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After spending four hours, 37 minutes and 12 nerve-racking innings wresting the American League Central title from the Tigers in their one-game tiebreaker on Tuesday night, Twins players were lifted by adrenaline and the cheers of 55,088 fans in their victory lap around the Metrodome.
"I don't know where I had that extra energy," Mauer told the Minneapolis Star Tribune "I was just feeding off the crowd. It was an unbelievable atmosphere.
"I was surprised I got around there. It was a long game. The fans, they stuck around and gave us a great atmosphere. Players feed off of that."
Rockies have confidence in Street: The Rockies believe the back of their bullpen, led by Huston Street, can be a strength in their Division Series against the Phillies.
"The thing with Huston is that you know he's going to come into the game and throw strikes," setup man Rafael Betancourt told the Denver Post. "It's very important for him to show he's not afraid to throw the ball around the plate. Huston goes right after guys."
Street is 35-of-37 this season in save opportunities, helping the Rockies go 83-1 this season when leading after the eighth inning.
Martinez adapts quickly to Red Sox: Victor Martinez has been with the Red Sox for only two months, but the switch-hitting slugger acquired from the Indians before the July 31 non-waivers trade deadline has quickly put his stamp on the team.
"As he goes, we go," starter Paul Byrd, a former teammate in Cleveland, told the Boston Herald. "And I'm not just talking on the field, but in the dugout."
Kazmir brings confidence into Fenway: The Angels have had a tough time in the playoffs against the Red Sox, but left-hander Scott Kazmir, whom they acquired from the Rays, is 8-7 with a 3.59 ERA lifetime against the Red Sox and is 6-4 with a 3.05 ERA in Fenway Park.
"I kind of like that stage; I really do," Kazmir told the Los Angeles Times of pitching in Fenway. "The crowd is on top of you, just all over you. I get pumped up and rise to the occasion."
Billingsley ready for October: Chad Billingsley, named the Dodgers' fourth starter for the NLDS, believes he has corrected some mechanical problems and was encouraged by his last two starts of the regular season.
"It's a different story in the playoffs," Billingsley told the Los Angeles Times. "It's a new season. You get a new life. The regular season's over. It's postseason, it's October. The whole playoff atmosphere is exciting."
Gorzelanny hoped to see a hometown Olympics: Having grown up on the South Side of Chicago, Tom Gorzelanny was one of many people who were excited about the idea of the Windy City hosting the 2016 Olympics. Instead, the Games were awarded to Rio de Janeiro, Brazil.
"No one was expecting that," Gorzelanny told the Chicago Sun-Times. "You could see that on the faces of people at the Daley Center.
"It would have been a privilege to be a native and see something like that come to the city, to have world-class athletes come to our city and enjoy it as much as I do. It would have been great if they reinstated baseball [as an Olympic sport]. It was kind of a dream of mine to be part of a team that might have played here. It's disappointing, but [IOC members] didn't realize what a good city we have."
Bourn honored by writers as Astros MVP: Michael Bourn was voted the Astros' Most Valuable Player for 2009 by the Houston chapter of the Baseball Writers' Association of America. The chapter also voted Wandy Rodriguez as the Pitcher of the Year, Jeff Fulchino as Rookie of the Year, and Brian Moehler was the team's Darryl Kile Good Guy Award recipient.
Bourn hit .286 for the Astros and led the NL with 61 steals while playing outstanding defense in center field.
"I felt like I could play baseball," Bourn told the Houston Chronicle. "I just had to prove it at this level."
Buckner, Mulvey in contention for fifth spot: Both Billy Buckner and Kevin Mulvey finished the 2009 season well for the Diamondbacks, leaving the right-handed pitchers in position to compete for the fifth spot in the starting rotation next season.
"I think it's encouraging," manager A.J. Hinch told the Arizona Republic. "I think you temper your expectations until you truly get a look at your club in the offseason and what additions can be made. But I think they're in the mix."
Pena ends tied for home run lead: Despite missing most of the final month of the season, Carlos Pena still finished tied with Mark Teixeira of the Yankees for the AL home run title with 39. The Tampa Bay first baseman's season came to a premature end when he suffered two broken fingers after being hit by a pitch on Sept. 7 against the Yankees.
"When my injury happened, there was so much season left that the last thing on my mind was the fact that I was going to be able to be leading the league in home runs," Pena told the Tampa Tribune. "I didn't expect this to happen, so I'm extremely happy and thrilled."
According to the Elias Sports Bureau, Pena is the first player in the live-ball era (since 1920) to lead the league in homers after missing the last 25 games.
