Wednesday, March 31, 2010

San Angelo Threads to Obama's Health Reform


White House Health Czar Nancy-Ann DeParle twice had San Angelo in her cross hairs. As a board member of Triad Hospitals, she noted the planned merger between Shannon Health System (SHS) and Triad in October 2006. I wrote a piece critical of the merger in the Standard Times. The Board cancelled the deal shortly thereafter.

At the time SHS CEO Dr. Dan Stultz stood ready to assume Texas Hospital Association's CEO role. He said to me:

"There's no guarantee the nonprofit community hospital model will survive."

Nancy-Ann's second sighting of San Angelo came as managing director of CCMP Capital Advisers. Her private equity firm bid on Triad Hospitals in February 2007. At the time Triad owned San Angelo Community Medical Center (SACMC).

When CCMP lost to Community Health Systems, DeParle's firm bankrolled the start up of Legacy Hospital Partners, led by former Triad CEO Denny Shelton. In September 2007 Shelton spoke at Angelo State University on "The Future of Healthcare." The Obama White House position on health reform could've come straight from Denny's talk.

As a private equity underwriter (PEU) and board member Nancy-Ann DeParle bought and sold for-profit hospital companies. Her firms converted struggling or imploded nonprofit community hospitals to for-profit status. Her handiwork touched San Angelo before and it will again. The question is how?

While my piece on the SHS-Triad proposed merger is no longer available on the Standard Times website, it can be accessed here.

Tuesday, March 30, 2010

PPACA's Impact on Texas & Concho Valley in 2019


Now that health care reform has passed, it's time to look nearly a decade ahead. I've chronicled the four year wait before the number of uninsureds begins to drop in earnest, during which employer coverage continues its historical swoon. But there are happy times ahead.

CBO predicts 32 million Americans will gain coverage between 2014 & 2019. How might this play out in Texas? What will happen in the Concho Valley?

FamiliesUSA made projections for Texas. Had reform not passed, they predict over 7 million Texans without coverage in 2019. With reform, nearly 4.2 million Texans get health insurance. That leaves almost 2.9 million Texans without insurance come 2019. Here's the percentage breakdown:

60% get covered
40% remain uninsured
In 2006 the Concho Valley (plus Runnels County) had almost 34,000 uninsureds. Allowing for population growth, this increases to 38,000 in 2019. With 60% gaining coverage (22,500), that leaves 15,500 (40%) without health insurance.

The burden of providing care for the uninsured will decrease by more than half, should these predictions come to life. That's a very good thing, but local safety net providers will not see the elimination of the uninsured, not by a long shot. 2019 will find the arrow hitting the target, but the bulls eye of full coverage sits far away. Meanwhile politicians argue over the cost.

Dr. Berwick to Enter P4P Heaven, or is it Hell?


Dr. Don Berwick is the Obama administration's nominee for Chief of the Center for Medicare/Medicaid Services. Berwick founded the Institute for Healthcare Improvement, which grew from the National Demonstration Project on Quality Improvement in Health Care.

The Podesta blogging clan came out strong for Dr. Berwick, but they lack credible management theory. They follow the Obama method, "let's do what's practical, what's achievable," i.e how can we get what we want on a practical political basis? Dr. W. Edwards Deming might call this "off to the Milky Way." It requires no understanding of knowledge, variation, systems, psychology or their interactions.

What might Dr. Berwick face in his new job? The Obama administration clearly believes in incentives, outcomes based pay, pay for performance, or however bribing people to do good work is currently phrased. The Obama team will reform education and health care with incentive schemes, the very practices Dr. Deming decried as antithetical to achieving quality.

Let's look at the current state of federal incentivizing:


Over 70% of federal employees, under pay for performance plans, find the system unfair. A mere 26% find the rating and pay process equitable.

In education the President launched this beauty:


The President will teacher quality by dramatically expanding successful performance pay models and rewards for effective teachers, scaling up federal support for such programs in up to an additional 150 school districts nationwide.

Someone forgot the word "improve" or "increase". It's short of the writing and proofreading mark. That deserves a 95 for English, but the content is one of Dr. Deming's Seven Deadly Diseases.

Don't forget the Veterans Administration bonuses, where people sat on each other's bonus committee. It encouraged horse trading, or "I'll grant you yours, if you'll do likewise."

