This article published recently in the The Atlantic points out that unexpected, large hospital bills can happen to anyone. This caregiver was hounded by collectors, one even inviting them to connect on LinkedIn! As healthcare administrators, we have a good understanding of our average reimbursement and collection rates, as a percentage of the gross, billed charges. But do we really know what happens when the uncollected charges are turned over to collection agencies? Are we aware when and if they are then turned over or “sold” to other debt buyers? To me, poor treatment by collection agencies and debt buyers is still a reflection on the health system where the patient received their care. Can health systems and doctors afford this type of reputational risk?

I turned to a colleague, a revenue cycle professional and expert - the best I’ve ever worked with in the business. They provided a more balanced perspective:

There are two sides to this dilemma depending whether you are a patient or provider. From the patient perspective, medical debt is increasing and in too many cases crippling, often leading to financial ruin, depression and shattered lives. Statistics show the percent of total bankruptcy, because of medical debt, at over 50% and employers shifting costs through deductibles, now on average over $1,300 and growing, according to the Kaiser Foundation. On top of that, healthcare spending as a percent of GDP is approaching 20%; an unsustainable trajectory. Bottom line, patients and families are harmed by unaffordable medical debt and there is no solution in sight.

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In recent weeks Democratic candidates seeking the party’s nomination have given their preferences about how to reform U.S. health care. My experience in over 30 years of community hospital leadership led me to agree with the comments of John Delaney that Medicare-For-All would be a financial disaster for the vast majority of American hospitals. Very few U.S. hospitals have costs at or below Medicare payments.

Yet I don’t agree with Congressman Delaney’s statement that we shouldn’t touch the private health coverage market that covers 100 million Americans because those people will want to keep their coverage. I think there are a great number of Americans in the private coverage spectrum who have been saddled with enormous up-front deductibles and large co-payments and ever-narrowing health provider options who are ready to talk.

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These are extremely challenging times in healthcare.

We know changes are coming, but no one has a clear understanding of what those changes will be. When change happens, people look to their leaders to navigate them through. Are you prepared to be a successful leader in a time of such uncertainty?

Leadership Keys to Thriving Through Change:

Keep Consistent

Organizations should develop five key objectives and stick with them. Resist following the latest fads and avoid adding multiple new objectives. Overwhelming your people with too many objectives creates the “deer in the lights syndrome” and can hinder forward progress. Giving consistency will give your employees a feeling of security and will build both confidence and trust.

Solidify Trusted Relationships

Everything you read about America today suggests that the trust level of employees for their leaders and organizations are at an all-time low. It is imperative that you solidify relationships within all your key groups: Superiors, peers, and direct reports.

While you work to solidify interior relationships, also work to build relationships with experts outside your organization and possibly outside your industry. Connect with others who faced similar uncertainties and learn how they maneuvered through challenging situations

Be Agile and Adaptable

Remember, doing the same old things will get the same old results. Changes are coming quickly, and leaders must actively prepare. Some may consider hiring an executive coach to equip them with better leadership tools and enable them to produce better results.

Supersize the Soft Skills

According to the Carnegie Institute of Technology, 85% of your financial success is due to your personality and ability to communicate, negotiate and lead. Shockingly only 15% is due to technical knowledge. Communication, integrity, and empathy will pay dividends in the form of loyalty and engagement of your team. Encourage diversity of thought and embrace collaboration. Balance confidence and humility. By utilizing your soft skills, you will create an environment that each member can invest their best into and will cause the whole organization to succeed.

Change brings opportunity so don’t be afraid to take some risks. Great leaders became great because they could successfully navigate through the challenge of change. Utilizing these keys will allow companies not only to survive but also to seize the extraordinary opportunities that arise during periods of immense uncertainty.

