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The Definite Guide to Idaho Disease Case Report Form

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Check How to Enter the Idaho Disease Case Report Form

good afternoon and thank you for joining.us today to discuss certificate of need.laws.i just want to quickly introduce myself.my name is christina herron and.government relations.manager of health policy at the.heartland institute today we have a.great panel of experts in their field.you should have access to their bios.which has their recent and relevant work.attached down in the chat room.so feel free to access that and i want.to thank freedomworks and institute for.justice for partnering with us to make.this panel happen.and i'm going to pass it over to our.panel and let them introduce themselves.and anne marie.if we could start with you that'd be.great well hi.i'm very pleased to be here my name is.anne-marie sheeper i'm the managing.editor of healthcare news which is the.publication of the heartland institute.and the goodman institute.it is the only i believe only newspaper.that presents the free market.perspective.on healthcare policy and it's sent to.every elected.official in the nation state and federal.um.both both parties and.we send it out every month and we've.been doing that for many years so.i also work as a research fellow before.that i did quite a bit of work working.as an investigative analyst.uh here in my home state michigan.at the mackinac center and uh i did.mostly video.documentary production work i produced.over 140 videos.um trying to put the give the real.people.perspective to public policy problems.and we found that it was a very.effective tool in just really.broadening our reach um.i left a very long storied career in.television journalism.i worked all over the country in various.stations.mostly doing investigative reporting.and that's where i really got turned on.to public policy.and of course as we all know the media.world has changed.dramatically and i'm really glad to be.in the space.um josh would you go next and introduce.yourself.sure uh yeah my name is josh withrow i'm.a senior policy analyst at.freedomworks a dc based grassroots.activist group with uh millions of.activist followers around the nation uh.we're primarily a fiscal policy.um not a think tank but an advocacy.organization.uh and i've been working there um with a.with a brief gap.since 2011 and healthcare policy has.been.uh one of my dominant uh policies of uh.of interest since then great well we're.glad to have you on.and then um jamie from institute for.justice if you could give a brief.introduction to that'd be great good.afternoon my name is jamie cavanaugh.i'm a litigator at the institute for.justice.the institute for justice is primarily a.public interest law firm.but also does strategic research.legislative work.and grassroots activism.we work in a lot of different areas.protection of private property rights.first amendment rights educational.choice and.occupational licensing but we've been.litigating for almost 10 years in the.certificate of need arena.and right now i have a certificate of.need case in kentucky where we're.challenging.the certificate of need laws as they.apply specifically to home health.agencies.and on top of that we recently released.a report.i and for co-authors or five co-authors.sorry.published a report this summer about.certificate of need laws and.with specifically an emphasis on what.states had to do.in response to the pandemic and what we.found was that most of them had to.suspend.or loosen their requirements their.certificate of need requirements in.order to give.healthcare providers flexibility to.respond to the pandemic.great well thank you all so much for.being here with us today and i want to.start off by talking about the history.of con laws.and how we got to where we are today um.i guess this question is.pointed at the group so um any of you.can feel free to jump in but if you can.give a brief.overview of certificate of need laws and.the current anti-competitive practices.that are in place and impacting.healthcare today if anyone would want to.jump on that question.certainly speak to sort of the origins.and history of of con laws and i'll.let the more specific uh policy oriented.stuff uh.be taken over by uh by you two um.so just the the two to three minute.history lesson on how we got here.um certificate and need laws.come from the same sort of mentality and.train a train of thought as the great.society health care laws that were.passed right roughly around the same.time.and the first state uh certificate of.need law was actually passed in new york.state.in all the way back in 1964. uh and the.sprinkling of states followed by uh by.the mid 70s you had.about 20 states that had that.implemented these.um after medicare was passed in 1966 and.within the first handful of years after.that.uh you immediately started seeing the.costs to the federal government uh being.massively higher than had been.intended uh the certificate of need laws.were seen.as in in their their supposed intention.was to.was to drive down health care costs and.so they were seen as an expedient tool.to try to rein in the quickly ballooning.costs of this federal health care.uh uh program and so in 1974 the.congress passed.a law um the the national health.planning and resources development.act which uh basically it didn't.they did they realized that.constitutionally they couldn't mandate.that states passed certificate of need.laws but they did the classic washington.thing which is they uh.they attached federal healthcare.infrastructure funding to states having.uh a certificate of need law that.matched certain criteria.and so within uh within 10 years after.the passage of that law every state.except for louisiana.had uh had passed one um and then in.1986 that law was repealed and.immediately you started seeing states.drop.off um a number of states anyways drop.off part or.all of their certificate of need laws to.where uh now we're in the situation.where we have about 35 states.uh plus dc and a couple of territories.that uh that have certificate of need.laws and.one interesting one to point out is.indiana which repealed theirs and then.passed a new one two years ago.uh when their administration switched.parties.um and so the other thing i would note.in terms of sort of why these came about.um there were a number of claims as to.why they were necessary that to me uh.you know maybe it's easier with the.hindsight of decades behind us and a lot.of data.that strike me as pretty absurd which is.that a certificate of need laws.work by establishing a panel um.to evaluate whether or not capital.investments by healthcare providers.um are necessary uh that's the.certificate of need.um and the idea is that behind it or how.it was sold.is that it was supposed to one help.provide an adequate supply of health.care resources.by making it subject to government.approval whether or not you could build.new health care resources.it was supposed to ensure