A Guide To Maryland Law On Health Care Decisions: Fill & Download for Free

Are the Republicans "The party of No!"?Are the Democrats the party of "It's Bush's fault."?Let's examine that and where that answer takes us.PROLOGUEThere is a Presidential election in 2016, and it is not too early to start thinking about what is happening today. A full throated debate that will begin early in 2014. The Congressional mid-terms occur 04 Nov 2014. Republicans need to prepare. America needs to decide. Maintain course or make an adjustment. Both sides of this debate have their reasons for staying the course or making a hard turn.This map shows the Senate by party and by state. PPACA was passed under some chicanery by the Senate Democrats, with no Republicans voting in the affirmative. More on that in a moment. This type of legislation has been pushed by Republicans in some form, notably Rommey Care in Massachusetts, and in more dynamic forms by Democrats, for over the last 75 years. Since the New Deal under FDR.•••••••••••••••••••••••••••••••••••••••••••••••••••••The bill sent to the Senate, by the House, had the original House language in the bill gutted. The Senate had the language replaced and sent back to the House. All spending must originate in the House, and this bill fundamentally violates the Constitution."A challenge filed by the Pacific Legal Foundation contends that the Affordable Care Act is unconstitutional because the bill originated in the Senate, not the House. Under the Origination Clause of the Constitution, all bills raising revenue must begin in the House.The Supreme Court upheld most provisions of the act in June, but Chief Justice John G. Roberts Jr. took pains in the majority opinion to define Obamacare as a federal tax, not a mandate. That was when the Sacramento, Calif.-based foundation’s attorneys had their “aha” moment.“The court there quite explicitly says, ‘This is not a law passed under the Commerce Clause; this is just a tax,’” foundation attorney Timothy Sandefur said at a Cato Institute forum on legal challenges to the health care act. “Well, then the Origination Clause ought to apply. The courts should not be out there carving in new exceptions to the Origination Clause.”http://www.freerepublic.com/focu...http://cookpolitical.com/file/20...•••••••••••••••••••••••••••••••••••••••••••••••••••••Here is some Senate math on the seats as the 2014 mid-term elections approach.House seats in play:http://www.centerforpolitics.org...Senate seats in playhttp://rothenbergpoliticalreport...•••••••••••••••••••••••••••••••••••••••••••••••••••••15 Democrat Senate seats (*) are competitive, and 2 Republican(**) seats are competitive.(*) Oregon,(*) Alaska,(*) Hawaii,(*) Montana,(*) Colorado,(*) Minnesota,(*) South Dakota,(*) Iowa,(*) Missouri,(*) Louisiana,(*) Michigan,(*) West Virginia,(**) Kentucky(**) Georgia(*) North Carolina,(*) New Hampshire,(*) Massachusetts,http://en.m.wikipedia.org/wiki/U...CHAPTER ONEThe debate on who should be elected, and how to secure a dominate party to ease this country away from the Progressive movement that has been underway since 20 Jan 2009, needs to begin yesterday!Will the Republican's blame Obama, since the Democrats can't blame Bush anymore in 2014? Will the Democrats be blamed for the Patient Protection and Affordable Care Act, since "the bloom was off this rose" before it was jammed down our throats? The Republicans will be blamed for not helping fix something they vehemently disagreed with, never voted for, and tried to compromise on or defeat, but were rebuffed at every opportunity. It was going to be the Progressive's moment, finally, after scores of years. Generations of effort. Now was the chance, with a "Manchurian Candidate" to have a true "Mission Accomplished" moment!What will be the key issues after all the finger pointing is dismissed by both parties, and the media ignores the entire story as Republican obstruction?It should be the economy. It should be jobs. It should be energy; finally—no more "put on a sweater (Jimmy Carter) turn down the thermostat policy", for energy independence. We have the energy, we just have too many modern day "Luddites" who are afraid their "save the planet" jobs and the Earth will be destroyed. We will only be able to "save the planet" when we restore science and remove politics from the debate. Until then, the hateful ads that depict Santa as being melted out of the North Pole, and thus no more Christmas for the kids, is deplorable. This does nothing to advance the Environmentalist's cause.There should be a debate on privacy and the 4th Amendment. "The right of the people to be secure in their persons, houses, papers, and effects, against unreasonable searches and seizures, shall not be violated, and no Warrants shall issue, but upon probable cause, supported by Oath or affirmation, and particularly describing the place to be searched, and the persons or things to be seized."It should be about the separation of powers, the "take care clause" in Article 2, Section 1, Paragraph 7"Before he enter on the execution of his office, he shall take the following oath or affirmation: "I do solemnly swear (or affirm) that I will faithfully execute the office of President of the United States, and will to the best of my ability, preserve, protect and defend the Constitution of the United States.""There has been an erosion of the separation of powers under the current administration, and were outline in a Dec.4, 2013 House Judiciary hearing. See below for additional statements from that hearing.Statement of Judiciary Committee Chairman Bob GoodlatteFull Committee Hearing “The President’s Constitutional Duty to Faithfully Execute the Laws”Chairman Goodlatte: Today’s hearing is about the President’s role in our constitutional system.Our system of government is a tripartite one, with each branch having certain defined functions delegated to it by the Constitution. The President is charged with executing the laws; the Congress with writing the laws; and the Judiciary with interpreting them.The Obama Administration, however, has ignored the Constitution’s carefully balanced separation of powers and unilaterally granted itself the extra-constitutional authority to amend the laws and to waive or suspend their enforcement.This raw assertion of authority goes well beyond the “executive power” granted to the President and specifically violates the Constitution’s command that the President is to “take care that the laws be faithfully executed.”The President’s encroachment into Congress’s sphere of power is not a transgression that should be taken lightly. As English historian Edward Gibbon famously observed regarding the fall of the Roman Empire, “the principles of a free constitution are irrevocably lost, when the legislative power is dominated by the executive.” Although the President’s actions may not yet amount to the executive’s powers overtaking the legislative power, they are certainly undermining the rule of law that is at the center of our constitutional design.From Obamacare to immigration, the current administration is picking and choosing which laws to enforce. But the Constitution does not confer upon the President the “executive authority” to disregard the separation of powers by unilaterally