Barack Obama, 2015, SOTU: "If a bill comes to my desk that tries to do any of these things, I will veto it"

Part One

"Any of these things," that's what president Obama said during his SOTU speech. His meaning was clear: he referred to  four areas where he said that any Congressional amendments would be considered as "tinkering" and would be vetoed. He included immigration and the Affordable Care Act in this category. The promised vetoes revealed that our president was prepared to shift from a government characterized by the consent of the governed to one that would be more autocratic and unilateral. No previous president ever threatened Congress with four, count 'em, four vetoes. 

Our concern in this post is the Affordable Care Act (ACA), popularly known as Obamacare. It has long since been forgotten that the first important "tinkering" with the ACA was by Obama himself when he dropped the public option from the bill -- the public option was an awkward inconvenience at the time so the president "tinkered" with it. He used a hatchet.

Now efforts to improve the bill are either opposed by its far right opposition which would repeal the entire bill or get opposed by supposed supporters in favor of as much giveaway politics as is humanly possible. 

Here's the deal: the ACA contains two parts that are highly controversial, Sections 10320 and 3403. These sections in the ACA create the Independent Payment Advisory Board (IPAB) which has the power to decide what Medicare will actually cover. The IPAB will consist of 15 members; in fact, in 2012 $15,000,000 was appropriated for the IPAB whose members, while ruling on Medicare benefits, would not be obliged to report to Congress. Each member is to be paid about $165,000 annually -- without, one emphasizes again, without the pesky necessity of reporting to Congress which would still retain theoretical control although much abbreviated. 

Here's how it'll work: the IPAB gets the authority to make changes in the Medicare program but Congress retains power to overrule the IPAB's decisions if, and only if, it can muster a supermajority vote.  Otherwise, a gaggle of 15 appointees would make decisions on matters that are life and death to the elderly and to the especially vulnerable, e.g., age limits for surgery, or for insulin, or for renal dialysis. 

The far reaching effects of the IPAB were actually realized as early as 2010. In the second presidential debate, Gov. Romney had the temerity to ask President Obama who would be appointed to the IPAB. Obama's answer was "doctors et cetera."

Wrong. Obama's answer,  stated with finality, was wrong, but Romney didn't know it and let the issue slide by. Meanwhile the president got away with debate mayhem. He answered incorrectly and wasn't called on it by his opponent or the moderator.  The fact is that there is nothing in the language of Sections 3403 or 13020 that requires even a single physician to be appointed to the IPAB. The entire panel of 15 is to be political appointees with some modicum of interest in healthcare, e.g., the now ill famed coterie of "healthcare providers," anybody but knowledgeable physicians and scholars.THAT is what Obama would protect by threatening legislation that he considers "tinkering." 

The intent of the IPAB in its role as supporter of the ACA is to assess if cost projections exceed targeted growth rates. If that happens, then the IPAB without reporting to Congress is supposed to find ways to reduce Medicare spending -- in short, what will amount to deprivation of care from especially vulnerable patients with advanced or incurable disease. This category will include the elderly. It will be the modern day equivalent of the ancient Eskimo custom of turning frail and elderly citizens loose on ice floes. The trouble is that one can easily see that there may come a time when building a highway competes financially with elder care or with younger patients who need expensive care or advanced surgery. 

What could the president have told us about Obamacare that might have given us a little warning of potentially dire consequences that might just be around the corner, say, at tax time which is just around the corner?

That will be our Part 2, so tune in tomorrow.

OBAMACARE: IF YOU LIKE YOUR DOCTOR OR YOUR HEALTH-CARE PLAN ...

In 2009 President Obama declared that "I will ensure that no government bureaucrat gets between you and the care you need."

In fact, on 15 June 2009 President Obama declared that "if you like your doctor, you will be able to keep your doctor, period." That's when the president also promised that "if you like your health-care plan, you will be able to keep your health-care plan, period."

Now, four years later, as the ill conceived website for Obamacare crashes, and as more financial infusion and taxes are needed to float the Affordable Care Act (ACA), the president confesses, "Oh yeah, we did raise some taxes." Admittedly, that the website was badly conceived does not necessarily mean that the ACA itself was a mistake. The ACA boasts its own internal mistakes, one of which is the Independent Payment Advisory Board (IPAB).

Readers of this blog may recall our discussions of Sections 3403 and 10320 of the ACA which establishes the legal  basis for the IPAB. President Obama said that the IPAB would be composed of "doctors et cetera." The sad truth is that there is no provision whatsoever in the ACA that requires appointment of physicians. The IPAB will have the authority  to regulate the provision of healthcare and to restrict access to care -- here's how: the IPAB's job will be to make economic judgments and decide which diagnostic and  treatment protocols will be covered. Your doctor can prescribe diagnostic tests and treatment but an unelected panel will decide what is actually authorized. Patients can pay out of pocket for the rest. The IPAB panel is expected to include about 15 political appointees who, conveniently, won't be annoyed by such pesky requirements as reporting to Congress. IPAB board members are expected to be paid $165,000 per year, total cost to the public of about $2.5 million.

Spokespersons and publicists for the ACA do not mention the IPAB -- it's too sensitive.  When it was previously known in older legislation as the Independent Medicare Advisory Board it was reviled as a "death panel" for the elderly.

