The Law Library of Congress is excited to bring you a collection of World War I declarations of war from around the world. If you’re not familiar with our collections, you might wonder how we came to acquire these century-old foreign legal materials. The reason is that, as the United States assumed a greater role in international affairs, the Law Library of Congress developed a special competency in foreign law to fulfill its mission to serve Congress. To support our foreign law specialty, the Law Library has, and continues to, collect legal materials from across the globe. Approximately half of the 2.9 million volumes in our collection are foreign and comparative law materials. The Law Library relies on foreign legal specialists to read and interpret these legal materials for their respective jurisdictions in order to prepare law reports for Congress. You can read many of these reports on our site at Law.gov.
To join the Library of Congress in commemorating the 100th anniversary of the United States’ entry into World War I, we asked our foreign legal specialists to locate declarations of war in the official gazettes for their jurisdictions so we could share them with you. Many of these materials are over one hundred years old and a few were published by empires that disappeared from the map at the close of World War I. This display is just a small part of the “Echoes of the Great War: American Experiences of World War I” exhibition. We hope you can visit the exhibit in Washington when it opens on April 4, 2017. In the meantime, you can explore the Library’s vast holdings related to the Great War through the new Library of Congress World War I topic page.
As the country braces for a possible overhaul of the Affordable Care Act, consumers and patients are raising concerns that the more than 10 million people who purchased plans through the law’s insurance marketplaces could lose coverage. Some are also nervous that changes unleashed by any revamping of the law could throw insurance purchased by individuals outside of the marketplaces into jeopardy.
This individual insurance market has long been troubled with chronic problems, which helped propel efforts to pass Obamacare in 2010. Yet, consumers’ complaints about the resulting coverage have helped drive the Republicans’ arguments to dismantle the ACA.
Here is a primer on the individual insurance market and the potential consequences of repealing portions of the sweeping health law.
What is the individual insurance market?
It is used by people who do not have health coverage through the government or their employer when they purchase a plan directly from an insurer. It is sometimes called the non-group market.
These plans can be offered either on or off of the ACA marketplace, with the exception of the District of Columbia, which provides insurance solely through that marketplace.
What’s the difference between individual plans sold on the health exchanges and those sold outside the exchanges?
Plans sold on the health exchanges, also called marketplaces, provide several benefits to consumers. Enrollees earning up to 400 percent of the federal poverty level — about $47,500 for an individual and $97,200 for a family of four — qualify for a tax credit to offset the cost of the premiums. Additionally, many of the online portals allow consumers to compare plans side by side, helping buyers find a plan that fits their needs.
In contrast, plans purchased off the exchange do not qualify for the subsidies and are generally more expensive. However, the off-marketplace plans often offer broader benefits, particularly access to providers who are not part of the insurers’ networks. More than half of off-exchange plans gave customers some sort of out-of-network coverage, according to a Robert Wood Johnson Foundation analysis on the Health Affairs website, whereas just 36 percent of marketplace plans offered the same benefit.Use Our Content This KHN story can be republished for free (details).
How many people use these individual insurance plans?
The number is relatively small — roughly 8 percent of the U.S. population in 2015 — but it has been growing since the health law made such coverage more accessible and barred insurers from denying coverage to people with pre-existing health conditions. Among the people who might turn to an individual plan are self-employed business owners, someone taking early retirement, an unemployed worker who loses his access to job-based insurance and young adults who no longer qualify for coverage under a parent’s plan.
According to the latest data, 10.4 million people purchased an individual plan through the marketplace in the first half of last year.
It is harder to pinpoint the number of people buying insurance off the marketplaces. The Department of Health and Human Services last October estimated that total at 6.9 million. In that same report, HHS estimated that 2.5 million of these consumers could have qualified for tax credits available if they had purchased marketplace policies.
How do you buy these plans?
Plans on the federal or state marketplace online can be purchased online and often through insurance brokers. Some areas also provide enrollment assistance through trained personnel, often referred to as health care navigators.
Off-exchange programs can be purchased directly through the insurer or a broker.
How much do these plans cost?
Insurers offering any plans on or off the marketplaces can set prices based solely on five factors: age, location, tobacco use, individual-versus-family enrollment and the plan’s category, which denotes how much of the medical expenses, on average, the plan covers. Plans are categorized by metal tiers, with bronze plans covering 60 percent of costs, silver plans 70 percent, gold plans 80 percent and platinum plans 90 percent.
On average, plans on the marketplace are generally less expensive than those sold off of it. According to the Robert Wood Johnson analysis, the average premium for off-exchange plans in 2016 was 13 percent more expensive and had higher deductibles than on-exchange policies.