Federal bank regulators received millions in bonuses, despite missing signs of the financial system meltdown. Then there's the FDA's "employee incentive gift cards:"


Apparently there is little oversight of who gets these informal bonuses.

Stories suggest problems with government efforts to bribe people. An awake America can see the pattern of bad behavior with business leaders. Nearly 30% of executives back dated stock options over a decade long period, robbing millions from shareholders. Few paid any legal price.

Wall Street imploded from layers of incentive schemes, each fostering a race to the bottom on quality. Executives swung for the fences to achieve big payouts. Their vaporware "innovative products" brought the global financial system to its knees.

At one point Dr. Berwick eschewed manipulative reward systems. He's the second Obama appointee with this in their background. Surgeon General Dr. Regina Benjamin was the first. While they occupy key positions, they'll have a wicked headwind in improving quality. The best they can do is ameliorate the damage from reliance on extrinsic motivation systems.

One pundit believes Berwick is now a prominent supporter of pay for performance. I'm not sure that's true.

I look forward to hearing Dr. Berwick's testimony. How will he dance on the edge of Obama's razor blade of extrinsic motivators?

At least the President didn't appoint Nancy-Ann DeParle to implement her Heritage Foundation based health reform plan, crafted by conflicted insiders. She's free to follow Tom Scully into much greener, as in big money, pastures.

Update 4-16-11:  New Scientist raised deep concerns about the very foundation of pay for performance.  It quoted a research study from UK health care system, where years of P4P made zero difference in outcomes for patients with hypertension..

Disclosure: My quality track paralleled Dr. Berwick's during the 80's & 90's. I was an administrator in one of HCA's pilot hospitals, studying under Dr. Paul Batalden and HCA's Quality Resource Group. I moved into quality consulting with Quorum Health Resources, serving as a Strategic Quality Management coach for 10 Georgia hospitals. There I joined the Fraternal Order of the Willing Worker at a Deming 4 day workshop in Costa Mesa, California. (Red Bead Game participants know what this means.) I returned to hospital operations, later leading a community collaborative working to provide access to care for the uninsured in a fourteen county region of West Central Texas.

Friday, March 26, 2010

Pictures of PPACA





Uninsureds under Reconciliation


The top graph shows the millions of Americans without health insurance coverage under CBO projections for the Accountable Care Act (PPACA). Declines don't start in any significant way until 2014.

Conclusion: America suffers legions of uninsureds until 2014. There is a four year wait for help for most.


Bending ESHI Curve

The bottom graph shows employer sponsored health insurance under PPACA. The starting point 176 million with workplace coverage (2008 Census estimates, the latest data available). The orange line represents CBO projections for employer coverage.

Taking population growth into account, the red line indicates employers providing the benefit at 2008 levels. The blue line shows the number with employer provided insurance using the 1998 rate. The employer shortfall under reform ranges from 35 to 50 million people.

Conclusion: A seismic shift is underway, transferring responsibility to individuals and a tapped out Uncle Sam. Will he have empty pockets by 2014? Will you?

Update 3-27-14:  In 2009 I predicted PPACA would set the stage for employers to shed that pesky health insurance benefit.   NYT ran a piece with that very prediction, albeit five years later than mine.  The prediction was made by Dr. Ezekial Emanuel, who helped craft PPACA. 

Blue Team Goes Bush


"You're either with us or against us."-President George W. Bush

Obama White House officials warned House members who voted for health reform initially, then changed their vote to "no" on Reconciliation. Backpedalers shouldn't expect support for their reelection bids.

The Politico piece repeatedly cites Obama top aides, without providing names. This White House frequently drops anonymous dribblings. Here's one:

“There is not a whole lot of Barack Obama and Joe Biden to spare on a good day,” said one senior White House official. “We’re going to have to focus on our friends.”

Thursday, March 25, 2010

Who's Not Watching Your Back?


The aftermath of the health care reform battle finds a progressive blogger and health care expert teaming up. The Center for American Progress' Matt Yglesias joined hands with Maggie Mahar of Health Beat to extol the benefits of reform.