rural access.to health care which.you know remains a problem and um it was.also supposed to reduce redundant.building of infrastructure which it was.thought would pass on.the costs of this of these capital.investments onto.um onto the taxpayers uh once once.medicare came into the picture but also.just to consumers in general.by uh sort of our you know the idea that.hospitals would essentially just keep on.building building new beds and just.increasing the amount that they're that.they're building their patients.um and what i just leave with to start.here is.thinking about it you're making it more.difficult.and subject to a lengthy and sometimes.expensive approval process.to do something like build a new clinic.or expand a hospital or buy.a new imaging scanner and expecting that.that's going to.ensure an adequate supply of these.uh these procedures and facilities for.the populace.uh it probably shouldn't surprise.anybody that it didn't turn out that way.yeah well thank you so much josh um i.think you hit so many good.key points and it's just important to.note that the intent of con laws.was to lower costs and that just isn't.happening and we're actually seeing.higher health care costs in the states.that do actually have the con laws the.35 states that you mentioned so.that was great thank you and um moving.on to jamie i do just want to note she.has an excellent report.um that she did mention and that is.linked.in the chat under her bio and she did.write that with other colleagues um.titled conning the competition and this.report is a really great document and it.looks at each state by state.specifically um in their comma.specifically and jamie.can you just tell us what is the biggest.takeaway from this report.and how can legislators use this.information for change.so i would say there's there's two.main takeaways from the report um the.first is just that when you compare the.con.programs across states you see that.there's no rhyme or reason to.how states are applying their con.programs there's no cohesion here it's.not as if.states are all following a formula.because con laws actually produce.higher quality health care or increased.access to.health care or decreased costs or.something like that as josh.just mentioned con laws aren't.accomplishing any of their goals and.actually there's ample academic.literature.about this the federal government has.disavowed con laws.since 1986 consistently you know both.administrations or.you know administer republican and.democratic.administrations have continually.disavowed these laws.um so instead what we see is.programs that look kind of like with us.have a swiss cheese effect where um.[Music].they look the exact opposite in some.places where.we have states like nevada who require a.hospital to get.a con before opening only in rural areas.this is something josh just mentioned.that sure there's still concern about.rural areas but then we see states.like oregon washington alabama that.exempt.health care facilities from getting cons.in rural areas so they're doing the.exact.opposite thing um and saying but.but still saying that they're.accomplishing the same goal.you know so both of these things can't.be true it can't be true that we need.cons to keep facilities in rural areas.and yet we can't have states that exempt.rural facilities and then yet states.that you know keep the cons in place for.rural facilities um so instead what what.we think this means.and is that it's just the laws are a.result.of a lot of um lobbying and special.interest groups and.you know hospital associations and.different organizations that are all.in the capitals and arguing for their.own self-interest.and i can point out you know my own.example from my case in kentucky.my clients are immigrants from nepal.that wanted to open a very small.home health agency to cater to the.nepali speaking community.in louisville they looked around and.they saw the aging population couldn't.find home health services.from home health aides who spoke nepali.and so they thought.you know we can figure out a way to.offer this service to the community.and when they filed their application.for the certificate of need a two.billion dollar health.care conglomerate came in and opposed.their application and said.you know we're taking care of the area.there's enough home health.care services in louisville and the.state denied their application.on top of that the state in kentucky.anyway looks at a just a blanket formula.kind of this mechanical formula that.doesn't take things like.language into consideration and.um so you know that that's another.reason their application.likely would have been denied anyway.even if their direct competitors didn't.come in.and oppose them but um.you know the the system is built so that.at every step of the way.an entrepreneur a new medical provider.is it's almost impossible to open a new.business.um okay so i mentioned some examples of.how.the programs in different states you.know kind of look the exact opposite.another example is in new york state to.open a.um or sorry excuse me in new york state.to add.beds specifically that will treat.patients with aids at.skilled nursing facilities it's that.specific you need a con.for that and in connecticut they exempt.that exact.service in missouri they go further and.they say you can open a whole nursing.home without a con.even though nursing homes normally need.to come you can do it without a con.if your facility is going to treat.patients with aids.so again you see these really specific.carve outs that create these weird.incentives.or you know kind of box in providers.sometimes.and just don't give them the flexibility.to provide the services that patients.actually need so that was the main.finding from the study and the second.finding was just that.in response to covid 25 jurisdictions 24.states plus dc.had to suspend or loosen their con.requirements.and so obviously that tells us that con.programs just aren't allowing health.care providers the flexibility they need.if con programs were in fact.increasing access to healthcare or you.know accomplishing any of their laudable.goals you'd think that we would want.more of those during a pandemic.not not fewer right well.thank you for pointing that out and it.kind of seems.like we're coming to the conclusion that.con laws.are in nature arbitrary and.anti-competitive and crony.in some manner and so i think that the.covid.19 example is very important if the.regulations aren't necessary now.during covid should they be necessary.after and i think that that's happening.in.lots of different industries we're.seeing these um regulatory practices.come into question so i really.appreciate that.i was going to ask you about your.kentucky case but you kind of broke it.down for us.but moving to another state could you.mention what's happening in florida.since you did mention earlier there is a.case there as well.yeah um that's not an ij case but.florida's actually a great example.because.a year ago florida went through a big.con um reform and it got rid of.most