According to the federal Centers for Medicare & Medicaid Services, which oversees the health law marketplaces, 84 percent of marketplace shoppers qualified for premium tax credits in October 2016. And those earning less than 250 percent of poverty ($29,700 for an individual) who purchase a silver plan also qualify for subsidies that help cover deductibles, copayments and other out-of-pocket expenses.
What are the concerns?
Prior to the ACA, consumers often found it difficult to get comprehensive coverage on the individual market, especially since insurers could refuse to sell to customers who had pre-existing conditions. About 18 percent of applicants were denied coverage because of those health problems, according to one study. A 2011 report by HHS found half of non-elderly Americans lived with a condition that could have barred them from obtaining insurance.
Insurers could also include exclusion riders. These provisions cut out coverage for treatments related to specific diseases.
Because of those problems, many people turned to poor quality plans that had limited coverage, sometimes without realizing that their policies wouldn’t provide adequate insurance. Those who had comprehensive insurance often found it to be expensive. In addition, in some areas few plans were offered.
Although the health law standardized the benefits that policies must offer, it did not solve some of this market’s problems. Insurers complained that they were losing money because the market was attracting too many sick people and not enough healthy ones to stabilize their risk pools, which help spread the costs among health and sick customers. Some companies exited the exchanges, cutting down on competition and consumer choice. This year, 89 insurers have left the marketplace, according to a November analysis by consulting firm McKinsey and Co.
Others increased their premiums, reduced their provider networks and set higher deductibles that patients had to pay out of pocket before their coverage kicked in. The price for the silver marketplace plans on which subsidies are pegged increased an average of 22 percent nationwide in 2017, according to HHS. Several states experienced sharper hikes, including Minnesota, where premiums increased 50 to 67 percent.
What happens if the ACA is repealed?
Most political observers believe that Republicans cannot repeal the entire law since they don’t have the 60 votes needed in the Senate to avoid a filibuster. As a result, GOP leaders are working to repeal portions of the law through a complicated process known as budget reconciliation, which requires a 51-vote majority. Provisions in a reconciliation bill can deal only with federal spending, so it might affect parts of the law such as those that set up the financial subsidies for exchange customers, the Medicaid expansion and the tax penalty for those who don’t get coverage.
The Republicans, however, have not yet come together on a plan for replacing those provisions with their alternatives, an effort that would be separate from the repeal legislation.
Many analysts suggest that the upheaval could push enough healthy individuals out of the marketplace plans to upset insurers’ risk pools. The change could also erode the exchanges by driving more insurers out of the marketplace. According to a report by the Congressional Budget Office, a Republican repeal plan vetoed last year by President Barack Obama would have resulted in 32 million Americans losing coverage by 2026.
An Urban Institute report found that if lawmakers go forward with their partial repeal and do not have adequate safeguards to help insurers keep healthy customers, “significant market disruption would occur,” including the loss of some insurers quickly.
But the shocks could also cause enough chaos that insurers would pull out of the entire market, said Paul Ginsburg, a professor of health policy and management at the University of Southern California.
“That would not only wipe out the coverage that the subsidies underwrote,” he said in reference to a partial repeal through reconciliation, “it would also wipe out the rest of individual market.”
End-of-life counseling sessions, once decried by some conservative Republicans as “death panels,” gained steam among Medicare patients in 2016, the first year doctors could charge the federal program for the service.
Nearly 14,000 providers billed almost $35 million — including nearly $16 million paid by Medicare — for advance care planning conversations for about 223,000 patients from January through June, according to data released this week by the Centers for Medicare & Medicaid Services. Full year figures won’t be available until July, but use appears to be higher than anticipated.
Controversy is threatening to reemerge in Congress over the funding, which pays doctors to counsel some 57 million Medicare patients on end-of-life treatment preferences. Rep. Steve King, R-Iowa, introduced a bill last month, the Protecting Life Until Natural Death Act, which would revoke Medicare reimbursement for the sessions, which he called a “yet another life-devaluing policy.”
“Allowing the federal government to marry its need to save dollars with the promotion of end-of-life counseling is not in the interest of millions of Americans who were promised life-sustaining care in their older years,” King said on Jan. 11.This KHN story also ran in USA Today. It can be republished for free (details).
While the fate of King’s bill is highly uncertain — the recently proposed measure hasn’t seen congressional action — it underscores deep feelings among conservatives who have long opposed such counseling and may seek to remove it from Medicare should Republicans attempt to make other changes to the entitlement program.
