Freedom Line Blog

Robert Costa says that if the Senate passes the Gang of Eight’s comprehensive immigration reform bill, the House of Representatives stands ready to put the brakes on the latest piece of “must pass” legislation. Their mechanism: Regulator order.

“Regular order” allows House Republicans to dictate the pace of legislation and makes “grand bargains” of any sort harder to pass. Consider immigration. Several sources close to the leadership say that even if the Senate passes something on immigration, the bill will be immediately sent to the committees, and then either sent back to the Senate with changes, or rewritten in a bicameral conference committee. This means that the chance of the Senate’s Gang of Eight bill coming to the House floor, as is , is nearly non-existent. House Republicans would first have to mull it, schedule hearings, and then tinker with its legislative language .

That tweaking process could take months, which is just fine with many Republicans, who’d like the public to have as much time as possible to chew over the controversial elements of Obama’s prized bills. The caucus consensus is: The more time Congress takes to consider a bill, the more time the public has to sour on its components.

Unlike ObamaCare where Nancy Pelosi’s Democratic majority rubberstamped the Senate’s rewrite of the nation’s health insurance market, House Republicans want to make sure they know exactly what’s in the Gang’s immigration bill before voting on it.

If necessary, House Judiciary Committee Chairman Bob Goodlatte (R-VA) is even floating the idea of breaking the Gang’s carefully balanced 1,500 page bill into separate pieces. That way, the most popular measures – such as enhanced border security measures – would likely become law, leaving less desirous elements out until supporters can figure out a way to sell them to the American people.

For a caucus that runs only one-half of one branch of government, regular order sounds like a good strategy to employ.

Hat tip to Investor’s Business Daily for pouncing on what will be a very unpopular unintended consequence of passing the Senate Gang of Eight’s immigration reform bill:

Under the immigration reform bill, some employers would have an incentive of up to $3,000 per year to hire a newly legalized immigrant over a U.S. citizen.

In avoiding one controversy — the cost of providing millions of newly legalized immigrants with ObamaCare subsidies — the Senate “Gang of Eight” may have risked walking into another.

The bipartisan legislation released Wednesday dictates that those granted provisional legal immigrant status would be treated the same as those “not lawfully present” are treated under the 2010 health law.

That means they would neither be eligible for ObamaCare tax credits nor required to pay an individual tax penalty for failing to obtain qualifying health coverage. It also means some employers would face no penalty for failing to provide such workers affordable health coverage.

So, in order to avoid the charge that legalization would give illegal immigrants citizen-like access to ObamaCare subsidies, the Gang of Eight simply bars them from access. But that means that legalized immigrants are cheaper to hire than comparable native-born workers who will be competing with more people for less jobs.

There may be a fix, but it will be messy.

Good luck with that.

Don’t look now, but with ObamaCare failing to deliver on its promises before it even takes effect, Democrats are already starting to lay the blame on the one party least responsible for this policy monstrosity: Republicans.

Kathleen Sebelius, Secretary of Health and Human Services and the point person for ObamaCare’s implementation, told a Harvard School of Public Health audience that instead of saying, “let’s get on board, let’s make this work,” Republican opponents coerced her into fighting “state-by-state political battles.” Sebelius complained, “The politics has been relentless,” according to Investor’s Business Daily.

This from the woman whose refusal to honor the conscience rights of religious employers elevates the right to “free” contraception over the First Amendment.

But just because Sebelius’ charge that ObamaCare’s completely foreseen failure is actually Republicans’ fault is laughable to anyone who knows the facts, don’t assume that the GOP communications apparatus can be counted on to frame those facts effectively.

After all, this is the same universe of consultants and staff that got outmaneuvered last election season on liberal talking points like the GOP’s “War on Women,” and Mitt Romney’s “47 percent” comment.

If the Left wants to present Sandra Fluke and “The Life of Julia” as exemplars of modern feminism, why can’t the Right counter with the common sense observation that what liberals really want is a government sugar-daddy who pays for sex and then subsidizes any consequences thereafter?

And rather than deny that 47 percent of Americans don’t pay federal income taxes, why don’t Republicans instead hit back with the explosive growth of food stamps and the unprecedented extension of unemployment benefits in the Age of Obama?  Throw in the Obama Phone mentality, and people will start to understand that there are real costs to the liberal vision of welfare.

