RED KOOL-AID,RED KOOL-AID,BLUEBLUE KOOL-AIDKOOL-AIDDelivering Quality Healthcare Despite Morons and Delivering Quality Healthcare Despite Morons and

Crooks on Capitol Hill and the Nation’s Premier Crooks on Capitol Hill and the Nation’s Premier Cancer Hospital Cancer Hospital

Leonard A. Zwelling, M.D., M.B.A.Leonard A. Zwelling, M.D., M.B.A.Graduate-The Robert Wood Johnson Foundation Graduate-The Robert Wood Johnson Foundation

Health Policy Fellowship ProgramHealth Policy Fellowship ProgramUT Chancellor’s Health Fellow in Comparative UT Chancellor’s Health Fellow in Comparative

Effectiveness ResearchEffectiveness ResearchSeptember 2012September 2012

““They were more morons They were more morons than crooks, but the than crooks, but the

crooks were higher up”crooks were higher up”Michael Lewis in Michael Lewis in The Big The Big

Short Short quoting Vinnie Danielquoting Vinnie Daniel

The Basic Thesis Of The Basic Thesis Of Red Kool-Red Kool-AidAid, , Blue Kool-AidBlue Kool-Aid

Moral relativism will trump core values Moral relativism will trump core values and principlesand principles

Good people will perpetrate, rationalize Good people will perpetrate, rationalize and justify performing criminal and near-and justify performing criminal and near-criminal actscriminal acts

Groupthink will stifle innovation and Groupthink will stifle innovation and accountability when both are most accountability when both are most neededneeded

The unintended consequences of these The unintended consequences of these activities will affect real peopleactivities will affect real people

Health Care Reform to Most Health Care Reform to Most AmericansAmericans

(M. Scott-Houston Chronicle)(M. Scott-Houston Chronicle)

The AgendaThe Agenda Is Washington, DC the best place to Is Washington, DC the best place to

discuss health care reform?discuss health care reform? Is there an American Health Care System?Is there an American Health Care System? DC Truths-No BullDC Truths-No Bull Health Care Reform is….?Health Care Reform is….? PPACA-how did it pass and what does it PPACA-how did it pass and what does it

mean?mean? June 28, 2012-The Supreme Court’s June 28, 2012-The Supreme Court’s

decisiondecision What does this have to do with America?What does this have to do with America?

Why Washington, DC Is the Center of the Why Washington, DC Is the Center of the Health Care Universe (from CMS (National Health Care Universe (from CMS (National

Health Expenditures (NHE) Fact Sheet)Health Expenditures (NHE) Fact Sheet) 2009-total NHE $2.5T;$8086/person; up 2009-total NHE $2.5T;$8086/person; up

4%4% 17.6% of GDP17.6% of GDP Medicare spending: $502B; 20% of NHE; Medicare spending: $502B; 20% of NHE;

up 7.9% (47.7 million)up 7.9% (47.7 million) Medicaid spending: $374B; 15% of NHE; Medicaid spending: $374B; 15% of NHE;

up 9 % (58+ million)up 9 % (58+ million) Private insurance: $801B; 32% of NHE; up Private insurance: $801B; 32% of NHE; up

1.3%1.3%

WHAT WAS THAT ABOUT MARKET WHAT WAS THAT ABOUT MARKET FORCES IN HEALTH CARE?FORCES IN HEALTH CARE?

Some Critical American Health Some Critical American Health Care FactsCare Facts

The US spends more per capita on health care The US spends more per capita on health care than any other major country (exception, East than any other major country (exception, East Timor), typically about twice as much as other Timor), typically about twice as much as other Westernized democraciesWesternized democracies

US life expectancy ranks about 42US life expectancy ranks about 42ndnd. We are . We are behind Cuba.behind Cuba.

About 50 million Americans have no health About 50 million Americans have no health insurance, about 1/6 of the populationinsurance, about 1/6 of the population

The US is the only Westernized democracy The US is the only Westernized democracy without a system of universal health care.without a system of universal health care.

WHY?WHY?