waiving, suspending, or revising the laws. It is a bedrock principle of constitutional law that the President must “faithfully execute” Acts of Congress. The President cannot refuse to enforce a law simply because he dislikes it.Certainly, presidents have from time to time made broad claims of executive power. However, assertions of executive authority have traditionally been limited to the area in which presidential powers are at their strongest—foreign affairs.The Obama Administration though has been equally assertive in the realm of domestic policy, routinely making end runs around Congress through broad claims of prosecutorial discretion and regulatory actions that push executive power beyond all limits. Indeed, President Obama is the first President since Richard Nixon to ignore a duly-enacted law simply because he disagrees with it.In place of the checks and balances established by the Constitution, President Obama has proclaimed that “I refuse to take ‘no’ for an answer” and that “where [Congress] won’t act, I will.” Throughout the Obama presidency we have seen a pattern: President Obama circumvents Congress when he doesn’t get his way.For instance, while Congress is currently debating how to reform our immigration laws, the President effectively enacted the DREAM Act himself by ordering immigration officials to stop enforcing the immigration laws against certain unlawful immigrants. When he couldn’t get his preferred changes to the No Child Left Behind education law, he unilaterally waived its testing accountability provisions. When he objected to the work requirements in the bipartisan welfare reform law, he granted waivers that are specifically forbidden by the statutory text. Instead of working with Congress to amend federal drug enforcement policy, he’s instructed prosecutors to stop enforcing certain drug laws in certain states and mandatory minimum sentences for certain offenses.And, most notably, the President has—without statutory authorization—waived, suspended, and amended several major provisions of his health care law. These unlawful modifications to Obamacare include: delaying for one year Obamacare’s employer mandate; instructing States that they are free to ignore the law’s clear language regarding which existing health care plans may be grandfathered; and promulgating an IRS rule that allows for the distribution of billions of dollars in Obamacare subsidies that Congress never authorized.The House has acted to validate retroactively some of the President’s illegal Obamacare modifications. However, rather than embrace these legislative fixes, the President’s response has been to threaten to veto the House passed measures.The President’s far-reaching claims of executive power, if left unchecked, will vest the President with broad domestic policy authority that the Constitution does not grant him.Those in the President’s political party have been largely silent in the face of this dangerous expansion of executive power. But what would they say if a president effectively repealed the environmental laws by refusing to sue polluters or the labor laws by refusing to fine violators?What if a president wanted tax cuts that Congress would not enact? Could he instruct the IRS to decline to enforce the income tax laws? President George H. W. Bush proposed, unsuccessfully, a reduction in the capital gains rate. Should he have instead simply instructed the IRS not to tax capital gains at a rate greater than 10 percent?The point is not what you think of any of President Obama’s individual policy decisions. The point is that the President may not—consistent with the command that he faithfully execute the laws—unilaterally amend, waive, or suspend the law.We must resist the President’s deliberate pattern of circumventing the legislative branch in favor of administrative decision making.We cannot allow the separation of powers enshrined in our Constitution to be abandoned in favor of an undue concentration of power in the executive branch. As James Madison warned centuries ago in Federalist 47, “the accumulation of all powers legislative, executive and judiciary, in the same hands . . . may justly be pronounced the very definition of tyranny.”http://judiciary.house.gov/heari...Written Statement Jonathan Turley,Shapiro Professor of Public Interest Law George Washington University"The President's Constitutional Duty to Faithfully Execute the Laws" Committee on the Judiciary United States House of Representatives 2141 Rayburn House Office Building December 3, 2013http://judiciary.house.gov/heari...Two recent rulings from a District Judge lay a heavy emphasis on these complaints above. They go directly to the encroachment of a President on the separation of powers, and diminish our freedoms.Judges rulings against OBAMAJudge orders Obama foreign aid order releasedRejecting one of the Obama White House's most aggressive attempts to preserve executive branch secrecy, a federal judge Tuesday ordered the disclosure of a government-wide foreign-aid directive President Barack Obama signed in 2010 but refused to make public.The Justice Department asserted that the Presidential Policy Directive on Global Development was covered by executive privilege, even though it is unclassified and reflected standing guidance to agencies rather than advice given to the president.Acting on a Freedom of Information Act lawsuit brought by the Center for Effective Government, U.S. District Court Judge Ellen Huvelle concluded that the presidential order is not properly within the bounds of the so-called "presidential communications privilege." The judge went further, calling "troubling" the sweeping nature of the government's argument's in the case."This is not a case involving 'a quintessential and nondelegable Presidential power' — such as appointment and removal of Executive Branch officials...where separation of powers concerns are at their highest. Instead, the development and enactment of foreign development policy can be and is “exercised or performed without the President’s direct involvement," Huvelle wrote in her opinion.Huvelle noted that she ordered the document delivered to her under seal last month and said she disagreed with the government's contention that the order is "'revelatory of the President's deliberations' such that its public disclosure would undermine future decision-making." She also found that "'the President's ability to communicate his [final] decisions privately' ... is not implicated, since the [order] was distributed far beyond the President’s close advisers and its substance was widely discussed by the President in the media.""Here there is no evidence that the [directive] was intended to be, or has been treated as, a confidential presidential communication," wrote Huvelle, a Clinton appointee.The Obama Administration argued that the distribution of the document was restricted to those with a "need to know," but the judge dismissed that contention as "amorphous.""The government has not, even after plaintiff raised the issue...defined what 'need to know' means," Huvelle wrote.The judge also suggested the administration had lost sight of the purposes of the Freedom of Information Act and transparency itself."The government appears to adopt the cavalier attitude that the President should be permitted to convey orders throughout the Executive Branch without public oversight ... to engage in what is in effect governance by 'secret law,'" Huvelle said.The White House referred a request for comment on the ruling to the Justice Department, which did not immediately respond to a query about the case.http://www.politico.com/blogs/un...