of its let's see it got rid of most.of its con.requirements and then it sunset.additional requirements so it has many.con laws on the books now that will.sunset.next july so this was a really.interesting way for the legislature to.go through.con repeal it's really giving all of the.providers kind of.time i guess to adjust to the changing.circumstances um i don't know the exact.contours of.the florida con case that's not an ig.case i can talk about a case in nebraska.that we have.where um we have a.another um entrepreneur an immigrant who.opened a home health agency because in.nebraska you don't need to get a con to.open a home health agency.unlike in kentucky where our clients do.need a con to open a home health agency.so he started his home health agency but.he does need a con.to provide non-emergency medical.transport so that means transporting his.patients.to their doctor's appointments or.transporting them to the pharmacy to.pick up.medication and so he likes to say that.he's allowed to.drive his patients to walmart.to help them grocery shop as part of the.home health services but he's not.allowed to drive them to walmart to go.to the walmart pharmacy.that's how the regulations in nebraska.apply right now.so we're suing there to challenge that.com law but again.you know it's his patients who are.already comfortable using his service.they.have to call and schedule their.transportation to doctor's appointments.with a totally separate service they've.all had experiences where they've been.left waiting at their doctor's office.for hours waiting for.this other transportation company to.come pick them up.it's these barriers to the services that.patients need.that are created by con regulations that.we see over and over again.and sometimes it's hard there's a little.bit more distance between.the barriers created by con regulations.and the harms to the patients it's not.as direct as in some other types of.regulation.um but so finding human interest stories.is sometimes a little bit more difficult.but.in a lot of these areas i think the.problem is that.cons were originally envisioned to.regulate expensive things like hospitals.the original idea was that we don't want.two hospitals to open around the block.from each other and sit.half empty but when we get down to.things now like home health or.non-emergency medical transport these.are things that don't have a large.expenditure that aren't going to be a.drain on capital.or you know if if a home health agency.opens there aren't really any capital.expenditures.in the kentucky case we just had this.great opinion on just the motion to.dismiss stage where the judge said what.is the capital expenditure for opening a.home health care it's just.one employee and a tank full of gas in.their car that's it there's no.overhead to open a home health agency.right well thank you for sharing that.case as well and.um yeah it does seem like there's a huge.issue with um.there's a huge barrier to access that.con creates for so many patients and on.that note.um i also want to bring up the fact that.it's not only barrier to access.but also um there's regular regulatory.burdens.putting limits on innovation and.technological advancements.and um anne-marie i want to direct this.question toward you.and some of the work and research you've.been doing on the regulatory burdens.limiting.um limiting technological advances and.medical advancements.from cons.looks like we may have lost ann marie.here oh no.okay well i know she has great work on.it so hopefully she'll be able to hop.back on and really start talking about.um the technological advancements.there but moving forward i have a.question for um.josh and jamie while i have you both.still on um.can you also i know you got um talked a.little bit about.the connection um of cobit 19.to com laws and really poking holes.in these um regulatory policies that.have been enacted in the states can you.give a few more examples.um whether it's a lack of bed or.not enough ventilators or even you know.the number of hospitals that have been.available can you point to a few.examples where kovid.you know has really poked holes in the.con law.certainly i mean uh uh i'm not.remembering.off the top of my head the the full list.but uh i think it's 25 states.that had that in part or in or in full.uh suspended a number of their con.provisions uh.in direct response to covet and it was.for exactly the sort of reasons that you.just said like in.like in new york where they were worried.about hospital capacity and wanted the.ability to set up uh you know to expand.beds or set up new facilities quickly.and they just had to make the con laws.go away in order to allow that to happen.in a timely fashion.uh and and that was that was true for uh.basically major cities all over the uh.all over the country who were worried.about bed capacity which fortunately.mostly didn't get tested.uh but it did go it did show though if.they're if you're worried about the.capacity existing why was that capacity.not there in the first place well one of.the reasons why it wasn't there in the.first place was probably.the existence of these certificates.right need.yeah and i'll just add to that mercatus.the mercatus.center at georgia mason university has.done research that shows.non-con states went into the pandemic.with more hospitals per capita with more.hospital beds per capita.um with more surgery centers per capita.with more dialysis centers per capita so.things like that you know they were.already better equipped and then on top.of that they didn't have to make their.providers.jump through additional hoops and fill.out additional paperwork.to respond to the pandemic and so.josh is right that number is 25 25.states had to suspend or loosen their.con requirements to respond to the.pandemic but included in that number are.states that still.are making their providers fill out.emergency con.applications so unfortunately you know.they're still.creating some hurdles even though it's a.reduced burden it's not a full-blown con.application they're still forcing.providers right now to spend time.on paperwork and ask permission to add.hospital beds or add ventilators things.that.you know kind of seems absurd the.hospital isn't.the hospital you know is is adding beds.because.it wants to be ready to provide the.public with these services.sure yeah i completely agree and think.it's shocking that we're even having.this discussion and are in this.situation.um i also have my last question for you.all.is there any solution or um strategies.to repealing con laws.that you all can think of for state.legislators is there.um obviously the lawsuits that your work.the.um the community members you're working.with and.um you know suing the state or different.governors and their capacity is there.anything else that.um folks can do to educate people or.move forward with repeal.well i i would say one thing to start.with and you know.happily flank another organization's.work uh on on this is in just a double.down on what jamie said about the.research that