The United States Does Not Have The United States Does Not Have One Health Care System-One Health Care System-

IT HAS 4!IT HAS 4!(With full credit to T. R. Reid)(With full credit to T. R. Reid)

NAMENAME PHILOSOPHYPHILOSOPHY FEATURESFEATURES EXAMPLESEXAMPLES US EQUIVALENTUS EQUIVALENT

BismarckBismarck Private Private providers providers

and payersand payers

Non-profit Non-profit insurers; insurers; uniform uniform

and and controlled controlled

pricingpricing

GermanyGermany

FranceFrance

JapanJapan

SwitzerlandSwitzerland

Workers< 65 Workers< 65 with with employer-based employer-based insuranceinsurance

BeveridgeBeveridgeBevanBevan

Health Care Health Care as a public as a public

serviceservice

Govt owns Govt owns and and

controlscontrols

UKUK

Hong KongHong Kong

ItalyItaly

SpainSpain

CubaCuba

IndiansIndians

VeteransVeterans

MilitaryMilitary

National National Health Health InsuranceInsurance

Sense of Sense of communitycommunity

Single Single payer; payer; private private docs; docs;

WaitingWaiting

CanadaCanada

TaiwanTaiwan

South South KoreaKorea

MedicareMedicare

Self-Self-pay=No pay=No InsuranceInsurance

I got my I got my insurance, insurance, what’s your what’s your problem?problem?

Paid by Paid by patient or patient or not at allnot at all

AfricaAfrica The Uninsured-The Uninsured-ER, free clinics, ER, free clinics, no care, no care, bankruptcybankruptcy

Basic PremiseBasic Premise We can learn how to improve by We can learn how to improve by

studying how other countries care for studying how other countries care for their citizens.their citizens.

The key is “comparative policy The key is “comparative policy analysis”—how Dwight Eisenhower analysis”—how Dwight Eisenhower built the interstate highway system built the interstate highway system after the German autobahn. after the German autobahn.

““The Window of Opportunity” in Taiwan The Window of Opportunity” in Taiwan (Tsung-Mei Cheng, economist)(Tsung-Mei Cheng, economist)

Public demand for universal health carePublic demand for universal health care Majority party wasMajority party was challenged by minority challenged by minority party that supported national health party that supported national health

insurance insurance Sustained economic growth made Sustained economic growth made

funding possiblefunding possible

DO ANY OF THESE DO ANY OF THESE CONDITIONS CURRENTLY CONDITIONS CURRENTLY

EXIST IN THE U.S.?EXIST IN THE U.S.?

The Essential Yet Unspoken The Essential Yet Unspoken Questions for AmericansQuestions for Americans

Which inequalities will our society tolerate?Which inequalities will our society tolerate? Is it acceptable for some people to die because Is it acceptable for some people to die because

they cannot see a doctor, cannot pay for they cannot see a doctor, cannot pay for adequate health care, or become bankrupt due to adequate health care, or become bankrupt due to overwhelming medical bills?overwhelming medical bills?

IS HEALTH CARE A IS HEALTH CARE A RIGHT?RIGHT?

In Other Words:In Other Words: Is health care like the police, the fire Is health care like the police, the fire

department, the right to vote and the department, the right to vote and the services of the military (as in all other services of the military (as in all other democracies)?democracies)?

OROR

Is health care like pork bellies, wheat Is health care like pork bellies, wheat futures, toilet paper and Gucci loafers (as in futures, toilet paper and Gucci loafers (as in the U.S. today)?the U.S. today)?

AND WHEN WILL WE HAVE THIS AND WHEN WILL WE HAVE THIS DISCUSSION BECAUSE WE DISCUSSION BECAUSE WE

HAVEN’T HAD IT YET? HAVEN’T HAD IT YET?

Why Health Care Feels Like Why Health Care Feels Like Getting Your BMW RepairedGetting Your BMW Repaired

It costs a small fortuneIt costs a small fortune No matter what they tell you, it No matter what they tell you, it

seems to be costing you more each seems to be costing you more each time you go intime you go in

The more that gets done, the more The more that gets done, the more the doer makesthe doer makes

Some Basic Truths Some Basic Truths About Our GovernmentAbout Our Government

(The Rules of Life in DC (The Rules of Life in DC by Dr. Marie Michnich-by Dr. Marie Michnich-Director of the RWJF Director of the RWJF Fellowship Program)Fellowship Program)

Congress is not there to make good laws, Congress is not there to make good laws, it there is to prevent the making of bad it there is to prevent the making of bad lawslaws

Never compromise your Never compromise your

honesty. Answer a differenthonesty. Answer a different

question.question.

