Bloggers are focusing on how the law will be implemented, what the roleÌýof states may be, how patient care will be affected and how the work left to be done will shake out. Here’s a sampling:

Health Affairs’ Blog has three pieces on how the law moves forward: The from Christine Vestal and Michael Ollove, of Stateline, examines two key decisions facing each state: whether to join the Medicaid expansion and whether to createÌýtheir own health insurance exchange. “Most Democratic-led states are expected to fully participate in both, although some may seek flexibility. But among the 30 states that will be run by GOP governors starting next year, it is unclear how many will opt in. Many predict that the federal government’s offer of covering the full cost of the Medicaid expansion for the first three years, and 90 percent after that, will be too rich for states to refuse” (11/8).

The , authored by Chas Roades, examines the impact of the election on health systems and providers: “For most provider organizations, the election’s outcome represents a confirmation of the twin efforts so many have already started to control costs and transform patient care. A few implications stand out: Controlling costs and shifting management of cases to more efficient and higher quality settings remains critical in advance of potential Medicare payment reductions. … The transition toward new payment models will continue apace. … All eyes on the states as coverage expansion looms (11/7).

Timothy Jost also examines, in a , what work remains to be done, including his hope for a technical corrections bill: “Finally, if a new spirit of bipartisanship settles on Washington, it would be nice to finally get a technical corrections bill through Congress to fix a lot of the glitches in the ACA that bedevil implementation.Ìý But this would presumably open up the ACA to further special interest pleading and political point-scoring, and is perhaps too much to hope for” (11/7).

Bob Laszewski to-do list on his Health Care Policy and Marketplace Review blog: “It will be implemented. It will also have to be changed but not until after it is implemented and the required changes become obvious and unavoidable. We can all debate what those things will be (cost containment is on top of my list) but it doesn’t matter what we think will happen–time will tell” (11/7).

At The Health Care Blog, Dr. Joanne Conroy in carrying out the law: “The Obama team can ignore the growing physician shortage — but at their peril. Unfortunately, we also continue to debate within specialty societies about who should provide the services, rather than talking about how we can deliver care as a team more efficiently. Use of interprofessional teams holds great promise for improving the efficiency of the physician workforce, and we anticipate that the administration will continue to support innovative reforms in health care delivery” (11/7).

At The Daily Beast, David Frum about implementation of the health law. Among them: “We should call for reducing regulation of the policies sold inside the health care exchanges. The Democrats’ plans require every policy sold within the exchanges to meet certain strict conditions. American workers will lose the option of buying more basic but cheaper plans. It will be as if the only cable packages available were those that include all the premium channels. No bargains in that case. Republicans should press for more scope for insurers to cut prices if they think they can offer an attractive product that way” (11/7).

Peter Suderman at Reason : “The federal government faces other challenges to setting up its own exchanges as well. For one thing, there was no money appropriated to build the federal exchanges. Perhaps money can be found, but so far no one knows where. One adviser charged with helping Department of Health and Human Services create those exchanges hasÌýadmittedÌýthat in order for HHS to build the exchanges, the federal government will likely have to ‘get creative about the financing.’ … Those who oppose Obamacare are going to have to learn to live with the law. But those who support it are going to have to learn to live with its inevitable failures” (11/7).

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Here’s a sample of how some bloggers around the nation are seeing the debate:

At , Alyssa Rosenberg provided questions that she was waiting for moderator Martha Raddatz to ask the candidates: “If you believe abortion should be illegal except in cases of rape, incest, or where the life or health of the mother is at risk, how would you enforce a ban on abortions performed for other reasons? What sentences would doctors who performed abortions or women who solicited them have to serve if found guilty of violating the ban? How would you fund enforcement mechanisms?” (10/12).

Irin Carmon at says the way Raddatz framed the abortion question favored Ryan: Ìý“She chose to frame the late-breaking, much-yearned for question about ‘social issues’ in just the way Republicans prefer: in terms ofÌýreligion.Ìý… Everyone at Salon’s debate-watching party groaned, and with good reason. Please, let’s hear more from two religiously observant white men about their personal experiences with women’s reproductive freedom and access! It’s not that religion, or men, have no place in the debate over abortion rights; it’s that her question left women out of the equation from the start” (10/11).

