Trigeminal neuralgia -- one helluva headache! One helluva denial of care!

President Obama made this ringing declaration when he was promoting the Affordable Care Act:  "I will ensure that no government bureaucrat gets between you and the care that you need." 

Now comes Trigeminal Neuralgia,  known in medical neurological parlance as a particularly vicious type of headache, so severe  that some victims contemplate suicide. All the same there is a treatment for this disease that is remarkably successful in most cases. The usual treatment is with a medicine known as tegretol. Today's story is about a star-crossed patient who was unable to tolerate tegretol and what happened to her when Gubbamint Bureaucrats got their hands on her case.   

Initially, the patient was overjoyed. Her debilitating headaches evaporated under treatment with tegretol. Imagine, then, her consternation when she developed an allergic reaction to the medication. The allergic reaction included skin rash and an alarming development of abnormal hepatic function tests. There was no choice but to discontinue the tegretol. 

Doctor X replaced the tegretol with gabapentin which also worked. However, there were physiological non-allergenic side effects, e.g., dizziness, impaired balance, and sedation. So now the second successful medication had to be replaced. This step was taken with an extended release form of gabapentin known as Gralise. Medicare approved the use of Gralise but after a year another application to continue use of this medicine had to be submitted to the Center for Medicare and Medicaid. The Center for Medicare and Medicaid then rejected the proposed use of Gralise even though it had now been the patient's chief headache prevention medication for over one year. 

The reason was that FDA had approved Gralise for Herpetic Neuralgia only, not for Trigeminal Neuralgia. On this flimsy basis, Medicare in one fell swoop allowed the misery of intractable headache to invade this patient's life once again. Use of the medication for a different type of pain was called "off label" and subjected to unthinking automatic rejection. 

Doctor X appealed at the state level. In California the law allows continuation of care under such circumstances, e.g, AB 974 (Gallegos), a managed care reform bill that requires managed care plans to continuously provide prescription drugs. Unfortunately, this state legislation can be overruled by federal law that precludes "off label" prescribing. The next step was appeal to the Medicare Appeals and Grievance coordinator who pointed out that Medicare only allows medications to be covered on Part D when the FDA has approved the medication for that specific use -- in this case FDA had approved the medication for one form of neuralgia but not for another. Next, Doctor X sought a hearing before a judge in the Office of Medicare Hearings and Appeals. The case was made that FDA approved the medication for one form of neuralgia so it was reasonable in this case, especially since the medication had worked well for this patient for over one year, to allow renewal. 

Unfortunately, logic and science lost out to rule-making and semantics. The court ruled that the patient could not have the Gralise covered under Medicare. The judge's final letter of denial was issued on 2/18/16. The question arises as to what extent the federal system is responsible for denial of care when an adverse event occurs as a result of governmental ineptitude. 

In 1999 the Oregon Board of Medical Examiners disciplined a doctor for insufficiently treating pain. In discussing an analogous situation in California in 1979, Dr. Wm. Steinmith wrote that "a variety of official police bureaus -- under the rubric of protecting the public from professional abuse and abusers -- are rapidly destroying the professional foundations of humane and rational medical care." This author's opinion is that the Center for Medicare and Medicaid acted arbitrarily and wrongly in this case. 

Previously, The Weinmann Report, www.politicsofhealthcare.com, 3/18/14, and workcompcentral, 3/26/14, showed how an insurance company's Utilization Review company declined authorization of analgesic medication. 

This writer's finding is that the newest epidemic is the denial of medications by one or another form of Utilization Review at both state and federal levels. Physicians will take the blame while patients get the shaft. We need to hold the presidential podiatry to the fire on this issue lest all of us in due course get burned by the "government bureaucrats" from whom President Obama promised to protect us. 

References

"Utilization Review: Hypocrisy in Velvet Gloves," workcompcentral, 2014-03-26 and The Weinmann Report, www.politicsofhealthcare.com, 2014-03-18;

The Hill Newspaper, Washington, DC, 9/16/09, "What Obama should've said about health reform," by Robert L. Weinmann, MD;

Headache Quarterly, V. VII.  #4, 1996, "Predatory Policies in Health Care: Headache Patients as 'Marks,' " by Robert L. Weinmann, MD;

New York Times, National, 09/04/99, "Oregon Board Disciplines Doctor for Not Treating Patients' Pain;" 

San Francisco Medicine, "Professional Judgment," July 1979, by William Steinsmith, MD. 

MEDICARE VERSUS THE INDEPENDENT PAYMENT ADVISORY BOARD (IPAB)

Here is how it works: The Affordable Care Act (ACA) grants coverage to about 15 million persons not previously covered by what passed for health care coverage before passage of the ACA. Trouble is that Covered California and other ACA derived plans have now raised their premiums to cover the influx. But the premiums can't be raised enough to cover this influx. It has been determined that a better way  is to reduce utilization to keep costs below or equal to the pre-ACA expenditure. This method is a form of rationing with a special dagger aimed at the hearts of the elderly. It is called the Independent Payment Advisory Board (IPAB). 

Here's a pre-IPAB example: programs that provide vision care advise patients that refraction is not covered by Medicare or by most commercial PPO plans. Refraction is the method by which corrective lenses are prescribed. Medicare and the commercial PPOs determined that refraction isn't a medical procedure after all. Medicare and the involved PPOs conveniently decided that refractive errors requiring prescribed lenses are a result of changing eye-shape and are not because of disease.  Hence, coverage is denied.  