Matt cheer lead through the contentious battle, waving poms poms for the Blue Team. The tissue paper hid a shiv, which he repeatedly stuck in the gut of high profile Red members. After pronouncing Nancy Pelosi the greatest Speaker ever and Obama the greatest President in history, Matt described the bill's provisions:


almost comically delayed implementation

phased in incredibly slowly (with no Biden f bomb)

a blunder
Matt didn't suddenly wake up post bill signing. The Senate moved implementation of major coverage expansion from 2013 to 2014. The House didn't change it under Reconciliation. CBO projected 6 million Americans will go off Medicaid & CHIP between 2011 and 2013. The bleeding of employer sponsored health insurance is clear from a look at 2008 Census data and the 2010 CBO estimation:


176 million Census 2008

150 million CBO Reconciliation

That's a drop of 26 million from workplace coverage. But the shift continues under health reform. Who might be concerned about that? The Century Foundation lists as an interest:


persistent economic inequality combined with the shift to American households of financial risks previously borne by employers and government.

The Century Foundation sponsors Maggie Mahar's Health Beat blog. Here's her take on employer coverage:


I also would like to see employers out of the loop. But as I have noted before, "better paid" workers are more likely to have employer-based insurance, and their employers typically pay between 70% and 100% of the premium. These employees do not want to give that up. So I don't think we can dismantle employer-based insurance all at once--but we can begin taxing at as income, at least above certain levels--and if we do that, more employers are likely to drop out of the insurance business. . .

Which is clearly the intent of the plan. Delayed implementation and a seismic shift to the individual and a tapped out Uncle Sam. That leaves who to pay? When groups claiming to have your back, don't, you're truly on your own.

Matt is a mouthpiece for Blue power player John Podesta, head of CAP. Podesta is on the board of The Century Foundation, Maggie's sponsor.

CAP Senior Fellow Jeanne Lambrew had 35 visits to the White House. Thirteen were with Nancy-Ann DeParle. Tom Daschle, another CAP Senior Fellow, had a large imprint on health reform. Podesta's people helped design the bill with all its "features."

With health care done, retirement might be next. Which progressives will sell you down the road?

At least the lobbying Podesta family had a banner year financially. How about you?


10-29-10 update:  Yglesias cited PPACA's "exquisitely slow" phase-in pace, as a problem for Democrats in the midterm elections.

Update 8- 24-11:  More large employers plan to drop their health insurance benefit come 2014.  I theorized long ago:  It's the plan, not a feature.

Wednesday, March 24, 2010

"Four More Years"


The cry of "Four more years" is not for President Obama's reelection. It's the wait for significant help under health reform.

From 2011-2013 CBO projects 6 million people go off Medicaid & CHIP. From 2008 to 2010 26 million lose employer sponsored health insurance (from Census & CBO projections). America's legions of uninsureds aren't going away anytime soon.

A progressive blogger referred to clearly the intentional plan as a "blunder". Backpedaling isn't pretty by either party, Red or Blue. Who knew Vice President Joe Biden's "f-ing incredible" was for the snail's pace of implementation?

Update: President Obama spoke in Portland, Maine. His message: "It could take four years for the full overhaul to take hold."

Monday, March 22, 2010

President Clinton Lobbied Congress for Health Reform Alongside Creator of Harry & Louise


White House Press Secretary Bob Gibbs described President Bill Clinton's role in pushing passage of health reform at the 52:38 mark of his press conference. Clinton made calls Saturday evening. Below are Gibb's words (without the and's and uh's):

Look, obviously President Clinton has relationships with many members of Congress on the Democratic side going back to his time here. We made use of his offering to do whatever he could to help pass this legislation. He asked for calls, obviously Rahm knows who President Clinton knows well and we handed him members to reach out to. I think in the end he was successful in helping us get some of those votes. I'll say this too, prior to coming out here, I was in a meeting in the Situation Room where Secretary Clinton was. She was very happy to see what happened yesterday. When the President came in, walked over and gave him a big hug for what had been accomplished. Thanks guys.


Oddly, Bill Clinton and Chip Kahn, the creator of Harry & Louise ads that took down Clinton era reform, supported the Reconciliation bill with its massive privatization and pay for performance.

President Clinton believes in the power of private money, even in the face of a huge natural disaster. Chip is CEO of the For-Profit hospital lobby. He knows HCA paid its private equity owners $1.75 billion in special dividends, borrowing to do so.

Clinton privatized government security operations, which The Carlyle Group later flipped for huge profits. Altegrity-USIS is on its fourth owner.

As for pay for performance, it will do for health care what it did for Wall Street. Incentives distort the performance of good work. President Obama could've learned this from Dr. Gawande's New Yorker article. It's difficult to believe Obama read the piece.