For more …

Some others didn’t buy Biden’s defense of his abortion stance. At , Ed Morrissey writes: “It’s nonsense to say as a government official that you believe that human life starts at conception but that you can’t act to protect it. Ìý Certainly many people believe that human life doesÌýnotÌýstart at conception, butÌýthat’s less science- and reason-based than the Catholic doctrine that opposes it” (10/12).

Both the and had live blogs during the debate. At Cato’s Michael Cannon wrote of the candidates’ contention that Medicare must change: “Wrong. Medicare doesn’t HAVE to change. Congress can prop it up by doubling tax rates. Still appears the most likely scenario.” At The Heritage Foundation’s live blog, Alyene Senger writes: “The allegation that premium support in Medicare would cost seniors over $6,400 more is both wrong and misleading. Heritage expertÌýRea Hederman explains, ‘[T]his dollar amount is incorrect, and the charge is erroneous. Such false charges are based on an outdated Congressional Budget Office (CBO) model of House Budget Committee chairman Paul Ryan’s (R–WI) 2011 budget proposal.’ In fact, under Ryan’s current proposal, a senior would be guaranteed at least two health plans whose premiums meet 100 percent of the contribution amount” (10/11).

Avik Roy, at his , also visits the premium support model that Ryan champions: “Ryan patiently explained that, under theÌýcompetitive bidding model, not a single senior is exposed to rising health costs relative to the level of premium support. Biden kept interrupting Ryan so as to prevent him from completing his sentences, and then falsely claimed that Democratic Sen. Ron Wyden opposed the Romney-Ryan plan. Indeed, Ron Wyden supported a planÌýto the rightÌýof the Romney-Ryan plan” (10/12).

Finally, at , a blog at the Atlanta Journal-Constitution, health care attorney Elizabeth Richards examines if a Medicare voucher program would work. “The truth of the matter is that until one is put in place, we just will not know. However, it seems like a pretty decent idea to me. One thing is for sure, what we are doing currently is not working on multiple levels. It is not sustainable long term for its patients, and its rules and payment rates are not sustainable for the providers. … The best insurance policies are not one size fits all. The voucher plan, or premium assistance as the Republicans like to call it, will likely not cover the entire cost. I understand that this is a concern” (10/12).

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: It Will Be Tricky For Romney To Keep Best Of Health Law While Repealing It Mitt Romney’s pledge to guarantee access to health insurance for people with longstanding medical problems confused some experts and highlighted the difficulty of repealing the new health care law while keeping some of its popular features (Pear and Goodnough, 9/10).

: Mitt Romney’s Shifting Stance On Health Care Mitt Romney seemed to make health care news in a Sunday interview on NBC’s Meet the Press. He said he might not want to repeal all of the Affordable Care Act. … Of course not getting rid of the entire Affordable Care Act is not only an express violation of the Republican Party 2012 platform, but also is at odds with Romney’s own position as detailed on the campaign’s website. So, not surprisingly, it was only a matter of hours before the campaign walked the candidate’s comments back (Rovner, 9/10).

For more headlines …

: Mitt Romney Struggles With ACA Replacement Goals By the time Mitt Romney faces President Barack Obama for their first debate next month, he’ll have to figure out a sharper way to explain what he would do to replace “Obamacare.” That’s the lesson of his “Meet the Press” experience this weekend, when he tried to tell the viewers that he’d pursue two of the most popular goals of the health care law — insurance for people with pre-existing conditions and coverage for young adults — and promptly had to reassure conservatives that he didn’t actually mean he’d leave parts of “Obamacare” in place (Norman, 9/11).

: Among Likely Voters, Obama-Romney Close Last week’s Democratic National Convention helped President Obama improve his standing against Republican Mitt Romney, according to a new Washington Post-ABC News poll, but did little to reduce voter concern about his handling of the economy. The survey shows that the race remains close among likely voters, with Obama at 49 percent and Romney at 48 percent, virtually unchanged from a poll taken just before the conventions. But among a wider sample of all registered voters, Obama holds an apparent edge, topping Romney at 50 percent to 44 percent, and has clear advantages on important issues in the campaign when compared with his rival (Balz and Cohen, 9/11).