All this to say I hope Republicans have learned their lesson about how to contest Democratic smear campaigns.  It would be a shame if when ObamaCare comes off the rails next year the GOP fails to capitalize electorally because no one clearly makes the case that only liberals are to blame for the mess they created.

States looking for flexibility under ObamaCare in how to structure and pay for expanding Medicaid can take a hike, according to an analysis by the Heritage Foundation.

States like Arkansas and Indiana have requested waivers from the health reform law’s expansion formula that creates millions of new enrollees at an eventual cost of billions of dollars to states.

The hope was to use existing state-based models like Indiana’s successful health savings account for low-income Hoosiers to increase Medicaid enrollment while retaining cost certainty for state budget writers.

But those hopes were dashed after the federal Department of Health and Human Services released a frequently asked questions (FAQ) sheet that flatly denied any request to deviate from ObamaCare’s one-size-fits-all, open-ended spending commitment for Medicaid.

With this announcement, the Obama administration has definitively articulated its idea of bipartisan reform.  Republican governors who capitulate and get in line are welcomed with open arms.  Those like Indiana’s Mike Pence can take their policy entrepreneurship somewhere else.

Fox News is reporting that the implementation of one of the two state-based, federally-regulated health insurance exchanges is being delayed for an entire year (2015 instead of 2014).

The decision applies to the exchange that will be created to let small businesses shop for affordable insurance policies, not the similar and more well-known exchange for individuals and families looking for insurance.

While it would be easy to blame poor planning and bad execution on the part of the federal government, another explanation seems just as likely.

As originally written, ObamaCare contained a so-called “public option” that would have been offered by the federal government on the exchange as competition with private alternatives.  Conservatives opposed the public option because it threatened to undercut private competitors with an artificially low price since the government, unlike a private business, doesn’t have to make a profit.

After a few years of running private businesses out of the market with artificially low prices, conservatives reasoned, the public option would become the only option as more and more consumers opted for a deal that would be too-good-to-be-true.  When that happened, government could claim the market failed, paving the way for a government-run, single-payer health system.

Of course, the public option was stripped out of the final version of ObamaCare.  But the intent to move America toward government-run health care did not.  Since there’s no requirement under the law for small businesses to provide health insurance, many may now stop bothering if the small business exchange is delayed.  That puts their employees on the individual and family exchange, which as estimates are showing, will cost people much more than originally advertised, even including the government subsidy.

With private insurance unable to deliver a product that covers the heightened floor created in ObamaCare that is also affordable for the people required to buy it thanks to the individual mandate, don’t be surprised if activists and policymakers start clamoring for government to declare a market failure and nationalize the system.

Such a scenario may sound far-fetched, but can anyone seriously say that with the Obama Administration in charge that it’s not at least possible?

The Indianapolis Star reports that Indiana Republican Governor Mike Pence, a possible 2016 presidential candidate, cleared an important hurdle today when the state’s House Public Health Committee approved a bill to expand Medicaid eligibility without relying on ObamaCare’s open-ended spending incentives.

Pence’s plan would increase Indiana’s Medicaid enrollment by an estimated 400,000, but within the state’s Healthy Indiana initiative begun in 2007.  As a health savings account, Healthy Indiana allots a certain amount of money to qualifying Hoosiers who then shop for doctors and treatment options within their budget.  In effect, it transfers the decision making process for health care away from government bureaucrats to private citizens.  By capping the amount, Healthy Indiana also gives state budget writers more certainty about the cost of Medicaid expansion in future years.

Contrast this with the unlimited spending commitment envisioned by the Medicaid expansion system under ObamaCare, and conservatives will see why Pence’s proposal should be watched closely.  Under ObamaCare, states would pay no cost for expanding their eligibility pool up to 138 percent of the federal poverty line.  But starting in 2017, those that expanded enrollment would pay for 10 percent of the increase.  Though seemingly a small percentage, the costs will run into the billions, with even more likely if the federal government decides to reduce its 90 percent subsidy, as President Barack Obama has already hinted at doing.

The future of health insurance reform looks like it will include some mix of government-regulated exchanges, subsidies, and cost controls.  The question dividing conservatives like Mike Pence and Paul Ryan on one hand from liberals like Obama on the other, is who gets to make the lion’s share of the decisions on how health insurance dollars are spent.  Conservatives value individual choice, while liberals favor centrally planned mandates.