Jurrjens taking pointers from Vazquez: Jair Jurrjens was selected as the NL Pitcher of the Month for September after going 4-1 with a 1.25 ERA in the game's final month. Jurrjens credits a lot of his success this year to fellow Braves starter Javier Vazquez.
"I haven't had any problems throwing strikes, but I had problems putting people away," Jurrjens told the Atlanta Journal-Constitution. "I watch [Vazquez] pitch and see him go up and down [in the strike zone]. I went up [in the zone] on my strikeouts for a couple this year. Just watching him pitch and seeing how he set up people, I try to take that same approach to my game."
Gload and Helms join pinch-hitting elite: Ross Gload and Wes Helms combined for 38 pinch-hits this season for the Marlins, which tied a Major League record set in 1936 by Ed Coleman and Roy Peppers of the St. Louis Browns. Gload had 21 pinch-hits while Helms added 17.
"We would love to have broken it, but just to be mentioned in that category is an honor for me and him," Helms told the South Florida Sun-Sentinel. "That's our role, and that's our job, and it just makes us feel proud of the job we did off the bench this year."
Cain not going anywhere: General manager Brian Sabean threw cold water on media speculation that the Giants might consider parting with ace Matt Cain in an effort to bring a big bat to their lineup.
"I have a hard time trading anybody of that ilk, and why would we?" Sabean told the San Francisco Chronicle.
"Trust me," Sabean said, "it's very difficult to trade for a middle-of-the-order hitter even with somebody like Matt."
Scales appreciative of opportunity: Bobby Scales is almost 32 years old, spent 11 years in the Minor Leagues, and reached the Major Leagues for the first time this season with the Cubs. He had a month-long call-up in May and was re-called in September.
"I never questioned my ability," Scales told the Chicago Sun-Times. "I just questioned whether I'd get the opportunity. I'm very blessed and fortunate to have the opportunity to play here."
Hoffman quick to sign another deal with Brewers: The Brewers and Trevor Hoffman have reportedly agreed on terms for a new a one-year deal with a mutual option for 2011. Hoffman, who turns 42 this month, finished with a 1.83 ERA and 37 saves despite missing most of April with an oblique strain.
"Looking from the outside, you would have concerns about age. Being around him for a year, that's a non-factor," assistant general manager Gord Ash told MLB.com.
This story was not subject to the approval of Major League Baseball or its clubs.


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AROUND half of eligible Australians are failing to be screened for bowel, breast and cervical cancer.
Department of Health and Ageing statistics show that only 55 per cent of women are undergoing breast screens and just 57% are having tests for cervical cancer.
While only 40% of Australians taking part in the Bowel Cancer Screening kit program.
Darling Downs Hospital and Health Service acting executive director of medical services Dr Peter Gillies said this is despite researchers estimating 20-30 lives per week could be saved by a higher take-up rate throughout Queensland.
"Cancer screening is the best way of finding cancers early before they can be felt or seen.
A recent Breast Screen Victoria study of those who had never or only rarely had a screening found 78% thought it was worthwhile but simply kept putting it off.
BreastScreen Queensland Toowoomba Service health promotion officer Jessica Hobbs said one in eight women will develop breast cancer at some point in their life.
"Ninety per cent of women who develop breast cancer will in fact have no family history. It's a free service and it only takes ten minutes.
"Women who are screened for breast cancer have experienced a 25-35% decrease in mortality compared to those who are not screened," she said.
For more information visit the websites below or talk to their GP.
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Open Box (Blemished) Squier Tele Custom II Electric Guitar with P-90 Pickups Black 886830610318
Sku #519584005001090
Solid Body Electric Guitars
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Based on one of the hottest Tele designs ever.
The Custom II is a super-affordable temple of tone with some tasty Tele tweaks that include a pair of blistering Duncan Designed P-90s with independent tone and volume controls. The agathis body snugs up to an all-maple neck/fretboard with dot inlays, medium-jumbo frets, and a 25-1/2" scale.
- Duncan Designed P-90s
- Indepedendent tone and volume controls
- Agathis body
- All-maple neck/fretboard with dot inlays
- Medium-jumbo frets
- 25-1/2" scale
Never has so much Tele attitude cost so little. Order yours today!
REVIEW SNAPSHOT®by PowerReviews
Most Liked Positive Review
This thing really rocks!
First things first, I bought this on the east coast of Canada so I had to dress the frets and tighten all the screws. I will replace the plastic nut with a graphite or...Read complete review
First things first, I bought this on the east coast of Canada so I had to dress the frets and tighten all the screws. I will replace the plastic nut with a graphite or bone. The neck has almost a vintage feel and the saddle is great. The tuners are good and you can get some great tones from the pickups. From nasty screaming leads with bite to nice rich full bodied power chords to full bodied clean jazz chords. The tone wood body is part of the pine family and is like mahogany. Nice tight straight grain. It is a hardwood and gives great highs and mids with medium bass. Great with the P-90's. I bought a real Fender flight case for it. It's a real player with a vintage feel.