: Poll: Obama Has Double-Digit Advantage On Health Care, Medicare According to the poll, 54 percent of likely voters think Obama would better handle the issue of health care, compared with 45 percent for Romney. Before the conventions, on Aug. 22-23, Obama led by only 1 point on the issue, 49 percent to 48 percent. On Medicare, the disparity is even more pronounced: Obama leads Romney by 11 points, 54 percent to 43 percent, compared with a 1-point lead back in the pre-convention August poll. Health care is an issue on which the public has been deeply divided, even in the wake of the Supreme Court ruling earlier this summer (Schultheis, 9/10).

: Critics: We Were ‘Kind’ To Mitt On Medicare On Sunday, President Barack Obama’s campaign used a new report from the Center for American Progress to argue that Romney’s Medicare plan would force seniors to pay more out of pocket to provide tax cuts to the wealthy while padding insurance company profits. The Romney campaign fired back, arguing that the report’s authors included a former Obama campaign adviser and a former Democratic Senate aide who worked on the Affordable Care Act. In a conference call Monday afternoon, report author David Cutler — the former Obama campaign adviser — argued that he relied on conservative estimates to conclude, among other findings, that the average senior retiring a decade from now would have to pay $59,500 more for lifetime care under the Romney plan (Millman, 9/10).

: Nominees Leave Congressional Candidates To Stump Alone Out on the campaign trail, President Obama talks about Medicare (Republicans would gut it), tax cuts (Mitt Romney wants to give them to rich people like himself) and Osama bin Laden (Did you know? He’s dead.). He even talks about the unemployment rate (it is still too high, but job growth has increased 30 straight months after the economic mess that greeted him when he took office). And he talks about Congress (lawmakers should get moving and pass his jobs bill). But what the president never talks about is getting more of his party members elected to the House and the Senate. And, for that matter, neither does Mr. Romney (Cooper and Peters, 9/10).

: Missteps And Surprises Turn Battle For The Senate Into A Guessing Game The fight for the Senate has shifted significantly over the past weeks, with fierce races breaking out in states where they were not expected and other contests dimming that were once ablaze with competition. With less than two months until Election Day, the Senate landscape is both broader and more fluid than it has been in years, with control of the upper chamber now anyone’s guess. Both parties have seen new opportunities and new challenges, but the net result is that Democrats appear to be in less danger of losing the Senate, while Republicans have a more difficult path to gaining the majority (Weisman and Steinhauer, 9/10).

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The score from the CBO had bloggers writing about what fate inclusion of the new numbers hold for coverage for the poor in America, and sounding off about that found expanding Medicaid saved lives in three states.

Matt Salo, at the , writes that the finding from the CBO might not be the last word from federal policymakers on the subject: “Ultimately state-level dynamics, such as the nuances of individual Medicaid programs, the Medicaid-Exchange interactions, and state fiscal conditions, combined with the Administration’s decisions about the optional aspects of the expansion will require policymakers to repeatedly revisit these estimates. … The ACA offers states many incentives.Ìý Nonetheless, the reality is that for some states, the Medicaid expansion may not necessarily or immediately be a “no-brainer” as some have suggested. … While numerous entities are tracking state officials’ public statements about the Medicaid expansion, it is likely the decisions will shift dramatically over time for both policy and political reasons” (7/25).

Dan Diamond, writing at , says the numbers “reframe the debate over the ACA yet again. As I notedÌý, more than two-thirds of states are waffling on whether to participate in the law’s Medicaid expansion, and the new CBO numbers will offer new targets for supporters and opponents of ObamaCare to make their case. But the CBO score is also more of a political story than policy news. And as both parties continue to haggle over the ACA’s price and impact, keep in mind that the CBO’s projections about health law costs areÌý” (7/26).