Never get between a big dog and a fire Never get between a big dog and a fire hydranthydrant

The first thing a member of Congress The first thing a member of Congress does every morning is read his or her own does every morning is read his or her own local newspaper. local newspaper.

Allen Schick-The Yoda of the Allen Schick-The Yoda of the Federal BudgetFederal Budget

When the President and the When the President and the Congress are from different parties, Congress are from different parties, everyone behaves better.everyone behaves better.

In the House, the majority wins IF it In the House, the majority wins IF it stays together.stays together.

More Allen SchickMore Allen Schick In the Senate, the magic number is 60.In the Senate, the magic number is 60.

Congressional Budget Congressional Budget Office (CBO) scoring meansOffice (CBO) scoring means everything to a piece everything to a piece of legislation.of legislation.

What Is “Regular Order” to Pass a BillWhat Is “Regular Order” to Pass a Bill

Bill originates in House or Senate except revenue Bill originates in House or Senate except revenue bills must originate in House (Article 1, Section 7)bills must originate in House (Article 1, Section 7)

Bills usually go to committees for discussion Bills usually go to committees for discussion (mark-up) and amendment(mark-up) and amendment

The amended bill must pass each committeeThe amended bill must pass each committee Most bills do not pass both houses of Congress or Most bills do not pass both houses of Congress or

their committees in identical formtheir committees in identical form A conference committee is formed by legislative A conference committee is formed by legislative

leaders in both houses and from both parties to leaders in both houses and from both parties to resolve the different versions of the bills resolve the different versions of the bills

The new version must be passed through both The new version must be passed through both houses of Congresshouses of Congress

Then it goes to the President for signatureThen it goes to the President for signature

As Senator Mitch McConnell’s As Senator Mitch McConnell’s Chief Health Staffer Megan Chief Health Staffer Megan

Hauck taught me when I asked Hauck taught me when I asked her why this had to be so hardher why this had to be so hard

——

“It’s supposed to be hard”“It’s supposed to be hard”

The 4 P’s of GovernmentThe 4 P’s of Government(in reverse order of importance)(in reverse order of importance)

PPOLICYOLICY

PPROCESSROCESS

PPOLITICSOLITICS

PPERSONALITYERSONALITY

HEALTH CARE HEALTH CARE REFORMREFORM

The The Devil Will Be In The DetailsDevil Will Be In The Details

Everyone’s definition of health Everyone’s definition of health care reform is the same---care reform is the same---

I PAY LESS!!!!I PAY LESS!!!!

Dr. Norman Ornstein-Dr. Norman Ornstein-American Enterprise American Enterprise InstituteInstitute

The Bottom LineThe Bottom Line

AccessAccess-Who gets to see -Who gets to see the doctor and where?the doctor and where?

CostCost-Who pays and how -Who pays and how much?much?

QualityQuality-How good is the -How good is the care and how do we even care and how do we even measure this?measure this?

Friendly ReminderFriendly Reminder

Every cost reduction Every cost reduction is someone’s is someone’s

income. income.

At the Dawn of 2010, Where Was the Health At the Dawn of 2010, Where Was the Health Care Reform Process?Care Reform Process?

The new President had made the health care The new President had made the health care reform legislation his top priority despite the reform legislation his top priority despite the faltering economyfaltering economy

For the first time since the 1960’s, a health care For the first time since the 1960’s, a health care bill had gone through mark-up in a Congressional bill had gone through mark-up in a Congressional committee.committee.

Bills were reported out to both houses of Bills were reported out to both houses of CongressCongress

November 7, 2009: House version passes 220-November 7, 2009: House version passes 220-215215

December 24, 2009: Senate version passes 60-39December 24, 2009: Senate version passes 60-39 The two bills are not identicalThe two bills are not identical Regular order? YES or NO?Regular order? YES or NO?

Uh-Oh!-Massachusetts-January 19, Uh-Oh!-Massachusetts-January 19, 20102010

ObamaCare?-Nope-PelosiCareObamaCare?-Nope-PelosiCare House Speaker Nancy Pelosi avoids need for House Speaker Nancy Pelosi avoids need for

conference committee by passing Senate version conference committee by passing Senate version of bill through Houseof bill through House

President Obama signs into law on March 23, President Obama signs into law on March 23, 20102010

President signs letter preventing federal funds President signs letter preventing federal funds being used for abortion codifying the Stupak being used for abortion codifying the Stupak provision of the former House versionprovision of the former House version

Final package passes March 25, 2010Final package passes March 25, 2010 Violence eruptsViolence erupts

WHY?WHY?

