Thursday, November 4, 2010



Inadvertently, some would say, Obamacare contains provisions that effectively ration care. With all due intent, others assert, it's no accident that the present version of Obamacare contains language creating pre-authorization restrictions. Here's how it works.

In the autumn of 2009 President Obama said "I will ensure that no government bureaucrat gets between you and the care you need." At the same time, however, Congress was considering HR 3200 which contained a provision to establish "a private-public advisory committee" to "recommend" treatment options. The public reaction was tepid, but House Minority Leader John Boehner (R-Ohio) and Speaker Nancy Pelosi (D-CA) noticed problems. The difference was that Boehner wanted to expose these discrepancies but didn't at the time have enough information to do so. The bill was only in its formative stages even though it was being rushed through the legislative process (see The Hill's Blog Briefing Room, story by Michael O'Brien with comment by the undersigned, 3/04/10). Pelosi didn't worry about internal problems in the bill --her agenda and that of President Obama was to get the bill passed no matter what flaws might be in it.

HR 3200 then gave way to HR 3962 which included a provision to set up a Health Benefits Advisory Committee which was further described as "a private-public advisory committee which will be a panel of medical and other experts to be known as the the Health Benefits Advisory Committee to recommend covered benefits." In other words, Medicare patients were on the verge of being "recommended" out of the care they needed. Patients generally were on the verge of being "protected" out of the care they might need by a new bureacracy for health care regulation that was actually contained in legislation that was being hurried past Congress.

HR 3962 would include an Independent Medicare Advisory Board (IMAB) that would be empowered to regulate care before-the-fact by utilizing techniques known as "pre-authorization" and "utilization review." At this point, chills should have radiated down President Obama's back. His allies in Congress had undercut his promise. Did he understand that? Nancy Pelosi should have been alerted that the IMAB would be a bureaucratic adjustment that would toss Presidents Obama's promise onto the scrapheap of political rhetoric.

Still there was no hue and cry about specifics in the bill which went unread by many Congressional representatives who didn't notice that key words such as "provider" or "other medical experts" were often used to hide the fact that non-doctors would be making medical decisions pertaining to access to care. Red flags were flying but a divided Congress wasn't arguing technical issues that should have been openly discussed. After all, it is not too difficult for most of us to recognize when we're being "protected" out of our rights and property.

That's when the next metamorphosis occurred, namely, changing the name of the IMAB to the Independent Payment Advisory Board (IPAB). Now the cat was out of the bag -- the bill, as critics had opined all along, wasn't about medical care after all. It was about cost-containment. President Obama's promise was now consigned to the proverbial scrapheap -- without a word in protest from the President.

The IPAB language, now inserted into the Affordable Health Choices Act of 2009, was fleshed out by Section 10320 of the legislation. The IPAB removes Congress from the ability to make decisions. In the opinion of this writer, it is a danger to patients, doctors, and hospitals. Organizations purportedly interested in affordable healthcare should seek repeal of Section 10320 -- repeal of this section does not spell the demise of the entire bill. Repeal of Section 10320 should be a priority of the hospital associations, the medical associations, and the unions -- in fact, everybody. It is just as harmful to a corporate CEO as it is to the lowest paid worker -- that is why the unions should also seek repeal of Sec. 10320.

The IPAB is a sneaky attempt to restore rationing by enabling denials of care in advance. It is a utilization review mechanism designed to reduce costs by reducing access to care. It should be repealed.