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Photo of man who supports obamacare at the supreme court in washington dc on 6/28/12.
The healthcare wonks putting the Affordable Care Act together back in 2009-10 had a lot of ideas about a lot of small, varied projects that could reduce healthcare spending. They tried one of them—accountable care organizations for Medicare, and based on the results so far, it's working really well. They saved $384 million in just two years.

The Pioneer Accountable Care Organization (ACO) concept is to test how to change the regular fee-for-service system we've always used in this country—you pay a certain amount to the provider for certain procedures—to a system that doesn't reward doctors or hospitals for the number of procedures they conduct, but for the results they achieve. If the participating hospitals provided care for Medicare patients at lower-than-expected costs, they get to keep 70 percent of the savings, and the remaining 30 percent goes back to the government. If the hospitals spend more than expected, they have to pay back the difference. It really appears to have worked, with $384 million saved. What's remarkable in that number is that just an initial 32 hospitals (13 dropped out after the first year) achieved those savings, about $300 per patient on average.

This wasn't because doctors skimped on care: quality metrics show that patients in and outside the Pioneer ACO program generally reported similar satisfaction rates. And in some ways, the Pioneers did better: patients in those programs reported more timely access to their doctors, perhaps because hospitals wanted to put more effort into preventing costly complications down the line.

The Pioneer ACO program was always meant as an experiment. Once it started, new hospitals couldn't join even as some participants dropped out. The Obama administration did launch other ACO programs in the meantime but they were generally less aggressive, with smaller rewards for the doctors who did the best (and, in tandem, smaller penalties for those who screwed up). And those programs really haven't saved much money at all, not nearly as much as the Pioneers.

With these new, positive results in hand, the Obama administration now says it wants to expand the Pioneer approach to other hospitals. And, of course they do: if they can deliver better care at a lower cost, that's pretty much delivering on the Holy Grail of health care right now.

How scalable this project is remains a big question. The hospitals that joined the program were larger and more advanced than the average, and thus had kind of a leg up in incorporating this new system. Spreading it to more traditional hospitals will likely be much more challenging, and the results probably aren't going to be as dramatic. There's also the possibility that savings at these rates aren't sustainable. The Pioneer ACOs have already claimed the low-hanging fruit for savings, like switching to generic drugs. But they're still spending less than they had been, and still saving Medicare money. It's a project definitely worth expanding.
U.S. Senator Ted Cruz (R-TX) gestures as he confirms his candidacy for the 2016 U.S. presidential election race during a speech at Liberty College in Lynchburg, Virginia March 23, 2015. Cruz, a conservative firebrand who frequently clashes with leaders of
He might just make the cut with primary voters.
People who still self-identify as Republican live in a totally different world than the rest of us, one made up primarily of fear. At least that's the findings of the the new NBC News/Wall Street Journal poll. When asked to rank what issues were most important to them:
Republican primary voters' leading response was national security and terrorism (27 percent said it was their first choice).

That's followed by the deficit and government spending (24 percent), job creation and economic growth (21 percent) and religious and moral values (12 percent).

By comparison, the top priority for Democrats in the poll was job creation and economic growth (37 percent)—followed by health care (17 percent), climate change (15 percent) and national security and terrorism (13 percent).

As if Republican primary candidates needed more incentive to base their campaigns on fear and God and—never forget!—all the money the federal government spends on the poors.
Republican leaders Senator Mitch McConnell (R) and John Boehner speak after a bipartisan meeting with President Barack Obama at the White House in Washington June 10, 2010. REUTERS/Kevin Lamarque (UNITED STATES - Tags: POLITICS)
Congress has a little under a month to reauthorize expiring provisions of the Patriot Act—including Section 215, the provision that is being used to allow bulk collection of cell phone data. But conflicts both within and between the two chambers put that reauthorization into question. Last week, the House Judiciary Committee approved the USA Freedom Act, legislation that it worked out with the Intelligence Committee, but a bipartisan group of members wants more reform than that bill includes, and they've met to plot how they can strengthen the bill.
Among those on hand for the meeting were Democratic Rep. Mark Pocan, a card-carrying ACLU member from the liberal mecca of Madison, Wisconsin, and GOP Rep. Thomas Massie, a tea party adherent from Kentucky.