Most Liked Negative Review
All of the semi - pros raved about it!.I bought a blonde model. Nice looking, fit and finish. But it hummed like crazy. It wasn't my amps. (I have 4...Read complete review
All of the semi - pros raved about it!.I bought a blonde model. Nice looking, fit and finish. But it hummed like crazy. It wasn't my amps. (I have 4 of them) I was bummed.I returned it for a TELE CUSTOM with the hum-buckers.Just didn't feel like messing with the noise issue. I loved the old blonde look!
Reviewed by 16 customers
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Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
If you're looking for a good guitar, this is the one for you. It sounds great and it doesn't go out of tune easily which is a very good thing. The next thing is the most important thing is it doesn't kill your budget.
I would highly recommend this guitar, for anyone.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
based on reviews & the fact that i have become a hugh fan of the p90 sound, i took a chance on this axe. I changed the strings right away & did a slight adjustment on the neck (the action was too high after the 12thn fret). i am pleasantly surpised at the bridge & saddles plus the maple neck is fast & comfortable. where this guitar, shines is the "tone", & combinations avalible since there is a volume & tone control for both pick-ups. forget this guitar says "squire" & just rock on with that "bad-ass" p90 sound...every bit as good as my epihone gold-top!!!
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
I usually put guitars together myself. I prefer the custom neck shapes, woods and hardware choices doing that offers. I needed a P90 guitar and I did not have the time or budget to build a custom guitar. So I thought I would give this one a try. Well.. I'm truly impressed! For the money you get a guitar with a classic design, cool color, nice neck, and pickups that sound suprisingly great. Yep, I was prepared to tear it apart review wise, but what came out of the box was a great surprise. I first set out to set the neck the way I like it, no relief. It was already nearly flat, nice! I then went to set the intonation, it was perfect! Shocker! So all that was left was to adjust the string height to my liking and I was jamming away in no time. There were a few things that weren't perfect, but for the tone, the feel and the cost, I can live with it. The finish had a fish eye on the front where your forearm rest. It is very hard to see. The tuners seem "tall" to me and I don't like string trees which this guitar has two. I bypassed the D,G tree and all is fine. The nut did need a little graphite to prevent "pinging". The frets were nice, no high spots. Overall I am very pleased with this guitar. It made it to a local jam night and it got passed around and everyone loved it. I have recommended this guitar to others and if it's a solid guitar that gives you a really nice tone with plenty of headroom, easy set up, and a value price point that your after, I would recommend it to you too.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
This guitar is one of the Best Bang for your buck deals anywhere anytime.P-90 pickups give a great dark fat tone that I was looking for.Exceptional crafsmanship for this price point,expect a few minor blems.I give it a five star because I'm so HAPPY!!!!Forget the hum....all single coils hum...just turn yourself 90 degrees to the amp and it goes away.The pickups are not HUMBUCKERS but their great.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
Ratings are hard. 5 stars based on quality or bang for the buck. In this case, I would grade this 5 stars bang for the buck. 4 stars overall. It's certainly not a perfect guitar. The neck feels a little wavy in one spot (around the 14th fret area). The frets, especially on the high side, are a bit rough. The nut is pretty cheap feeling plastic. And, I had to do a pretty extensive setup, i.e., adjust the neck a bit & set the intonation (all easily remedied, by the way). But aside from that, this thing is a really nice piece of work. I regularly play an American Deluxe Strat, PRS Custom 24, and an old ES-335. Each is quite unique in it's feel and sound. This little guitar does very well in such good company. I got this guitar mainly for two reasons: I wanted to learn how to set up a guitar and I was drawn to P-90 pickups. These P-90's have a great sound & are pretty much worth the price alone. The body, made of some weird wood that I can't remember the name of, is fairly heavy, like mahogany. But, frankly, I don't mind that. It kind of feels like a Les Paul (weight-wise, anyway). So, while this might not be some high--priced, eventual collector's piece guitar, it sounds great, plays well, and is easily worth the money.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
This is the second time I've posted a review on this guitar........but there's a reason. I've found that behind every magical masterpiece....there's a fault, and the fault with this is the bridge......but don't worry cuz that's pretty much that isn't good about it. But I still love this guitar anyway because the sound is highly original and sounds better than most fenders to me but that's just me cuz I prefer metal. But this is one of the best Axes I've ever played I love it. I recommend this guitar for anybody and especially metal players. I can compare the sound of this guitar with the guitaring on Cowboys From Hell album by Pantera. No I'm not a big pantera fan or anything....that's just what the guitar sounds like to me. It sounds great. Even though the bridge is A default.....this is still a great guitar just when you buy it make sure it doesn't fret out....play it and then take it to the shop and have them adjust it.....and don't ever think the necks bowed because it's just the bridge. This guitar is so awesome for the price......buy it tomorrow.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
With this low price, nothing beats this guitar. The natural tone is absolutely sweet, just plug it in and the nice fat sweet clean tone is there. I play metal, rock, and blues, and this guitar did them all. Hi treble, hi bass metal tone sounds even more evil than my friend's Jackson. I've got a blonde one, looks sweet. Some problems though, once I received it, the set-up hasn't been done. And 1 or 2 screws are loosen. So better bring it out for a set-up or sth. And P90 pick up, sounds awesome, sweet tone, metal tone, no problem! But it's always being very noisy, not a good idea for recording.but other than those matters, this guitar gonna give u what u want!