•••••••••••••••••••••••••••••••••••••••••••••••••••••Judge: NSA phone program likely unconstitutionalThe ruling is the first significant legal setback for the NSA’s surveillance program.A federal judge ruled Monday that the National Security Agency program which collects information on nearly all telephone calls made to, from or within the United States is likely unconstitutional.U.S. District Court Judge Richard Leon found that the program appears to violate the Fourth Amendment ban on unreasonable searches and seizures. He also said the Justice Department had failed to demonstrate that collecting the information had helped to head off terrorist attacks.Acting on a lawsuit brought by conservative legal activist Larry Klayman, Leon issued a preliminary injunction barring the NSA from collecting so-called metadata pertaining to the Verizon accounts of Klayman and one of his clients. However, the judge stayed the order to allow for an appeal.“I cannot imagine a more ‘indiscriminate’ and ‘arbitrary invasion’ than this systematic and high-tech collection and retention of personal data on virtually every single citizen for purposes of querying it and analyzing it without judicial approval,” wrote Leon, an appointee of President George W. Bush.The preliminary injunction Leon granted Monday does not require him to make a definitive ruling on the constitutional questions in the case, but does take account of which side he believes is more likely to prevail.Leon’s 68-page opinion is the first significant legal setback for the NSA’s surveillance program since it was disclosed in June in news stories based on leaks from former NSA contractor Edward Snowden. For seven years, the metadata program has been approved repeatedly by numerous judges on the Foreign Intelligence Surveillance Court and found constitutional by at least one judge sitting in a criminal case.The Justice Department persuaded those courts that the collection of information on the time and length of calls, as well as the numbers called, did not amount to a search under the Fourth Amendment because that information is routinely available to telephone companies for billing purposes and is shared with those firms voluntarily.Government lawyers and the judges who found the NSA program legal pointed to a 1979 Supreme Court ruling, Smith v. Maryland, which found no search warrant was needed by police to install a device which recorded the numbers dialed on a particular phone line.But Leon said the three-decade-old precedent was not applicable to a program like the NSA’s because of its sophistication and because telephone use has become far more intense in recent years.“The ubiquity of phones has dramatically altered the quantity of information that is now available and, more importantly, what that information can tell the Government about people’s lives,” the judge wrote. “I cannot possibly navigate these uncharted Fourth Amendment waters using as my North Star a case that predates the rise of cell phones.”The judge went on to conclude that the searches involved in the NSA metadata program were likely not permissible under the Fourth Amendment in part because there was little evidence the program has actually prevented terrorism.“I have significant doubts about the efficacy of the metadata collection program as a means of conducting time-sensitive investigations in cases involving imminent threats of terrorism,” Leon wrote. “The government does not cite a single instance in which analysis of the NSA’s bulk metadata collection actually stopped an imminent attack, or otherwise aided the Government in achieving any objective that was time-sensitive in nature.”Edward Snowden himself praised the decision.“I acted on my belief that the NSA’s mass surveillance programs would not withstand a constitutional challenge, and that the American public deserved a chance to see these issues determined by open courts. Today, a secret program authorized by a secret court was, when exposed to the light of day, found to violate Americans’ rights. It is the first of many.”The judge’s ruling was issued just before White House press secretary Jay Carney took the podium for the daily press briefing. Carney said he was unaware of the decision and he referred inquiries to the Justice Department.“We are reviewing the court’s decision,” DOJ spokesman Andrew Ames said.Similar lawsuits challenging the program are pending in at least three other federal courts around the country. In addition, criminal defendants are beginning to challenge the program after the Justice Department disclosed it had played a role in investigating their cases.Critics of the NSA program leapt on Leon’s decision as evidence that the legal foundation of the surveillance effort is deeply flawed.“The ruling underscores what I have argued for years: The bulk collection of Americans’ phone records conflicts with Americans’ privacy rights under the U.S. Constitution and has failed to make us safer,” Sen. Mark Udall (D-Colo.) said in a statement urging passage of legislation ending the so-called bulk collection program. “We can protect our national security without trampling our constitutional liberties,” he added.At a hearing last month, Leon said he knew that his decision would be far from the last word on the issue, which is almost certain to wind up at the Supreme Court.However, he added some flair to his opinion Monday, referring at one point to the Beatles and at another to Federalist Papers author James Madison, who later became president.“Surely, such a program infringes on ‘that degree of privacy’ that the Founders enshrined in the Fourth Amendment. Indeed, I have little doubt that the author of our Constitution, James Madison, who cautioned us to beware ‘the abridgement of freedom of the people by gradual and silent encroachments by those in power’ would be aghast,” the judge wrote.http://www.politico.com/story/20...There is little doubt that the public's appetite for this level of overreach will help the Democrats position in the next two election cycles ('14 and '16), and this is central to this discussion here.CHAPTER TWOVarious other "phony scandals" according to President Obama that the American public is not buying.(1) Obama, without Congressional approval or consideration, unilaterally chose to specifically violate the oath of office (see quoted above) and by deferring the implementation of the ACA for the employer mandate did extend it by one year. This is a clear violation of the constitution.(2) The President did not seek Congressional approval to invade and subsequently overthrow the President of Libya.(3) CENSUS.gov Mess in 2012 where election was influencedByron's Blog: Which are the phony Obama scandals, and how do we know which is which?(4) IRS.gov Mess in 2014 where TEA Party was blocked from approvals.Malik Obama: The IRS and Health CareLois Lerner: Tom Byron's answer to The White House: What are examples of US administration officials having been rewarded in spite of their incompetence?