the mercatus center has.done.on this uh uh um tom stratton and chris.koopman there over the past.over the past five eight years i've.produced some of the absolute best.uh sort of empirical studies that i've.seen anywhere in terms of just.documenting these 50 years now of.of uh results um that.and economic data that prove pretty.conclusively uh the ways that com laws.have actually harmed.the uh the cost of and access to to.health care across the nation.and so you know armed with these facts.uh um.i think it's becoming pretty easy.to convince people that con laws are.problematic in terms of.uh and i think the other thing that.helps is that people.inside the healthcare industry are.finally starting not the hospitals so.much because they now have a vested.interest in keeping these laws around.but doctors and other other you know.stakeholders within the healthcare.community are increasingly starting to.realize that.um the market concentration that is.being created artificially by laws such.as certificates.of need they're not the only law but.certificates of need are.a factor in this uh are are preventing.them from being able to adequately.deliver carrots it is.impacting their ability to help people.which is which is their job and so uh.you're starting to see organizations of.actual.physicians uh one that i work with that.i'm familiar with is physicians for.reform there are others.um who are speaking up about the need to.to deregulate and.um including getting rid of a.certificate of need laws at the at the.state level and you know doctors are a.very trusted voice.it's one of those things where we can we.can feed people the economic numbers.uh until uh uh you know all day but.uh when you start getting medical.professionals speaking up and going guys.this is a problem that's.that really changes hearts and minds.faster than anything that.any numbers i can shout at you right.yeah that's great.that's a great point we have another.case in north carolina where we're.representing a doctor who wants to do.surgeries and he actually owns his own.surgery center.but the state says you can't use your.surgery center without getting a con.you have to go to a hospital to perform.these surgeries and it would be much.less expensive for patients if they.could use.the surgeon's his surgery center but.instead he has to go to the hospital and.pay the hospital's.surgery fee and so his patients are.paying you know two thousand three.thousand dollars more.every time at least at a minimum more.for their surgeries every single time.um so there's you know all these.benefits yes josh is absolutely right.that doctors are becoming aware.of the burdens of con and there's all.these benefits to patients as well if we.reduced.cons so you know you asked about what.are the ways i guess to.move forward with repealing cons new.hampshire was the last date in 2016 that.was able to.fully repeal its con program but if that.is something that isn't politically.feasible in a state.then there's still other things that can.be done as i mentioned florida was able.to get rid of a lot of its con.requirements without getting rid of all.of them and it included these sunset.provisions that.gave providers a lot more time to kind.of adjust to the new climate.another thing that states can think.about doing if they don't want to get.rid of the entire program.is to um add expenditure minimums.to so that cons don't kick in until a.provider is going to spend a certain.amount.on a new service or on building a new.building if we make these.expenditures really high like 10 million.or 20 million dollars then most people.are going to be able to do what they.want to do.in the healthcare arena without having.to get a con.which is a good thing the other thing to.do is to look at the regulations and ask.what kind of application requirements.are there what kind of application fees.are there.how active are the applicants.competitors allowed to be.a lot of times the con application.process.looks like a full-blown civil trial the.direct competitors like i mentioned in.kentucky my clients.were opposed by a two billion dollar.healthcare conglomerate.um that were represented by attorneys.and you go to what looks like a trial.they have exhibits you go in front of an.administrative law judge.you have to be represented by attorneys.um it's very expensive and so.if you get rid of some of those.requirements states like nebraska and.michigan don't allow.competitors to be involved in the.application process you at least are.decreasing some of the barriers that are.imposed.on applicants who are trying to get cons.right that's really creative too to work.within the confines of con laws just.making them not applicable.to what people are actually doing that's.um a smart way to go about it.um ann marie we're glad to have you back.on i did want to touch.um on the tech the limiting of.technological advancements and medical.advancements we're seeing in the.industry and how con laws really do.impede on those if you want to touch on.some of the work.um that you guys have been putting out.on in healthcare news that'd be great.i would like to speak a little bit more.to why.we need to change khan as to how.um you know there is a lot about khan.that we can discuss and i'd like to.focus a little bit on the disbursement.of technology and.knowledge sharing so you know one of the.main premises of con laws.has been to restrict market competition.so that we could create these centers of.excellence you know the idea was that if.you had too many people.offering the same service no provider.would get good.at what they were doing and you know.that might have been fine in the 70s and.80s when we had many new technologies.and healthcare.coming on the scene organ transplants.for example.but you know we have come a long way and.look at what we now know.about covet in just a few months um that.we've been dealing with it.you know a study came out recently from.mercatus that found mortality rates were.higher in states with con laws.and that there was a significant.reduction in death not just in covid but.other diseases.um when these states temporarily.restricted their con laws.so more and more evidence is showing.that you know these are really becoming.a problem competitive.very quickly changing um.climate um you know information and.knowledge spreads rapidly.with digital technology when we prohibit.professionals from gathering.information and developing expertise we.could spurn.a lot of new or we could block a lot of.new innovation.and um you know if we allow people to be.able to practice and get more into the.health.sphere we can maybe you know come up.with even more innovation and better.ways to develop healthcare.and you can't do that when you have a.small panel of people.not working in the trenches calling the.shots everybody loses.and i think the best way to describe.what i'm talking about is to share a.personal experience.um you know 16 years ago my my husband.was told that he had non-hodgkin's.lymphoma.and it was it was devastating news he.was in the