Ironically, if the President wants ObamaCare to be fiscally sustainable, he’ll have to accept that the only way to do it is allowing conservatives like Pence and Ryan to inject into it as much personal freedom as possible.

With President Barack Obama’s legally required budget proposal arriving two months late (April 10 when it was due February 4), here’s a suggestion to ensure the document is something other than a White House-approved paper weight.

Because of the President’s unprecedented delay, both the Republican House and Democratic Senate have passed budgets, each with only party-line support.  Now that both sides have put their opening bids on the table, it would be wise to make the White House version a kind of third way compromise that includes some elements that both sides like.

One example would be to incorporate Paul Ryan’s idea for putting Medicare plans on a state-based, federally-regulated health insurance exchange.  Then, make the now obvious point that this plan, coupled with ObamaCare’s exchange for non-seniors indicates bipartisan agreement on a major aspect of health insurance reform.  Doing that would help change the focus of the debate on what Republican and Democrats have in common when it comes to moving forward on this issue.

Peter Ferrara, a budget expert at The Heartland Institute, a free market think tank, reminds us where many of Paul Ryan’s ideas on Medicare reform originally came from:

This Medicare reform plan was actually developed by President Clinton’s Medicare Commission, so it had bipartisan support at a time when the Democrat Party had grown ups in influential positions, rather than just adolescent, Marxist, revolutionaries posing in grown up drag.  The legislation providing for these reforms was actually introduced in the Senate by liberal Democrat Sen. Ron Wyden of Oregon.  It has been endorsed by long time liberal academic Alice Rivlin, the Godmother of the CBO, serving as its first director.

Indeed, the plan was developed from an initial proposal in 1995 by two lifelong liberal scholars, Henry Aaron of the Brookings Institution, and former CBO Director Robert Reischauer.  They were the first to propose a premium support system for Medicare in a 1995 article in the journal Health Affairs.  The Reischauer/Aaron concept was later embodied in Medicare Parts C and D in the 2003 Medicare reforms, where they have already worked very effectively.

That’s right – Proposed by liberals, passed by conservatives.

With this in mind, who’s out of the mainstream now?

Kudos to Sarah Kliff at Wonkblog for tracking down a draft copy of an ObamaCare application. It’s the one a person would use to get access to a state-based health insurance exchange, and the subsidies to buy coverage that go along with it.

At 21 pages and asking for lots of sensitive information, the document is likely to be much more cumbersome than most people bargained for. That’s one of the biggest hurdles facing implementation, according to Kliff:

The administration is caught in a bit of a bind here. On the one hand, Obamacare is tricky business. In order to figure out how much Americans will pay, the federal government needs to collect lots of information, everything from the size of the family to its income to whether any family members are Alaska Natives (which would make them eligible for additional services through the Indian Health Service). It’s hard to collect all that data in a way that isn’t a bit complex.

At the same time, the whole goal of the Affordable Care Act is to maximize health insurance enrollment. That puts a premium on making the applications simple and easy to use—not the kind of documents that you’d get half way through and give up on.

To find a space between the two of these, there are likely a lot of support services that will start springing up over the next few months. This could include traditional agents and brokers, whose whole line of business is understanding applications like this one.  The Affordable Care Act also envisions a group of navigators, financed by state exchanges, who will—as the name implies—help navigate the insurance system.

Meet the new middle men, the same as the old middle men.

True, cost-efficient health insurance reform would reduce reliance on “navigators” in order to eliminate the transactions costs they generate. If a product is so hard to buy that it requires help to do so, you can bet that the cost of said product will go up. And up, up, up…

The bright side? At least there will be thousands of health insurance broker jobs that the Obama Administration can claim credit for creating or saving.

Republicans in the Florida house and senate have rejected Governor Rick Scott’s plan to expand the state’s Medicaid population.  Under ObamaCare, states are promised three years worth of federal funding to cover the cost increases.  Last week, Scott reversed his earlier opposition and accepted those terms.

The move by Florida’s Republican legislators is a welcome corrective to the knee-buckling capitulation of Scott and other GOP governors.  Borrowing a play out of Rep. Paul Ryan’s budget proposals, State Senator Joe Negron is using his no vote to pivot in a new direction.