Proponents of advance care planning, however, cheered evidence of program’s early use as a sign of growing interest in late stage life planning.
“It’s great to hear that almost a quarter million people had an advance care planning conversation in the first six months of 2016,” said Paul Malley, president of Aging with Dignity, a Florida nonprofit. “I do think the billing makes a difference. I think it puts it on the radar of more physicians.”
Use of the counseling sessions are on track to outpace an estimate by the American Medical Association, which projected that about 300,000 patients would receive the service in the first year, according to the group, which backed the rule.
Providers in California, New York and Florida led use of the policy that pays about $86 a session for the first 30-minute office-based visit and about $75 per visit for any additional sessions.
The rule requires no specific diagnosis and sets no guidelines for the end-of-life discussions. Conversations center on medical directives and treatment preferences, including hospice enrollment and the desire for care if patients lose the ability to make their own decisions.
The new reimbursement led Dr. Peter Sutherland, a family medicine physician in Morristown, Tenn., to schedule more end-of-life conversations with patients last year.
“They were very few and far between before,” he said. “They were usually hospice-specific.”
Now, he said, he has time to have thorough discussions with patients, including a 60-year-old woman whose recent complaints of back and shoulder pain turned out to be cancer that had metastasized to her lungs. In early January, he talked with an 84-year-old woman with Stage IV breast cancer.
“She didn’t understand what a living will was,” Sutherland said. “We went through all that. I had her daughter with her and we went through it all.”
The conversations may occur during annual wellness exams, in separate office visits or in hospitals. Nurse practitioners and physicians’ assistants may also seek payment for end-of-life talks.
The idea of letting Medicare reimburse such conversations was first introduced in 2009 during debate on the Affordable Care Act. The issue quickly fueled allegations by some conservative politicians, such as former Republican vice presidential candidate Sarah Palin and presidential candidate John McCain, that they would lead to “death panels” that could disrupt care for elderly and disabled patients.
The idea was dropped “as a direct result of public outcry,” King said in a statement.
“The worldview behind the policy has not changed since then and government control over this intimate choice is still intolerable to those who respect the dignity of human life,” he said.
But in 2015, CMS officials quietly issued the new rule allowing Medicare reimbursement as a way to improve patients’ ability to make decisions about their care.
End-of-life conversations have occurred in the past, but not as often as they should, Malley said. Many doctors aren’t trained to have such discussions and find them difficult to initiate.
“For a lot of health providers, we hear the concern that this is not why patients come to us,” Malley said. “They come to us looking to be cured, for hope. And it’s sensitive to talk about what happens if we can’t cure you.”
A 2014 report by the Institute of Medicine, a panel of medical experts, concluded that Americans need more help navigating end-of-life decisions. A 2015 Kaiser Family Foundation poll found that 89 percent of people surveyed said health care providers should discuss such issues with patients, but only 17 percent had had those talks themselves. (KHN is an editorially independent program of the foundation.)
Use of the new rule was limited in the first six months of 2016. In California, which recorded the highest Medicare payments, about 1,300 providers provided nearly 29,000 services to about 24,000 patients at an overall cost of about $4.4 million — including about $1.9 million paid by Medicare.
The data likely reflect early adopters who were already having the talks and quickly integrated the new billing codes into their practices, said Dr. Ravi Parikh, an internal medicine resident at Brigham and Women’s Hospital in Boston, who has written about advance care planning. Many others still aren’t aware, he said.
Data from Athenahealth, a medical billing management service, found that only about 17 percent of 34,000 primary care providers at 2,000 practices billed for advance care planning in all of 2016.
The numbers will likely grow, said Malley, who noted that requests from doctors for advance care planning information tripled during the past year.
To counter objections, providers need to ensure that informed choice is at the heart of the newly reimbursed discussions.
“If advance care planning is only about saying no to care, then it should be revoked,” Malley said. “If it truly is about finding out patient preferences on their own turf, it’s a good thing.”
KHN’s coverage of end-of-life and serious illness issues is supported by The Gordon and Betty Moore Foundation.
The confirmation of Tom Price, the orthopedic surgeon-turned-Georgia congressman, as secretary of Health and Human Services represents the latest victory in the ascendancy of a little-known but powerful group of conservative physicians in Congress he belongs to — the GOP Doctors Caucus.
During the Obama administration, the caucus regularly sought to overturn the Affordable Care Act, and it’s now expected to play a major role determining the Trump administration’s plans for replacement.
Robert Doherty, a lobbyist for the American College of Physicians, said the GOP Doctors Caucus has gained importance with Republicans’ rise to power. “As political circumstances have changed, they have grown more essential,” he said.