prime of his life our.children were quite young.and we lived in a great community except.for the fact.that we did not live near a cancer.center.the doctors told him the only way of a.cure would be to get a stem cell.transplant and the closest place.offering this procedure.was two hours away i won't go into too.much depth.of what this procedure involves except.to say that at that time.stem cell transplant was a very risky.deal.what they do is they blast away your.cells and pump in new ones either from.your own body that are treated or from.someone else in his case on his donor.was his brother.um you know we were not in a position of.moving we were both employed.in our city our kids were in school and.so we decided to commute.to get this care and we had no idea what.we were getting into.um after the transplant which is a.really uneventful thing it looks like a.blood transfusion.um you're required to live in the area.for a couple of months.because you can come become legally sick.very quickly.and if you're back home your your local.hospital may have no idea what your.history is.so we rented an apartment and for a.couple of months he stayed out there.various relatives would come in.and care for him as a caregiver uh.within a month he got incredibly sick.uh he caught he got something called.graft versus host disease.and he was hospitalized again generally.what happens is your stem cells.the new cells reject the host body and.so to fix this doctors have to shut down.your immune system which makes you.extremely prone to infection.so after a month he came home for about.a week and then came down.with something really really threatening.called uh fungal pneumonia.and that's even more dangerous than.graft versus host disease or.cancer uh it's very difficult to treat.doctors have to use.very toxic drugs to do it he was in the.icu for about a month.he did get out and of course uh once.again the.graft versus host disease came back to.wrap it up he was in the hospital for.four entire months in that first year.two hours away from our home and my.biggest fear.that um he would die alone and i.i knew somebody that that had happened.to and.you know he he never to make a long.story short.he never recovered he lived four more.years um.grafford's host just took over his body.eventually attacked his lungs.you know there were various treatments.he could have had.um but they were very time intensive he.did one of them was.a really cool thing using uv light but.again he had to travel to this.cancer center two hours away several.times a week and sit there for hours on.end.um and i kept wondering why isn't it why.do we not have these services in our.home town.and that's when i came to discover con.laws.um you know it's the state's com board a.group of appointed.uh people who decided things like where.which hospitals can do a stem cell.transplant you know why were they.concentrated in one.area of the state was it you know you.had to wonder was it political.uh you know the local hospitals in my.neck of the woods were not mom and pops.they were growing they had a lot of.philanthropic.support um you know they were approved.for transplants for children.um and in fact you know like i said they.could not get access to.he he actually they did get some.treatment in there.um and but they just were not up to.speed and how to do it he would come.home.with lots of complications bruises on.his arms and so forth.so they just never really were able to.catch up.to this other center that had this.privilege of being able to do.transplants you know 15 years later.you would wonder that con laws would.have.um would be gone but they're not they're.still here and they're getting in the.way of technology.you know when the trump administration.announced last year that medicare would.be covering this innovative.treatment that could save lives for some.blood cancers.it gave patients a lot of hope it's.called car t cell.therapy and you know basically they.collect patients t cells and genetically.modify.them um so that when they're reinfused.in the patient that they can latch onto.these tumor cells and kill them.you know had this treatment been around.15 years ago.perhaps my husband would be alive.because the technology behind the.process has already been done the.treatment has been done.you know cms has allowed anybody to.offer this facility as long as they are.enrolled in the fda's drug safety.program and in mice.the con board decided that it was going.to impose an additional accreditation.recommendation a requirement on top of.the cms guideline.and so what happened was you know.naturally the dominant cancer centers.had this accreditation.so competitors could be locked out well.heartland center learned about this this.was not that long ago.a couple of months ago and yeah.we started writing papers op-eds.michigan state senator.vanderwaal took the lead in this he.objected at the con hearing.um to make a long story short there was.a provision in the law that allowed the.state to override this decision.and fortunately they have been able to.block.this extra requirement that the con.board was trying to change.and i think that has also helped um.propel.or motivate lawmakers to realize how.serious this is.we have these new technologies coming.onto the scene and you know if we're.going to block them we're not going to.give places the opportunity to develop.the expertise we're not going to be able.to share this technology with a broader.um with a broader range of consumers and.and everybody.loses so even more now than ever you.know it's really important i think it.was matt ridley.who said that innovation cannot be.forced but it can be quashed.and and when we lose when we use panels.to restrict the organizations that can.develop this expertise we all lose.well thank you so much for sharing that.story with us.and um you know i will make sure to.attach some of the work.um regarding the con laws that.healthcare news has put out.under your bio as well when we publish.this video.and to the audience i just want to ask.if anybody does.have any questions feel free to type.those up.in the q a below and i will read those.to our members if anyone has questions.or if anyone on our panel has any final.words.for our audience while they're thinking.of some questions.christina can i add just um there's a.link that i'm gonna i'd like you to.include is an interview that i did with.three lawmakers who were really trying.to reform repeal con.in their states missouri and tennessee.and they gave.very candid answers uh responses.to what the obstacles were where they.were facing.you know who they were up against the.kinds of arguments they heard i mean.they're still pushing away cover changed.a lot of it.you know they were really you know.spearheaded really going full force on.this.and so it might be interesting if.anybody's looking to reform to hear the.experiences of other lawmakers in other.states and.and how what they came up across yeah.that's phenomenal i'll make sure to.attach that as well.yeah one quick thing i would add