Privateer Bill Clinton runs in fast circles. He spoke Saturday night at the annual Gridiron Dinner. Somehow he fit in phone calls to Congressmen on Rahm's list, before traveling to Haiti with George W. Bush. Soon Clinton will run around the beach in Miami. He should find the view inviting.

As for Mr. Gibbs, he's already back pedaling on his boss' promises. Insurance reforms will be phased in by the end of the year, not immediate as President Obama stated in his congratulatory fund raising e-mail.

Arbitrary premium hikes, insurance cancellations, and discrimination against pre-existing conditions will now be gone forever.

Contrast the President's words with CNN Money's description:

* Insurers will no longer be able to set rates or exclude coverage based on pre-existing conditions, and can vary premiums only by geographic location, age, and tobacco use.

These restrictions, however, would not kick in until 2014. Going into effect immediately: a ban on lifetime limits on coverage, and on "rescission" (canceling policies already issued) except in cases of fraud.

Or the NYT's summary:

High risk pools will operate until 2014, when insurance companies can no longer refuse applicants with pre-existing health problems.

Back to Obama's e-mail:

Because of you, every American will finally be guaranteed high quality, affordable health care coverage.

Not even in 2019, when CBO scoring shows 22 million people without insurance.

President Obama spins like his Democratic predecessor. Populist rhetoric, corporatist implementation. This is what change looks like. You don't want to hear how it sounds.

Update: President Bill Clinton told ABC News, "Hillary and I lobbied people all over the weekend before the vote."

West Texas Paper Leads on National Scoop


The San Angelo Standard Times beat many big papers to the punch on a key political story. Was it?

1. Rep. Mike Conaway's Global Delta earmark and the peculiar timing of donations by the company's owners (also lobbyists).

2. The Bush White House's
Lessons Learned omission of the hospital with the highest patient death toll post Hurricane Katrina and corporate political ties.

3. Texas Governor Rick Perry's redoing the terms of a $35 million grant to The Carlyle Group's Vought Aircraft Industries. Vought also donates to Rep. Mike Conaway's campaign.


4. The identity of the "Baby Killer" shouter in the House Reconciliation debate on health care.

The scoop is #4, the offender Rep. Randy Neugebauer (R-TX). Neugebauer hasn't been this mean since he threatened FASB's Chief Accountant on fair value accounting rules. Randy apologized to Rep. Bart Stupak for his boisterous behavior. Would giving Bart a ride on Randy's yacht add a healing balm to the situation?

Stay tuned to the Standard Times for more national political stories. First, the gay mayor runs to Mexico with his illegal immigrant lover. Now, a rude Congressman confesses to a West Texas reporter (living in Washington, D. C.). Who could have predicted?

Update: While the Standard Times was not the first to break the story, it did beat a number of national papers to the press, including USA Today and WaPo.

Bending Employee Benefit Curve


176.3 million Americans had workplace health insurance in 2008. CBO projects this to decline to 162 million in 2019. The graph above shows the deterioration of the employee health insurance benefit. The Census Bureau projects 338 million Americans in 2019.

What if Americans were insured at the rate employers provided coverage in 1998? That's the blue line. 212 million would have workplace coverage

What if they just did the same as 2008 (already a bad year for the uninsured)? That's the red line. 197 million would have employer sponsored health insurance.

The orange line is the Reconciliation bill. 162 million get a health insurance benefit at work.

A picture is worth one thousand words. America will be more competitive in a global economy. With employers doing less, citizens and Uncle Sam will step up. Only Uncle Sam is tapped out.

House Democrats Deliver on White House Back Room Deals


Tom Daschle, a close outside adviser, said Mr. Obama believed that health care would be his legacy. “This is what his presidency is about,” he said. (NYT)

Make no mistake, the Blue Team's credibility rested on delivering health care reform. Last year Nancy-Ann DeParle, Ezekiel Emanuel, and Peter Orzag negotiated back room deals with major industry players. Jim Messina led a campaign style push with big donor money. It failed miserably.

The public paid attention, while the Fourth Estate didn't. WaPo's Ezra Klein interviewed Nancy-Ann DeParle. Her calling big Pharma "our industry" flew over his head. At one point the White House bragged about these deals.