Avik Roy, atÌý blog, points out: “Key to the CBO’s math is their guess that 6 million fewer people will enroll in Medicaid or its cousin, the Children’s Health Insurance Program (CHIP), while 3 million more people will sign up for the law’s subsidized exchanges for private insurance. … Now that several governors have come out against the Medicaid expansion, the CBO has budged a bit in their direction. ‘CBO anticipates that, instead of choosing to expand Medicaid eligibility fully to 138 percent of the [federal poverty level] or to continue the status quo, many states will try to work out arrangements with the Department of Health and Human Services (HHS) to undertake partial expansions. For example, some states will probably seek to implement a partial expansion of Medicaid eligibility to 100 percent of the FPL, because, under the ACA, people below that threshold will not be eligible for subsidies in the insurance exchanges.’ If all states were allowed to do this without any pushback from Washington, theÌý could be in the trillions” (7/24).

At the blog, Michele Madison worries what happens when states decide not to expand Medicaid: “It means that there will be millions of people who will not be eligible for Medicaid benefits and who also may not be able to afford the insurance through the state insurance exchanges due to their level of income. Moreover, it may be less expensive for these individuals to pay the penalty/tax instead of purchasing insurance. Therefore, one of the foundational tenets of the Healthcare Reform Act would be undercut” (7/25).

But in the meantime, a new New England Journal of Medicine report says three states that expanded their Medicaid programs saved lives.

At , Aaron Carroll and Harold Pollack examine assertions of the “questionable” quality of Medicaid in light of the NEJM study: “The bottom line is that, according to these findings, state Medicaid programs need only cover 176 additional adults to avert one additional death every year. This allows for a crude but intriguing cost-effectiveness calculation.Ìý. The cost per averted death (176*6,000) is thus about $1 million. This $1 million figure isÌý. … There’s been a wide, often misplaced debate over whether Medicaid helps or hurts its own recipients. We need to stop that. Medicaid helps” (7/26).

But Michael Cannon, at the blog, says that he expects that Medicaid, at a price tag of $460 billion per year, does save lives: “Even so, that doesÌýnotÌýmean politicians should expand Medicaid. If saving lives is the goal, then politicians should insteadÌý, because that enables the greatest number of lives to be saved with the available resources. It is generally accepted among health economists that other strategies (e.g., discrete health programs targeted at hypertension or diabetes) could save more lives per dollar spent than expanding health insurance.ÌýThis study says nothing about how much it costs to save lives through Medicaid, much less whether alternative uses of those resources could save even more lives” (7/26).

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Already, Republicans in are considering rejecting the Medicaid expansion dollars: Florida, Ohio, Pennsylvania and Colorado. Additionally, said they would have trouble coming up with even 10 percent of the total cost to put more people on the Medicaid rolls.

Bloggers are breaking down what implications the moves could have for health care coverage in America:

Kevin Russell, at , explains the justices’ bottom line: “(1) Congress acted constitutionally in offering states funds to expand coverage to millions of new individuals; (2) So states can agree to expand coverage in exchange for those new funds; (3) If the state accepts the expansion funds, it must obey by the new rules and expand coverage; (4) but a state can refuse to participate in the expansion without losing all of its Medicaid funds. Instead the state will have the option of continue the its current, unexpanded plan as is” (6/28).

Michael Cannon writes in the blog that the ruling severely limits the Medicaid expansion. The ruling effectively gives “states the green light to refuse to expand their Medicaid programs” helping to put the law in “a very precarious position,” Cannon writes (6/29).

More …

Frederick Hess, at the , writes that the ruling on Medicaid could have broader implications in other policy as well: “In their legal challenge, 26 states argued that the federal government’s decision to make expanding Medicaid the condition for receiving any federal Medicaid funding had the practical consequence of coercing them to comply. … it strikes me that the Court has this generally right. Anybody who has spent much time working with state and local officials knows that, once conditional federal funds have been baked into place, the resulting constituencies and budget realities make it incredibly difficult to pry them out. So, as it stands, the ruling could prove a useful constraint on Congress’s ability to dictate ed policy to states.” (6/29).

Still Jordan Weissmann, at , quotes University of Michigan law professor Samuel Bagenstos, who filed an amicus brief with the court in favor of the expansion. Bagenstos says, “My initial reaction is it probably isn’t going to mean a whole lot for the Medicaid expansion in the Affordable Care Act, because the Medicaid expansion is such a good deal for the states. You’ll probably hear a lot of complaining about it, and then quiet acceptance by the complaining states. The $64,000 question as to Medicaid is how many states are going to decide that they don’t want to cover this expanded population, even with the very substantial financial incentive” (6/28).

