiaries went to the doctor’s office and the hospital and filled prescriptions more frequently than those without coverage.

“I think the study dispels two extreme arguments about Medicaid,” said Harvard’s Katherine Baiker, one of the study’s principal authors and a former member of President George W. Bush’s Council of Economic Advisors.

“Some people say this is a terrible program. Beneficiaries don’t see any improvement in health. It is a waste of resources…. That is clearly not the case. The improvements in mental health are substantial. And there are real economic protections. Medicaid very clearly improved the well-being of beneficiaries,” said Baiker, a professor of health economics.

“At the same time, the study also dispels the opposing view that this is a wonderful program that keeps people out of the hospital and that it provides all this preventive care that saves money. That is also not true.”

The study, to be published Thursday in the New England Journal of Medicine, tracked 12,000 low-income Oregonians who entered a lottery in 2008 to get into that state’s Medicaid program.

The lottery gave researchers a unique opportunity to assess Medicaid by tracking two similar, randomly selected groups: those who won a spot in the health insurance plan and those who didn’t and remained uninsured. Such a randomized trial — standard practice in scientific research — has not been possible in other Medicaid research, some of which has suggested the program leads to worse health outcomes.

Medicaid, which has generated controversy since it was created in 1965, covers more than 60 million people in the course of a year and costs taxpayers nearly $500 billion annually.

The Medicaid debate has taken on new urgency as the Obama administration pushes states to take advantage of the 2010 Affordable Care Act, which provides generous federal aid to help them expand their programs. The law’s supporters hoped state expansions would cover as many as 16 million more low-income Americans over the next decade.

But many states led by Republicans have rejected the option, saying that Medicaid is ineffective. Several conservative critics have even argued that the program is worse than no health coverage.

John Goodman, who heads the conservative National Center for Policy Analysis and advised Republican Sen. John McCain’s 2008 presidential campaign, called the study’s findings about health outcomes “stunning.” “It suggests to me that Medicaid doesn’t matter very much,” he said. “A lot of people are way too focused on health insurance and not focused enough on healthcare.”

Goodman, an economist and health policy expert, favors moving low-income Americans into commercial insurance rather than Medicaid.

The study did not analyze whether health outcomes would have been better in private insurance. But research has consistently shown that, in general, Americans in either public or private health insurance plans often fail to manage chronic medical conditions, such as diabetes and high blood pressure, though some individual health plans and medical providers have succeeded in helping patients do this.

The authors of the study note that factors other than insurance may explain why Medicaid beneficiaries did not control their blood pressure and cholesterol levels, including possible problems with access to good medical care or failures to adhere to prescriptions and doctors’ orders.

But Baiker stressed that the study’s findings of benefits from Medicaid should not be understated.

Beneficiaries were 30% less likely to suffer from depression than those without coverage and nearly 10% more likely to report that their health was the same or better than it had been a year earlier.

And researchers found a dramatic increase in financial security. “That is a basic function of health insurance,” Baiker said. “It is not just supposed to give you access to care. It is supposed to prevent you from being evicted from your house if you suffer a medical emergency.”

One writer’s opinion of where Obamacare stands right now

By David Brooks of the New York Times

It was always going to be difficult to implement Obamacare, but even fervent supporters of the law admit that things are going worse than expected. Implementation got off to a bad start because the Obama administration didn’t want to release unpopular rules before the election. Regulators have been working hard but are clearly overwhelmed, trying to write rules that influence the entire health care sector — an economic unit roughly the size of France. Republicans in Congress have made things much more difficult by refusing to provide enough money for implementation.

By now, everybody involved seems to be in a state of anxiety. Insurance companies are trying to put out new products, but they don’t know what federal parameters they have to meet. Small businesses are angry because the provisions that benefited them have been put on the back burner. Health care systems are highly frustrated. They can’t plan without a road map. Senator Max Baucus, one of the authors of the law, says he sees a “huge train wreck” coming.

I’ve been talking with a bipartisan bunch of health care experts, trying to get a sense of exactly how bad things are. In my conversations with this extremely well-informed group of providers, academics and former government officials, I’d say there is a minority, including some supporters of the law, who think the whole situation is a complete disaster. They predict Obamacare will collapse and do serious damage to the underlying health system.

But the clear majority, including some of the law’s opponents, believe that we’re probably in for a few years of shambolic messiness, during which time everybody will scramble and adjust, and eventually we will settle down to a new normal.

What nobody can predict is how health care chaos will interact with the political system. There’s a good chance that Republicans will be able to use unhappiness with what is already an unpopular law to win back the Senate in 2014. Controlling both houses of Congress, they will be in a good position to alter, though not repeal, the program.