How about something more current than refraction? Let's take a look at what's happening to cardiac pacemakers. The Center for Medicare and Medicaid Services (CMS) has determined that as of 6 July 2015 coverage for cardiac pacemakers will be restricted to patients with "non-reversible symptomatic bradycardia." This decision means that patients with asymptomatic complete heart block would not be covered and that the exclusion will apply even to patients with asymptomatic Mobitz Type II heart block. So far our information is that the American Medical Association (AMA) has not filed a protest. We're now obliged to ask would-be presidents of AMA and contingent state medical associations where they stand on this matter.

We all recall Sarah Palin's barbs about "death panels" for Medicare. Suddenly, it doesn't seem as though she was all that far off the mark, does it?

That's where the Independent Payment Advisory Board (IPAB) comes in -- the IPAB was formed to manage costs that the ACA might run up due to the influx of previously non-covered patients. The IPAB owes its existence to Sections 3403 and 10320 of the ACA. The official job of the IPAB will be to control and cut Medicare spending. The IPAB according to the ACA will be appointed, not elected, and will not be obliged to report to Congress. In effect this technique will remove Congressional  oversight of Medicare spending. Instead,  unelected IPAB members will have this power. The salary for the 15 IPAB members is proposed to be about $165,000 annually -- once again we see there's money enough for bureaucracy but not for patients and citizens. The IPAB is ripe for repeal before it can do damage.

In the second Obama-Romney debate, Gov. Romney asked President Obama who would be appointed to the IPAB. Obama's answer, and I quote same in toto, was "doctors et cetera."
Although the reply was short, it was also wrong. Trouble is neither Romney nor Obama knew it. The fact is that there is nothing in Sections 3403 or 10320  or in the rest of the ACA that requires even one physician to be appointed to the IPAB. While it's likely that an acquiescent physician can be found, the fact is that there is no legal requirement under the ACA to appoint even one physician to the IPAB. The IPAB should be repealed forthwith -- so doing will improve the ACA by removing what to all intents and purposes looks as close to Palin's death-panels as one can get without handing the IPAB a portable gallows. 

WHEN PATIENTS GET TOO EXPENSIVE TO TREAT

What do insurance companies do when medical expenses get too high for comfort?  How may insurance companies deal with expanding medical costs that lower shareholder return and that may cause reduced executive compensation?

Currently, rituxin is one of the newer agents recommended for the active phase of acute demyelinating disease, multiple sclerosis in particular, but also extending to a complicated condition known as "lupoid sclerosis." Robyn G. Young, MD, Alameda, formely, president of the California Neurology Society,  states that this treatment is a preferred regimen for active system disease. e.g., MS/demyelination accompanying systemic SLE.

However, reluctance on the part of payers to cover this regimen has been noticed by frustrated clinicians whose treatment decisions may be delayed or denied by insurers who may assert that a specific treatment regimen is "experimental" and therefore not eligible for coverage under the plan. If that happens, the patient is then denied insurance coverage and may have to pay for treatment out-of-pocket while the insurance company continues to bill for its alleged coverage, whatever of that remains once what the patient currently needs is denied. 

Insurance companies have other ways of controlling costs. One of these other ways is to limit access to physicians to cover the number of enrolled subscribers. That increases the length of time it'll take to see a physician, especially a specialist, which in turn reduces expenses for the insurance company, which in turn allows more favorable financial quarterly reports to be issued. Another technique is to drop physicians from the MPN (medical provider network) based purely on business reasons -- no allegation of poor medical practice need be made. This latter technique reduces short-term expenses, allows for more favorable financial reports on a quarterly basis, and runs little risk of collectively increased long-term expense because of delays of care. Keep in mind that in workers comp, for instance, Temporary Disability (TD) runs out in two years. 

Doctor Young stated that "our patients should not be the victims of either insurance or pharma greed ... the physician has been devalued while all the other entities with financial interests in rationing patient care have been elevated in control and influence."

That is why some medical organizations seem poised to fight simultaneously for their patients' rights as well as for the rights of member physicians lest the latter become indentured servants dependent either on the corporate mentality that rules Big Biz or the other corporate mentality that rules government. In this regard watch for a likely take-down on an aspect of Obamacare (Affordable Care Act). The case is King versus Burwell, Docket # 14-114, set for SCOTUS argument beginning on 4 March 2015. The case deals with an IRS ruling re availability of federal tax subsidies to persons who bought health insurance on exchanges run by the federal government -- we'll cover more on that in future columns.

In the meantime, Doctor Young's conclusion  that "it is time that we (physicians) took back our role as patient care advocates" should be shouted from physician rooftops everywhere.