Bob Laszewski, at the blog, writes that since the federal law makes the Medicaid expansion available to people who earn up to 133 percent of poverty, if their state decides to not expand Medicaid to them, people who make between 100 percent and 133 percent of poverty could still get federal subsidies to help afford private insurance. The benefit for them, however, would be a mixed bag. “But they would have to pay 2% of their income in premiums—$600 a year if they make $30,000 a year. And, unlike Medicaid, they would be subject to standard deductibles and copays—perhaps an upfront $1,000 deductible per person” (6/28).

Sarah Kliff at The Washington Post’s : “Poorer Americans—those who live below the poverty line—could be caught in a sort of ‘no man’s land.’ They’re not eligible” the the federal subsidies that are part of the overhaul “because the law worked with the assumption that they would fall under the Medicaid plan” (7/2).

Avik Roy, at his , writes that the decision could dramatically increase the deficit: “Democrats structured the law this way because Medicaid is much less expensive, on a per-person basis, than are the subsidized exchange plans. In addition, Medicaid is partially funded by the states. However, now that states can opt out of the law’s Medicaid expansion, states that currently cover people above 100 percent of FPL with Medicaid now have a significant financial incentive to shrink Medicaid eligibility down to 100 percent of FPL, and let the federal government (read: taxpayers in other states) pay for the rest. This, again, will lead to substantially higher costs for the federal government, because exchange subsidies are much more generous than Medicaid is” (6/28).

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That’s the case this week as the blogosphere reacts to President Barack Obama’s comments that he is confident the Supreme Court will uphold the health reform law and

Here’s a sample:

At Reason, Steve Chapman writes that punishing judges for exercising their duties : “In any event, Obama’s criticism could well have come from a hard-line conservative with a crabbed view of the role of the judiciary. … Conservatives, of course, exhibit a strange new respect for judicial review, which they have often reviled for letting unelected elitists ride roughshod over prevailing public opinion. But that’s no excuse for Obama to suggest that the court would be acting illegitimately in striking down his health care plan.”

For more …

At the Cato@Liberty blog, Roger Pilon writes that : “After the Court’s oral arguments over ObamaCare,Ìýit’s finally dawning on modern liberals that their project for ubiquitous government is under serious political and even legal attack, so they’re fighting back. … What Obama and his liberal apologists fail to accept, of course, is that their welfare-state project is spent, literally. They pose as defenders of welfare programs for the poor and, now, the middle class, while either ignoring the deficits and debt those programs have run up or, at best, arguing that taxing the rich will solve the problem, all evidence to the contrary notwithstanding.”

Jonathan Cohn of the NewÌýRepublic, however, arguesÌý: “At most, Obama was warning that he took the case seriously and was prepared to criticize the court, loudly, if it ruled the law unconstitutional. Surely that’s within acceptable bounds of presidential behavior.” Using the Supreme Court case Lochner v. New York to illustrate its implications for economic law in America, Cohn writes Obama meant: “By invalidating the Affordable Care Act, theÌýSupreme Court would be resurrecting a vision of constitutionally limited government that, quite rightly, went out of fashion a long time ago.”

In the meantime, Sen. Chuck Grassley, R-Iowa, called Obama “stupid” for his comments on the Supreme Court. Ian Millhiser : “Obama’s statement, which closely mirrors rhetoricÌý, sent those very same conservatives into apoplexy. … Grassley’s objection to President Obama would have far more credibility if Grassley himself did not have a long history of using this very same rhetoric. Indeed, as recently as 2011, Grassley harshly criticized people who ‘turn to the courts’ after they ‘can’t get their policy views enacted through the legislative process.’”

At The Volokh Conspiracy, Orin KerrÌý: “In my experience, there are several different things people might mean when they label a judicial decision as ‘activist.’ … (1) The decision was motivated by the Justices’ personal policy preferences or was result-oriented.Ìý… (2) The decision expands the power of courts to determine the rules of our society. … (3) The decision was not consistent with precedents. … (4) The decision struck down a law or practice. … (5) The decision was wrong. … As I have explainedÌýmany times before, I think existing Commerce clause precedents combined with the presumption of constitutionality point pretty clearly in the direction of upholding the mandate. … Depending on how the decision might be written, a decision striking down the mandate could fairly be called activist in some ways but not in other ways.”