Jim

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Healthcare expenditures in the U.S. exceed $2.9 trillion each year, representing more than 17.4% of the GNP(1). It should be noted that 80% of this expenditure is associated with chronic disease and, therefore, it is no surprise that Population Health is addressing the identification of at-risk populations and patients with early stage chronic conditions, not to mention the growth of our aging population. With Healthcare Reform driving the shift from volume to value, Urgent Care Centers (UCCs) represent a key care component of the Patient Protection and Affordable Care Act (PPACA) as well as the IHI Triple Aim that directly impacts access/convenience and reduced costs.

Between UCCs and retail medical clinics that are in stores like Walgreens, CVS and Target, convenient care is approaching 10,000 sites throughout the U.S. The Urgent Care concept originated in the late ‘70s and has proliferated in recent years, fueled by a shortage of primary care physicians and overbooked primary care offices, long emergency room wait times and the high cost of emergency room care. This leaves patients frustrated and feeling like they have no place to turn when they have an immediate need for medical attention but their condition is not an emergency. In fact the Centers for Disease Control and Prevention stated in 2012 that nearly 80% of visits to emergency departments were due to a lack of access to other healthcare providers(2). The niche market of urgent care therefore has a huge opportunity to make an impact.

To the credit of many physicians, they saw and are trying to meet the community need of access at lower cost by starting and owning a majority of the UCCs. These UCCs are designed to function for the convenience of the consumer on a walk-in, no appointment basis and be open for extended hours.

Health Plans, large Medical Groups, Hospitals and Health Systems are realizing the importance of establishing this type of convenient care model and have different strategies for providing Urgent Care such as building their own or affiliating with existing urgent care operators as strategic partners in providing quality outcomes at a lower cost with greater satisfaction.

For Hospitals and Health Systems, UCC affiliations are mutually beneficial. They can relieve excess volume in the hospitals’ overcrowded emergency departments and, by virtue of having a lower volume it will result in a reduction of the hospital write-offs. These relationships will generate downstream referrals for the hospitals when there is a need by the UCCs for a higher level of diagnostics, when specialist referrals are required and when patients with conditions requiring emergency care show up first at the UCCs and need to be directed to emergency departments. UCCs can also assist hospitals by functioning in the capacity of discharge clinics to reduce the hospitals’ readmission rates.

For Primary Care physicians and Medical Groups, there can be a delay of weeks or months for patients getting appointments. The number of aging patients with chronic diseases is increasing as well, making the timely delivery of care challenging. These physician groups can look to UCCs for arrangements to cover after-hours or for vacations as well as for more patient-convenient certified laboratory collections and testing, imaging, suturing, in-house medication dispensing and durable medical equipment.

For Health Plans, UCCs pose a more cost-effective alternative than emergency rooms. Additionally, as it pertains to population health, it is crucial that the respective electronic health records interface so that at-risk patients can be identified and treated for early stage chronic conditions. An EHR would allow a seamless connection with an ACO or a Medical Group as well.

In conclusion, UCCs that are appropriately integrated in the healthcare delivery system will effectively meet the intent of the ACA and Triple Aim by providing greater convenience, satisfaction, reducing cost and be integral in achieving Population Health.

(1) https://www.washingtonpost.com/news/wonk/wp/2014/12/03/heres-exactly-how-the-united-states-spends-2-9-trillion-on-health-care
(2) http://www.cdc.gov/nchs/data/nhis/earlyrelease/emergency_room_use_january-june_2011.pdf

Last week CMS announced a new Next Generation ACO Model, which asks providers to agree to take on greater risks related to their performance in return for potentially sharing in a greater proportion of savings. In return for accepting more risk, CMS is providing a “predictable benchmark and flexible payment options that support ACO investments in care improvement infrastructure.”

A key aspect of the new model involves a greater level of care coordination between providers and beneficiaries. CMS is offering additional coverages for tele-health services as well as post-discharge home services, and beneficiaries will be financially rewarded for receiving their healthcare from the ACO’s staff; however, participating beneficiaries will retain the freedom to engage any Medicare provider.