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
Looking for something a bit different for small money, I spied this Tele and checked all the reviews. I was a bit concerned about the 'quality control' issues I've seen mentioned here and elsewhere, but needn't have worried. My Tele feels lovely to play (nice medium neck with medium frets, and sounds fantastic. It seems to be able to manage thick, creamy Gibson tones from the neck PU and bright Strat/Tele/Rick tones from the bridge PU. Mixing the two PUs at different volumes gives me an amazing variety of tones which came as some surprise as I'm usually an 'all on 10' player :) It looks lovely. I've always liked the 4-pot Tele look and this one (mine's black) looks like it means business. Re: the build quality, there were no rough edges anywhere (well rounded fret ends) and the worrisome plastic film pulled off easily from the scratchplate and PUs. I'm so glad I bought this, any of you considering one should just go and buy it. I honestly feel it's a future classic.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
I have had my Tele II for about 12 mths now. When I first got it, the thing was not set up well. I persevered because I had previously heard one played and I loved the tones it produced. I am glad I did. A good setup and some remedial work (poor quality control) has left me with a real gem which I really love. The P90s pickups are probably really P100s. From what I have read, they are apparently stacked coils, but wired differently to humbuckers to retain the P90 sound without the hum. I get little in the way of hum. (As long as I stay clear of the TV) The tone is classic P90 however. More top end than a humbucker and more mid and bass than a single coil. They have a nice bite which I really love and if you have never heard P90s, you don't know what you are missing.I bought the black version of the Tele II. The butterscotch one was just a bit out there for me. The neck is a lovely piece of maple and I subsequently bought a maple neck Strat on the strength of the feel of the Tele II's neck. I would have given the unit 5 stars, except that Fender let themselves down by their lack of quality control. At the price of Squiers these days, we are entitled to expect more.
Comments about Squier Tele Custom II Electric Guitar with P-90 Pickups:
Got the blond model and this thing looks sweet! When I first got it, the neck was mounted crooked... not warped... crooked. The high E string was very very close to the edge of the frets up toward the body and the low E was about 1/4 inch in. Bad crooked. I started wondering how this could happen, as these things are drilled in a jig. Didn't make sense. Ended up being the order they assembled things in. I removed the neck and noted that the black pick guard was protruding out over the neck socket. This pushed the neck down and resulted in the high E string being on the very edge of the fingerboard as I mentioned before. I filed the pick guard even with the neck socket (took about 30 seconds) and re-installed the neck and it is dead center perfect. I was right. the actual holes drilled to mount the neck were perfect as was the neck socket. Just that little edge of thick plastic was enough to prevent the neck from being installed properly. The fix was easy, as was smoothing the fret edges which were a little rough at their ends -- they were fine and smooth all the way across the fingerboard. Other set up items were as good as I've seen on $2500 guitars -- meaning they were fine.With having to straighten such an obvious manufacturing blunder... why'd I give this board a five? Well... next I played it.These P-90s sound better than any P-90s I've ever heard. They actually sound better than any other pickups of ANY type or brand that I've ever played! That includes all the actual Seymour Duncan MADE P-90s (these are Duncan "designed") and Gibsons and the Dimarzios that Leslie West is bragging on now. Now... those ARE excellent pickups! Leslie should be bragging on them. These cheap little Squire-mounted blackies are better! They have an absolutely beautiful growl when pushed, but that's not the amazing part. The clean tone on these is that tone I've been looking for for over 30 years! I did some country two-string stuff, letting it sustain... and almost started crying! Who could have guessed? This instrument plays beautifully. I cannot put it down nor wipe the big grin off my face! I played a Les Paul Personal for years and years so I do know how a guitar should play.Now, if I hadn't fixed the neck myself, Music123 would have taken this baby back and sent me another. They don't even squeak about stuff like that. And the rough fret edges? Fixed! If I built a guitar for what this one cost me, it probably wouldn't even have frets! And that clean tone off these cheapo P-90s! My tone! That one tone I've been listening for all my life! Feels like someone is pouring syrup down my back every time I pluck a string and listen! Feels kinda illegal to own this guitar for this price!!And yes, I agree with the other reviewer about the 51! Now I'm gonna have to get one of those too! The blond one, of course.