“They will have considerable influence over the considerable discussion on repeal and replace legislation,” Doherty said.
Price’s supporters have touted his medical degree as an important credential for his new position, but Price and the caucus members are hardly representative of America’s physician in 2017. The “trust us, we’re doctors” refrain of the caucus obscures its heavily conservative agenda, critics say.This KHN story also ran on NPR. It can be republished for free (details).
“Their views are driven more by political affiliation,” said Mona Mangat, an allergist-immunologist and chair of Doctors for America, a 16,000-member organization that favors the current health law. “It doesn’t make me feel great. Doctors outside of Congress do not support their views.”
For example, while the American College of Obstetrics and Gynecology has worked to increase access to abortion, the three obstetrician-gynecologists in the 16-member House caucus are anti-abortion and oppose the ACA provision that provides free prescription contraception.
While a third of the U.S. medical profession is now female, 15 of the 16 members of the GOP caucus are male, and only eight of them are doctors. The other eight members are from other health professions, including a registered nurse, a pharmacist and a dentist. The nurse, Diane Black of Tennessee, is the only woman.
On the Senate side, there are three physicians; all of them Republican.
While 52 percent of American physicians today identify as Democrats, just two out of the 14 doctors in Congress are Democrats.
About 55 percent of physicians say they voted for Hillary Clinton and only 26 percent voted for Donald Trump, according to a survey by Medscape in December.
Meanwhile, national surveys show doctors are almost evenly split on support for the health law, mirroring the general public. And a survey published in the New England Journal of Medicine in January found almost half of primary care doctors liked the law, while only 15 percent wanted it repealed.
Rep. Michael Burgess, R-Texas, a caucus member first elected in 2003, is one of the longest serving doctors in Congress. He said the anti-Obamacare Republican physicians do represent the views of the profession.
“Doctors tend to be fairly conservative and are fairly tight with their dollars, and that the vast proportion of doctors in Congress [are] Republican is not an accident,” Burgess said.
Price’s ascendancy is in some ways also a triumph for the American Medical Association, which has long sought to beef up its influence over national health policy. Less than 25 percent of AMA members are practicing physicians, down from 75 percent in the 1950s.
Price is an alumnus of a boot camp the AMA runs in Washington each winter for physicians contemplating a run for office. Price is one of four members of the caucus who went through the candidate school. In December, the AMA immediately endorsed the Price nomination, a move that led thousands of doctors who feared Price would overturn the health law to sign protest petitions.
Even without Price, Congress will have several GOP physicians in leadership spots in both the House and Senate.
Those include Rep. Phil Roe of Tennessee, the caucus co-chair, who also chairs the House Veterans Affairs Committee, and Burgess, who chairs the House Energy and Commerce subcommittee on health. Sen. Bill Cassidy of Louisiana sits on both the Finance and the Health, Education, Labor and Pension Committees. Sen. John Barrasso of Wyoming chairs the Senate Republican Policy Committee.
Roe acknowledges that his caucus will have newfound influence. Among his goals in molding an ACA replacement are to kill the requirement that most people buy health insurance (known as the individual mandate) as well as to end the obligation that 10 essential benefits, such as maternity and mental health care, must be in each health plan.
He said the caucus will probably not introduce its own bill, but rather evaluate and support other bills. The caucus could be a kingmaker in that role. “If we came out publicly and said we cannot support this bill, it fails,” Roe said.
The GOP Doctors Caucus has played a prominent role in health matters before Congress. For example, in 2015, when former House Speaker John Boehner needed help to permanently repeal a Medicare payment formula that threatened physicians with double-digit annual fee cuts, he turned to the GOP Doctors Caucus. It got behind a system to pay doctors based on performance — the so-called doc fix.
“When the speaker had a unified doctors’ agreement in his coat pocket, he could go to Minority Leader Nancy Pelosi and show that, and that had a lot to do with how we got this passed,” Roe said.
But not all doctors are unified behind the caucus. Rep. Raul Ruiz, one of the two physicians in the House who are Democrats, said he worries because few doctors in Congress are minorities or primary care doctors.
Ruiz, an emergency room physician from California who was elected in 2012, said he is wary about Price leading HHS because he is concerned Price’s policies would increase the number of Americans without insurance.
Indeed, many doctors feel the caucus’ proposals will not reflect their views — or medical wisdom. “My general feeling whenever I see any of their names, is that of contempt,” said Don McCanne of California, a senior fellow and past president of the Physicians for a National Health Program. “The fact that they all signed on to repeal of ACA while supporting policies that would leave so many worse off demonstrated to me that they did not represent the traditional Hippocratic traditions which place the patient first.”