The new model features two “risk tracks,” one of which is a 100% “Full Performance Risk” while the other involves more shared risks. The stated overarching goal of the ACO approach involves “paying providers based on the quality rather than the quantity of care they give patients;” and with increased financial incentives for providers, CMS believes the approach has the potential to simultaneously decrease costs while improving health outcomes.

Interested organizations will have two opportunities to apply, one this year and one next year, and participation in the new ACO model is expected to last up to five years. Providers are required to submit a Letter of Intent by May 1, followed up with a formal application by June 1, 2015. The second round of applications will be accepted next spring, 2016. For more information, see the links below.

HHS Press Release: http://www.hhs.gov/news/press/2015pres/03/20150310b.html

CMS Next Generation ACO Model: http://innovation.cms.gov/initiatives/Next-Generation-ACO-Model/

Frequently Asked Questions: http://innovation.cms.gov/Files/x/nextgenacofaq.pdf

CMS is developing and testing new payment and service delivery models in accordance with the Affordable Care Act and other legislation. Some models are designed to demonstrate whether various approaches are more effective than others at improving care and/or fostering innovation in the healthcare industry. There are seven broad categories used to group the models:

● Accountable Care
● Bundled Payments for Care Improvement
● Primary Care Transformation
● Initiatives Focused on the Medicaid and CHIP Population
● Initiatives Focused on the Medicare-Medicaid Enrollees
● Initiatives to Speed the Adoption of Best Practices
● Ways to Accelerate Testing of New Payment and Service Delivery Models

CMS provides a website (link below) that displays the various models and their current status, for example, whether they are Under Review, Accepting Applications, Ongoing, No Longer Active, etc.

The information available at the website can help you stay informed about changes as they evolve; other resources allow you to identify hospitals and other healthcare providers that are participating in the various programs.

As an example of the type of information that is available, one “demonstration model” tracked patients after they left the hospital to determine whether hospital-physician collaborations prevented complications, avoided duplication of services, improved quality and/or eliminated unnecessary costs. You can access these resources as well as other data and reports at: http://innovation.cms.gov/initiatives/index.html#views=models

Financial pressures continue to take their toll on rural hospitals. Many of these small facilities are working to develop and implement strategies to stay viable, however their situations are challenging, to say the least.

Here’s a roundup of recent activities occurring in several states, but these developments are representative of what is occurring in many communities across the country.

In Georgia, a “Rural Hospital Stabilization Committee” was created by Governor Nathan Deal in March to facilitate communications between hospitals and the state. The committee met earlier this week to evaluate how “free-standing emergency room models” could work in rural hospitals.

In Alabama, six rural facilities have closed in the previous 18 months, but 22 are experiencing serious financial pressures. In Tennessee, at least 28 hospitals are facing significant budget cuts or outright closures, such as Haywood Park Community Hospital, which stopped providing inpatient services July 31.

In Arkansas, Crittenden Regional Hospital in West Memphis announced it is closing September 7, and the East Texas Medical Center Regional Healthcare System recently announced it is closing its facility in Gilmer at the end of this year.

In South Carolina, where average occupancy rates are at 60 percent, some rural facilities are reporting rates under 10 percent. One S.C. facility with 59 beds, Wallace Thomson Hospital in Union County, operated for several years at less than 25 percent capacity. After adding over $20 million in debt to its balance sheet, it recently filed for Chapter 9 bankruptcy protection.

The “Post and Courier” newspaper in South Carolina recently reported that the state legislature has approved some funding to help hospitals “transition from business models based on filling beds to other models less reliant on inpatient services.” Other financial assistance is available through CMS, which recently extended its program to increase payments to hospitals with low Medicare inpatient volumes.

For more information on the state of rural hospitals, visit: http://www.fiercehealthfinance.com/story/rural-hospitals-struggle-keep-doors-open/2014-08-26

Last week the American Hospital Association released a report (link below) on the variety of approaches being taken by hospitals and health plans regarding price transparency. The report also includes a high-level analysis of related government initiatives at the state and federal levels.