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text:
Hello, I'm new to C++ object programming, I've been working for one year with C.
I googled and searched through this forum, but found nothing.
I'm now trying to use some classes in my C application, so I'm having an "adaptation" work: I'm trying to compile the c++ part in an obj, and then using the classes through C functions and structures.
I need to know where are placed in memory the methods of Cpp structures. To be clear:
How can I copy the members of a A_cpp_object in a A_c_object as fast as possible?Code:struct A_cpp_base { int buf[100]; void A_cpp_base( void ){ memset( this , 0 , sizeof( *this ) ) }; void method( void ){......}; ........ }; struct A_c_base { int buf[100]; }; struct A_cpp : public A_cpp_base { int a; int b; int d[100]; void A_cpp( void ){ memset( this , 0 , sizeof( *this ) ) }; void method( void ){......}; ........ } A_cpp_object; struct A_c{ A_c_base publicFromACppBaseAdapted; int a; int b; int d[100]; }A_c_object;
I was thinking about something as:
But I need to know where are placed the public components of the base class of the object that I need to copy.Code:memcpy( &A_c_object , &A_cpp_object , sizeof( A_c_object ) )
Thank you for help,


text:
Man faces domestic violence charges for attack with dreadlocks
By Krister Rollins
Jan 9, 2013
PORTLAND, Oregon (KGW) – A Portland, Oregon man is accused of using his dreadlocks to choke his girlfriend in a domestic violence attack.
The woman was taken to a Portland hospital with "numerous, non-life threatening injuries," according to Sgt. Pete Simpson with the Portland Police Bureau.
She told officers that Caleb Grotberg attacked her just after 2 a.m. Monday at a residence in the 3200 block of Southeast 22nd Avenue. Her detailed description helped police find Grotberg in the neighborhood and arrest him.


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On a steamy Tuesday this September, Republicans and tea-party groups, eager to drum up support for killing the 2010 health care law now that Congress had returned from its August recess, gathered for a noon rally on the Capitol's West Lawn. Crowds arrived by bus from neighboring states for the "Exempt America From Obamacare" protest, and a parade of Republican members of Congress bestrode the dais.
Democrats had held their own event, a 10:15 a.m. press conference on the Senate side of the Capitol Visitors Center, to denounce the GOP's efforts to "sabotage" the law. Republican lawmakers David Vitter, a senator from Louisiana, and Rep. Ron DeSantis of Florida riposted with a 3:30 p.m. press conference in the "Senate Swamp" on the northeast side of the Capitol to introduce legislation requiring Washington officials to purchase their health insurance through the law's new online marketplaces and deny them certain federal subsidies. It was a presser-rally-presser sandwich — enough to dizzy a Washington health care reporter.
The political war raging over the Affordable Care Act is unprecedented — and unlikely to abate soon. The GOP has spoken out against what it says is a costly, privacy-invading, job-killing law, even before its central provisions have been implemented. Democrats defend the ACA, arguing that the nation's inefficient, unfair, and costly health care system had to be changed. Come October, as the law is implemented, dueling anecdotes of triumphs and tribulations will no doubt feed both parties' message machines.
The reality on the ground will be more nuanced. Yes, the Affordable Care Act is a big-bang moment for the nation's health care system, and it has few historical precedents. Everything will look a little different after the law's core provision — the individual mandate for health insurance — goes into effect on Jan. 1, 2014. But despite the apocalyptic rhetoric, the law is hardly the most disruptive health care makeover America has seen. At least not yet. It comes with a big question mark that, over time, could alter the nation's health care system — and culture — forever.
When the clock strikes midnight on Dec. 31, nearly all Americans will be required to have health insurance or pay a penalty. New rules will shape how and where people buy their coverage. Seven million are expected to purchase insurance plans through the exchanges next year. Employers have a 12-month reprieve before they must ensure that the coverage they offer their employees meets minimum affordability and value standards. The law's overall goal is to expand the public's access to health care without sacrificing quality. It's a lofty, transformative aim.