“The collection of data is still way too wide and can still be too easily abused,” Pocan said of the NSA program exposed by Edward Snowden two years ago.

Along with Pocan and Massie, the Thursday gathering drew Reps. Justin Amash (R-Mich.), Zoe Lofgren (D-Calif.) and Jared Polis (D-Colo.). The lawmakers, many of them privacy zealots with libertarian leanings, discussed the USA Freedom Act, bipartisan legislation that would rein in the bulk collection of telephone records and reauthorize expiring anti-terror surveillance provisions in the PATRIOT Act.

They haven't yet determined whether to introduce their own, stronger legislation or to rally behind amendments to the USA Freedom Act. Among the changes they want to see: making sure restrictions included in the legislation are broad enough to encompass all current and future technologies, and ending the "backdoor" warrantless searches the government requires companies to allow by creating holes in their hardware and software products the NSA uses to snoop. House Speaker John Boehner has signed off on the legislation as passed by Judiciary, and it's going to be a challenge for the reform group to derail it, unless they can get enough bipartisan members to force amendments, or to defeat the bill entirely.

Then there's the Senate side, where the reform legislation has been introduced, but where Majority Leader Mitch McConnell is so far insisting that he will only allow a straight reauthorization of the Patriot Act—no reforms, no changes. Thus far, he's got Judiciary Committee chairman Chuck Grassley with him, but is likely to encounter pretty significant opposition from both Republicans and Democrats who want to see real reform. Boehner can probably pass his version of the reform bill, but he'd face a real problem getting McConnell's clean reauthorization through, if McConnell can even get it through the Senate.

Right now the House is slated to take the last week of May off, as is the Senate. Between long weekends off and planned recess, there's around a dozen working days for them to figure this out. Which is likely what McConnell is planning on exploiting. He'll likely push this out as long as he can, then create panic over the fact that the provisions are about to expire, allowing for a least a shorter-term clean extension.

Speaker of the House John Boehner (R-OH) speaks at a news conference at the U.S. Capitol in Washington February 26, 2015. Conservative Republicans urged House of Representatives Speaker John Boehner not to capitulate in a fight with Democrats over Preside
House Speaker John Boehner visited the National September 11 Memorial & Museum last month when he was in New York on a fundraising trip. Here's what he had to say about the visit.
"So you hear what they're telling you, but you are also reliving what happened. Your heart breaks for the families. The resolve pushes its way through. You stop to collect your thoughts. You are right back there." He concluded, "I'm glad I had the chance to go. God bless America."
Apparently Boehner's heart only breaks for the families of the people who died in the World Trade Center that day, because he's got nuthin' for the first responders who are living today with the aftermath of their heroic actions.
The Speaker remains publicly opposed to the James Zadroga 9/11 Health and Compensation Act, which helps those first responders get healthcare. Due to a compromise to ease passage in 2011, the act will start to expire this year if Congress does not extend it.

Through the bill, about 33,000 people, and counting, receive treatment for a least one health issue, ranging from asthma to terminal cancer, linked to exposure to toxins around Ground Zero.

Boehner voted against the bill in 2010. He has not changed his view, spokesman Michael Steel said last week.

Granted, Boehner doesn't generally believe in the government helping regular folks out with health care, but you'd think he could make an exception for the men and women who actually ran into the inferno that day. Clearly, you'd be giving him too much credit.
Screenshot of Chuck Todd interviewing House Speaker John Boehner on Meet the Press.
House Speaker John Boehner was Chuck Todd's star interview on Sunday's Meet the Press, where he faced "tough" questioning about lots of things. Luckily for Boehner, he didn't face tough follow-up when he lied about Obamacare in his answer.
TODD: You made some dire predictions about health care. 2014 you said fewer people would have health insurance. According to plenty of surveys, more people have health insurance today than they did before it went down from—the uninsured rate went down 17 percent to just under 12 percent. You said it would destroy jobs. The first year it was implemented, the country added 3 million jobs. Why…

BOEHNER: Obamacare made it harder for employers to hire people. The economy expands and as a result, you are going to have more employees because businesses have to. But if you can ask any employer in America, and ask them whether Obamacare has made it harder for them to hire employees, they'll tell you yes. Because it's a fact.

When you look at—you know why there are more people insured? Because a lot more people are on Medicaid. And giving—you know, we expanded Medicaid in a big way. And giving people Medicaid insurance is almost like giving them nothing. Because there aren't—you can’t find a doctor that will see Medicaid patients.