(5) Healthcare.gov Mess since 2010Mandate or pay fine? NoKeep your doctor? NoKeep your insurance? NoKeep your hospital? NoKeep you drug plan? NoHigh deductibles? YesHigh policy premiums? YesCHAPTER THREERepublican alternatives that aren't anywhere nearly as many pages, nor as complex or intrusive as ACA:http://rsc.scalise.house.gov/upl...And also we have over 100 members of Congress now (Nov. 2013) that have co-sponsored it. And we had medical doctors who serve in Congress, like Dr. Phil Roe, help write this bill. This is a bill based on putting patients back in charge of their health care and lowering the cost and getting government out of health care decisions.http://m.cnsnews.com/news/articl...John Podesta will help Obama extend the President's executive power. Congress will become even more irrelevant.Why didn't Obama know about various issues? Podesta will help clear this problem by advising the Chief of Staff for Obama. No more secrets will be kept from the President!KEILAR: Obama was unable to. And with the window closing on his chance for second term achievements, Democratic sources tell CNN Podesta's expertise is much needed.As President Clinton's disciplined chief of staff, Podesta guided that White House through a sex scandal, impeachment and a war in Kosovo. He was known for cracking the whip, one former Clinton colleague telling CNN his co-workers made him a name plate. On one side, "John D. Podesta."http://transcripts.cnn.com/TRANS...CHAPTER FOURBlacks used to be Republicans, but in the years since FDR, they have, sadly, become a group of voters the Democrats have exploited. If you are a Conservative Black in America, you get the full wrath of of the left. You get audited if you speak out (Dr. Ben Carson). http://touch.baltimoresun.com/#s...Additional reading on this topic.http://www.digitalhistory.uh.edu...Compare the rhetoric of these politically active individuals and how the media treats them:Alan West v. Al SharptonJC Watts v. Jessie JacksonCondie Rice v. Sheila Jackson LeeREPUBLICANS NEED ANOTHER MARGARET THATCHER OR MAYBE ANOTHER RONALD REAGAN.

Lets take a look at a similar situation. Bill Clinton was under investigation between January 1997 till January 1999. Here is a list of some of the select accomplishments during that time.1997February 19Launched Youth Anti-Drug Media CampaignThe President unveiled his National Drug Control Strategy that set forth a long-term national effort to reduce illicit drug use and its consequences. Highlights of the Strategy included: a new $175 million national media campaign targeting illegal drug use by youth; 500 additional border patrol agents to stem the flow of illegal drugs across the Southwest Border; and $40 million for counter-drug programs in Peru — the primary cocaine source country.March 4Banned Federal Research on Human CloningBecause of the profound ethical issues raised by advances in cloning technology, the President issued a memorandum prohibiting the use of federal funds to clone human beings and urged the entire scientific and medical community to adopt a voluntary moratorium on the cloning of human beings. (Exec. Memorandum, 3/4/97)April 24Chemical Weapons Convention RatifiedThe Senate ratified the Chemical Weapons Convention, which makes the production, acquisition, stockpiling, transfer and use of chemical weapons illegal. (Ratified 4/24/97)May 20Created the Welfare to Work PartnershipThe Welfare to Work Partnership was launched at the President's urging to lead the national business effort to hire people from the welfare rolls. Now 20,000 businesses strong, the Partnership has helped an estimated 1.1 million welfare recipients move to employment. Under Vice President Gore's leadership, the Administration has also done its fair share, hiring 50,000 welfare recipients, and has fostered partnerships between employers and community and faith-based organizations that help families move from welfare to work.June 4Individuals With Disabilities Education Act ReauthorizedThe expanded IDEA applies the same high academic standards for all children, ensuring that children with disabilities learn the same things with the same curricula and the same assessments as all other children. It also ensures that more children with disabilities can be in regular classrooms and take part in all school functions including field trips and extracurricular activities. (Signed 6/4/97)June 12Established the Initiative for One AmericaTo help facilitate a national dialogue aimed at narrowing America's racial divide, the President appointed a seven-member Advisory Board on Race. Over the next 15 months, Board members, individually and in teams, held hundreds of meetings involving thousands of people in every region of the country. They submitted several policy proposals that have guided the Administration in its effort to close the racial gaps that still exist in America. These include increased civil rights enforcement, increased early childhood education and undertaking efforts to make sure all Americans benefit from our country's prosperity. The work of the Advisory Board also led to the creation of the One America Office in the White House to promote the President's goals of educating the American public about race, encourage racial reconciliation through national dialogue on race, identify policies that can expand opportunities for racial and ethnic minorities, and coordinate the work of the White House and federal agencies to carry out the President's vision of One America.July 16Stronger Air Quality Regulations ReleasedThe President approved the strongest air quality standards in history to control pollution from smog and soot. The standards could prevent 15,000 premature deaths every year and will improve the lives of millions of Americans suffering from respiratory illness. Enforcement of the new standards has been delayed by court action. (7/16/97)August 5Balanced Budget Agreement ReachedIn February, the President submitted the first plan to finish the job of eliminating the deficit and the balanced budget in 27 years. On August 5th, he signed the Balanced Budget Act of 1997, which finished the job of eliminating the $290 billion budget deficit. (PL 105-34, signed 8/5/97)$500 per Child Tax CreditAs part of the Balanced Budget Agreement, the President secured a $500 per child tax credit for approximately 27 million families with children under 17, including thirteen million children from families with incomes below $30,000. (PL 105-34, signed 8/5/97)Children's Health Insurance Program CreatedAt the urging of the Clinton-Gore Administration, Congress invested $48 billion for the State Children's Health Insurance Program — the single largest investment in health care for children since the enactment of Medicaid in 1965. This new program, together with Medicaid, will provide meaningful health care coverage for up to five million previously uninsured children — including prescription drugs, vision, hearing, and mental health services. Within three years of enactment, all 50 states have implemented S-CHIP programs, and over 2 million children have been covered. In addition, the number of states covering children up to 200 percent of poverty