The Patient Protection and The Patient Protection and Affordable Care Act of 2010Affordable Care Act of 2010

The first major piece of social legislation passed The first major piece of social legislation passed entirely with the votes of one partyentirely with the votes of one party

32-34 million more Americans will gain access to 32-34 million more Americans will gain access to health insurance. What about access to health health insurance. What about access to health care?care?

Costs are only marginally addressedCosts are only marginally addressed Ditto quality-demonstration projectsDitto quality-demonstration projects 2409 pages plus 150 page reconciliation bill2409 pages plus 150 page reconciliation bill CBO scored at $143B deficit reduction over 10 CBO scored at $143B deficit reduction over 10

years and $1.2T over 20 yearsyears and $1.2T over 20 years 10 Titles including private insurance, public 10 Titles including private insurance, public

insurance, prevention, work force issues, follow-insurance, prevention, work force issues, follow-on biologics, long-term care and taxes.on biologics, long-term care and taxes.

What the Democrats MissedWhat the Democrats MissedPelosi: constitutionality of health care Pelosi: constitutionality of health care reform 'ironclad‘reform 'ironclad‘

PPACA is not about PPACA is not about

Healthcare. It’s about Healthcare. It’s about

moneymoney-”How Congress-”How Congress

Chose to raise money toChose to raise money to

Pay for it”. (Bard-HoustonPay for it”. (Bard-Houston

Chronicle-June 16, 2012)Chronicle-June 16, 2012)

The Mission Statement of the The Mission Statement of the United States of AmericaUnited States of America

The Key ConceptThe Key Concept““A ruling about whether there is explicit A ruling about whether there is explicit

constitutional authority for the way constitutional authority for the way Congress Congress chose to fund a system chose to fund a system to to make health insurance affordable and make health insurance affordable and accessible to all Americans…how accessible to all Americans…how Congress Congress chose to fund the system chose to fund the system it set it set up”.up”.

-Jennifer S. Bard-Jennifer S. Bard

Texas Tech University Texas Tech University School of Law in Houston School of Law in Houston

Chronicle June 15, 2012Chronicle June 15, 2012

The The Devil Will Be In The DetailsDevil Will Be In The Details

Everyone’s definition of health Everyone’s definition of health care reform is the same---care reform is the same---

I PAY LESS!!!!I PAY LESS!!!!

Dr. Norman Ornstein-Dr. Norman Ornstein-American Enterprise American Enterprise InstituteInstitute

The ‘Sleeper’ Issues Before the Supreme Court

(from TR Goldman-Health Affairs 31:471, 2012)

Individual mandate-Is it constitutional? Individual mandate-Is it a penalty or a tax?

Obama Administration has taken both sides (1867 Tax Anti-Injunction Act)

Severability-if mandate out is it all out? Does Medicaid expansion commandeer the

rights of the states? (all under 65 at 133% of FPL or less)

OR—Could The Supreme Court Kick the Can Down the Road?

Tax Anti-Injunction Act Reconstruction era law Cannot bring suit to injoin the collection of

a tax Only bring suit to get refund after tax is

paid (not until 2015!!!!!) Is the individual mandate penalty a “tax”?

Some of the Enumerated Powers of Congress from Article I, Section 8 of the United States Constitution

Taxes Borrow money Regulate commerce (clause 3) Naturalization and bankruptcy laws Money and post offices Patents and copyrights Declare war and raise an army “To make all laws which shall be

necessary and proper for carrying into execution the foregoing powers” (clause 18)

OCTOBER TERM, 2011 OCTOBER TERM, 2011 Syllabus Syllabus

SUPREME COURT OF THE UNITED STATES SUPREME COURT OF THE UNITED STATES

Syllabus Syllabus NATIONAL FEDERATION OF INDEPENDENT BUSINESS ET AL. NATIONAL FEDERATION OF INDEPENDENT BUSINESS ET AL. v. v.