References

"Regaining Control of Medical Practice," CLINICAL EEG,  c. 1995, V. 26, #1 (reprints available SSAE upon request to Dr. Weinmann, 2040 Forest Avenue, #4, San Jose, CA. 95128)

"Union head urges reform in health care," THE OAKLAND TRIBUNE,  4 November 1998 (White House press conference with then President Bill Clinton)

Barack Obama, 2015, SOTU, Physician Shortages and Tax Consequences

Part 2

In Part 1 we dissected important parts of the Affordable Care Act (ACA, known as Obamacare) that have not yet hit the American public in the proverbial gut but which, in our opinion, reflect a flurry of body punches that's just around the corner. In due course, the IPAB (Independent Payment Advisory Board) will be obliged to act. Keep in mind that the IPAB used to be known as the IMAB (Independent Medicare Advisory Board) which got scuttled when Medicare's constituency realized that it was aimed straight at them  -- then it was reconstructed in the ACA with a name-change. 

The president boasted that about 10 million uninsured Americans were enabled to sign up for health insurance under the ACA. What the president didn't tell us was which health care plans including Covered California did not have enough physicians to cover expected demand. He did not disclose the looming physician shortage that healthcare plans anticipate. By way of personal anecdote, my own personal doctors display signs in their waiting rooms that they don't accept Covered California. In a nutshell, Covered California subscribers and subscribers to many of the ACA plans technically have coverage under their plans; but the plans themselves don't have enough physicians.  The president could have advised potential subscribers to make sure that health care plans include the physicians we trust and rely upon. 

Not to worry. There is a solution although maybe not one that many will like. Covered California and the ACA-enabled plans need not retain physicians if they can fill their ranks with physician assistants, nurses, and eventually nurses with doctorates in nursing practice. All the plans need to do is fulfill the legislative mandate with so-called healthcare providers which can include nursing assistants and other non-physician personnel. Some subscribers will feel they've been swindled, but it'll be too late to make significant changes. Then the president will be an ex-president on high-priced lecture tours. 

But the more imminent surprise will be taxes. It has been stated all along that there may be tax consequences in addition to a fine that has been touted as the likely penalty for non-subscribers who seek coverage.  With the 2014 Tax Year payments looming,  we now know that many Americans will face penalties when they file their returns and that these penalties will reflect aspects of the ACA legislation. The president could have advised American taxpayers to check out this contingency before filing their 2014 returns. Instead, he left them in the lurch.

Many of us expected better. It will not be our last disappointment. 
  

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.

Proposition 45: pro and con

Robyn G. Young, MD, president, California Neurology Society, presents her case for Prop. 45 in her editorial available on ca-neuro-society.org (it is also summarized in our previous blog in the end-of-article listing of references).

Now comes Stuart A. Bussey, MD, JD, president, Union of American Physicians and Dentists, who writes in the "The UAPD Pulse" why Prop. 45 does not deserve passage.

Bussey's piece makes these points:

1. Prop 45 would shift regulatory authority from an independent commission to one political figure who would then become a "pressure point" subject to special interests.

Comment: the independent commission is also subject to special interest pressure, but it's more difficult to get to an entire committee than one person. On the other hand, commissioners get their jobs by appointment, political appointment, not by scoring well on achievement tests.

2. Bussey points out that under the ACA administrative costs are limited to 20% -- anything over that "must revert back to patient services."

Comment: Trouble is that the insurance companies often try to sneak administrative costs into the "patient services" sector. Example are utilization reviews requested by insurance companies that seek to disguise them as "consultations."

3. If  Prop. 45 passes a likely revenge step the insurance companies will take will be to slash provider reimbursement. Agreed, that's what they'll do, not that they don't already do it. The independent commission has not roared its disapproval of provider abuse.

Comment: It's also likely that the insurance companies and MPNs (Medical  Provider Networks) will jettison hundreds of doctors as a way to reduce expenses (not that that hasn't already been done). That in turn will force the remaining doctors to see more patients faster (the short visit you get now will be made even shorter).

My opinion: if Proposition 45 passes, the next step will be the implementation of rules and regulations. Proponents should be ready to take that matter on from Day One. That means day-to-day readiness to participate in the regulatory process. Proponents feel they have a better chance at fair regulation with Proposition 45 than without it. Opponents are skeptical, and with good reason, e.g., the unions bent over backwards to get Brown elected Governor only to find out yesterday that he vetoed all three of their bills. Would a single insurance commissioner be different?

The latest re the ACA: a laboratory in San Jose has just  billed a doctor's office for laboratory work done for Medicare patients. The lab in question said that changes in the Affordable Care Act made in January of 2014 allows them to do so. We'll look into this matter and see what the current insurance commissioner wants to do --  it'll be a prelude to what he'd do were Proposition 45 to pass.

In our next blog, we're planning on a few parting shots re Prop. 46,

Question: When should lawyers be tested for drugs?

Answer: When they're awake.

OBAMACARE, COVERED CALIFORNIA, PROPOSITION 45, A CONVENIENT ALLIANCE

It  is not commonly realized by participants in health care plans sponsored by health insurance exchanges derived from the Affordable Care Act (ACA) that these plans are subject to changes allowed under the law.  The meaning is that a plan purchased this year may have been compliant with the ACA (Obamacare) at the time of purchase but may not remain compliant with changes that the ACA allows these plans to make (including the annual premium which may be raised annually if that's what the executives of these plans want). 

We understand that the ACA and the exchanges have dealt death blows to many longterm relationships between patients and their doctors.  It is not uncommon to see posters in clinics that state that the clinic and its doctors do not accept Covered California subscribers. 