increased by more than sevenfold — to 30 states — during that time. (PL 105-34, signed 8/5/97)Strengthening the Medicare Trust FundWhen the President came into office, Medicare was projected to become insolvent in 1999. The Balanced Budget Act extended the life of the Trust Fund by an additional 10 years resulting in the longest Medicare Trust Fund solvency in a quarter century, extending the life of the Medicare Trust Fund by a total of 26 years and offering premiums that are nearly 20 percent lower today than projected in 1993.Modernizing the Medicare Benefit PackageThe BBA included a series of structural reforms which modernize the program, bringing it in line with the private sector and preparing it for the baby boom generation. These reforms: waived cost-sharing for mammography services and provided annual screening mammograms for beneficiaries age 40 and older to help detect breast cancer; established a diabetes self-management benefit; ensured Medicare coverage of colorectal screening and cervical cancer screening; ensured coverage of bone mass measurement tests to help women detect osteoporosis, and increased reimbursement rates for certain immunizations to protect seniors from pneumonia, influenza, and hepatitis.HOPE Scholarships/Lifetime Learning Tax CreditsPresident Clinton proposed and passed the largest increase in college opportunity since the GI bill. The HOPE Scholarship provides a tax credit of up to $1,500 for tuition and fees for the first two years of college. When fully phased-in, the Lifetime Learning tax credit will provide a 20 percent tax credit on the first $10,000 of tuition and fees for students beyond the first two years of college, or taking classes part-time. (PL 105-34, signed 8/5/97)Welfare-to-Work GrantsDue to President Clinton's leadership, the Balanced Budget Act included $3 billion over two years for Welfare-to-Work grants to help states and local communities move long-term welfare recipients and certain non-custodial parent in lasting, unsubsidized jobs. This funding, used for job creation, placement and retention efforts, has helped the hardest-to-serve welfare recipients and promotes parental responsibility among non-custodial parents who need to find work to honor their responsibilities to their children.Landmark Education Investments: America Reads, Charter Schools, Education TechnologyThe President succeeded in doubling investments in education technology, increasing charter school funding, expanding Head Start to reach more than 800,000 children, and increasing the maximum Pell Grant by 63 percent, to the largest maximum award ever. The Budget also provided $300 million for the President's America Reads Challenge. Together, these programs are the most significant increase in education funding at the national level in 30 years. (PL 105-34, signed 8/5/97)Created 20 more Empowerment Zones and 20 more rural Enterprise CommunitiesFollowing Congress' 1994 designation of Cleveland and Los Angeles as EZs, the President requested a Round 2 of 20 new EZs and 20 new rural Enterprise Communities. The Round 2 EZs received expanded tax-exempt bonding authority to increase their ability to stimulate private-sector job creation for low-income residents.August 9Created Smoke-Free Federal WorkplacesPresident Clinton issued an Executive Order protecting Federal Government employees and members of the public from exposure to tobacco smoke in the Federal workplace and encouraged Federal agencies to establish programs to help employees stop smoking. The Clinton-Gore Administration has also made our nation's health a priority by developing the first-ever plan to protect our children from tobacco, raising the federal tobacco tax, and by giving the American people their day in court against the tobacco manufacturers who engaged in decades of deception about the dangers of tobacco.August 13Required Drug Companies Provide Adequate Testing for ChildrenPresident Clinton directed an important Food and Drug Administration regulation requiring manufacturers to do studies on pediatric populations for new prescription drugs — and those currently on the market — to ensure that prescription drugs have been adequately tested for the unique needs of children.August 27America Reads Child Literacy Initiative LaunchedThe President set a national goal of making sure that every child can read independently by the end of third grade. To reach this goal, the President issued the America Reads challenge, calling for one million tutors — college, university students, senior citizens, and private sector employees — to help children learn to read. In 1997, Congress funded the initiative, with $300 million in grants to help states improve children's reading skills. More than two million children have been tutored to read by national service programs such as AmeriCorps, VISTA, and Foster Grandparents.October 9Reached Agreement to Provide Child-Safety Locks With HandgunsThe President announced an agreement with eight of the country's largest gun manufacturers to include child safety locks with all new handguns. The voluntary agreement was reached after negotiations between the President, the gun manufacturers and the American Shooting Sports Council. The President had previously issued an Executive Memorandum requiring federal law enforcement authorities to provide child safety locks for their officers' firearms.November 19Adoption and Safe Families Act PassedThis bipartisan legislation enacted many of the recommendations of the President's Adoption 2002 report. In order to meet the President's challenge of doubling the number of adoptions by 2002, the Act provides incentives to states to permanently place children in foster care. In 1999, 46,000 foster care children were adopted — more than a 64 percent increase since 1996 and the biggest increase in adoptions since the National Foster Care Program was created almost 20 years ago. (PL 105-89, signed 11/19/97)November 20Endorsed the Recommendations of the Historic Quality Commission.In 1996, the President created a non-partisan, broad-based Commission on quality and charged them with developing a patients' bill of rights as their first order of business. In October of 1997, the President accepted the Commission's recommendation that all health plans should provide strong patient protections, including guaranteed access to needed health care specialists; access to emergency room services when and where the need arises; continuity of care protections; and access to a fair, unbiased and timely internal and independent external appeals process. The work of the Commission lay the foundation for subsequent administrative and legislative initiatives to improve patient protections and quality improvement.November 21FDA Reform Legislation SignedThe President supported and signed the FDA Modernization Act of 1997, the first major food and medical products reform in 35 years. The Act cut approval times of new drugs in half, simplified the review process for medical devices, expanded participation in experimental treatments for AIDS, Alzheimer's and cancer patients, and protected consumers by ensuring accurate food labeling. (PL 105-115, signed 11/21/97)December 16NATO Expanded to Eastern EuropeSecretary of State Madeleine Albright signed