The law’s biggest defenders will then become insurance companies and health care corporations. Having spent billions of dollars adapting to the new system, they are not going to want to see it repealed or replaced.

The experts talk about the problems that lie ahead in cascades. First, there is what you might call the structural cascade. Everything is turning out to be more complicated than originally envisioned. The Supreme Court decision made the Medicaid piece more complicated. The decision by many states not to set up exchanges made the exchange piece more complicated. The lines of accountability between, for example, state and federally run exchanges have grown byzantine and unclear.

A law that was very confusing has become mind-boggling. That could lead people to freeze up. Insurance companies will hesitate before venturing into state exchanges, thereby limiting competition and choice. Americans are just going to be overwhelmed and befuddled. Many are just going to stay away, even if they are eligible for benefits.

Then there is the technical cascade. At some point, people are going to sit at computers and enroll. If the data process looks like some 1990s glitchmonster, if information doesn’t flow freely, then the public opinion hit will be catastrophic.

Then there is the cost cascade. Nearly everybody not in the employ of the administration agrees this law does not solve the cost problem, and many of the recent regulatory decisions will send costs higher. A study in California found that premiums could increase by an average of 20 percent for people not covered by federal subsidies. A study by the Society of Actuaries found that by 2017 costs could rise by 32 percent for insurers covering people in the individual exchanges, and as high as 80 percent in states like Ohio.

Then there is the adverse selection cascade. Under the law, young healthy people subsidize poorer, sicker and older people. But the young may decide en masse that it is completely irrational for them to get health insurance that subsidizes others while they are healthy. They’ll be better off paying the fines, if those are even enforced, and opting out. Without premiums from the young, everybody else’s costs go up even higher.

Then there is the provider concentration cascade. The law further incentivizes a trend under way: the consolidation of hospitals, doctors’ practices and other providers. That also boosts prices.

Over all, it seems likely that in some form or another Obamacare is here to stay. But the turmoil around it could dominate politics for another election cycle, and the changes after that — to finally control costs, to fix the mind-boggling complexities and the unintended consequences — will never end.

Regulatory regimes can be simple and dumb or complex and sprawling. When you build complex, it takes a while to work through the consequences. 

 

The Silver Lining on Gun Control: A Bi-Partison effort to help the Mentally Ill

By Robert Koenig, Beacon Washington correspondent

WASHINGTON – While efforts to restrict assault weapons have grabbed the headlines, a quieter campaign is gaining support on Capitol Hill to try to curb gun violence by bolstering mental health services at the community level.

On Thursday, Oscar-nominated David O. Russell – director of “Silver Linings Playbook,” whose main character has bipolar disorder – appeared at a news conference with lawmakers including U.S. Sen. Roy Blunt to back a new effort to strengthen mental health care in medically underserved areas.

The bipartisan Excellence in Mental Health Act, whose main sponsors are U.S. Sen. Debbie Stabenow, D-Mich., and Blunt, R-Mo., aims to boost mental health centers to a more equal footing with other health centers, mainly by improving their quality standards and expanding access to people who need the care.

Would such improvements make much of a difference in the prevalence in gun violence? On one hand, studies indicate that people with a serious mental illness are more likely to be victims of violence than perpetrators.

On the other hand, some individuals suffering from first-break psychosis – unless diagnosed and treated quickly – have been shown to be at risk of committing acts of violence at a rate 15 times higher than fast-treated patients.

“In the wake of tragedies like Sandy Hook,” Blunt said, “we must work together to spend federal dollars more wisely when treating people who are mentally ill.”

Stabenow, noting that “most people living with mental illness are not a danger to themselves or anyone else,” warned that “the cost of inadequate treatment can be dire in some cases.”

Russell, an activist for better mental health care whose young son has suffered from mood disorders, applauded efforts to lessen the stigma of mental illness and “expand care for those living with mental illness who need it. We talk about diabetes, we talk about heart disease, so why can’t we talk about mental illness in a regular way?”

The new bill would require the 2,000 “federally qualified community behavioral health centers” to cover a wider range of mental health services, including 24-hour crisis care, and integrate mental health services with other health services. Mental health centers that provide the new services would be enabled to bill Medicaid. The cost would be $1.4 billion over a decade.

“We have a moment that works and a model that works,” said Blunt, who opposes curbs on gun ownership. He said the bill would “help address our fragmented mental health system and ensure that more patients have access to the care they need.”

Blunt’s initiative appears to parallel the emphasis of Missouri Gov. Jay Nixon, who said at an event in Arnold on Wednesday that his $10 million proposal to expand the state’s mental-health services should be a component of any state effort to prevent school-shooting tragedies.