After Congressional sausage making added "sweeteners" for holdouts, atop vague White House deals, the public threw up their hands in disgust. A politically astute President Obama recanted.
"I didn't make a bunch of back room deals."
He failed to mention his White House staffers did.

Reform's death meant huge problems for the Blues. Industry leaders expected Obama to live up to his commitments. They wouldn't lock up corporate donors for years as Rahm Emanuel intended, but they needed to deliver for the ones they had left. Thus Jim Messina got another chance to run his campaign magic. NYT reported:


At the White House, Mr. Obama’s political arm was mobilizing, as Jim Messina, a deputy chief of staff, guided a team of party strategists. Fed by information from lobbyists, Hill aides and others, they tracked how every lawmaker intended to vote and prepared a television and radio campaign to counter the bill’s opponents, who were vastly outspending them.
The coalition of about 50 groups, from the AARP to labor unions — some of whom called themselves “Winter Soldiers” to describe their steadfast support — held daily conference calls. They isolated three dozen lawmakers and had influential people in their communities — doctors, insurance agents, business owners — reach out to them.

Who stood steadfast in Obama's corner? The For-Profit hospital lobby, ironically the man who brought America Harry & Louise, the ad campaign that sunk Clinton era health reform. NYT reported:


Some White House allies say the session proved critical in putting health care back on the national agenda. “When the history of this is written, it will be looked at as both a turning point and a brilliant idea,” said Chip Kahn, who as president of the Federation of American Hospitals has been one of the administration’s main supporters.

What did Chip get out of the bill? Nonprofit community hospitals were renamed "private tax exempt facilities." Kahn had two reasons to drink champagne, given the weekend's news. With reform's passage, Kahn's for-profit hospitals have four years to pick off weak PTEF's.

Despite promises that 32 million Americans will get coverage, major enrollment doesn't start until 2014. Under Reconciliation CBO projects Medicaid & CHIP to decline by 6 million enrollees between 2011 & 2013. Hospitals caring for the uninsured will struggle under the crushing burden for four years.

Health risk and responsibility will shift from employers to individuals and a tapped out Uncle Sam. In 2008 176 million Americans had employer coverage (Census data). CBO projects 150 million to have workplace insurance in 2010. That's a drop of 26 million before the bill is enacted. The bleeding continues under Reconciliation. More than the cost curve is bent.

But there's good news, the U.S. Presidency is bolstered.


If we fail at this,” Rep. Grijalva recalled Mr. Obama saying, “it’s going to be harder for us to pull the line on this other stuff. It is going to weaken our presidency.”

The Blue Team delivered on its industry promises. Jim Messina's campaign magic is back. Congress kept any legislative entrails out of the public eye. Thus celebration was in order.


It was nearly midnight when Obama invited aides to the Truman Balcony for champagne.

Obama's privatization/pay for performance train chugs past the health care station. Onward to public infrastructure and education. Obama's legacy is "populist rhetoric, corporatist implementation."

Update 1-13-11:  The employer risk shift to the individual is on, as "large employers are moving away from traditional retiree benefits and are eyeing a defined-contribution approach and the individual market."

Saturday, March 20, 2010

Illinois Supreme Court Rules NonProfit Hospital Must Pay Taxes


Champaign area Provena Covenant Medical Center must pay property taxes, the Illinois Supreme Court ruled. Provena didn't provide enough charity care, at least in the court's eyes. It mattered not that the hospital is part of a Catholic health system.

Other Illinois hospitals at risk for owing taxes include Michelle Obama's employer, University of Chicago Hospitals. She is currently on a leave of absence.

With this development, it appears all my health deform predictions may come true. This is no reason to celebrate, although Senator Chuck Grassley and Federation of American Hospitals CEO Chip Kahn may break out expensive bottles of champagne. They've long had a beef against nonprofit community hospitals.

Chucky and the Chipster get two wins today, the Illinois Supreme Court decision and a Reconciliation bill renaming community hospitals "private tax exempt facilities (PTEF)." PTEF uniquely rolls off the tongue.

Adding taxes won't bring down health care costs. Deform continues. Nonprofit community hospital survival is not the least bit guaranteed, not in this For-Profiteering environment.

Friday, March 19, 2010

Will Nonprofit Community Hospitals Make it to 2014?


President Obama stumped for health care reform, which provides coverage to millions in 2014. He failed to mention the current dire straits of many nonprofit community and government owned hospitals. Recent news shows:

Miami's Jackson Health System is in critical need of financial assistance to continue caring for the area's uninsured.

