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In Washington, “reconciliation” allows a budget road map to pass with a simple majority vote in both chambers. This is most important in the Senate, where otherwise 60 votes are required to cut off debate on legislative proposals. Democrats used reconciliation to pass the Affordable Care Act in 2010 over stiff Republican opposition. Now that the Republicans have won control of the Senate, they will soon be in a position to return the favor. As long as a topic requires spending money or changing taxes, it can be included in reconciliation legislation. A key question is how many of the far-reaching proposals likely to come out of the House–such as repeal of the Affordable Care Act, changing Medicare to a premium-support system, changing Medicaid to block grants, or fundamental tax reform–would Senate Republicans want to push through in the reconciliation process. (Robert Litan, 11/12)

But here’s the dirty little secret: Mr. Gruber was exposing something sordid yet completely commonplace about how Congress makes policy of all types: Legislators frequently game policy to fit the sometimes arbitrary conventions by which the Congressional Budget Office evaluates laws and the public debates them. In the case of the Affordable Care Act, that meant structuring the law so that the money Americans must pay the Internal Revenue Service if they fail to obtain health insurance under the law’s mandate is a penalty, not a tax. (Neil Irwin, 11/12)

Critics of the Affordable Care Act have long called the law and its fiscal projections inaccurate, deceptive, and completely unrealistic. The staggered structure of revenues and outlays were designed to get the Congressional Budget Office to deliver a deficit-neutral verdict on the bill just long enough to gain passage, even though every year in which outlays and income take place produced deficit spending even under the rosiest projections. (Edward Morrissey, 11/13)

Republican leaders in the House and Senate have made clear that they’ll deploy every weapon in the legislative arsenal to repeal the Affordable Care Act. They’ll try to chip away at the taxes that support it and abolish the mandates that make its insurance markets work. They might even stand on their heads and stop breathing if that would do the trick. ... It’s something else again if another part of the conservative power structure does a lot of the dirty work in undermining the law before Congress has to. I refer here to the hyper-activist conservative justices on our Supreme Court. (E.J. Dionne Jr., 11/12)

The Supreme Court's surprising decision last week to hear a new challenge to the Affordable Care Act has once again focused attention on Chief Justice John Roberts, who cast the deciding vote in a 2012 decision that saved Obamacare from being declared unconstitutional. Many court watchers expect that he will once again be the swing vote in deciding a case crucial to the healthcare law, this one involving questions about who qualifies for subsidies under the law. But Roberts' vote in a recent voting rights case suggests he might not step in to save the health law this time. (Richard L. Hasen, 11/12)

Nearly a week has gone by since the Supreme Court’s unexpected decision to enlist in the latest effort to destroy the Affordable Care Act, and the shock remains unabated. “This is Bush v. Gore all over again,” one friend said as we struggled to absorb the news last Friday afternoon. “No,” I replied. “It’s worse.” (Linda Greenhouse, 11/12)

Via Nina Martin of ProPublica comes word that America's Catholic bishops are moving toward tightening religious restrictions on physicians and nonsectarian hospitals that join with them in mergers and partnerships. This can't be good news for anyone concerned about the state of women's healthcare. That's where medical practice and Catholic doctrine are most frequently in conflict. And it's happening as Catholic hospitals are playing a more influential role in the American healthcare system. (Michael Hiltzik, 11/12)

In the ideal world, police responding to a disturbing-the-peace or petty crime call arrive at the scene with the training to discern whether the subject's behavior is due at least in part to a mental health problem. They defuse the situation and turn the subject over to the just-arrived psychiatric evaluation team, or else they take the subject to a crisis center where the intake process is efficient, allowing the officers to go back on patrol while the subject is stabilized, diagnosed and monitored by mental health professionals. ... the gap between the real and the ideal worlds is slowly shrinking, a point brought home Wednesday when Dist. Atty. Jackie Lacey updated the board on her proposed mental health diversion program. (11/12)

Here’s a story of utter irresponsibility: About one-third of American girls become pregnant as teenagers. But it’s not just a story of heedless girls and boys who don’t take precautions. This is also a tale of national irresponsibility and political irresponsibility — of us as a country failing our kids by refusing to invest in comprehensive sex education and birth control because we, too, don’t plan ahead. (Nicholas Kristof, 11/12)

The new demographic reality for the United States, Europe and many countries in Asia and Latin America is an aging population. Governments will face increasing financial pressure as the number of taxpayers shrinks and baby boomers retire. Many see a broad threat to their economies; some countries have begun actively encouraging young people to have more children through tax breaks, subsidized child care, expanded parental leave policies and more. But are birthrates really too low? In a study published this fall in Science, we found that the answer is yes for a few countries, but for many more, higher birthrates would actually lead to lower standards of living. With a few important exceptions, raising birth rates would be ill-advised. (Ronald Lee and Andrew Mason, 11/12)

It's not every day that you hear a person rave about the work of a dental hygienist. But that's exactly how Paul, a 40-year old roofer, described the hygienist he met at the recent Mission of Mercy free health care clinic in Henderson. Paul's teeth required extensive work just to prepare him to see a dentist who would extract the damaged teeth and fit him for dentures. Colorado is making great progress in caring for the dental health of its citizens. In May 2013, Gov. John Hickenlooper called oral health "a winnable battle for Colorado" when he signed into law a bipartisan bill that provides dental benefits for low income adults through the state's Medicaid program, beginning in 2014. (Fay Donohue and Maureen Hartlaub, 11/11)

Through the Physician Payments Sunshine Act and the Open Payments website launched in October, the U.S. government is beginning to publicly report industry payments to physicians and academic medical centers. In turn, the proportion of doctors reporting receiving visits from sales representatives has fallen, from 77% in 2008 to 55% in 2013. One possibility, however, is that marketing of drugs and devices to physicians is taking new forms rather than diminishing. Pharmaceutical companies currently spend 25% of their marketing budgets on digital technologies, such as websites and social media. (Christopher Manz, Joseph S. Ross and David Grande, 11/13)

It is well known that new brand-name drugs are often expensive, but U.S. health care is also witnessing a lesser-known but growing and seemingly paradoxical phenomenon: certain older drugs, many of which are generic and not protected by patents or market exclusivity, are now also extremely expensive. (Jonathan D. Alpern, William M. Stauffer and Aaron S. Kesselheim, 11/13)

Attempts to roll back the modernization and improvement of school-meal standards threaten future progress in reducing obesity and other chronic diseases that originate in early childhood. After 30 years of escalating prevalence of childhood obesity, recent plateaus suggest that progress has been made on many fronts. Federal improvements to school meals represented a key victory — yet now they are under attack. As pediatricians, we worry that this attack undermines schools' ability to foster health-promoting behaviors and represents a disinvestment in children's health. (Jennifer A. Woo Baidal, and Elsie M. Taveras, 11/13)