In the meantime, Ezra Klein, at The Washington Post’s Wonkblog,Ìý, and how a Supreme Court ruling against the individual mandate might be seen as a product of a long-held conservative view of that constitutional provision: “Based on existing precedent, the individual mandate is clearly constitutional. Free riders in the health insurance market clearly have ‘a substantial economic effect on interstate commerce.’ But many conservatives believe the Supreme Court has been wrong on the Commerce Clause for seven decades now. The problem, in other words, isn’t so much the individual mandate as the large body of case law that makes the mandate — and so much else that the federal government does—constitutional. That’s where you get Republican politicians like Rick PerryÌýarguingÌýthat almost everything the federal government does— Medicaid, Medicare, Social Security, etc. —is properly understood as unconstitutional.”

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Here’s a look at what was done when:

For a full list of regulations:Ìý For more on regulations: see Or seeÌý

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Here are brief clips of what Santorum and Romney said in their speeches Tuesday night:

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At The Washington Post’s Wonkblog, to criticism from some quarters that the press did not treat both nonprofit organizations equally. “As Lena Sun and IÌýreportedÌýin yesterday’s Washington Post, Planned Parenthood had a very aggressive media strategy: Within a day of the Komen decision, the organization blasted out the news it had raised $400,000 from 6,000 online donors. … Throughout the past week, I’ve repeatedly called and e-mailed Komen requesting comparable data. So far, nothing. … The lessened coverage of supporters of Komen’s initial decision to defund Planned Parenthood could simply be a product of the fact that most Americans supported it. Or, as [Ross] , it might represent the media ignoring a lot of people. As a reporter covering this story, it’s been incredibly difficult to figure out which explanation is right when Komen declines to discuss the impact this past week has had on its organization” (2/6).

At The Washington Post’s Right Turn blog, that the backlash against Komen is “remarkable, when you think about it: One private foundation decides not to give money to a charity but instead to pursue its core mission through other entities. And for this, a storm of vitriol descends on the foundation from elected officials and elite opinion-makers. If it were any other issue (e.g., pet rescue, education, save the whales), it would be unthinkable for members of Congress to weigh in. I mean a private charity kind of gets to decide where to spend its money, while its donors can continue to give or not as they see fit, right? Ah, but when the topic is abortion, all rules go out the window” (2/3).

Laura Bassett, at The Huffington Post, writes that Karen Handel, Komen VP for public policy, : “Emails between Komen leadership on the day the Planned Parenthood decision was announced, which were reviewed by HuffPost under the condition they not be published, confirm the source’s description of Handel’s sole ‘authority’ in crafting and implementing the Planned Parenthood policy. Handel’s strategy to cut off Planned Parenthood involved drafting new guidelines that would prevent Komen from funding any organization that was under investigation by local, state or federal authorities. Since Planned Parenthood is currently the target of a congressional inquiry prompted by House Republicans into the way it uses government funds, the family planning provider would have been immediately disqualified from receiving new Komen grants” (2/5).

At Hot Air, : “Komen would be better off sticking with outcome-based criteria for grants.Ìý If Planned Parenthood performs the mammograms needed for screening, then certainly it’s a legitimate action to offer a grant funding that activity.Ìý If all they’re doing is providing referrals, though, why not just fund the organizations actually performing the mammograms that catch cancer early enough for treatment, as well as the organizations actually providing that treatment?” (2/3).

At Cato@Liberty, : “It does not mean that politics has been banished from Komen’s decisions. It just means that Komen has again made a political decision that more closely reflects the values of Planned Parenthood’s supporters than its detractors. But that is how we should settle the question of who funds Planned Parenthood: with vigorous debate and by allowing individuals to follow their conscience. When Obamacare ‘settles’ the question by forcing taxpayers to fund Planned Parenthood, it violates everyone’s freedom and dignity” (2/3).