Price transparency across the nation is a patchwork of activity. Currently, 35 states are requiring hospitals to release data on some of their charges. Seven states are saying the release of this data is only voluntary. It’s a fluid situation, so having a strategy in place to address these requirements is must for hospital executives involved in these areas.

At the federal level, CMS has released hospital-specific average charges and Medicare reimbursement rates (link below) for 100 of the most common inpatient procedures and 30 of the most common outpatient procedures since June 2013. The data shows the amounts that providers are billing for services, procedures and medical items.

At the local level, hospitals are implementing a variety of efforts aimed at achieving price transparency, but the tasks are complicated by contractual obligations that restrict hospitals from releasing rates negotiated with payers. As a result, these activities require expertly managed collaboration among all of the various stakeholder groups.

To learn more, visit the links below to access the AHA report and CMS charge data.

AHA Report: “Price Transparency Efforts Accelerate”
http://www.ahacommunityconnections.org/content/14tranparency-trendwatch.pdf

Charge Data Released by CMS:
http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-Provider-Charge-Data/

Hospitals are increasingly seeking out business relationships (alliances, partnerships) as a means to gain competitive advantages in the marketplace. It’s a trend that’s been growing, in part, because the Federal Trade Commission is beginning to take a closer look at how mergers and acquisitions are affecting competition and patient access to care. However, there are a variety of variables involved, including goals such as expanding clinical expertise and increasing quality.

For example, Tenet has formed an alliance with Yale New Haven to develop clinical networks; Tenet gets access to Yale’s clinical expertise and Yale gets access to Tenet’s large cash reserves. Also, a new “quality alliance” was announced last week by Kaiser Permanente and Johns Hopkins; Kaiser gets access to Johns Hopkins’ research capabilities and Johns Hopkins can tap into Kaiser’s vast database of population health statistics.

Other activities include joint ventures such as the recent agreement between Tenet and Dignity Health to take over operations of southern Arizona’s largest hospital system, Carondelet Health Network.

To learn more, see the article: “Hospital Mergers Are Out. ‘Strategic Alliances’ Are In. Is Obamacare Responsible?” published by California Healthline at http://www.californiahealthline.org/road-to-reform/2014/hospital-mergers-are-out-strategic-alliances-are-in-is-obamacare-responsible

An article published last week by Becker’s Hospital Review discussed ten concerns and trends that can be viewed as opportunities and/or threats depending on the hospital’s size, market and other factors. The article is linked below; here’s a high-level summary:

1. Growth of High-Deductible Plans – Patients are looking for lower-cost healthcare options, including urgent care centers and other clinics.

2. Growth of Accountable Care Organizations – An analysis conducted during May identified 626 ACOs covering 20.5 million lives in the country; expect more ACOs led by hospitals and physicians for Medicare, Medicaid and commercial health plans.

3. Intensity of Rivalries – Competition for patients, doctors and payer contracts is intensifying, however, the intensity varies across geographic areas; rivalries are developing not only locally, but also nationally and sometimes even internationally.

4. Reduced Inpatient Procedures – The average inpatient procedure generates revenue that is 600% to 1,000% higher than outpatient procedures; declining numbers of inpatient procedures appear to be occurring across all service lines offered by hospitals.

5. Layoffs – Approximately 100 hospital layoffs have been noted so far this year by Becker’s Hospital Review.

6. Narrow Networks – To attract consumers by offering low premiums, some insurers are selling narrow-network policies through the ACA health insurance exchanges; hospitals in these narrow networks are at risk for decreased revenue due to lower payment rates, which is typically not the case in broader contracts; however, hospitals that avoid these narrow-network contracts are vulnerable to losing market share.

7. Shift to Population Health/Managed Care – Providers are increasingly embracing pay-for-performance models; a study published last month by McKesson found that 81% of hospitals and 90% of payers have signed on to or are currently offering complex reimbursement models that combine fee-for-service and other models.