protocols for the accession of Poland, Hungary and the Czech Republic into NATO. The expansion of NATO to include these three former Warsaw Pact nations was a historic step in ensuring peace and stability in Eastern Europe. NATO expansion was ratified in May 1998 after it was approved by a strong bipartisan Senate majority.1998January 7Child Care InitiativeThe President successfully initiated an historic effort to improve child care for America's working families. President Clinton's initiative responded to the struggles our nation's working parents face in finding child care that they can afford, trust, and rely on. The President's initiative helped working families pay for child care by more than doubling funding for child care subsidies and nearly doubling funding for Head Start; it built a supply of good after-school programs that will serve 1.3 million children in 2001; and, it is working to improve the safety and quality of care, and promote early learning through the recently passed Early Learning Opportunities Act.February 20Implemented the Patients' Bill of Rights for Federal Health PlansIn order to ensure that 85 million Americans in federal health plans benefit from essential health protections developed by the President's Health Care Quality Commission, President Clinton ordered federal health plans to comply with provisions of the Patients' Bill of Rights. The President's order guaranteed choice of providers and plans, access to emergency services, participation in treatment decisions, confidentiality of health information and a fair complaint and appeals process. Medicare, Medicaid, S-CHIP, the Indian Health Service, FEHBP plans, the Veterans Administration facilities, and the Military Health System are responding by ensuring that all protections that can be extended under current law be provided.April 11Good Friday Peace Accords SignedPresident Clinton helped conclude the Good Friday Peace Accords, a historic peace agreement between all the major parties to the long conflict over Northern Ireland. The accord represents the best hope in a generation for a just and lasting peace in Northern Ireland. (4/11/98)July 16Child Support IncentivesThe President signed into law the "Child Support Performance and Incentive Act of 1998," which built on prior legislative and executive actions to improve child support collections by establishing performance-based rewards for states on a range of key child support goals. The Clinton Administration has taken great strides in promoting responsible fatherhood; since 1992, paternity establishment has tripled and child support collections have doubled.July 21Improving Nursing Home QualityIn July of 1998, President Clinton initiated a new nursing home quality initiative that ensures swift and strong penalties for nursing homes failing to comply with standards, strengthened oversight of state enforcement mechanisms, and implemented unprecedented efforts to improve nutrition and prevent bed sores. Finally, the Administration recently instructed states to eliminate corrective periods during which nursing homes could avoid the imposition of sanctions, such as fines, when a nursing home is found to have caused harm to a resident on consecutive surveys, in order to put additional pressure on nursing homes to meet all health and safety standards.August 7Workforce Investment ActLong championed by President Clinton and Vice-President Gore, this bi-partisan legislation was enacted to streamline and bring greater accountability to our nation's job training system. (signed 8/7/98)October 7GEAR UP Initiative CreatedIn his 1998 State of the Union address, President Clinton urged Congress "to support our efforts to enlist colleges and universities to reach out to disadvantaged children, starting in the 7th grade, so that they can get the guidance and hope they need so they can know that they, too, will be able to go on to college." Congress enacted GEAR UP without a single dissenting vote. GEAR UP provides intensive early intervention services that have helped prepare up to 700,000 students at high-poverty middle schools for college. GEAR UP was included in the Higher Education Amendments of 1998, which also reduced student loan interest rates, saving students about $50 for every $1,000 in debt; supported partnerships between universities and school systems to strengthen teacher preparation and quality; and created the first federal performance-based organization to administer student aid. (signed 10/7/98)October 21Class Size Reduction Initiative LaunchedAfter initially refusing to provide any funding at all, Congress agreed to provide $1.2 billion for the first year of the President's new initiative to hire 100,000 new teachers to reduce class size in the early grades to a national average of 18. This initiative is the first comprehensive effort to reduce class size across the nation. (PL 105-277, signed 10/21/98)21st Century Community Learning CentersIn 1998, a Clinton Administration initiative launched a series of dramatic funding increases for before- and after-school programs, turning a small demonstration program into one of the most popular Federal education programs. President Clinton won $846 million for the 21st Century Community Learning Centers program for 2001, up from only $1 million in 1997, and it will serve about 1.3 million children.October 23Wye Middle East Peace Agreement SignedAfter nine days of negotiations at the Wye Conference Center in Maryland, Israeli Prime Minister Benjamin Netanyahu and Palestinian Authority President Yasser Arafat signed an agreement that will strengthen Israeli security, expand the area of Palestinian control in the West Bank, and enhance opportunities for the Israeli and Palestinian people. (10/23/98)October 27Head Start Expansion and Reauthorization (Human Services Reauthorization Act)The reauthorization of Head Start paved the way for further quality improvements, doubled participation in the Early Head Start program and moved toward the President's goal of providing quality Head Start opportunities for one million children. (PL 105-285, 10/27/98)Individual Development AccountsIn addition to reauthorizing Head Start, the Human Services Reauthorization Act of 1998 also created the Individual Development Account Demonstration Program to encourage low-income families to save for a first home, post-secondary education or to start a new business. (PL 105-285, 10/27/98)December 12Global Warming Protocol Signed in Kyoto, JapanWith critical leadership from the Clinton-Gore Administration, 160 nations agreed on the basic architecture of a strategy to combat global warming on December 12, 1997. This agreement is the first time that major nations of the world ever committed themselves to a comprehensive plan to cut greenhouse gas emissions.December 16Air Attacks on Saddam HusseinBeginning December 16, 1998, American forces attacked Iraq's nuclear, chemical, and biological programs, and its military capacity to threaten its neighbors. Saddam Hussein had announced that he would no longer cooperate with UN inspectors to conduct inspections that would guarantee that Iraq does not try and rebuild its capacity to create weapons of mass destruction.So… Perhaps Trump could spend a little less time crying like a child and get to work.