Christina Jewett contributed reporting.
Energy-producing states that rely heavily on volatile energy-related tax revenues offer a cautionary tale for other states, our new report shows.
Libraries are great places to learn about love. There are books about love and romance, of course, but you might also have or discover a lifelong love of books, or even meet the love of your life! You might not associate law libraries with love, but if you think about it, where else can you find so much written about the various practical implications of falling in (and out of) love? There are laws on cohabitation and marriage, property law, laws related to children, succession law, of course separation and divorce as well, and even immigration law.
It is therefore not surprising that over the years In Custodia Legis has developed a nice collection of posts related to love and the law. As our small contribution to Valentine’s Day celebrations, here’s what I found:
- Chocolate, Candy and the Law (2011): while not directly about love, this post on laws in England and the U.S. that regulate what can be labelled as ”chocolate” provides good information for those who might be deciding what chocolates to buy for Valentine’s Day.
- In Love and War: The King of Chocolate and St. Valentine’s Day (2014): this post goes back further into the history of chocolate, including its use in love and war. It also provides information about St. Valentine himself.
- Love and the Law (2014): part of a fun series on movies and the law, this post surveys several movies that have themes of love and the law, including Green Card, Shakespeare in Love, and The Proposal.
- Love, Adultery, and Madness (2015): this post tells the story of a court case that resulted from an affair between the wife of a member of Congress and one of Francis Scott Key’s sons, which had led to the latter being shot dead by the aggrieved husband. The case may have introduced the defense of temporary insanity in American jurisprudence.
- Law and Mrs. de Winter (2016): another tragic love story, this post looks at the legal topics contained in the novel Rebecca, including divorce, inheritance, blackmail, and murder.
- My Beloved Eliza: The Final Letters from Alexander Hamilton to His Wife (2016): in this hugely popular post, you can learn about and view the the letters that Alexander Hamilton wrote to his wife, Eliza, during the week prior to his being killed in a duel with Aaron Burr.
- Magna Carta: A Love Story (2015): this post tells of a more modern-day love story, involving a couple who had originally met while conducting research at the Library of Congress. They came back to the Library as part of the celebrations for their fiftieth wedding anniversary and were given a tour of the Law Library’s wonderful Magna Carta exhibit.
- On the Shelf: LGBT Pride Month (2016): this post highlights some of the more unique items in our collection that relate to laws on same-sex marriage in different jurisdictions or that focus on family law in relation to LGBT individuals and families.
- Family Law: A Beginner’s Guide – Part 1: Formation and Dissolution of Marriage (2014): this post provides information on some of the resources available at the Law Library and online that relate to marriage and divorce (maybe not the best topic for Valentine’s Day, but the law doesn’t tend to be overly sentimental).
- DOMA and LGBT Commemorative Month (2013): this post provides information on the Defense of Marriage Act and some of the earlier cases that challenged it, prior to the 2015 case of Obergefell v. Hodges. We also have a post showing scenes outside the Supreme Court in 2013 during oral arguments in two high-profile same-sex marriage cases.
- Mazel Tov! I Now Pronounce You Husband and Wife (Under Israeli Law) (2015): Israeli law requires couples to marry in accordance with their religion. This post discusses how this works and some developments in the area of providing a civil marriage option, with more information available in a report on spousal agreements.
- Do You Have to Actually be Present on Your Wedding Day in The Gambia? (2014): in another post on marriage laws in different countries, we learn about proxy marriage and divorce under the laws of The Gambia.
- Laws on Homosexuality in African Nations (2014): this post provides information on a Law Library survey of the laws of African countries that relate to the treatment of the LGBT community.
- “My Devise for the Succession” (2014): the tale of Henry VIII and his many wives is not very romantic, but it does include various legal issues, including the development and application of laws related to succession to the crown.
- Will and Kate Plus a Pre-nup? (2011): still on the royal theme, but this time much more modern, this post looks at English laws related to prenuptial agreements, with reference to the union between Prince William and Kate Middleton.
- Finally, in the area of laws related to children, we have had posts on China’s “one-child” policy and its replacement with a new family planning policy in 2015, as well as a post contrasting the policy with the approach in Israel. There is also a beginner’s guide on child custody and adoption law and posts about restrictions on baby names, or on changing names, in New Zealand, Iceland, and Taiwan.
The experiences of the energy-producing states demonstrate how better fiscal policy decisions would help lawmakers preserve and invest in the services that underpin their economies and quality of life.