Wow, what a load. Boehner must be talking to a very selective group of employers, because 75 percent of them surveyed last year said that Obamacare wasn't making any difference in their hiring practices. What's more, it's turned out to be not a job-killer, either. The easiest way to prove just how not unhappy American business is with Obamacare is the fact that not one major business organization filed a brief in support of the King v. Burwell challenge to the law.

As for more people being insured? No, Medicaid—which is real coverage, by the way, and darned efficient coverage—doesn't account for all the new coverage. Charles Gaba has the information to refute Boehner readily available. At his last count, there were 10.8 million private plans purchased through the exchanges, and 13.2 million Medicaid enrollments. But there are a lot more sources—Gallup, Commonwealth Fund, Rand Corporation, or the Urban Institute, just to confirm that there are lots of insured people. Kaiser Family Foundation will tell you that six in 10 of the people buying private health insurance through the exchanges—that's private insurance—were previously uninsured. You could also note how many private insurers jumped into the Obamacare marketplace when they saw how successful it was in the first year.

But apparently Chuck Todd had none of that information at his fingertips. Because his follow-up question, after Boehner spewed all that bullshit—and I am not kidding here—was: "So you don’t see Obamacare as good for the country?"

U.S. House Speaker John Boehner (R-OH) (L) and Senate Minority Leader Mitch McConnell (R-KY) speak at a news conference about the U.S. debt ceiling crisis at the U.S. Capitol in Washington July 30, 2011. REUTERS/Jonathan Ernst  
The House Judiciary Committee struck a blow against Senate Majority Leader Mitch McConnell this week. McConnell is trying to force a five-year extension of the Patriot Act, without any revision of the controversial bulk data collection provision. But a growing number of members in both the House and Senate are likely to thwart him.
On Thursday, a bill that would overhaul the Patriot Act and curtail the so-called metadata surveillance exposed by Edward J. Snowden was overwhelmingly passed by the House Judiciary Committee and was heading to almost certain passage in that chamber this month.

An identical bill in the Senate—introduced with the support of five Republicans—is gaining support over the objection of Senator Mitch McConnell, Republican of Kentucky, who is facing the prospect of his first policy defeat since ascending this year to majority leader. […]

The debate has resulted in a highly unusual alliance of House Speaker John A. Boehner, the White House, the Tea Party and a bipartisan majority in the House. They are in opposition to Mr. McConnell, his Intelligence Committee chairman, and a small group of defense hawks. In addition, two Republican presidential candidates in the Senate, Ted Cruz of Texas and Rand Paul of Kentucky, have made it clear they will not accept a straight extension of the current Patriot Act.

The legislation would end bulk collection, but still request that phone companies hold on to records that would have to be accessed with a court order. So that still allows for a more narrow or targeted collection, the bill's authors say, and would still allow for the tracking of U.S. residents in communication with suspected terrorists.

The big question is how much leeway is still going to be included in that "narrower" collection program. When it comes to actually calling records, it does seem to narrow the process down enough to "ensure only specific individuals, accounts, and devices qualify as specific selection terms." Selection terms are what the NSA uses to query a database, or set up a collection system. But beyond calling records, the legislation seems to allow for broader selection terms. This version of the legislation has also lost the "super minimization" requirements in last year's version of the bill, which very narrowly failed in the Senate. Minimization is the requirement that any collected information that doesn't pertain directly to an investigation be deleted. Those procedures weren't included this time and should be in the amendment process on either side of the Hill.

The bill is certainly better than McConnell's alternative, but could be made an awful lot stronger in the amendment process. In fact, Section 215—the provision that the FISA court interpreted to allow for bulk collection—should be allowed to sunset as the original law's authors intended.

New Jersey Governor Chris Christie gives a news conference in Trenton January 9, 2014. Christie on Thursday fired a top aide at the center of a brewing scandal that public officials orchestrated a massive traffic snarl on the busy George Washington Bridge
Gov. Chris Christie's high-school buddy and former Port Authority of New York and New Jersey appointee, David Wildstein, has pleaded guilty to plotting to create a 2013 traffic jam on the George Washington Bridge as political payback against a Christie opponent.
On Friday morning, Judge Susan D. Wigenton, who presided over the case, laid out the conspiracy involving the three Christie confidants. She asked Mr. Wildstein a laundry list of questions, all of which he answered with a soft “yes,” while standing at the defense table.