Take a look at what it means to buy into a Bronze, Silver, Gold, or Platinum Plan. These plans reflect "actuarial values" which means the percentage of the covered benefits that each of the plans is expected to pay, e.g., Bronze Plan subscribers pay the least in annual premiums while paying the highest co-pays. Conversely, Platinum Plan subscribers pay the most for their annual premiums and in return pay the lowest co-pays. 

Currently, the Bronze Plan covers about 60% of health care costs. The Silver Plan covers about 70%. The Gold Plan covers about 80%. The Platinum Plan covers about 90%. The unpaid gap is the subscriber's co-pay, highest for patients who are strapped for cash and are obliged to purchase the lowest price plan, lowest for patients who can afford the Platinum Plan. That means that doctors, clinics, and hospitals who have a high percentage of Bronze Plan participants are most likely the ones who'll be stiffed on required co-pays. 

Here's the rub: each of the plans has a range that it's supposed to cover, e.g., at the time of this writing the Bronze Plan is reported to cover from 58 to 62 percent. It is expected that as time marches on there will be changes, even favorable changes in these plans. Because of how the ACA is written and because of how the exchanges function, a Bronze Plan that now covers 60 percent may at some time in the future cover 65%. The rub is that the next step up in the ACA division is the Silver Plan which starts coverage at 68 percent which means that your Bronze Plan no longer qualifies as a Bronze Plan but also doesn't qualify as a Silver Plan. So your plan is no longer valid under the ACA. 

What may be even harder to understand is that the Platinum Plan also has limits. It cannot cover more than 92 percent. So doing is not legal under the ACA.

So where does Proposition 45 which is on the November ballot in California fit in? Proponents of the ACA or Obamacare fear that passage of Proposition 45 could prove harmful to the ACA since the Covered California exchange recently negotiated a rate increase for its over one million plus enrollees. 

The ACA makes purchase of healthcare insurance mandatory but does not regulate premium prices. Covered California, like other insurers, does not want to have rate increases it can currently negotiate subject to being rescinded by an insurance commissioner. Proposition 45 would  empower the insurance commissioner to do just that. The Insurance Department in California is reported to have found that rate increases from 2013 to 2014 are from 22 to 88 percent (the Covered California board has not voted a position one way or the other on Propostion 45 as of the date of this article).  

References for this piece: 

1) THE HILL Newspaper,  Washington, D.C., "What Obama should've said about healthcare reform," 9/16/09, by Robert L. Weinmann, MD;
2) POLITICO, "GOP govs could gum up Obamacare," 2/10/10 ("I will ensure that no government bureaucrat gets between you and the care you need"), by Robert Weinmann, MD; 
3) John C. Goodman (www.Forbes.com/sites/John Goodman, 9/23/14 ("if you like your insurance you can keep it");
4) SAN JOSE MERCURY NEWS, "Measure creates odd alliances," Tracy Seipel, 9/26/14;
5) Editorial, Robyn G. Young, MD, President, CALIFORNIA NEUROLOGY SOCIETY, 9/17/2014 (www.ca-neuro-society.org): these three points are emphasized:
  a) Prop 45 will require public disclosure of hearings re health inssurance rates;
  b) Prop 45 will require approval of changes in health insurance rates by the California Insurance Commissioner;
  c)  Prop 45 will require sworn statements about the accuracy of information submitted to the insurance commissioner to justify proposed rate changes.

  Comment: Prop 45 proposes transparency that the ACA (Obamacare) has consistently denied, e.g., Pelosi's laughable comment that the ACA had to be passed so we could see what's in it and then an Independent Payment Advisory Board (IPAB) that by law need not include even a single physician. The Covered California board likes the murky mists of non-transparent legislation. THAT is what Prop 45 seeks to change. THAT scares insider deal-moguls to the very core of their existence.  

CALIFORNIA CUTS NUMBER OF UNINSURED

"California cuts number of uninsured" was the headline for the San Jose Mercury News Editorial on July 15, 2014." The editorial iself stated that California "has cut the percent of residents without health insurance in half since last summer, from 22 percent to 11 percent of the population." The editorial then blurts out that "the percentage of uninsured Americans has dropped from 18 to 13.4 percent in the same time"and "would have dropped even more if all the states were taking advantage of the Affordable Care Act's health exchange program."

Comment: these statements show how correctly quoted statistics can cause misunderstanding and to all intents and purposes lie outright. I personally queried ten doctors at a local hospital. It turns out that none of them accept Covered California since the plan sticks it to them

WE ARE ALL VETERANS: COMMENTS ON THE CURRENT VETERANS' ADMINISTRATION FIASCO

WE ARE ALL VETERANS: will the same dismal outlook overtake our military veterans in the VA system as it did the Post-Traumatic Stress Disorder victims at Madigan General Hospital (see our blog from Sunday, February 26, 2012)?

The latest ringing quote from President Obama, "I  will not stand for it!" is vaguely reminiscent of other outstanding verbalizations from the president, e.g, when he said that "I will not let any bureaucrat stand in the way of the care that you need," then stalwartly pushed ahead with the IPAB (Independent Payment Advisory Board) woven deftly into the ACA (Affordable Care Act) in Section 10320 (see our previous posts on this issue wherein we tell how the IPAB is designed to limit access to care without pesky Congressional oversight).