But hardly the first, or even the biggest, transformation. From the early days of doctors making house calls, to the first cooperatives offering insurance, to the rise of employer-sponsored health benefits, followed by the introduction of Medicare and Medicaid, the decade of health maintenance organizations, and the Medicare Part D prescription-drug benefit of 2003 — the U.S. health care system has been in a near-constant state of flux. Two overhauls were more radical than Obamacare will be next year: the dramatic rise of employer-sponsored insurance during the World War II era, and the adoption of Medicare and Medicaid in 1965.
In the 1930s, business owners began offering a form of insurance to their workers, signing prepaid contracts with physician groups to care for their employees. The war's wage-and-price controls accelerated the trend; fringe benefits such as health insurance, which weren't limited by law, could be used to attract workers when salary could not. After WWII, unions' collective bargaining for health coverage — as well as an Internal Revenue Service ruling in 1954 clarifying that premiums paid by employers were exempt from income taxes — contributed to the surge in the number of employees who received health coverage through the workplace.
This transformation had several important consequences. David Blumenthal, then a Harvard Medical School professor, wrote in 2006 that employer-sponsored insurance "has provided the essential underpinning of an insurance system by creating work-based risk pools, in which healthy, low-risk participants subsidize the health costs of sick, high-risk participants." But it also had the effect of shielding people from the cost of their care. People no longer had to reduce spending for medical care during tight financial times, because the money that paid for their coverage didn't come directly from their pockets — premiums were just deducted from their paychecks. "The biggest consequence is the obscuring of the true cost of health care from those who ultimately pay it," says Paul Starr, a sociologist at Princeton University whose 1982 book chronicling the history of American medicine won the Pulitzer Prize. "I think that created the single largest source of pressure for rising health care costs."
The decade following the IRS clarification on the tax status of employer-sponsored insurance brought two even more dramatic forces: Medicare and Medicaid. The introduction of Medicare in 1966, which overnight guaranteed health care for people age 65 and up, came with doomsday rhetoric (Medicaid was adopted more slowly). Some worried that a huge influx of newly covered patients would overtax hospitals. "Medicare May Result in Severe Hardships" the New York Herald Tribune warned in a headline before the bill passed. The newspaper (not unreasonably) fretted about a serious shortage of doctors and hospitals: When President Johnson signed the Social Security Amendments of 1965 into law, 18 million seniors became eligible for Medicare coverage overnight, with benefits beginning July 1, 1966.
The Associated Press unleashed a herd of reporters to hospitals across the country to document the law's first day in effect; they found that implementation went smoothly, with paperwork being the biggest challenge. (Among the few additional problems noted was "one woman who got mad and swung her purse at a hospital worker," apparently upon being informed that Medicare wouldn't cover all of her health expenses. Another woman refused to produce her Medicare card until she could unpin it from her underwear in the privacy of the restroom.) In 1965, only about half of the elderly population was covered by health insurance; by 1967, nearly 100 percent had insurance. Bang.
It was the volume of patients rather than the substance of the coverage that made Medicare such a radical change for the health care system. Medicare plans were designed to mimic the popular Blue Cross Blue Shield insurance of the 1960s, not to tell doctors what to do. Even the statute made this clear: "Nothing in this title shall be construed to authorize any Federal officer or employee to exercise any supervision or control over the practice of medicine or the manner in which medical services are provided."
Nevertheless, the impact was massive. Physicians saw more demand and fewer nonpaying cases. Amy Finkelstein, an MIT economist, found that the introduction of Medicare led to higher "treatment intensity" — more money spent per patient, per day — greater hospital spending, and faster adoption of new technology inside hospitals. "The estimated effects are large," Finkelstein wrote in 2005.
The law's greatest unintended consequence was its soaring price tag. Joseph Califano Jr., who was Johnson's adviser and later became secretary of Health, Education, and Welfare, recalled that at the time, the focus was on access rather than cost. "In order to neutralize physician opposition, we agreed to pay doctors their "˜reasonable, customary, and prevailing fees,' " he wrote in 2009. It was akin to having doctors write their own paychecks. In the first 10 years alone, spending on the program climbed from $4.9 billion to $22.9 billion. Last year's bottom line was $574 billion to cover the country's 50 million Medicare enrollees.