“This will be the beginning of a transformation of the entire Medicaid system,” committee Chairman Sen. Joe Negron said. “My goal is that we will get out of the federal Medicaid system as we know it. Now, we can’t do that all at once, but we have an opportunity to begin that process.”

Negron wants the state to create a basic health insurance plan for the expanded Medicaid population and require recipients to pay a sliding scale premium based on their income. He suggested using Florida Healthy Kids, a managed care program that provides health insurance to low-income children, as the vehicle for delivering the new system.

Negron and his colleagues are showing real policy leadership.  Now that Scott’s dash for cash is on hold, it’s time for the former health care executive to rediscover his private sector creativity and help Negron put Florida on a path toward sustainable social safety net spending.

H/T: Tampa Bay Online

Pennsylvania Republican Governor Tom Corbett may be wavering on his refusal to expand Medicaid under ObamaCare’s bait-and-switch funding scheme.

I don’t envy him.  He’s surrounded by states like Ohio and New Jersey, whose GOP governors opted to indulge the fantasy that they can accept the federal government’s promise of full funding at face value.

To his credit, Corbett isn’t allowing himself to act like there are no costs associated with agreeing to so-called “free” Medicaid expansion for the next three years.

Here’s some refreshing honesty from Corbett’s spokeswoman Christine Cronkright:

The Corbett administration has estimated that participating in the Medicaid expansion that would add 800,000 people to medical assistance would cost Pennsylvania $1 billion through 2014-15 and a total of $4.1 billion. Advocates maintain that the Medicaid expansion would pay the way for $43 billion in federal contributions, beginning with three years in which the federal government would pay 100 percent of the expansion.

“Regardless of the federal government’s claims, the presumption that they will cover 100 percent of the costs of full expansion is simply not true. Regardless of any other costs under the (Affordable Care Act) that we’d have to bear, there are still IT and staffing costs, costs for additional clients coming into the system that may have been eligible before, and costs for those we believe will drop employer-based coverage,” Cronkright said.

So it turns out “free” really means $1-4 billion.

The simple truth about ObamaCare’s Medicaid expansion is that it establishes a one-way street toward greater federal intervention in every individual’s health care decisions. Democrats know this, and are using the “free” money trope to lure weak-willed Republicans into a federally-dominated system from which a state will not be able to extract itself.

GOP governors who agree to expansion and believe that they will have the political support to simply cut off access to Medicaid when the feds pull back funding are deluding themselves. Besides, what kind of leadership is it to support welfare expansion on the condition that someone else pays for it with their debt-laden credit card?

So far, Governor Corbett is standing firm in the face of tremendous opposition to fiscal sanity.  Let’s hope he continues.

The key passage from Governor Chris Christie’s budget speech yesterday speaks volumes about where the New Jersey Republican stands on principle:

Let me be clear, I am no fan of the Affordable Care Act. I think it is wrong for New Jersey and for America. I fought against it and believe, in the long run, it will not achieve what it promises. However, it is now the law of the land. I will make all my judgments as governor based on what is best for New Jerseyans. That is why I twice vetoed saddling our taxpayers with the untold burden of establishing health exchanges.

But in this instance, expanding Medicaid by 104,000 citizens in a program that already serves 1.4 million, is the smart thing to do for our fiscal and public health. If that ever changes because of adverse actions by the Obama Administration, I will end it as quickly as it started.

Almost all of the same criticisms I leveled at Florida Governor Rick Scott this weekend apply to Christie and his reasoning.

The Governor’s characteristic bluntness, though, merits one further point.

By claiming that the Affordable Care Act (aka ObamaCare) “is wrong for New Jersey and for America,” and that “in the long run, it will not achieve what it promises,” Christie is admitting that he has decided to entangle New Jersey in a fundamentally flawed program that will fail to achieve its goals.  But don’t worry.  In the meantime, New Jerseyans can breathe easy because Christie, like Scott and the other Republican capitulators, will make sure to gobble up as much “free” federal taxpayer money as possible until he decides to pull the plug rather than help cover the costs.

One of the first rules of persuasion is to be coherent.  Christie’s tortured, self-serving logic doesn’t come close.

In case you haven’t seen it yet, check out the ObamaCare Burden Tracker (pdf), a summary of 157 rules and regulations that will impose an annual paperwork burden of 127,602,371 hours on the American economy.