The latest medical scandal concerns the Veterans Administration (VA). On the rack at the moment is former General Ric Shinseki. The issue is to what extent the VA may have cooked the appointment books such that 40 veteran patient-deaths are attributable to delayed medical care at the Phoenix VA.

Speaking out in evident ire, President Obama said "it is dishonorable ... it is disgraceful." As a result 26 VA facilities are now under investigation. While Shinseki  promises to get to the bottom of the matter, the press noticed he wasn't standing next to President Obama during the president's  press conference (speculation is the General was in a roadside foxhole  as would be any sensible soldier while a hostile straffing mission worked the skies above).

"If there is misconduct it will be punished," the president declared, ringingly adding, "I will not stand for it!" Meanwhile, Ron Nabors will supervise review of the VA and the expected IG Report which will tell us what's to be done and whether or not Shinseki still has a job. Obama, meanwhile, declares "we all know it takes too long for veterans to get care" while simultaneously inserting commens that the problem was also true for previous administrations regardless of party lineage. Trouble is these remarks come from the same source that first promised that no bureaucrat would interfere with the care we need, then said that we could keep our doctors, and finally for strike three that we could keep our current insurance if that's what we wanted to do.

"What we don't want is people making ... decisions based on money instead of care of the troops!" So said Representative Norman Dicks, D-Belfair.  The issue then was lifetime benefits for soldiers diagnosed with PTSD (post-traumatic stress disorder). 14 soldiers with this diagnosis were reportedly costing the government from $400,000 to $1.5 million in lifetime benefits. To save this money, a forensic psychiatry team changed the diagnosis.  President Obama needs to apply the same language he used re the Veterans Administration, in short, it's time to ask if bureaucrats in the Madigan decision "cooked the books."

This writer was never satisfied with the explanations put forward at the time. Neither are we satisfied with the way in which the VA situation is being investigated -- it looks like Gen. Shinseki is being prepared and prepped to take a fall. The immediate reasonable solution is to assign more physicians to each of the 26 VA facilities now under review. This adjustment should start in Phoenix. The Madigan  situation should also be reviewed with possible restoration of benefits that remain denied.


The overriding issue is whether or not the entire country is being prepared for reduced access to  care, what Philip Klein referred to as "access shock." The issue is to what extent "choice" will be sacrificed by the ordinary citizen so that insurance companies can enhance profits by reducing costs by such methods as simply offering less in terms of physician access and access to diagnostic and treatment facilities. It's called scrimping and skimming.

Now we find out that scrimping and skimming in the Veterans Administration may have led to the death of former troops just as it is expected that the IPAB portion of the ACA will lead to derelict care, diminished levels of treatment, and even to the death of patients mired in a bureucracy of healthcare mandates that has been a disappointment from rollout despite constant revisions.

"I will not stand for it," he said? No, WE will not stand for it, or better not, lest we hoist ourselves on the same rope we used to strangle PTSD care at Madigan and VA care everywhere. We are all veterans of unwise decisions that have converted medicine into a succession of programs beneficial mostly to insurance companies and like-minded corporate interests.

The time has come for all of us to shout "I will not stand for it!"

Disclaimer

The writer is an Army veteran, Captain, USAMC (U.S. Army Medical Corps), and admits to bias on the part of the veterans.

References

The Weinmann Report (www.politicsofhealthcare.com, 2/26/12

"Head of Madigan removed from command amidst PTSD probe," Seattle Times, 2/20/12,  by Hal Bernton

"Army insists doctors at Madigan aren't discouraged from diagnosing PTSD," The News Tribune, 2/10/12,  by Adam Ashtone

"Rationing comes home to roost in the form of denial of care," www.politicsofhealthcare.com, 2/17/12, and www.workcompcentral.com, 2/24/12

"President Obama's oblique references to healthcare," www.politicsofhealthcare.com, 2/27/12

"President Obama apologizes and promises to interfere with care you don't need," www.politicsofhealthcare.com, 11/08/13

"Obamacare insurer says Americans have to break the 'choice' habit," www.washingtonexaminer.com/article/2548386, 5/13/14
 

DISILLUSIONMENT INVADES MEDICAL PRACTICE

"The best decision I ever made was coming to the USA for advanced training. The worst mistake I ever made was deciding to stay."


So sayeth a respected physician, a department chairman in his specialty, whose name is being withheld since he didn't give us permission to use it. The point is that this doctor's doctor expected to spend his life caring for people, healing the sick, the force behind the profession for so many neophytes in medicine. They did not expect to become nursemaids to insurance companies or to the Affordable Care Act.  But that has become their fate because taking care of patients, actually comforting them, has taken second place to the requirements of paperwork without which neither doctor nor hospital can be paid. Today after  interviewing  a bevy of doctors who spent about an hour each on computerized hospital discharge orders (it used to take 10 minutes if you wrote legibly) it became clear how disillusioned they were.


In our previous column we described how the internists found a way to mega-wealth by opting out of clinical practice and opting into the rarified world of industrialized and corporate billing ($800,000 for the board chair according to that year's IRS 990 form). But here's the other side of that coin: according to Kathy Kristof's report in MONEYWATCH,  internists see one patient every 30 minutes, put in 54 hours per week, but waste 23 percent of their time doing paperwork for insurance companies. Take home pay is around $185,000 (about a half-million less than the board chair's 800 grand). The lesson is learned: income has shifted away from clinical medicine and patient care and towards control of capital just as in business.