8. Huge Growth in Health IT Spending – A survey of hospital executives completed this year by the research firm Premier found that almost half of the executives said their largest capital investment this year will be for health information technology.

9. Competition for Physicians – The nation’s aging population will contribute to a shortage of physicians in the US; one study shows a shortage of 130,600 physicians by 2025, and another study shows the need for specialists to care for the elderly will double between 2013 and 2025.

10. Staying Independent – Standalone hospitals with revenue under $300 million will face greater difficulties because of: a) their lack of clout with payers, b) the need to invest large sums in health information technology, and c) the shift to pay-for-performance.

For more details, see Becker’s Hospital Review at: http://www.beckershospitalreview.com/leadership-management/10-concerns-and-trends-facing-hospitals-right-now.html

A 12-page “Trendwatch” report published in June by the American Hospital Association (AHA) provides excellent guidance on how hospitals can adjust their operations to remain competitive in light of the Affordable Care Act (ACA). The report (available at the link below) discusses the impact of the ACA on multiple variables:

1) Increasing coinsurance and deductibles will make consumers more price sensitive at the point of care

2) Consumers will demand cost information to guide decision-making

3) Providers will carry the burden of patient education at the point of care

4) Greater exposure to costs may lead to delayed or avoided care

5) Higher patient cost-sharing can increase bad debt

6) Hospitals may lose volume to lower-cost providers

7) More options leave consumers to balance multiple plan features in decision-making

The bottom-line takeaway from the report is that hospitals will have to implement new strategies to succeed in today’s rapidly evolving marketplace, where consumers are more actively engaged in the purchase of coverage and care-delivery services.

At the end of the report, the AHA provides five strategic questions for hospital executives, including options for how to answer/address those questions. This is a valuable report for all hospital executives and will help you provide proactive “thought leadership” throughout your organization.

The report is available for download at: http://www.aha.org/research/reports/tw/14june-tw-consumerchc.pdf

In a recent study conducted by L.E.K. Consulting, approximately 150 hospital CEOs and other senior decision makers were asked how they expected to respond to the Affordable Care Act. Their answers indicated they were planning to implement the following strategies:

69 percent – Increase process efficiency
51 percent – Reduce costs by renegotiating with suppliers
45 percent – Reduce redundant procedures in care
45 percent – Delay capital expenditures
35 percent – Increase utilization
30 percent – Lower costs at care centers
18 percent – Delay acquisitions
05 percent – Do nothing

Other findings noted in the four-page “Executive Insights” report (link below) include:

"Typical suburban hospital’s margins are currently approximately 4% but this is expected to decline to 0%, primarily due to payer-mix shifts.”

"The top 100 hospital systems in the U.S. will account for more than 60% of hospital spending, up from 40% in 2008.”

“While most hospitals still operate as standalone institutions, the majority will likely eventually move towards joining large, consolidated, and increasingly strategically integrated systems.”

The concise report also includes data on the percentage of respondents indicating their interest in specific medical technology solutions to address issues such as disease management, hospital management, clinical analytics, etc.

L.E.K. Consulting is a 30-year-old management consulting firm with clients in the private and public sectors. You can access their report at: http://www.lek.com/sites/default/files/LEK_HospitalSurveyEI0214_Final%28v4%29.pdf

Historically, hospitals have experienced difficulties managing physicians. But with the new healthcare reform initiatives, employing physicians is seen as critical to reaping new revenue streams tied to greater coordination of healthcare. As a result, health systems have been acquiring physician groups at an accelerating pace.

In the article linked below, “Making Physicians Pay Off,” Beth Kutscher of Modern Healthcare does a great job explaining the cost-benefit factors that hospitals are reviewing when trying to balance the “current costs” versus “future benefits” of employing physicians.

Here’s a key takeaway offered in the article: “Given a median loss of $176,463 for employing a doctor, some analysts are predicting a pullback on physician buys this year.”