The ObamaCare Burden Tracker is a joint project of the House Committees on Ways and Means, Education and Workforce, and Energy and Commerce.

Scrolling through one discovers such things as

• The new “340B Drug Pricing Program Forms” (#6) will impose an annual paperwork increase of 14,504 hours
• A new “Medicare Enrollment Application” (#32) will be 70,693 hours
• Navigating the “Process for Obtaining Waivers of the Annual Limits Requirements of PHS Act Section 2711” (#50) will cost 178,183 hours per year
• The process to file a “Letter Requesting Waiver of Medicare/Medicaid Enrollment Application Fee; Submission of Fingerprints; Submission of Medicaid Identifying Information; Medicaid Site Visit and Rescreening” (#71) will add a whopping 1,248,082 hours per year
• Changes to Medicaid eligibility (#77) will mean 21,279,702 new hours
• The form to get credits for Small Employer Health Insurance Premiums (#131) will be 40,189,456 additional hours

There are many, many more.

Though depressing to read, the report is due to a lot of tedious work by hardworking committee staff members.  Because of it, Americans can see just how much economic productivity is being sacrificed in compliance costs.

According to America’s Health Insurance Plans (AHIP), ObamaCare’s health insurance tax needs to be repealed as soon as possible:

• Starting next year the ACA imposes a new $100 billion tax on health insurance.  The tax will start at $8 billion in 2014, increasing to $14.3 billion in 2018, and will continue to increase each year.

• The health insurance tax is larger than the device tax and the prescription drug tax combined.

• The health insurance tax will increase costs for individuals and families purchasing coverage on their own, small businesses, seniors and people with disabilities enrolled in a Medicare Advantage plan, and state Medicaid managed care plans.

• The health insurance tax is far greater than the minimum penalty for those who choose not to buy health insurance – further incentivizing young, healthy people to forgo purchasing insurance until they need medical care.

The health insurance tax is just one of twenty-one new taxes imposed by ObamaCare on the health industry and its consumers.  Thankfully, there is already bipartisan legislation filed in the House of Representatives to repeal this monstrosity, but unless there is a major breakthrough to convince liberals how bad ObamaCare will hamper health care, it looks unlikely to become law.

Unless the Department of Health and Human Services (HHS) decides to once again bump back the deadline that passed yesterday, as of right now 24 states have told the Obama Administration they will not create a state-based health insurance exchange.

Under the terms of ObamaCare, this means that HHS will now take over the process in these states, adding hundreds of millions in new costs to federal taxpayers.  Moreover, the short time horizon between now and October when the plans must be available on the exchanges (they’ll be effective next January), means that there is likely to be an enormous push to hire more HHS bureaucrats to get the job done.

It’s been said that when it comes to something being fast, accurate, and cheap, you can have any two but not all three.  If history is any guide, the feds will go oh-for-three.

H/T: Washington Times

Like Ohio’s John Kasich and four other Republican governors, Indiana’s Mike Pence seriously considered expanding Medicaid eligibility under ObamaCare.  But unlike Kasich & Company, Pence ultimately decided against it when HHS refused to grant him one sensible reform.

Established under Mitch Daniels, Pence’s predecessor, the Healthy Indiana program allows uninsured adults aged 19-64 to use a state-based health savings account to pay for medical expenses, such as doctor’s visits, hospital services, diagnostic tests, and prescription drugs.  Incentives apply to reward cost-effective spending, but it’s critical to point out that the spending decisions within the account are determined by the policyholder, not the state.

In order to go along with expansion under ObamaCare that increases the eligibility pool for Medicaid, Pence asked permission to use Healthy Indiana accounts to help keep costs down.  The request is imminently reasonable.  If the purpose of Medicaid expansion is to cover uninsured people, why not let Indiana migrate a state-based program with a 94% satisfaction rating?

Predictably, Kathleen Sebelius’ Department of Health and Human Services said no, preferring to retain federal control over coverage and spending.  Without a program like Healthy Indiana in place, costs are likely to spiral upward since Medicaid beneficiaries are not tethered to the consequences of their spending decisions.

So, Pence said no to the Medicaid expansion.  But I think it’s crucial to understand that his response was not a kneejerk reaction against helping the uninsured get normal access to healthcare.  Instead, he proposed a sensible reform that would have accomplished the same goal as Medicaid expansion, but with more cost certainty for the state budget, and thus less tax receipts from taxpayers.