The new motto is "profits before patients." Keep that in mind as your doctor rushes out the door from your clinical visit. You are important, yes, but the paper trail is crucial. That's where the money is. By the way, Kristof's article is entitled "$ 1 million mistake: Becoming a doctor."


References


$1 million mistake: Becoming a doctor, MONEYWATCH, by Kathy Kristof, 9/10/13 (my editorial comment-- insurance companies are increasingly forcing hospitals and their doctors to process patients as though they were produce, get 'em in,et 'em out, and bill 'em quickly)


Obamacare enrollees hit snags at doctor's offices, LOS ANGELES TIMES, by Chad Terhune, 2/04/14 ("people are having trouble finding doctors")


LifeForSale.com,  documentary movie, Evelyn Li, MD, Medical Consultant ("Life For Sale explores dangerous nooks and crannies of healthcare that until now have remained hidden from public view" -- RLW, Editor, www.politicsofhealthcare.com)

Late addition to post, 2/24/2014: "Doctors, insurers face off over pay," SAN JOSE MERCURY NEWS, by Tracy Seipel, 2/14/14,  ("... insurers are often caving in to the doctors ... medical costs are the largest component of a health insurance premium ..."  What this otherwise well researched story doesn't tell is that physicians' share of the health care policy premium is from 17 to 18% and that the insurers get the last word in the 'face off' when they use Utilization Review to deny specialty services, e.g., consultations, or refusing to cover physical therapy or to approve expensive diagnostic studies)




 

YOUR DOCTOR ISN'T IN THE PLAN ANYMORE. NEITHER IS YOUR PLAN.

"I'm sorry," tolls the receptionist in a bored voice, "but your doctor isn't in our plan anymore."

Senator Reid opts out: click on comments at end of this editorial re Reid's Obamacare snub

Item A concerns a doctor whose healthcare policy was abruptly canceled when her own physician announced he was quitting the health care plan, would no longer accept insurance, and would henceforth require monthly "concierge" style payment, plus a cash fee for office visits, and that she'd have to have separate insurance for hospitalization whether needed or not.  As for the healthcare plan he was leaving -- the plan would either be disbanded or taken over by doctors who could speak English.

Note: for the uninitiated, "concierge" style practices require advance payment arrangements such as monthly, quarterly, or annual payments plus fees applicable to the services patients use. Medications are not included. Insurance plans are not accepted.

Item B is about several doctors in various settings who have in common that they've sold their practices to corporate entities, foundations, exchanges, or other business groups. It works like this: the corporate entity buys the practice, then employs the doctor or somebody else to run it on a day-to-day basis. The corporate entity pays the staff, the rent, and the expenses. To recoup its money, and to make more money, the practice is required to double or triple its volume. To accomplish this task, the time spent with  each patient must be reduced, say, to a few minutes. That'll be the job of the staff who now no longer works directly for the doctor or the patient but who instead is responsible to the employer. In this plan, insurance is still accepted, in fact, is welcome. If the on-site managing doctor and his staff can't meet these goals, they'll be replaced.

Healthcare Plans that cover patients, doctors, and insurers vary widely. They may assign doctors to multiple plans and keep track of so-called "production," how many patients each doctor sees and how long the average visit takes. Doctors whose "production" numbers are profitable to  the company will have a higher rate of retention providing they don't rock the corporate boat in other ways (then they're called "disruptive" and get fired anyway).  What procedures and surgeries are allowed will be a corporate decision dependent on cost-benefit ratios, not patient need.

Healthcare Plans may be narrow and include a minimal number of specialists and no highly sub-specialized surgeons. It's your  personal out-of-pocket lookout if services not included in your medical provider network are sought.

Utilization Review (UR) is already used in California for injured workers who may be denied access to specialized care by a UR doctor who is not licensed in California and who has never seen the patient. The UR doctor's judgment may nonetheless overrule the California-licensed primary treating physician's judgment even though the primary physician has spent hours with the patient.

In this way, UR in California and the ACA throughout the USA are joined -- see our previous editorials on the Independent Payment Advisory Board (IPAB) which was originally rejected for Medicare under its previous name, the Independent Medicare Advisory Board (IMAB). Some pundits assert that the ACA under the guise of Obamacare is actually a nationwide watered down HMO and that to keep it that way it's necessary to eliminate as many hospitals and specialized centers as possible, and as many doctors as possible, while making the remaining doctors act like cattle herders trying to avert a stampede.

Stay tuned. These issues have long legs.

References

"How to practice medicine without a license," San Francisco Chronicle, 8/29/08

OBAMACARE: FURIOUS BACKPEDALLING DETRACTS FROM ALREADY DIMINISHED CREDIBILITY

When is the last time that an American president asked to have the law set aside so that presidential credibility might be restored? How about right now?

Even though California Insurance Commissioner Dave Jones has indicated that California should go along with the president's request to allow older insurance policies that don't meet the required criteria of the Affordable Care Act (ACA) to be extended, Covered California Executive Director Peter Lee says no dice because the state of California cannot force the insurance companies to grant extensions. Covered California voted 5 to 0 that allowing these older policies to continue would undermine the ACA even though President Obama himself, in a spectacularly furious backpedalling gesture, asked for just that. In so doing the president hoped to restore his diminished credibility when he promised so loudly and so often that if you liked your current doctor or your current policy you could retain either or both.