The health reforms of the ensuing decades were more incremental. President Reagan changed the way Medicare reimbursed hospitals with the introduction of a "diagnosis related group." President Clinton attempted to install universal health coverage early in his first term, but the effort collapsed, and the biggest change wrought in the 1990s was the surge in health maintenance organizations, which were devised as a means of maintaining quality health care while controlling costs. They did have a large impact on the system at the time, but managed care fell out of favor dramatically at the end of the decade. In 2003, Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act, which allowed seniors to buy drug coverage on top of their other care, beginning in 2006. As with original Medicare, millions gained coverage virtually overnight in 2006, when the benefit went into effect.
President Obama signed the Patient Protection and Affordable Care Act into law on March 23, 2010. It sits somewhere near the introduction of employer insurance benefits and the passage of Medicare in the scheme of massive policy changes that have reshaped health care: a big-bang moment followed by a question mark. "This is going to have a more gradual impact on care, on care delivery, and on coverage," Mark McClellan, who was head of the Centers for Medicare and Medicaid Services during the Part D rollout, says of Obamacare. "It's not going to be the case like it was in Medicare in 1965 or Part D in 2006 that, you know, at the end of the first year, you're basically done…. This is going to be a several-year process." The Congressional Budget Office estimates that 7 million Americans will sign up for coverage on the exchanges in 2014, and 25 million will do so by 2019.
The heart of the Affordable Care Act is a "three-legged stool," but the Supreme Court partially kicked one out leg in June 2012. The three legs are insurance-market reforms, such as the prohibition against denying coverage to people with preexisting conditions; the individual insurance mandate; and the subsidies and Medicaid expansion intended to make health coverage affordable. Last summer, the Supreme Court ruled that Washington cannot require states to expand their Medicaid programs for low-income residents. This has muted the "bang" nature of the coverage expansion, because an estimated 7 million people will remain uninsured in the 25 states that have currently declined to widen their programs.
For the majority of the country (roughly 316 million Americans), little will change Jan. 1. "This is something which is coming in and having a profound influence on the lives of a small minority of Americans, and leaving most Americans unaffected," says Jonathan Gruber, an MIT economist who advised both Obama on the ACA, as well as then-Gov. Mitt Romney on Massachusetts' health reform in 2006. Life won't feel very different for the person who continues to get her insurance through her employer. Undocumented immigrants will continue to live without coverage. Some folks will get caught in a coverage gap, thanks to the Supreme Court decision. The law assumed that states would cover residents earning up to 133 percent of the federal poverty level under the Medicaid expansion, and it offers subsidies on the exchanges for people who earn between 100 percent and 400 percent of the poverty level. But Texas, for example, opted not to expand its Medicaid program, and it covers working parents earning up to only 25 percent of the poverty line. So some residents will be too rich for Medicaid and too poor for subsidies, even if their annual salary just barely tops $5,000 a year for a family of three.
The insurance reforms and coverage expansion will ripple through the system in some significant ways. Insurance companies will be working under a whole new set of rules; they will now have to offer plans with a minimum level of benefits, and some plans offering just a few benefits will go away. Insurance companies have gained millions of new customers, but insurance brokers fear that the new exchanges jeopardize their jobs, in the same way that websites like Expedia threaten travel agents, Starr says.
Doctors will also have new patients — and paying ones, at that. This is both good and bad. As with Medicare, the coverage expansion has exacerbated concerns over a national physician shortage. The Association of American Medical Colleges estimates the nation will be short 91,500 physicians by 2020, partly because of the Affordable Care Act. To address this deficit, a debate is taking place in the medical community over the scope of duties that nurses should be permitted to perform. But even as more Americans seek care, hospitals will also lose reimbursements for treating uninsured patients, whose numbers will dwindle under the law, although not as much as originally expected, and this loss will counter some of the benefits for hospitals of treating a more broadly insured population.
Alexander Li, the CEO of the ambulatory care network for the Health Services Department in Los Angeles County, says his staff isn't preparing for huge changes come Oct. 1, when the rollout of the insurance exchanges begins. The ACA won't solve his staff's biggest headache — the paperwork associated with patients who receive insurance from a large range of providers. But his network, which manages the county's outpatient clinics, among other services, is preparing its staff to be more patient-centric as health care consumers gain freedom under the law. "I think, for us as a safety net, it means that just like everyone else, we now have to work hard to be customer-friendly and retain our patients, because now they have a choice to leave," Li says. His staff is being trained to nurture relationships with patients, who may more regularly seek care once they have coverage but who can now seek care outside of the safety-net hospitals that specialize in caring for the uninsured.
Despite these effects, Gail Wilensky, who directed the Medicare and Medicaid programs from 1990 to 1992, says that with passage of the ACA, "we took on the easy part." "It's not politically easy, but it's the technically easy part of health reform. It's not health care reform at all. It's coverage expansion," she says. In other words, it changed who was insured, not how much their care costs.