“Clearly we’re trying to get in a prevention mode here,” Nixon told reporters. Linking mental illness among youths to some violence, Nixon said, “prevention, when it comes to mental health, is very, very important.”

The Stabenow/Blunt federal bill would help pay for modernizing many community mental health centers – which now serve over 8 million people, including 2.2 million young people – and the establishment of new behavioral health centers.

Lawmakers said such expanded centers would be able to treat up to 1.5 million more people as a result of this legislation. And, with about a quarter of Iraq and Afghanistan vets reporting mental health issues, such health centers would be expected to serve about 200,000 veterans.

Stabenow said a third of the 4.8 million people suffering from mood disorders do not currently get treatment, and fewer than half of the people with severe mental disorders receive treatment of any kind in a given year. That lack of mental health care means that police often respond to psychiatric emergencies.

One cosponsor of the bill is Sen. Patrick Leahy, D-Vt., who chairs the Senate Judiciary Committee, which is developing gun-control legislation.

“Ensuring that those suffering from mental illness have access to the health care and support they need is important,” he said, in part to “help prevent debilitating mental and behavioral health problems, suicide, and violent acts like we saw at an elementary school in Connecticut.”

House Democrats outline proposals to deter gun violence 

The renewed debate over gun violence was sparked by public reaction to the Dec. 21 mass shooting at Sandy Hook Elementary School in Newtown, Connecticut, where 20 first-graders and six adults were killed by a mentally disturbed young man who also took his own life.

Vice President Joe Biden, who led a White House effort to develop proposal to lessen gun violence, told House Democrats this week that “there’s an overwhelming consensus about the need to act.”

On Thursday, President Barack Obama told House Democrats at their retreat in Virginia that “we’ve got to be mindful about steps we can take to end the cycle of gun violence in this country.”

At that Virginia meeting, two California Democrats — House Minority Leader Nancy Pelosi and U.S. Rep. Mike Thompson, the chairman of the House Democratic Caucus’s Gun Violence Prevention Task Force — announced the group’s ideas, which include proposals to:

• Reinstate and strengthen a prospective federal ban on assault weapons.

• Reinstate a prospective federal ban on high-volume ammunition magazines.

• Require a background check for every gun sale, while respecting reasonable exceptions for cases such as gifts between family members and temporary loans for sporting purposes. 

• Strengthen the National Instant Criminal Background Check System (NICS) database.

• Prosecute those prohibited buyers who attempt to purchase firearms and others who violate federal firearm laws.

• Pass legislation to crack down on illegal gun trafficking and straw-purchasing.

• Restore funding for public safety and law enforcement initiatives aimed at reducing gun violence. 

• Close the holes in our mental-health system and make sure that care is available for those who need it.

• Help communities get unwanted and illegal guns out of the hands of those who don’t want them or shouldn’t have them.

• Support responsible gun ownership. 

• Address the “glorification of violence” seen and heard through movie screens, television shows, music and video games.

 

 

Are you dialing in to the debates?

According to CNN, 3.6 million people watched the Tea Party Express Republican Presidential Debate on CNN last night, 1.1 million of them in the coveted age bracket between 25 and 54.  What is interesting to me is that means 2.5 million of them were either under 25 (unlikely) or over 54.  My guess is it was the over 54 crowd that tuned in in a big way to hear about Medicare, Medicaid and Social Security.  Social Security was one of the dominant topics.  While Gov. Rick Perry has referred to it as a Ponzi scheme in the past, he said Monday night that it will be there for anyone who has paid in.  Mitt Romney gets the bold stroke award for having the guts to come out and say it will be there for those now drawing benefits but it probably won’t be there in its current form for those in their 50s and young people just starting to pay into the system.  Don’t forget the Congressional Budget Office has already said Social Security will be paying out more than it gets by 2016. 

In the meantime, I thought I would highlight some of the better quotes from the debate.

Newt Gingrich quoting Ronald Reagan, “Turn up the light for the people so they can turn the heat up on Congress.”

Jon Huntsman on Mitt Romney on Social Security, “Gov. Romney called it a fraud.  Don’t know if that was written by Kurt Cobain.”  Kurt Cobain?  As in Nirvana?  Hmmm.

Michelle Bachmann, “It’s easy to turn around this economy.”  You don’t really think that, do you?

Jon Huntsman, “We have a heroin like addiction to foreign oil.”

Newt Gingrich, “We can balance the Federal Budget.  Be smart rather than cheap and actually modernize the Federal Government.”

 http://www.washingtonpost.com/blogs/fact-checker/post/fact-checking-the-cnn-and-tea-party-express-debate-in-tampa/2011/09/12/gIQAPCkXOK_blog.html

http://www.politico.com/news/stories/0911/63445.html