All the same, as of this writing, the ACA is doing well in California. About 80,000 persons have signed up for policies. Nevertheless,  about 220,000 non-compliant policies in California may be extended despite Peter Lee's exhortations otherwise. The reason, however, isn't as much the presidential plea for mercy as it is the insurance companies' assertions that they didn't have enough time to notify clients and don't have enough time anymore to make necessary adjustments.

By now it has become evident that ACA-compliant policies are likely to cost more than the non-compliant policies they replace -- we've already seen the example of the woman who congratulated the president on Obamacare and then found out that she couldn't afford it and would now be worse off than before when she had a non-compliant policy. Now she has none. Evidently, Peter Lee thinks that "none" is a suitable alternative for her. Lee may turn out to be even more of an ideologue than the president himself. It took a while for the president to acknowledge his mistake, but, in due course, he did just that. Meanwhile the ideologues stomp ahead, trampling opposition, no matter how small and desperate they are.

In general, the idea of insurance for all should take hold, but not in an atmosphere of partisan bickering, party affiliation, and ultimate hypocrisy where Congressional representatives, as one of their perks, may seek medical care at any American military hospital on a "prn" basis.

Yessirree,"prn" is the abbreviation for "pro re nata," which means according to need, their needs, not ours. Once again Congress looks out for itself first. Citizens like us get promises, then dregs, then raised premiums that push the ACA into offering policies that often turn out to cost more than the policies they replace. The risk now is that the ACA will protect us out of more health care than it'll provide in return. We hope not lest the ACA become known as the Unaffordable Care Act (UCA).  

OBAMACARE: "NOT ENOUGH IS BEING DONE IN WASHINGTON THAT HELPS ME WITH MY LIFE!"

No doubt about it, President Obama heard the criticism and has responded in kind.  His announcement today that the individual mandate would be postponed by one year is designed to assuage the millions of subscribers who were satisfied with their health plans because they'll now be enabled to keep them for another year even if they're not compliant with the Affordable Care Act (ACA).

When queried by press about his constant reaffirmations of the original plan to promote the ACA in the face of a failed internet sign-up program, the president spoke to the people's hearts when he said "I'm not stupid enough" to have promoted an internet program had he known in advance that it was about to be an abject failure. He admitted the "fumble." Now that's language we can understand although we'd still like to know who in our capitol was stupid enough to have left the president holding the bag. In private business, such persons get reassigned to life-at-home although we've become inured to their walking away with golden parachutes.

Issues that weren't faced up to entirely include why increased cost may be an inevitable outcome. One argument we've used in this blog is that the ACA requires 60 year old grandmothers to purchase policies that include maternity care. Ridiculous? Maybe not. The same ACA requires 27 year olds to pay a rate that'll include prostate disease coverage for older men. That's just how all inclusive insurance works.

There's no denying that  private insurers used to dump patients once sickness and injury claims were filed and that previous administrations tolerated this rueful practice. There's no denying that some insurers used to resurrect claimants' healthcare histories and retroactively cancel a claimant's policy because the applicant had acne that came under medical treatment at age 17 and wasn't reported at the time the applicant bought insurance coverage -- but that, too, was tolerated. 

There's no denying that annual limits and lifetime limits would often ensnare the very sick into bankruptcy -- but this egregious insult and harm was also allowed by previous administrations. Obama's credit is that he sought to resolve these inequities but in his eagerness failed to keep  his eye on the ball and misled the public. He is now gradually trying to dig himself out of the hole he dug -- today's step is a shovelful in the right direction.

But will a one-year postponement do enough or will it just give everybody breathing room until the inevitable cancelation catastrophe one year from now?

One problem is that pro-private-insurance interests opposed to the ACA are rooting for failure and will inevitably point out that President Obama is unilaterally suspending the law to recoup his own popularity with midterm elections pending. Proponents will support the president or seek further enabling legislation.  

California will be a statewide workshop since we're being told on the one hand that  in California one million cancelations have been sent out and will now need to be rescinded -- what will be the cost of that and who will pay for it? On the other hand, we're also told that California leads the nation in ACA sign ups.

Political pundits will notice that today's discussions have so far not mentioned the Independent Payment Advisory Board (IPAB) -- that is Sections 3403 and 10320 of the ACA that'll allow cancelation of benefits once the ACA  gets too expensive. The IPAB is to be staffed by appointed bureaucrats at $165,000 per year. They will not need to report to Congress. Now there's something to worry about! Ask your Congressional representatives about it -- if they're making a beeline for legislation, tell them to take this item under advisement to strip the IPAB of its power to take away our increasingly hard-won benefits.

PRESIDENT OBAMA APOLOGIZES AND PROMISES TO INTERFERE WITH CARE YOU DON'T NEED!

"I am sorry that they are finding themselves in this situation based on assurances they got from me" is as much of an apology from President Obama as we're likely to get. This apology isn't abject but it's a remarkable turn around from the president's previous wholehearted support of the Affordable Care Act (ACA). It's a far cry not only from his June 2009 promises but also from his September 25th statement in Maryland where he ringingly declared, once again, that "if you already have health care, you don't have to do anything."