In California where Covered California is out-performing equivalent programs in other states, the meaning is that most, not necessarily all, Californians who are citizens or legal residents can get coverage. Of course, as companies drop the health care coverage citizens or legal residents already have, the premiums are likely  to go up -- so the ACA may not be so "affordable" after all. On the other hand, it won't have pre-existing condition preclusions and there won't be so-called "lifetime limits" or annual benefit limits.  Mental health benefits, often not included in employer owned programs, will be included. Expectedly, the cost of premiums is likely to go up.  Four basic programs are anticipated, bronze, silver, gold, and platinum. Bronze will have the lowest premium cost and the highest out-of-pocket co-pay. Platinum will have the highest premium and the lowest co-pay.

 Doctors have already been summarily dropped by Medicare Advantage programs in New York. CBS reported in California that Kaiser Permanente canceled policies covering 150,000 persons. In Florida, 300,000 persons have lost their health care coverage. They weren't asked if they preferred to keep the doctors or health care plans they already had.

References

"What Obama should've said about health reform," THE HILL, Washington, D.C., 9/16/09, Robert L. Weinmann, MD

"User's Guide to the Affordable Care Act (Obamacare) and the Independent Payment Advisory Board," http://totalcapitol.com/?blog, posted by bobweinmann, www.politicsofhealthcare.com,
June 28, 2012

"Affordable Care Act Loses Debate," The Weinmann Report - politicsofhealthcare.com, 10/04/12

"Obamacare: Separating Fact from Fiction...", www.politicsofhealthcare.com, 9/20/13

"Congress Keeps its Subsidies," www.politicsofhealthcare.com, 9/30/13

The Affordable Care Act (Obamacare) with emphasis on the Independent Payment Advisory Board (IPAB):  Memo to Subscribers & Followers of www.politicsofhealthcare.com   The hot-button issue in healthcare this week is the Affordable Care Act (ACA), known as Obamacare to some.  Within the text of the ACA is an item known as the Independent Payment Advisory Board (IPAB). The IPAB is the section of the law that will allow unelected appointees to overrule treatment decisions made by our personal physicians. The IPAB is empowered by Sections 3403 and 10320 of the ACA. This writer has found large enough fault with the IPAB to have called for its repeal regardless of whatever fate befalls the rest of the ACA. The fate of the ACA is likely to be decided on November 6th -- President Obama wants to keep the ACA as is, Governor Romney wants to repeal the whole thing. Check out our posts on this topic, e.g., January 18, 2011; June 29, 2012; October 4, 2012; and October 20, 2012 (this last one updated on October 29, 2012). When you check out the posts of 1/18/11, 6/29/12, and 10/20/12 you'll see reprints of my comments in POLITICO. Click on the box to enlarge the print to read the comments. Let me know what you think by commenting directly on-line at www.politicsofhealthcare.com (we do not sell, rent, or share your e-mail addresses with others.  Your comment will be considered for publication unless you ask us not to publish). -- RLW, Ed.

AFFORDABLE CARE ACT LOSES DEBATE

OBAMA and ROMNEY Debate each other but the loser is The Affordable Care Act.

It appears as though President Obama likes the name, Obamacare, for the Affordable Care Act (ACA). It wouldn't hurt if he understood his own legislation better. On other hand, why should he? He and Congress are exempt from it. Romney simply doesn't need it.

Romney said during the debate of 3 October 2012 that Obamacare "puts in place an unelected board that's going to tell people ultimately what kind of treatments they can have." Romney doesn't like that idea. Except he has incorrectly, some would say on purpose, misconstrued the unelected board,  named  the Independent Payment Advisory Board (IPAB). It will consist of political appointees none of whom need be a physician. Its purpose will be to oversee Medicare costs. The IPAB will have the power to shut down certain costs incurred by Medicare if costs soar out of control and Congress fails to intervene. The IPAB will not be enabled to tell individual physicians what tests to order or what treatment should be used. It will not be allowed to ration care on a patient-by-patient basis. It will not be empowered to raise the Medicare eligibility age or shift costs to retireds. What the IPAB will have will be the power to determine which diagnostic and treatment protocols aren't worth  funding anymore and will in that way ration care for the entire Medicare population, the same as when private insurance companies tell hapless patients that they're seeking what they determined in cloaked boardrooms were actually "non-covered benefits," i.e., you pay for it yourself because this or that benefit is not included in your private health care plan. The IPAB method constitutes a form of sophisticated rationing, but it's not on an individual patient-by-patient basis.

Obama said that the IPAB would be composed of "doctors et cetera." Not necessarily. There's no provision in the ACA that requires doctors to be appointed to the IPAB. Obama himself evidently didn't know that when he made his comment, either that or he sought to hoodwink the audience. The 15 or so appointees to the IPAB will be political appointees who will not need to report directly  to Congress. They will not be elected so they won't represent the public or an electorate. Their job will be to make economic judgments when they decide which diagnostic and treatment protocols will be covered by Medicare and which won't be covered. In short, your doctor can prescribe whatever he wants. But your doctor can't make Medicare pay for it. And neither can you.

The IPAB is empowered by Sections 3403 and 10320 of the ACA.  These sections of the ACA should be repealed. We'll have more to say in due course. So should Obama and Romney. The October 3rd debate showed that both candidates have lots more to learn about the ACA. For instance, they can tell us if it's correct that the members of this board are to be paid $165,000 per year at a total public cost of $2,475,000. Repealing these two sections of the ACA will save taxpayers nearly $2.5 million.