just.because i i am the.uh of this group the the the dc.uh swamp dweller um there is a there is.a federal.component to this that i think uh may.bolster some of the arguments against.con laws at the state level which is.that.um there's an increasing amount of focus.at the federal level in congress on this.level of market concentration that we're.seeing.among hospitals um that's created by.all of these barriers that exist of.which con are only one to to.establishing new services and.competition um.there are some very alarming proposals.that are.coming about uh actually and the worst.part is that they're coming around from.both parties.uh in terms of how federally uh they.might try to deal.with this uh with these these regional.and local hospital monopolies.and instead of you know knocking down.the barriers to why they don't have.competitors uh they're.talking about doing things like.antitrust enforcement uh.which you know uh you know breaking up.some of these hospital monopolies might.in the short term.stop their their dominance over the.markets but it won't stop their ability.to.uh to block construction new facilities.through con laws.and also will impose a massive cost if.you want to talk.about a service that's going to cause.hospitals to divert uh divert.large amounts of money away from the.actual care of patients and towards.towards litigation and that that will in.fact increase prices.um you know ftc antitrust cases take.years and sometimes even sometimes you.know a decade or more and.uh impose massive massive costs um.so not only is it not a good free market.way to handle the problem and it kind of.ignores the reason why we have this.market concentration in the first place.but it will uh it will have adverse.consequences at least in the short term.that are going to cause.uh major headaches in the states where.these cases are pursued so i just i.think people should be aware that that.is actually a conversation that's being.had in some.some of the halls of congress that is um.ominous yeah that's that's really.important to note.josh about the federal angle to this.because i think a lot of.federal legislators maybe don't know.what to do or don't know that they.could be involved in kind of combating.this con loss situation because it.really is a state focus.issue but there are examples here.where federal legislators could in some.capacity get involved and i also want to.address this question to the panel this.is from.alyssa hutchinson she says so would you.say that khan is a bipartisan issue.or does one side tend to defend them.more than the other.now for everyone they're worried about.getting re-elected.and you know your deal you're up against.some really powerful forces lawyers.um and you know the thing is we don't.see how the.the activity that is you know that.doesn't come into estate because they're.so.afraid of going through this process you.know when investors come in.um they're going to do their diligence.they are going to make sure there is a.market there they're probably going to.do it much better than a con.board can and you know i i've heard.comments too where the hospitals are.using these laws to even do their own.bargaining there's some laws there that.where con does not apply to expenditures.under a certain amount so they'll go.back to a provider and say.get it under this price so we don't have.to go through this process.i mean we shouldn't have governments for.you know doing the negotiating.for providers um you know that's.basically what this comes down to.they're using these laws.to to to um to promote the market.in the interests of very few players.and i don't know you know i i think you.can get everyone.that i've talked to has been on one.party the republican party.but i think this is just this has to you.know i don't know how you could.make this a partisan issue would apply.it's a very pro-consumer.idea do you all have any thoughts.any other thoughts on that i've seen.some.hesitancies sometimes from.democrats um to the idea that.if we admit that con laws aren't working.it might be a general admission that.central planning for health care doesn't.work.or you know it's an admission that like.medicare for all.isn't going to work or something like.that so um.you know to be in line with this general.idea that we have to have a united front.about.centralized government funding for.medical services.i think there's less appetite at least.in my limited experience i think there's.less appetite from democrats for.con reform but that might change in the.era of.cobid because now we've seen democratic.governors.issue orders suspending con programs.right agreed especially at the federal.level that's even more more.more true than in the state in the state.houses uh even though the evidence is.is plainly there to show that the con.laws are not achieving.uh a great deal of benefits for patients.they are.in some ways a part a sort of a key part.of the.the broader vision uh among and.democratic policies.progressive policy circles towards.concentration of the markets and you.know like the the aca when it was passed.one of its primary goals as written by.some of its authors was.to actually increase the concentration.in health care because then it would be.easier to.to administer centrally and so the fact.that it is in fact restricting access to.care in rural areas.is seems to be at least by their actions.perceived as a unpleasant but necessary.side effect.of the greater plan which is to achieve.a.national health system right.well republicans who blocked con reform.as well so i don't know that this is a.very partisan issue there's so many.special interests involved.we knew one state where um they tried to.repeal it because.there was a nursing home going up in.somebody's backyard they didn't want it.there so they went to the convoy.and they tried to change it that way i.mean that's not what we should be using.government laws for.to to you know to exercise the special.interests of a limited few.right yeah and i i do just want to.comment if you are a free-market.liberty-minded individual um you know.i think that you would definitely be in.support of repealing.con laws at least in some capacity or.rolling them back so you should be.at least um if there aren't any other.questions from.our attendees which i haven't gotten any.other.questions here oh here's one more.question um.is there a collaborative way to work.with corporations.as well to target the issues with big.corporations pushing out new providers.from opening so i don't know if this is.referring to a private.public partnership um and this is from.anonymous attendee if anyone wants to.address that.so i can read it again it was a little.is there a collaborative way to work.with corporations as well to target the.issue.with big corporations pushing out new.providers.from opening so i guess the.anti-competitive practices and it says.referring to competitors being able to.argue a new.one from opening so but one thing i can.kind of speak to.is so in terms of the the hospital.associations themselves.i