However, many hospital executives continue to say that these acquisitions are critical because their current balance sheet numbers don’t reflect the future reality: capitalizing on new revenue opportunities will require much greater coordination of healthcare for patient populations, and having doctors and hospitals tightly integrated is essential in that regard.

Dr. Alan Kaplan, president and CEO of a 12-hospital system based in Iowa, is quoted in the article, saying, “You have to bring them in—and then you have to bring them in as efficiently as you can. It's really a strategic asset that requires investment.”

To learn more about the pros and cons of acquiring physician groups, you can read the article in its entirety by copying this link into your web browser:
http://www.modernhealthcare.com/article/20140222/MAGAZINE/302229986/making-physicians-pay-off?AllowView=VXQ0UnpwZTVDUGFjL1I3TkErT1lBajNja0U4VUNPUmZFQk1JQWc9PQ==#

Wiederhold and Associates will from time to time be presenting articles on subjects of interest and importance from our clients, past clients and most active network members. Mark Phelps will address the very hot topic of insurance exchanges under the affordable care act. Mark looks forward to your comments on his article.
____________________________

Insurance Exchanges and the Affordable Care Act

With President Obama's reelection a part of history, the movement to implement the Patient Protection and Affordable Care Act (ACA) has been ensured. When the ACA was heard by the Supreme Court, one case under consideration was filed by the National Federation of Independent Businesses. 1 The arguments in that case concerned the issue of whether Congress exceeded its power by requiring most Americans to buy health insurance or pay a fine. This provision was known as the individual mandate. 2

That mandate, along with four other major approaches, was the reason the ACA was drafted to attack the problem of the uninsured in our society. 3 The other approaches to combat un-insurance in the ACA were: 1) guaranteed coverage in plans provided by insurance companies; 2) the mandate to individuals to obtain health insurance; 3) state-run health insurance markets, called “exchanges,” where individuals and small employers’ workers can shop for insurance packages; and 4) expansion of the federal-state Medicaid program of care for the poor and the disabled. 4

The theory of insurance exchanges in the ACA was to offer "one stop shopping" for individuals and small businesses with affordable coverage. 5 It would also be the only place for Members of Congress to obtain their health insurance. 6

Insurance exchanges offer individuals and small businesses the ability to pool risk and purchasing power and therefore pay lower rates. 7 Affordable Insurance Exchanges are also modeled to provide users with the ability to determine if tax credits are applicable or if the user can enroll in programs such as the Children's Health Insurance Program (CHIP). 8

Rules were published by the Department of Health and Human Services (HHS) on March 12, 2012 regarding Affordable Health Insurance Exchanges. 9 The operational date for the Exchanges is January 2014. The rules published in March 2012 included standards for the following:

• The establishment and operation of an Exchange
• Health insurance plans that participate in an Exchange
• Determinations of an individual’s eligibility to enroll in Exchange health plans and in insurance affordability programs
• Enrollment in health plans through Exchanges
• Employer eligibility for and participation in the Small Business Health Options Program (SHOP) 10
• Those rules also specified that exchanges will perform certain functions listed below:
• Certifying health plans as “qualified health plans” to be offered in the Exchange
• Operating a website to facilitate comparisons among qualified health plans for consumers
• Operating a toll-free hotline for consumer support, providing grant funding to entities called “Navigators” for consumer assistance, and conducting outreach and education to consumers regarding Exchanges
• Determining eligibility of consumers for enrollment in qualified health plans and for insurance affordability programs (premium tax credits, Medicaid, CHIP and the Basic Health Plan)
• Facilitating enrollment of consumers in qualified health plans 11