People become addicted because they are human and how their "old brain" is controlled, or not, by their "new brain/ neocortex"See….Chemical Addiction, Drug Use, and TreatmentIntroductionThe disease of addiction is one of the least understood, and frequently misunderstood, of all chronic diseases. While it would be absurd to assert that other diseases of the brain such as schizophrenia or depression are due to weak will or moral character, it is still the prevailing opinion of many, including healthcare professionals, that drug addiction is about improper choices rather than improper brain function. Current scientific evidence has revealed that chemical addiction is a process that is caused by a malfunctioning cascade of neurotransmitters which is further exacerbated by drug use. With the advent of single positron emission computerized tomography (SPECT) scan brain images of people using drugs, we now have objective evidence of the effects that drugs of abuse have on the addicted brain.[1]Evolution of the BrainIn order to truly understand addiction, we have to look at the evolution of the human brain. Human beings, being highly evolved, have an incredibly large neo-cortex compared with other living beings. This neo-cortex can be described as our "new" or "thinking" brain. However, we still share with other beings an "old" or "instinctual" brain that controls all of our involuntary functions, including our instinctual drives (eg, hunger, sex, and nurturing). It is in this old or instinctual brain that the pathophysiology of addiction resides, an area within the limbic system that controls our moods, a reward pathway within the medial forebrain bundle that includes the nucleus accumbens (NA) and the ventral tegmental area (VTA).The Reward PathwayIt is the reward pathway that governs our instinctual drives, and when this pathway malfunctions, any number of instinctual drives may also malfunction. We now know that this malfunctioning process has been associated not only with drug addiction, but also food addiction, sex addiction, and a number of other compulsive disorders including attention-deficit hyperactivity disorder. In an otherwise normal individual, there is a cascade of neurotransmitters, which includes dopamine, that acts as a satiation or "off switch" when fulfilling an instinctual drive. Individuals who are predisposed to becoming addicted have been shown to have a variant gene that causes this reward cascade to malfunction. These people do not experience the same level of neurochemical reward when fulfilling an instinctual drive, and there is no satiation mechanism or "off switch" telling them that they have become satiated by the behavior.The reward pathway, like all neurochemical pathways, is an electrochemical process involving electrical signals being transmitted across billions of nerve cells by way of neurotransmitters. As a nerve impulse is sent to a presynaptic neuron, the vesicles containing neurotransmitters merge with the presynaptic membrane and spill their contents into the synaptic junction. These neurotransmitters then bind with the postsynaptic receptor, which allows the signal to continue. At the same time, there are neighboring neurons that can potentate or inhibit the response. In the individual who is predisposed to addiction, this process is malfunctioning in the NA and VTA of the brain.Early animal models showed that when a catheter containing cocaine was placed into the NA of a rat, the animal became addicted to the drug and learned to press a lever to get a dose of the drug. Once the animal was addicted, an electrical stimulus was connected to the lever that provided an ever-increasing shock each time the animal attempted to get his "fix." In every case, the animals electrocuted themselves rather than cease the drug use. When this study was conducted again with food instead of a drug, the animals starved to death rather than endure the electrical stimulus. Finally, this study was replicated with the drug-containing catheter placed in the spinal cord, and no addictive behaviors were observed. The findings of this study included: (1) the drugs of abuse have a specific site of action in the brain; (2) this area of the brain must have a similar area in human beings (ie, the instinctual brain); (3) no amount of unpleasant stimuli was great enough to get the animal to stop seeking the drug; and (4) this process was greater than other instinctual drives, including the drive to eat.The addictive process manifests itself in human beings as the behaviors that we normally associate with being an addict (eg, inability to control drug use, replacement of important activities by drug use). When the reward pathway is exogenously stimulated by drug use, it sends exaggerated signals to the prefrontal cortex, an area of the brain that control reasoning and judgment. This signal highjacks the prefrontal cortex into believing that, with drug use, an instinctual drive was just fulfilled and should be repeated. Unfortunately, while many people are able to experiment with psychoactive drugs with little or no adverse effects or continuous use, the person predisposed to addiction has the previously described malfunctioning satiation process, and therefore progresses into uncontrolled drug use.Understanding this process at a cellular level is not overly complicated. Medical science has already unlocked many of the secrets of brain function. We have identified hundreds of neurotransmitters that control brain function. We know that too little serotonin within the limbic system can lead to depression, and we prescribe selective serotonin reuptake inhibitors (SSRIs) to treat depression. It can be argued that drug addiction is nothing more than individuals taking a substance that they have found to medicate their dopamine deficiency within the reward pathway. However, when treating depression, we use highly researched compounds, prescribed at the lowest dose necessary and under close medical supervision.Drug UseNormal brain function, whether it is within the neo-cortex or the reward center, is a process involving appropriate nerve stimulation, transmission, and reception. How well that process works depends on having an adequate number of nerve synapses and the appropriate amount of neurotransmitters and receptors within that synapse. When an individual ingests a mood-altering substance, he or she is exogenously altering the amount of dopamine and other neurotransmitters that are present in the synapses of the NA, within the reward pathway.Heroin for example, binds to the endorphin receptors of the brain. This in turn causes a decrease in the release of GABA, one of our inhibitory neurotransmitters, which modulates normal dopamine release. By inhibiting GABA, there is a corresponding increase in dopamine release, which leads to an increase in dopamine receptor stimulation. This fools the brain into thinking that an instinctual drive has just been satisfied.Cocaine, on the other hand, has a more direct effect in that it acts as a dopamine reuptake inhibitor, much like the SSRIs inhibit the reuptake of serotonin. By blocking the reuptake of dopamine, cocaine use allows the dopamine molecule to remain within the synaptic gap for a longer time period, which