I’ve speculated before that Pence might be the GOP’s best bet in the 2016 presidential race.  A moment like this, even when it doesn’t result in a “win” politically speaking, helps confirm that suspicion because it’s based on sound principles.

The Wall Street Journal shows us that the price of “affordable” health care is a reduced standard of living:

The Affordable Care Act requires large employers to offer a minimum level of health insurance to employees who work 30 hours a week or more starting in 2014, or face a penalty. The mandate is a particular challenge for colleges and universities, which increasingly rely on adjuncts to help keep costs down as states have scaled back funding for higher education.

A handful of schools, including Community College of Allegheny County in Pennsylvania and Youngstown State University in Ohio, have curbed the number of classes that adjuncts can teach in the current spring semester to limit the schools’ exposure to the health-insurance requirement.

The scaled back hours and pay for adjunct professors is part of a larger trend in a wide variety of industries.  Faced with lower thresholds that require new benefits, employers from universities to fast food restaurants face three options: pay-up, pay-out, or tap-out.  In other words, they can increase their health care spending, be fined for not increasing such spending, or cap the hours and pay of otherwise eligible workers to avoid the spending and the fines.

Unfortunately for workers, capping hours and pay reduces their standard of living.  But don’t worry.  In 2014, Obamacare mandates that every state will have a fully functioning health insurance exchange where newly impoverished workers can get “affordable” health care – some even with government (i.e. taxpayer) subsidies – so it’s a safe bet that all will be well when the feds are in charge of at least 25 separate state programs.  Right…

Following up on Quin’s analysis, the Washington Times sheds light on another silver lining in yesterday’s fiscal cliff – formal repeal of Obamacare’s CLASS Act.  The Community Living Assistance Services and Supports Act is a giant unfunded mandate benefiting the long-term functionally disabled.  I say formally repealed yesterday because the Obama Administration already abandoned the CLASS Act in October of 2011 because it was unaffordable, and therefore unsustainable.

Sounds like logic that should inform the next round of fiscal negotiations…

Human Events kindly provides the full text of Senator Marco Rubio’s speech at last night Jack Kemp Foundation ceremony bestowing on him its annual Leadership Award.

While the entire speech is a must-read, a passage on a specific health care reform struck this conservative as especially attractive:

In addition to promoting Flexible Savings Accounts, we should create a health insurance system that focuses on empowering people, not bureaucracy. People should be able to buy a health care plan that fits their needs and budget, from any company in America that is willing to sell it to them. And they should be able to buy it with tax free money, just like their employers buy it for many of them now.

That is, until Obamacare fully kicks in.  Since Obamacare’s regulations on employers only apply to full-time workers, there is a regulatory incentive to minimize the amount of full-time workers one employs.  In order to avoid either the stiff compliance costs or the steep penalties for failing to comply, employers are likely to increase the trend of laying-off workers, scaling back hours, or using contract workers in order to avoid the profit-killing expense of paying for all of Obamacare’s new required benefits.

Because of the entirely predictable response to Obamacare’s mandates, millions of American workers are likely to be caught in an employment trap where they work just enough at two or more jobs not to qualify as full-time employees with benefits.  If Republicans are unable to repeal Obamacare, then fixing the tax code to allow independent workers to buy affordable health plans with pre-tax dollars is one of the next best moves.  Marco Rubio seems poised to lead that charge.

Recently, Quin argued that Obamacare’s medical device tax would be a huge job-killer if implemented.  A story from Fox News about massive layoffs at medical supply giant Stryker confirms his grim prediction:

The company will cut 1,170 jobs, or five percent of its worldwide workforce…

A “medical device excise tax” included in the mandate imposes a 2.3 percent levy on medical device manufacturers and suppliers, which critics say will raise prices on everything from pacemakers to prosthetics to stents. Companies will be required to pay the tax regardless if they have a profit or loss for the year. The tax is estimated to cost the medical device industry $20 billion.
…

“Here we are, one of the greatest industries in the country, and we’re staring down on Jan. 1, 2013 and the addition of a 2.3 percent excise tax, while meanwhile on the other side all the discussion in Washington is about creating jobs,” Stryker President and CEO Stephen McMillian said during a national conference of medical device manufacturers in Washington, D.C. last September.