Dr. Don Berwick will be recess appointed as head of the Centers of Medicare and Medicaid Services, without even a single committee hearing. “This way, Berwick will assume his post without having to explain statements such as this: ‘Cynics beware, I am romantic about the (British) National Health Service; I love it.’… Obama could have announced his CMS appointment at any time after winning the election in November 2008 if it were so urgent, but he waited almost a year and a half — until April of this year — to name Berwick. Conveniently, this was after the health care law had already passed. Had he appointed Berwick during the health care debate, it would have exposed how much Obama’s ultimate vision for U.S. health care borrows from the British model.”

“Just a few months ago, President Obama signed the health-care bill into law amid much fanfare. But we’re hearing a different tune from small-business owners. They’re asking: How much is this going to cost me, how can I opt out, isn’t there any way to stop this from taking effect?”

While the White House highlights their favorite parts of ObamaCare, the real work is being done in the depths of the federal bureaucracy. “Track two is the regulatory process, where Obamacare is sinking its roots deeper and deeper into the bureaucracy and the health sector. This is below the radar of most Americans, but the implementation rules are beginning to frighten many industry groups that thought their seat at the table would inoculate them against the wrath of the regulators. The Centers for Medicare and Medicaid Services just issued a 1,250-page proposed rule on Medicare payment policies for 2011. That follows a 121-page proposed rule limiting how companies can grandfather their employee health-insurance plans to avoid even more onerous federal mandates.”

The Patient Protection and Affordable Care Act represents more than a federal takeover of health care; it is a direct threat to federalism itself. Never before has Congress exercised its power under Article I, Section 8 of the Federal Constitution to force American citizens to purchase a private good or a service. Congress is also intruding deeply into the internal affairs of the states, commandeering their officers, specifying in minute detail how they are to arrange health insurance markets within their borders, and determining the products that will be sold to their citizens. If allowed to stand, this unprecedented concentration of political power in Washington will reduce the states to mere instruments of federal health policy. State legislatures and sympathetic Members of Congress should consider (among other actions) crafting a constitutional amendment to guarantee the personal liberty of every citizen in the area of health care. Given the trajectory of federal policy, state officials should take the lead in the next phase of the national health care debate, reclaim their rightful authority, and change the facts on the ground for Congress and the White House.

“If implemented as enacted, Obamacare will impose significant new Medicaid costs on states and constitute a major federal usurpation of long-standing state authority in regulating private insurance. This will be expensive and disruptive for those Americans who rely on individual or employer-based insurance for their health insurance. While some of the most expensive and disruptive provisions of the massive legislation do not take effect until 2014, other provisions are already going into effect and state lawmakers need to act right away if they are to implement their own Medicaid and private insurance market reforms to mitigate the harmful effects of Obamacare. State lawmakers must recognize that states are not mere agents of the federal government. They are not powerless, and there is nothing that requires them to assist in implementing this new, misguided federal health care agenda. They should assert their rightful authority, and represent and protect their citizens by resisting the disruptions entailed in Obamacare—taking actions that pressure the next Congress to scrap or redesign this harmful federal legislation.”

In addition to the direct costs of ObamaCare’s $500 billion in new taxes, there are also indirect costs from the new tax regulation. Section 9006 of the law puts vast new reporting requirements on businesses, forcing them to dramatically increase their administrative costs as they now have to report nearly every single business relationship.

By tying its subsidy program to the federal poverty rate, ObamaCare strongly discourages marriage. The level of subsidization is based on a family’s income as a percentage of the federal poverty level, which changes based on a person’s marital status. Thus two individuals living together would receive a substantial decrease in their subsidy were they to get married.

ObamaCare’s new tax on indoor tanning is now in effect, causing the 18,000 tanning salons around to country to worry about shedding jobs or going out of business.

Dr. Don Berwick will now head the Centers for Medicare and Medicaid without Senate confirmation, or even a single hearing, after Obama’s recess appointment. “The recess appointment was somewhat unusual because the Senate is in recess for less than two weeks and senators were still waiting for Dr. Berwick to submit responses to some of their requests for information. No confirmation hearing has been held or scheduled.” Berwick would have had to face tough questions about his views on rationing and his support for the British socialized health system, which would have been difficult since ObamaCare was guaranteed to not limit Medicare benefits.

Emergency room visits in Massachusetts have skyrocketed since their health care system was changed in 2006. “[E]xpanded coverage may have contributed to the rise in emergency room visits, as newly insured residents entered the health care system and could not find a primary care doctor or get a last-minute appointment with their physician.” ObamaCare will create similar results nationally, as its massive coverage expansion will exacerbate the existing doctor shortages.