in turn allows for more dopamine receptors to be stimulated. Ultimately, just like an opiate, cocaine fools the brain into believing it has just met an instinctual need.Some drugs may have a more indirect effect on the reward pathway. Alcohol, for example, has its immediate site of action within the globus pallidus, which ultimately alters dopamine levels within the reward pathway. Essentially, all of the drugs of abuse exert their effects by influencing the amount of neurotransmitters within the reward pathway.Treatment ImplicationsPharmacologic intervention of drug addiction generally consists of 2 approaches, abstinence-based treatment and replacement-based harm reduction. The primary goal should always be to assist in getting and maintaining the patient in a drug-free state. If for whatever reason (societal, environmental, financial, or motivational) abstinence is not possible, then methods developed to decrease the harm associated with addiction may be employed.Pharmacologic treatment in an abstinence-based model has typically been associated with drug detoxification, and has been well documented. Newer interventions involve agents designed to reduce craving and improve treatment outcomes. Naltrexone is currently the only drug available in the United States with an FDA-approved indication to reduce alcohol craving. Other approaches include nutritional therapy with amino acids, the building blocks or precursors to the brain's neurotransmitters. Amino acid therapy has been shown to decrease the incidence of patients leaving drug treatment programs against medical advice. Drugs such as acamprosate and nalmephene are being investigated for their ability to reduce drug craving.Harm reduction for opiate dependency involves prescribing agents that will occupy the opiate receptors much like their opiate addict's drug of choice, at a dose that will prevent the induction of withdrawal symptoms. It is also believed that by maintaining the saturation of the opiate receptor with an opiate agonist, the euphoric effects or heroin are blunted when taken at the same time. The underlying philosophy of harm reduction is to maintain the individual in an addicted state, but to a drug that is legal (less need to commit crimes to support habit), requires only 1 dose per day (increases functionality and ability to hold a job), administered orally (less risk of HIV or hepatitis infection), and has a less euphorogenic activity (lower risk of diversion and abuse).MethadoneThe mainstay of this approach has been the drug methadone. Methadone is not without its problems in that, although it has a long half-life and is less euphorogenic than heroin, it can still be abused. It can also cause respiratory depression and other opiate-related side effects, including death by overdose. Because of these risks, methadone is very tightly controlled, and regulated pursuant to the Drug Abuse Treatment Act. Currently, only clinics registered as a methadone maintenance program can dispense methadone for maintenance of opiate addiction.In an attempt to expand the harm reduction model, the FDA has amended the Drug Abuse Treatment Act to allow greater access to opiate replacement therapy. Rather than limit opiate replacement access only to methadone clinics, the amendment allows qualifying physicians to prescribe approved narcotic drugs in schedule III, IV, and V for the treatment of opiate dependence. There are, however, specific requirements that the drug and practitioner have to meet.BuprenorphineThe newest agent to be investigated for opiate replacement therapy is the drug buprenorphine. Buprenorphine is a partial mu receptor agonist, meaning it has less intrinsic activity for the mu receptor than a full agonist, and also a kappa receptor antagonist. Buprenorphine has high affinity and slow dissociation from the mu receptor sites. Since buprenorphine has both opiate agonist and antagonist properties, it is believed to have a much lower abuse potential than methadone, yet still able to occupy the opiate receptor site. It is further believed that due to its combined agonist/antagonist properties, there is a ceiling at which the drug is no longer capable of inducing a euphoric response. In fact, it is believed that at higher doses, the antagonist properties will create a dysphoric response. Finally, due to its long duration of action, less-than-daily dosing of buprenorphine may be appropriate.In the context of harm reduction, buprenorphine is expected to be a safer agent, with less potential for diversion and abuse. While buprenorphine's safety profile is preferable to that of methadone, it is not without any risk of abuse. One approach to combat the diversion and abuse is combining buprenorphine with naloxone, an opiate antagonist that will induce withdrawal symptoms when injected. Naloxone has very limited oral bioavailability and should not interfere with buprenorphine's effects when ingested orally.To date, there have been no specific educational requirements placed on pharmacists who will be expected to dispense buprenorphine. With regard to who is a "qualifying physician," only those physicians who receive 8 hours of approved CE training on buprenorphine from an approved organization, have the capacity to refer patients to appropriate counseling services, and whose individual or group practice sees no more than a total of 30 buprenorphine patients will be allowed a special Drug Enforcement Agency (DEA) number for buprenorphine treatment. Any drug used in accordance with this policy will be in schedule III, IV, or V, and will be approved by the FDA for the treatment of opiate dependence. This prohibits any schedule II drugs (ie, methadone) as well as any off-label usage of other opiate agonists. Built into the amendment is a 3-year evaluation period, at the end of which the DEA and US Department of Health and Human Services can decide whether the new law should remain in effect. If they decide against it, the new law would cease to be in effect within 60 days of that decision.SummaryDrug addiction is a chronic, life-threatening disease. As our understanding of the neuroscience of addiction continues to grow, so too will our treatment approaches to this devastating disease. Regardless of the treatment approach taken, we as healthcare professionals need to view addiction in the same context as other chronic diseases. There will be some patients who will recover completely, others who will have an occasional relapse and then recover, and, unfortunately, some who will die because they are not treated appropriately.ReferenceMarley D, Strain E. The neuroscience and practical applications of treating chemical addiction. Platform presentation of the American Pharmaceutical Association Annual Meeting; March 16-20, 2001; San Francisco, California.Suggested ReadingAmerican Society of Addiction Medicine. Principles of Addiction Medicine 2nd ed. Maryland: ASAM, Inc.; 1998.American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders 4th ed. Washington, DC: APA; 1994.Inaba DS, Cohen WE. Uppers, Downers, All Arounders, 4th ed. Oregon: CNS Publications; 2000.Substance Abuse and Mental Health Services Administration. A Guide to Substance Abuse Services for Primary Care Clinicians. DHHS Pub. Number (SMA) 97-3139, 1997.