Coffee Health Group, an Alabama nonprofit hospital system, is selling out to a for-profit chain due to financial difficulties.
What contributed to this sad state for some caregivers? Legions of uninsureds continue to grow, as employers shed jobs and/or the health insurance benefit. Consider the numbers covered in the workplace:


2008-- 176 million (Census data)
2010-- 150 million (CBO scoring of Reconciliation bill)
CBO projects employers to add insurance to 14 million more workers by 2015. This is virtually erased by 2019.

The other source of pain for community hospitals comes from Medicaid & CHIP.

2011-2013-- 6 million people lose Medicaid or CHIP
Help starts in 2014, but it could be too late for many community hospitals. How many will be forced to sell out? White House Health Czar Nancy-Ann DeParle has her for-profiteering roots. Take the Alabama sale:


Nancy-Ann DeParle’s old firm LHP Hospital Group, of Plano, Texas was in the running for Coffee Health Group. LHP, an affiliate of CCMP Capital Partners (Nancy’s former employer), didn’t win.
Before LHP lost in Alabama, board member Nancy-Ann helped convert a New Jersey hospital.

There is one provision in the bill ensuring the end of "nonprofit community hospitals." The Senate re-branded them as "private, tax exempt facilities," long the wish of the Federation of American Hospitals, the proprietary hospital lobby. There is no language in the House amendment changing this mendacious designation.

These are all clues that health reform is designed to benefit the For-Profiteers.

Update: Representative Mike Conaway called health reform projections "smoke & mirrors," while sharing no data of his own. No surprise there. It didn't take long for a smattering of nonprofit hospitals to implode or sell out.

Update 2: The Wall Street Journal did a piece on hospital sellouts.

Update 8-24-11:  Many large employers plan to dump the health care benefit come 2014.  This makes CBO's projections more suspect.

Update  2-6-12:  Stressed hospitals in New Jersey plan to sell out.

Health Care Reform Misery Milestones


Much attention is paid to the overall impact of health reform, as scored by the Congressional Budget Office (CBO). Two coverage line items bear closer examination. They are those with employer coverage and Medicaid/CHIP. CBO shows

Employer Coverage:

2010-- 150 million with employer coverage
2008-- 176 million with workplace insurance (Census data)

Twenty six million working Americans will have lost employer sponsored health insurance if CBO's initial projection is correct. Another 13 million lose it between 2016 and 2019. CBO expects employers to add 14 million to their insured rolls between 2011 & 2015.

Medicaid & CHIP

2011-2013-- 6 million people lose Medicaid & CHIP coverage.

Arizona is ahead of the game, eliminating its children's health insurance program and cutting back on Medicaid eligibility.

The pain for millions won't be relieved until 2014. Radical change is here and no, you can't keep your doctor or your plan. At least 32 million of you can't.

Thursday, March 18, 2010

Rep. Conaway Gets Earmark Religion


Congressman Mike Conaway posted his 2010 earmarks on his website for the first time in nearly six years in office. He vows not to ask for any earmarks in 2011. Does this new religion come after past sins? The Standard Times highlights the impact of Mike's shift. It states:

Conaway said he has sought earmarks for his district, advocating for legitimate projects. “I believe I have a responsibility to do so. However, a few bad apples spoil the bunch,” he said.

Two Congressmen asked for radar earmarks, Representatives Mike Conaway and John Murtha. Conaway obtained $1.6 million for Global Delta, a Virginia based company. It is owned by James and John Albertine, professional lobbyists. When did Rep. Mike Conaway begin representing Fredericksburg, Virginia instead of Texas? Add the synchronicity of earmark advancement to Albertine donations in 2008 and it looks more suspicious.

Rep. John Murtha has an equally murky radar earmark. He sent $3 million to KDH Systems for swimmer detection sonar. It had no technology expertise, other than making bulletproof vests. Lobbying firm KSA Consulting helped KDH get the earmark. After John Murtha passed away, KSA Consulting closed shop.

It's clear the Albertine Brothers continue lobbying. The fate of Global Delta is murkier. How many of their lobbying clients donate to the Conaway campaign or CONAPAC? They didn't need to. The lobbying principals ponied up $23,800.

Conaway's new religion on earmarks should come with a confession.