She asked if he conspired with Mr. Baroni and Ms. Kelly to shut down lanes to retaliate against Mayor Mark Sokolich of Fort Lee for not endorsing Mr. Christie in his 2013 re-election campaign.

“Did you agree with Mr. Baroni and Ms. Kelly to punish Mayor Sokolich by causing significant lane access problems,” the judge asked, staring down from the bench at Mr. Wildstein.

"Yes," Mr. Wildstein answered.

Wildstein's lawyer, Alan Zegas, says that "evidence exists" that Christie knew about the closings when they occured. So that should make the next few months of Christie's president campaign posturing interesting.

In addition, Bill Baroni, the former deputy executive director of the Port Authority of New York and New Jersey, and Bridget Anne Kelly, a former deputy chief of staff to Mr. Christie have been indicted by Paul J. Fishman, the United States attorney for New Jersey. Those indictments include "multiple counts of conspiracy to commit fraud, including 'knowingly converting and intentionally misapplying property of an organization receiving federal benefits.'" You can read the full indictment here.

So Wildstein throws Kelly and Baroni under the bus, and thus far Christie skates. Because despite the fact that his very old friend, his deputy chief of staff, and the guy he put in charge of the port authority were plotting political revenge on his behalf, Christie had absolutely no idea any of this was being concocted out of his office. To hear him tell it, he barely knows Wildstein. That's despite the fact that "records and interviews indicate that during his tenure at the Port Authority, Wildstein met at least twice with Christie and others in the governor's office, joined Christie at seven public events and had regular meetings with Christie's closest confidantes."

If you believe that, I've got another bridge in the greater metropolitan New York area to sell you. Still, it's hard to see how Christie manages to spin this into something that helps him run for president. Now, real right wingers might actually like the idea that he's vindictive enough to conspire on such a scheme. But the line he's decided to go with is that he was completely disconnected from this conspiracy happening right under his nose, in his office. He could go with either evil or incompetent, and has chosen the latter. Way to inspire confidence in your leadership!

There's ongoing discussion in Bethesda 1971's diary.

U.S. Senator John Barrasso of Wyoming speaking at the 2015 Conservative Political Action Conference (CPAC) in National Harbor, Maryland.
Sen. John Barrasso (R-WY)
Republicans might be at a total loss when it comes to creating a workable substitute for Obamacare, should the Supreme Court rule to strike subsidies down to some 8 million people. But they're not going to let their lack of a plan get in the way of making demands that President Obama gut the law in return for keeping those subsidies going until the next election.
Sen. John Barrasso (R-Wyo.), who is leading the Senate GOP’s response to King v. Burwell, said Republicans will be willing to strike a deal with Obama to ensure that the 7.5 million people who stand to lose their subsidies are protected, at least until the 2016 elections.

But in return, they would demand that Obama to do something he has long resisted: nix the employer and individual mandates for insurance coverage.

"Is the president going to say, 'Tough, I'm going to veto that?'" Barrasso said in an interview in his Dirksen office. "There will be, as part of that [deal], things we want to have happen."

There are at least six plans out there from Republicans, all premised on essential repeal of Obamacare, and none with enough consensus to actually make it through either the House or the Senate. But Republicans have one thing, according to Barrasso, even if they don't have an actual plan: "temporary aid for people who could lose their subsidies, which Barrasso said would be the crucial bargaining chip in a deal with Obama." So there you go, 8 million people who might lose your health insurance—you're just a GOP bargaining chip. Just to reinforce that:
"The president’s going to stand up and say, 'Meet so-and-so who's got cancer. Meet so-and-so who's got diabetes," [Gov. Bobby] Jindal, a longtime foe of the healthcare law, said. "And he'll say, 'These mean, stingy Republicans simply won't make a one-page change in the law."
So if you have cancer or diabetes and face losing health insurance because of the unrelenting attacks against this law by Republicans, it's your own damned problem. Republicans clearly don't care about that, they care about how they can leverage your misfortune into trying to make Obama gut his own law. Which he's not going to do. Which Barrasso knows very well: "Since we don't have a willing partner in the White House, the best idea for actually fixing health care is not things that the president isn't going to sign. He's not going to work with us on this. So we have to have a Republican president in 2016."