SEBELIUS, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. SEBELIUS, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE CERTIORARI TO THE UNITED STATES COURT OF APPEALS FOR THE

ELEVENTH CIRCUIT ELEVENTH CIRCUIT No. 11–393. Argued March 26, 27, 28, 2012—Decided June 28, 2012* No. 11–393. Argued March 26, 27, 28, 2012—Decided June 28, 2012*

In 2010, Congress enacted the Patient Protection and Affordable CareAct in In 2010, Congress enacted the Patient Protection and Affordable CareAct in order to increase the number of Americans covered by health insurance and order to increase the number of Americans covered by health insurance and decrease the cost of health care. One key provision isthe individual mandate, decrease the cost of health care. One key provision isthe individual mandate,

which requires most Americans to maintain“minimum essential” health insurance which requires most Americans to maintain“minimum essential” health insurance coverage. 26 U. S. C. §5000A.For individuals who are not exempt, and who do coverage. 26 U. S. C. §5000A.For individuals who are not exempt, and who do not receive healthinsurance through an employer or government program, the not receive healthinsurance through an employer or government program, the

means ofsatisfying the requirement is to purchase insurance from a private means ofsatisfying the requirement is to purchase insurance from a private company. Beginning in 2014, those who do not comply with the mandate must company. Beginning in 2014, those who do not comply with the mandate must

make a “[s]hared responsibility payment” to the Federal Government. §5000A(b)make a “[s]hared responsibility payment” to the Federal Government. §5000A(b)(1). The Act provides that this “penalty”will be paid to the Internal Revenue (1). The Act provides that this “penalty”will be paid to the Internal Revenue

Service with an individual’s taxes, and “shall be assessed and collected in the Service with an individual’s taxes, and “shall be assessed and collected in the same manner” as tax penalties. §§5000A(c), (g)(1).Another key provision of the same manner” as tax penalties. §§5000A(c), (g)(1).Another key provision of the

Act is the Medicaid expansion. The current Medicaid program offers federal Act is the Medicaid expansion. The current Medicaid program offers federal funding to States to assist pregnant women, children, needy families, the blind, funding to States to assist pregnant women, children, needy families, the blind, the elderly, and the disabled in obtaining medical care. 42 U. S. C. §1396d(a). the elderly, and the disabled in obtaining medical care. 42 U. S. C. §1396d(a).

The Affordable Care Act expands the scope of the Medicaid program The Affordable Care Act expands the scope of the Medicaid program andincreases the number of individuals the States must cover. andincreases the number of individuals the States must cover.

THE DECISIONSTHE DECISIONS-June 28, 2012-June 28, 2012The mandate is a The mandate is a taxtax: 5-4 (4 said OK : 5-4 (4 said OK

under Commerce Clause)under Commerce Clause)

The Medicaid expansion is upheld but The Medicaid expansion is upheld but limited: 7-2limited: 7-2

The shared responsibility payment is a The shared responsibility payment is a penaltypenalty under the Anti-Injunction Act under the Anti-Injunction Act 9-09-0

Roberts on Medicaid ExpansionRoberts on Medicaid Expansion

Medicaid expansion violates the Medicaid expansion violates the Constitution by threatening States Constitution by threatening States with the loss of their existing with the loss of their existing Medicaid funding if they decline to Medicaid funding if they decline to comply with the expansion.comply with the expansion.

Key Takeaways and Remaining IssuesKey Takeaways and Remaining Issues The “constitutionally ironclad” ACA survived by a The “constitutionally ironclad” ACA survived by a

whiskerwhisker If the “shared responsibility payment” is a tax, If the “shared responsibility payment” is a tax,

and the House passed the Senate version, did this and the House passed the Senate version, did this tax really originate in the House as all taxes must?tax really originate in the House as all taxes must?

If a state rejects the Medicaid expansion and DSH If a state rejects the Medicaid expansion and DSH and other supplements to safety net hospitals are and other supplements to safety net hospitals are gone, can the academic centers survive?gone, can the academic centers survive?

Will the results of the presidential election affect Will the results of the presidential election affect this?this?

Will the next Congress be any better at finally Will the next Congress be any better at finally addressing the health care reform issue for addressing the health care reform issue for Americans?Americans?

The ‘Sleeper’ Issues Before the Supreme Court

(from TR Goldman-Health Affairs 31:471, 2012)

Individual mandate-Is it constitutional? (YES, but not under Enumerated Powers)

Individual mandate-Is it a penalty or a tax? Obama Administration has taken both sides (1867 Tax Anti-Injunction Act) (Both)

Severability-if mandate out is it all out? (NO)

Does Medicaid expansion commandeer the rights of the states? (all under 65 at 133% of FPL or less) (YES, optional now)

Why Is Everyone So Angry?Why Is Everyone So Angry?