At Reforming Health, , writing before the Friday announcement by Komen, raised questions aboutÌýthe group’s tactics and advocacy. The move, she writes,Ìý“raises questions about the political and ideological forces that help guide a successful organization like the Komen Foundation. … Komen also uses a small portion of donor support to hunt down and threaten to sue other, far smaller cancer organizations that (often unknowingly) use the copyrighted phrase ‘for the cure’ or the color pink in their names or marketing materials. … And as for that early detection message, (a large part of the education programs that Komen spends a whopping 34% of its budget on) I feel less comfortable embracing Komen’s unquestioning support for the benefits of mammography — especially in low risk women under 50. It’s all part of what seems to be Komen’s aggressive role in fostering what has become a multi-billion dollar breast cancer industry. From expensive — and often unneeded — digital mammography to biopsies to chemotherapy that costs tens of thousands of dollars a year, there is a lot of money to be made in testing and treating breast cancer” (2/2).

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Yesterday on the main KHN site we had a talking about the American College of Physicians’ latest update of its . The manual encourages doctors to be “parsimonious” in doling out health care — that is, if you see our handy definition, “having an extreme reluctance to spend money.”

The term, which has actually been part of the ethics manual since 1998, has recently been the source of controversy. Some say docs shouldn’t consider cost when caring for patients and call the ideaÌý“rationing” — that minefield of a phrase — while others say doctors have an increasingly important role to help the U.S. control its healthÌýcosts.

After we talked to experts for the round robin,ÌýI also sauntered around the Internet looking for blog posts on the subject. Here’s a sampling:

Aaron Carroll, at The Incidental Economist,Ìýin the : “I think it’s fine for patients to see that some treatments may be a waste of money, and they might want to save that money. But I’m not sure that I think it’s as great an idea for doctors to consider “health care resources” in the same way. I’m just not as comfortable with that. At least, not when we’re talking “ethics.” Is a physician who advocates for a treatment that’s not cost-effective acting unethically? Again, I don’t think that’s what the ACP intended” (1/5).

Over at The Health Care Blog, Dr. Shilpa Iyer, in a crosspost from the blog, Ìýabout costs,Ìýby using a game:Ìý“I am not sure if and how practice patterns will or should change, but perhaps knowledge of the systemic charges will better inform our counseling of patients, and consideration of their resources. And, I did pause before obtaining an unneeded gonorrhea/Chlamydia culture the day afterwards with my newfound knowledge” (1/3).

For the SHOTS blog, NPR’s Rob Stein , of the American Enterprise Institute: “For Gottlieb, a parsimonious approach to medicine ‘really implies that care should be withheld. There’s no definition of parsimonious that I know of that doesn’t imply some kind of negative connotation in terms of being stingy about how you allocate something'” (Stein, 1/3).

At his National Center For Policy Analysis blog, : “Can you imagine a lawyer discussing the prospects of launching a lawsuit without bringing up the matter of cost? …ÌýOf course not.ÌýThen what is so special about medicine? Answer: the field has been completely corrupted by the idea that (a) patients should never be in a position to choose between health benefits and monetary cost, (b) doctors shouldn’t have to think about such tradeoffs either, (c) in order to insulate the patient from having to choose between health care and other uses of money, third-party payers should pay all the medical bills and (d) since no one else is going to think about what anything costs, the third-party payer is the only entity left to decide which services are worthwhile and which ones aren’t” (1/9).

At her ReformingHealth blog, Naomi Freundlich between the “virture or vice” of parsimony, in this cae: “In the pursuit of a cure or in an attempt to extend a child’s life a doctor might feel that his patient is the exception, one of the few who has a chance of responding to a treatment not considered cost-effective in most others. This hardly seems a breach of ethics. But I also can see the wider intent of the ACP authors who state very clearly in the same highlighted box:Ìý “The physician’s first and primary duty is to the patient.” This is followed by, “Physicians must base their counsel on the interests of the individual patient, regardless of the insurance or medical care delivery setting.” Parsimony shouldn’t override a treatment decision that could benefit an individual patient.ÌýThe real goal is to avoid wasteful, ineffective care that is not only costly, but likely to be harmful in the long run” (1/9).

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