i'm not sure that there is because.there's just a benefit to them in doing.that unless you can like publicly shame.them for their anti-competitive.practices to the point where they feel.the need to to play along but uh there.is this.uh this power dynamic that i that i see.pretty clearly in.uh in dc that can sometimes be useful.which is that.some of these anti-competitive practices.that benefit hospitals.and facilities do a great deal of.disservice to.the doctors the physicians practicing in.them and also sometimes to the insurance.companies in terms of skewing.uh skewing payments and so uh there is.in fact.it it's it's it's kind of icky but.there's definitely uh.uh it's necessary often to sort of play.those dynamics against each other so.that you can have some of these other.industries.uh you know sort of tattling on on the.guys who are the bad actors in this case.being like hey this is this is actually.hurting uh hurting patients and.isn't the right way to go so you know.sometimes yeah you can you can work with.the insurers against uh against hospital.concentration.sometimes not it depends on whether.their interests align uh i haven't.explored that dynamic on this particular.issue so i don't have a i don't have a.definite answer but that's just.something that becomes part of the.process when you're dealing with policy.at the federal level.sure you know oh go ahead.well i'll just say briefly another thing.is i think sometimes some of the things.hospitals are upset about are really.just medicare reimbursement rates.and so you know they they try and say.cons are necessary to pad our bottom.lines but that's not.really what cons are built to do either.so if that's.you know that is how they're being used.a lot of times but that's what we've.just been talking about that's not right.that the government isn't really.creating these laws to.keep out competition and in fact we have.all these negative externalities so.you know that's not a reason to keep con.laws on the books and this is something.we haven't mentioned today but.so when we say there's only 12 states.without any type of con program that.doesn't sound like.a ton but it's actually about 40 of the.population of the country lives in.a non-con state this includes states.like california.texas pennsylvania colorado but rural.states as well idaho the dakotas.so we really have the full gamut of you.know red states blue states.rural states less rural states.that have functioning healthcare markets.that have hospitals the hospitals.haven't gone out of business so we.really have a lot of data points to push.back.against hospital associations and other.organizations.um to say that the sky's not going to.fall if con laws are rolled back.you know one one thing we didn't mention.that's somewhat related to khan.is the growing use of non-compete.clauses for physicians as there's a lot.of concentration.going on in the hospital industry now.maybe this has changed with copic.because.um physicians are really rethinking.their practices.but over the years the trend has been a.number of doctors working for large.employer groups hospitals.and then locking them into contracts and.one of the problems is this.of this is they restrict them to from.from leaving and practicing in a market.for long periods of time.and i know states like indiana and south.carolina are really looking at these.clauses and trying to find ways to.um to allow physicians um.to be able to practice i mean you know.they're very prohibitive.and something maybe we need to be a look.on a look out for yeah.well thank you for that input i also.just want to give.you all on the panel um one last shot to.give any plug.for any cases we should be looking out.for organization.how folks can stay in touch with the.work you're doing or any other final.comments you have here.to wrap this up.i'll go ahead and mention that ij just.rolled out a new.legislative service where we're working.on the ground with legislators at the.state level and at the city level.um so if you go to 2021 initiative.com.you can see the types of services that.we're offering there.and it's really to address the myriad.crises that have occurred in.2020 and to make sure that 2021 is a.year of recovery but healthcare is.a big component of this initiative and.so of course repealing con laws is one.of our major.um goals with that initiative so you can.find out more about that at.2021initiative.com.great thank you yeah i would just say.for freedom worse is part i mean our our.primary purpose is to be a.service center to grassroots trying to.create change in their states.um and at the federal level but uh but.we actually had been.uh in talks and working with uh you know.both activists and folks in state.legislatures on.uh on con laws before the covet happened.and everything.and i think there's a i think there's a.momentum here that uh.that hasn't been present in years past.i'm back in 2012 and 2013.i tried to look around and see if there.was any interest in amending or.repealing con laws.in the states and it should there just.wasn't uh i there was i had no ability.to just even detect any interest to make.that happen now you're seeing you're.seeing movement.and actual real interest in in over a.dozen states or more so.what i would say to the audience.particularly those of you who are in.uh state legislatures is if you know if.there's any interest in that uh.definitely do reach out to us uh we may.be able to help.uh help educate uh at grassroots.activists and also just the public in.general in your states.and and to um to you know to maybe give.some extra tools to boost.uh boost your message and help make that.happen um so.definitely keep us in the loop we uh we.don't have a dedicated.you know a team of people in every state.watching what's going on we.do rely on folks like you guys coming to.us to let us know hey this is happening.and we need help.awesome i will uh i'll put a plug in for.healthcare news we mail it out every.month.free of charge and we're really keeping.tabs on this.one of the useful things about this.publication.is that you get names of other lawmakers.i've actually had.calls from state lawmakers wanting to.get in contact to somebody who.they read about in the newspaper so they.could figure out.you know maybe a different strategy and.getting some repo reforms passed.so it's been kind of a good.clearinghouse and um.if you're not on our mailing list do.please contact us and we'll be happy to.to add you.yeah that's awesome and thank you to our.panelists for being on here and talking.about this really important issue.and to our audience thank you for.hopping on and if you did miss anything.or do come across a question later on.please feel free to.reach out to me we will be posting this.on our heartland.youtube page and on the heartland.website so you will have access and i.can always relay a question.to one of our guest panelists if you do.need.more access to them to discuss this.issue so thank you all so much and.i hope you have a great weekend thank.you christina.all right bye-bye.