What does the Tea Party really want?What does the Tea Party really want? If they are “taking back our country”, If they are “taking back our country”,

who from?who from?

Why Is Everyone So Angry?Why Is Everyone So Angry? What does the Tea Party really want?What does the Tea Party really want? If they are “taking back our country”, who If they are “taking back our country”, who

from?from?

““It’s still the economy, It’s still the economy,

stupid!-Was this really astupid!-Was this really a

good time to reform good time to reform

Healthcare?Healthcare?

Cost in PPACA (But….) As long as doctors and hospitals work

on a fee-for-service basis (last of the guild system),

with variable prices for the same

activity (depending who is paying)

Using for-profit intermediaries that negate true market forces (insurance companies) not to spread risk or promote health, but to please shareholders…

COSTS WILL NOT BE CONTROLLED

From Woody Allen’s Zelig (1983)

“You are a great inspiration to the young of this nation who will one day grow up and be great doctors and great patients.”

What’s the Problem

Like the Massachusetts bill of 2006 (mandates, subsidies and exchanges), this does not really control costs (Does RomneyCare = ObamaCare?)

The “fee for service” system is unchanged We pay more for doing than for thinking

(remember our BMW?) If you want to change delivery, change

reimbursement. This bill does not change practice, delivery, reimbursement, teaching, work force control, remuneration or measures of quality

What Still Worries MeWhat Still Worries Me Where are the doctors going to come from? An Where are the doctors going to come from? An

insurance card is not healthcareinsurance card is not healthcare Why won’t the insurers simply raise premiums? Why won’t the insurers simply raise premiums? What happens when we realize that birth is a pre-What happens when we realize that birth is a pre-

existing condition? Genomicsexisting condition? Genomics What happens when we realize that death is What happens when we realize that death is

inevitable—no, I mean we really believe it!inevitable—no, I mean we really believe it! Who decides? Could Sarah Palin have been Who decides? Could Sarah Palin have been

right all along?right all along?

Can We Turn This Around?-The Betty Can We Turn This Around?-The Betty Ford Clinic Plan for Kool-Aid RehabFord Clinic Plan for Kool-Aid Rehab

• Moral relativismMoral relativism-The 10 Commandments and -The 10 Commandments and the Golden Rule. WWYMWYTD?the Golden Rule. WWYMWYTD?

• Criminal ActsCriminal Acts-Conflicts-of-interest, nepotism, -Conflicts-of-interest, nepotism, self-dealing, lobbying, and big money have self-dealing, lobbying, and big money have all got to go. No waivers!all got to go. No waivers!

• GroupthinkGroupthink-If you see something, say -If you see something, say something! something!

• Unintended consequencesUnintended consequences-Remember your -Remember your Hippocratic Oath-put your patients first and Hippocratic Oath-put your patients first and you will probably do just fine, and so will you will probably do just fine, and so will they!they!

Drinking theDrinking the KoolKool-Aid-Aid

Embracing a philosophyEmbracing a philosophy Completely buying into an idea or Completely buying into an idea or

system, whether good or badsystem, whether good or bad Going along with what the crowd Going along with what the crowd

desiresdesires

Jim Jones led over 900 people toJim Jones led over 900 people totheir suicide from drinking cyanide-their suicide from drinking cyanide-laced Kool-Aid on November 18, 1978laced Kool-Aid on November 18, 1978

Health Care Reform?-The TSA Is In!Health Care Reform?-The TSA Is In!(Austin American Statesman-Nov. 30, 2011)(Austin American Statesman-Nov. 30, 2011)

Who’s going to provide health care to the newly Who’s going to provide health care to the newly insured?insured?

Why not put the time on the TSA security line to Why not put the time on the TSA security line to good use?good use?

iPad when showing boarding pass for historyiPad when showing boarding pass for history Update vaccination, medication and allergy recordsUpdate vaccination, medication and allergy records Physical exam by newly-trained TSA agentsPhysical exam by newly-trained TSA agents Real CT scan=MRI (more radiologist income)Real CT scan=MRI (more radiologist income) Cancer screening (mammography, DRE, exposed skin Cancer screening (mammography, DRE, exposed skin

exam) for first class and frequent flyersexam) for first class and frequent flyers More health care; More security; More jobs!More health care; More security; More jobs!