Even when Obama isn't on the ballot anymore, this is all about beating Obama and repealing his signature achievement. So if you're sick of Obamacare being a political football, too bad. They're not going to let go of it. Eight million people potentially losing health insurance is just one more bargaining chip for them.

U.S. Attorney General nominee Loretta Lynch speaks as U.S. President Barack Obama (R) looks on, in the Roosevelt Room at the White House in Washington November 8, 2014. Obama on Saturday picked Brooklyn federal prosecutor Lynch to replace retiring Attorne
Attorney General Loretta Lynch capped her first, challenging week at the helm of the Justice Department by announcing a $20 million police body camera pilot project.
"This body-worn camera pilot program is a vital part of the Justice Department's comprehensive efforts to equip law enforcement agencies throughout the country with the tools, support, and training they need to tackle the 21st century challenges we face," Attorney General Loretta Lynch said in a statement. "Body-worn cameras hold tremendous promise for enhancing transparency, promoting accountability, and advancing public safety for law enforcement officers and the communities they serve."
The Omnibus Crime Control and Safe Streets of Act of 1968 authorizes the attorney general to provide a maximum of $20 million to local governments to modernize the technology they use. The DOJ said that they would provide 50 grants and that a third would go to smaller police departments. The grants have to have a 50-50 in-kind or cash match by the departments, and all of the departments receiving the grants will have to create implementation and training programs.
Rep. Tammy Duckworth pictured with members of the Illinois Farm Bureau, February 26, 2015
Rep. Tammy Duckworth, veteran, saves the day.
House Republicans were all set to undo protections for service members from predatory lenders this week, at the behest of the banking lobby.
The military has been struggling with the financial impact of predatory lending on service members for years. A 2014 report issued by the Consumer Financial Protection Bureau documents a host of abuses targeting troops. One family that took out a $2,600 loan ended up paying back $3,966.84 over the course of a year. Another borrower spent $1,428.28 to pay off a $485 loan in just six months. Thousands of service members receive short-term, high-interest loans each year.

In 2006, Congress passed legislation imposing a 36 percent cap on interest rates for payday loans, auto title loans and tax refund anticipation loans to military families. Lenders responded by slightly tweaking the terms of their loans to avoid the limits. Since the law applied to payday loans with terms of 91 days or less, and amounts of $2,000 or less, credit companies were able to shirk the rules with 92-day loans, or loans of $2,001.

Big banks were even more creative, issuing "deposit advance products"—functionally almost identical to payday loans, but with a different name and with effective annual interest rates of around 300 percent. Congress responded to these tricks in 2012 by passing another law directing the Pentagon to fix these loopholes, and new rules were finalized in September of last year.

House Armed Services Committee Republicans put their proposal to postpone those rules in the National Defense Authorization Act, and it was the sharp eye and action on the part of Democrats on the panel—including Rep. Tammy Duckworth (D-IL)—that stopped it from happening. Duckworth offered an amendment in committee to strip the language from the bill, and it very narrowly passed early Thursday morning. It's good to know that at least a few Republicans are capable of being shamed.

It's likely not the end of the banksters' efforts, though. There will almost certainly be another amendment offered on the floor to block these rules from protecting the troops when the bill comes up in a few weeks.

Congressman Tom Cotton of Arkansas speaking at the 2013 Conservative Political Action Conference (CPAC) in National Harbor, Maryland.
This is precisely what Republican leadership deserved to get when recruiting and backing unhinged zealots like the newly elected Sen. Tom Cotton (R-AR). Now the Republican conference in the Senate is as ungovernable as the House Republican conference.
Sens. Tom Cotton and Marco Rubio used a hardball procedural tactic on Thursday to force contentious votes on a bill allowing congressional review of a nuclear deal with Iran, a move that jeopardizes the measure’s future.

After being blocked by Democrats for several days, Cotton (R-Ark.) and Rubio (R-Fla.) used a parliamentary procedure to attempt to compel votes on amendments that would make Iran relinquish its nuclear facilities before getting economic sanctions relief and require that Iran recognize Israel’s statehood as a condition of any nuclear deal.