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Idaho Disease Case Report Form FAQs

Check the below common queries about Idaho Disease Case Report Form . Communicate with directly if you still have other queries.

Need help? Contact support

In what cases do you have to fill out an insurance claim form?

Ah well let's see. An insurance claim form is used to make a claim against your insurance for financial, repair or replacement of something depending on your insurance. Not everything will qualify so you actually have to read the small print.

How do I fill out form 26QB for TDS in case of more than one buyer and seller?

Hi, Please select Yes in the column of Whether more than one Buyer/seller as applicable, and enter the Primary Member details in the Address of Transferee/Transferor & no need of secondary person details. The reason to include this is to know whether the agreement includes more than one buyer/seller, so the option is enabled. Hope it is useful.

How do I fill out the ITR II form in case my MNC gave an awarded share in a foreign German account?

This is better answered by a CA. I can give my experience. There are two factors here. 1. Perquisite - This is the difference between the price of the share at the time of vesting (also called Fair Market Value) and the cost you paid for it (which is mostly zero). This would be taxed as part of the salary in the year of vesting 2. Capital gains - When you sell the shares, capital gains would be calculated on the difference between the selling price and FMV Since no STT would have been paid on the transaction, the stock would be treated as ‘non-equity’ and corresponding treatment would apply. Currently the tax is your marginal tax rate for holding period < 3 years, and 20% with indexation for period > 3 years. Also ensure that you list the foreign account in Schedule FA.

Am I supposed to report income which is earned outside of the US? I have to fill the 1040NR form.

If you are a US citizen, resident(?), or company based within the US or its territories, you are required by the IRS to give them a part of whatever you made. I'm not going to go into specifics, but as they say, "the only difference between a tax man and a taxidermist is that the taxidermist leaves the skin" -Mark Twain

What tax forms do I need to fill out for reporting bitcoin gains and loses?

IRS 1040 and 1099 forms. “For instance, there is no long-term capital gains tax to pay if you are in the lower two tax brackets (less than $36,900 single income or less than $73,800 married income). The capital gains rate is only 15% for other tax brackets (less than $405,100 single income) with 20% for the final bracket.” Reference: Filing Bitcoin Taxes Capital Gains Losses 1040 Schedule D Other References: IRS Virtual Currency Guidance : Virtual Currency Is Treated as Property for U.S. Federal Tax Purposes; General Rules for Property Transactions Apply How do I report taxes? Filing Bitcoin Taxes C Continue Reading

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Are you aware of the many first year elections that you will be making that will effect the future taxation of your business? Carl Heintz has great advice. SEEK YEA A CPA. The form may look innocent enough but this is NOT a DIY project.

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