The law, however, opens the door to tackling some of those technical care-based challenges through a number of experimental provisions. The Affordable Care Act has no Medicare-style preamble declaring that it won't change the practice of medicine. "There are seeds within the ACA of a restructured delivery system that could — and I emphasize "˜could' — over time really change the way we get care, and that would affect everybody," says Stuart Altman, a professor of national health policy at Brandeis University. Those are the attempts to "bend the cost curve." And it's a steep curve: Health care spending currently makes up 18 percent of the nation's gross domestic product.
The law created an "Innovation Center" at CMS to test and assess new payment structures and methodologies for Medicare, Medicaid, and the federal Children's Health Insurance Program. It established a Medicare pilot program that will be expanded in 2016 if it demonstrates that bundled payments to providers can improve the quality of care while bringing down costs; the law also established similar bundled-payment demonstration programs for Medicaid. Doctors can participate in new, voluntary "accountable care organizations," or ACOs, and be rewarded for meeting certain standards of care for their patients while coordinating with their other health care providers. States can receive "innovation waivers" in 2017 if they demonstrate new ways of providing coverage that's as good as that under the ACA.
How these experiments fare will determine just how transformative Obamacare will be. "It's one thing to have a lot of pilot projects, and it's another thing to have that actually become the law of the land and change the way things are done," says Wilensky, who is now a senior fellow at Project HOPE, a nonprofit that works to make health care accessible for people around the world.
Perception matters, too. "The mere fact that individuals are not going to be rated on the basis of their health — that is a very fundamental change," Starr says, referring to the law's ban on turning away people with preexisting or other conditions that previously made insurance coverage unaffordable or unavailable. "If the Affordable Care Act affects the way Americans think about health insurance, then it will have brought about a very big change." That is, of course, a big "if."
If a presidential candidate ran on a platform of eliminating Medicare and Social Security, "they'd be seen as crazy," Starr says. "It would so destabilize the institutions of American society that it, you know, it's just not possible. But I don't see the Affordable Care Act as getting entrenched to that degree. It doesn't cover enough people, and it's being implemented under different names in different states." The insurance exchange in Kentucky, for example, is called kynect; Oregon's is dubbed Cover Oregon. Neither bears government branding. "There's reason to be skeptical as to whether it will have that kind of staying power that other policies have had," Starr says.
Obamacare is unique in that regard. Although the health care system has tended to initially shun rather than embrace policy changes, experience shows that participants tend to come around before too long. The American Medical Association has a long history of resisting just about every major health care shift, including prepaid group plans like the ones adopted by employers early on. The physicians' organization opposed Medicare until a clever trap set by President Johnson forced AMA President James Appel to support the law in front of the White House press corps. The group's fierce opposition — which it said was based on concern that doctor-patient relationships would suffer, but which also seemed to include concerns the government would interfere with doctors' ability to charge their customary rates — was unfounded. Physicians no longer had to treat as many patients who couldn't pay their bills, and Medicare allowed them to set their own rates. The AMA has long since embraced the program.
With the Affordable Care Act, the AMA didn't put up that initial resistance, declaring its support for the Senate bill in December 2009, three months before Congress passed the legislation. The group has since stated that the law "includes many major provisions that are consistent with long-standing policy adopted by the AMA House of Delegates."
The provider community has been more receptive to the ACA than to previous changes, which speaks to the law's nonradical core. Resistance has instead come largely from the political and business communities. The pushback — and its continued intensity three years after the law's passage — is unprecedented. "I don't think we've seen anything like it since "˜massive resistance' to school desegregation in the South years ago," says Henry Aaron, a Brookings Institution economist and health care expert.
Aaron worries that if the opposition succeeds, it could hinder would-be reformers for years to come. More than 15 years passed between Clinton's failure to achieve health reform and Obama's success — but his success may have contributed to a midterm election beating for his party in 2010. "If [the ACA] ends up not succeeding, you will have had two presidents who paid really steep prices for fighting for a transformation of the health system. It's hard to see when the next president says, "˜Hey, I want to run that risk again for my administration,' " Aaron says.
Success, however, offers a sweet reward. "The nation's health policy trajectory will be permanently altered, and that's affecting something pushing 20 percent of the whole economy," Aaron continues. "So it's a big bet."
There's a lot we don't know — and can't know yet — about the Affordable Care Act. How many states will expand their Medicaid programs? How many of the cost-saving reforms will work and be implemented widely? We do know that the law will be life-altering for a handful of people and unremarkable, at least at first, for most others. But down the line, perhaps Obama's reform plan could shift the entire system for everyone. It may even be the most radical change the health care system has ever seen.