Cotton and Rubio’s maneuver, made under the guidance of top conservative policy aides, blew up a tentative agreement to vote on several other amendments on Thursday, likely including one from Sen. Ted Cruz (R-Texas) that would require Congress affirmatively vote for any nuclear deal with Iran. But that series was unlikely to include Cotton and Rubio’s proposals and a frustrated Cotton instead forced the chamber to consider their proposals.

Just consider that for a moment. Cruz had an amendment that wasn't as extreme as Cotton's or Rubio's (who is in presidential campaign mode and laboring under the misconception that he'll get the Jewish vote). Cotton, on the other hand, is viewing himself as some kind of fucking savior of the Senate or something. When Sen. Bob Corker (R-TN), the Senate Foreign Relations Committee chairman, actually managed to get the White House to agree to his plan along with Senate Democrats—that's called "winning," called out the senator's poison pills, Cotton responded "I would say these are not poison pills. These are vitamin pills."

The man is a total nutjob, as bad as any in the House who has over and over and over snatched Republican defeat from the jaws of victory. And no one deserves this more than Mitch McConnell.

Speaker of the House John Boehner (R-OH) speaks about funding for the Department of Homeland Security during a news conference on Capitol Hill in Washington February 25, 2015. Conservative Republicans urged House of Representatives Speaker John Boehner no
Republican lawmakers know very well that they're in an awful bind completely of their own making. They insisted on pursuing every possible avenue for destroying Obamacare, and now one might work out for them. The Supreme Court could very well decide in June to strike down subsidies to the around 8 million people who have purchased insurance on the federal exchange, making keeping that insurance impossible for many, and making those 8 million people very, very angry. Most Republicans have now come around to the idea that maybe that's not going to be such a great thing for them, particularly those who have to be re-elected next year. One of them, Sen. Ron Johnson (R-WI) has introduced legislation that would extend the subsidies into 2017. But Johnson isn't the only one who has some kind of fix, and most of those "fixes" create real problems going forward.
The Johnson plan would prohibit new customers in both the state and federally operated exchanges from receiving subsidies and repeal the individual and employer mandates. In addition, it would eliminate the Affordable Care Act's minimum essential benefit requirements, allow states to set those benefit rules, and grandfather in existing health plans that are not compliant with the ACA.

Another proposal, by Sen. Ben Sasse (R-Neb.), would continue premium subsidies for 18 months but phase them out over that period. For six months after the court rules, financial assistance for all subsidy-eligible exchange customers would be set at a flat 65% of premium costs. That would decrease by 5 percentage points each month until the subsidies were completely eliminated. During the transition period, insurers would be prohibited from raising premiums. In addition, the Sasse bill would prohibit HHS from providing federal exchange technology to states interested in establishing their own exchanges. […]

On the House side, House Ways and Means Committee Chairman Paul Ryan (R-Wis.) and two other committee chairmen have proposed to offer a flat tax credit to people now receiving subsidies through the federal exchange. In addition, they would let states opt into an alternative Republican reform model without insurance mandates and including traditional GOP policy nostrums such as allowing insurers to sell plans across state lines.

What the two Senate proposals would do is just to make the end to subsidies happen a lot more slowly, and force the law to wither on the vine. No new people could enroll in Johnson's plan and it's essentially a slow-walk back to the pre-Obamacare status quo, where insurance is too expensive for too many. Sasse's would have the same result, with the nice added bit of blocking states from forming their own exchanges. Ryan's plan is Obamacare lite, his tax credits being pretty much exactly the same as Obamacare's subsidies, just with some GOP stuff scattered in.

Here's the really fun part though: "in the wake of a Supreme Court ruling in King v. Burwell striking down subsidies, any proposal that offers any subsidies could be scored by the Congressional Budget Office as new spending." Get that? New spending. Republicans would have to spend new money on Obamacare or face the political consequences of millions of people losing their insurance—millions of people mostly in red states. Their only other option is to try to pass one of these "fixes" with reconciliation in the budget process, and do it before the Supreme Court rules an existing law is still the baseline that CBO uses to calculate costs.

Beyond this is their very basic problem of finding enough Republicans to vote for a fix, and if they even manage to do that in the House, keeping Ted Cruz or Rand Paul from derailing it in the Senate. Right now, you gotta believe that the most fervent wish of Republican congressional leaders is that the Supreme Court bails them out and upholds subsidies.

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