Going into the Presidential election of 2012, individual states had a looming deadline of November 16, 2012 to notify the Department of Health and Human Services if they intended to set up their own insurance exchanges or enter into a state-federal partnership.12 At the request of state governors, HHS granted an extension until December 14, 2012 to respond to this deadline. 13 HHS clarified that there would be no further extensions of deadlines regarding the implementation of Exchanges in a Memorandum of Frequently Asked Questions (Memorandum) dated December 10, 2012. 14 This additional time gave state officials who were trying to determine whether there was enough political will, technical knowledge and time in their respective states to organize their own new health benefit marketplaces. 15

HHS further clarified in the Memorandum that if "a state plans to operate the Exchange in its state in partnership with the federal government starting in 2014", the state will need to declare "what partnership role they would like to have by February 15, 2013". 16 The deadline of February 15, 2013 has come and gone. We now know that the federal government will run 26 of the state health exchanges. 17 (Maine, New Jersey, Pennsylvania, Virginia, North Carolina, South Carolina, Georgia, Florida, Alabama, Tennessee, Ohio, Indiana, Mississippi, Louisiana, Missouri, Wisconsin, Texas, Oklahoma, Kansas, Nebraska, South Dakota, North Dakota, Montana, Wyoming, Arizona, Alaska) It also will partner with seven states, where state and federal officials take joint responsibility for the marketplace. 18 (New Hampshire, Delaware, West Virginia, Michigan, Illinois, Iowa, Arkansas) Seventeen states and the District of Columbia will take on the task themselves. 19 (Vermont, Massachusetts, Rhode Island, Connecticut, New York, Maryland, District of Columbia, Kentucky, Minnesota, Colorado, New Mexico, Utah, Idaho, Nevada, Washington, Oregon, California, Hawaii)

The legislative intent of the originally filed federal House of Representative bill for Obamacare in which the federal government would operate one large national insurance exchange may come close to reality with the latest actions of many of the states deciding to have HHS operate their exchanges by default. 20 It seems the Executive Branch of the government may ultimately have significant political power over setting up its signature legislative accomplishment. 21 Further, this will allow HHS to use economies of scale in creating a minimal number of template exchanges that many of the 26 states will use. 22

Mark T. Phelps is a healthcare attorney and an Assistant Professor in the Department of Healthcare Administration at Texas Woman’s University in Houston. He currently is working with healthcare clients on a consulting basis. If you have some interest in learning more about Mark, please Wiederhold & Associates know.

1. Kever, J., Only certainty from ruling on health care law is change, Houston Chronicle, 03-25-2012, from http://www.chron.com

2. Id.

3. Denniston, L., Analysis: Health care’s other mandate, December 19th, 2011, from http://www.scotusblog.com/2011/12/analysis-health-cares-other-mandate,

4. Id.

5. Affordable Insurance Exchanges, from http://cciio.coms.gov/proframs/exchanges/index.html

6. Id.

7. Id.

8. Affordable Insurance Exchanges, from http://www.HealthCare.gov

9. Affordable Insurance Exchanges: Choices, Competition and Clout for States, from http://www.healthcare.gov/news/factsheets/2011/07/exchanges07112011a.html

10. Id.

11. Id.

12. Adams, www.CQ.com, 11/9/12

13. Alonso-Zaldivar; More States Reveal Exchange Choices As Administration Extends Deadline; http://www.washingtontimes.com/news/2012/nov/16/states-reveal-their- choices-obamas-health-law/; 11-16-2012

14. Frequently Asked Questions on Exchanges, Market Reforms and Medicaid, Department of Health & Human Services, 12/10/12, from http://www.healthlawyers.org/News/Health20Lawyers20Weekly/Documents/12141 2/FAQs.pdf

15. Adams, www.CQ.com, 11/9/12

16. Frequently Asked Questions on Exchanges, Market Reforms and Medicaid, Department of Health & Human Services, 12/10/12, from http://www.healthlawyers.org/News/Health20Lawyers20Weekly/Documents/12141 2/FAQs.pdf

17. Kliff, It’s official: The feds will run most Obamacare exchanges, THE WASHINGTON POST, February 18, 2013

18. id.

19. id.

20. id.

21. id.

22. id.