By now we know that millions of  policy holders have been skunked because private plans purchased directly from insurance companies have been arbitrarily and unilaterally cancelled by the insurance companies that so eagerly sold them in the first place. These plans have conveniently been declared non-compliant with the ACA. The convenience is that the same companies can now turn around, create ACA-compliant health care plans, and sell them to their own customers at a hefty mark-up. It may not quite be double-billing, but it sure as Hades qualifies as "double-selling."

Here's what another one of our knowledgeable sources says:
"It's not the ACA doing this, it's the insurance industry using the ACA as an excuse to institute more advantageous plans for themselves." Right on! Too bad the president and his devoted inner clique didn't tumble to that in time  or didn't speak out. In fact, that millions of people would lose their health-care plans was actually reported in the Federal Register in June of 2010. Therefore, the obligation of public disclosure was technically met. Too bad, isn't it, that President Obama and Secretary Sibelius didn't read it or decided to ignore it while they steamrolled the public instead.

Our source whom we'll call Josefina points out that "the insurance companies were allowed to set up and offer whatever they wanted as long as they include no cap, no discrimination for pre-existing conditions, and some basic care inclusions such as maternity care and mammograms."

In fact, given these required inclusions, it can be argued with reasonable medical assurance that the ACA-compliant policies are probably superior to the plans that are now being pulled off the market. On the other hand, the buyer lost his choice of product.

Here's what happened to Josefina: first, Blue Cross cancelled her  health care plan. Blue Cross blamed the ACA. Then Blue Cross told Josefina they would send her a replacement policy that needed to be accepted by December, 2013 "in order to delay implementation of the ACA provisions at the same rate of $1427/month. They made it sound like that would be a good thing for me when the advantage is all theirs, including being able to max me out of my plan." A reasonable argument can be made that Blue Cross is complying with the ACA by offering a superior replacement policy even though such plans in the future are expected to cost more.

Josefina, who understands insurance, pointed out how the new plan could be ACA-compliant while also decreasing other coverage included in her previous plan but which isn't mandated by the ACA. By now our reading public knows that the ACA compliant plans include mandatory coverage of mental illness and maternity care even for 60 year old grandmothers. So the public finds it has to buy superior plans that cost more in order to cover the previously uninsured population estimated to be around 22 million persons.

Here's Josefina's summary: "They (the insurance companies) blame it on the ACA (Obamacare) but it actually (is) the insurance company industry manipulation while pretending that it's the ACA." 

Our conclusion: we agree with this assessment but feel obliged to point out that the Federal Government knew about the scam as early as June of 2010 -- that's when the president and Secretary Sebelius should have told the rest of us what was cooking in a pot that was shortly to boil over and burn millions of people who believed the presidential assurances from as early as 2009 and as recently as September of 2011.

One can only be dismayed at such deception unless we buy the argument  that the president and his staff were simply incompetent. Remember, this president is the same one who also promised in a speech on health reform in 2009 that he would make sure that "no government bureaucrat gets between you and the care you need." 

Although President Obama admitted that "we weren't as clear as we needed to be in terms of the changes that were taking place," he did not acknowledge that he knew at the time, or should have known at the time, that millions of persons would lose their private healthcare plans. Now we see a welcome reversal of field: "we've got to work hard to make sure that we're going to do everything we can to deal with folks who find themselves in a tough position as a consequence of this." Our information is that the president has instructed his staff to "close some of the holes and gaps in the law" and to find out to what extent he can help as many persons as possible who lost their insurance.

Is that a promise to interfere with policies that foist insurance plans on us that we don't need? Sometimes there's no winning strategy. Instead, there's  a chance for restorative damage control. That could be the ultimate winning strategy in this otherwise fiasco of healthcare reform.

References

"User's Guide to the Affordable Care Act (Obamacare) and the Independent Payment Advisory Board (IPAB)," 6/28/2012, http://totalcapitol.com/?blog

"What Obama should've said about health reform," The Hill, Washington, D.C., 9/16/09

OBAMACARE: "IF IT HASN'T CHANGED SINCE THE LAW WAS PASSED..."

By now we all know the story: "water, water everywhere, but not a drop to drink," or, in its latest revision, "words, words everywhere, but not a syllable of truth anywhere."

"If you like your doctor, you will be able to keep your doctor. Period. If you like your healthcare plan, you will be able to keep your health care plan. Period."

Ooops, not 'zackly "period," more like a comma from a president who must have been in a coma when he misspoke so badly and so carelessly on 15 June 2009 when he recklessly promised so much only to deliver so little four years later.

The new version of "period" is "if it (your health care plan) hasn't changed since the law was passed." The president's awkward attempts to shred and parse his previous language are downright embarrassing particularly to those among us who trusted him at the time.

Here's the latest horror story we have, relayed by a subscriber who has asked us not to publish his name but whose revulsion at the deception he's been offered is palpable.

Joe B, we'll call him, had an individual policy with Blue Shield in which he enrolled in 2012 and which he intended to keep especially since his president told him that if he liked his health-care plan he could keep it, "period!"

Joe B's plan was HSA compliant with high deductibles, $4,000 individual, $8,000 family-embedded. There was no so-called "lifetime maximum." Joe B recently was advised by Blue Shield that the health-care plan he liked and expected to keep would not be available after 12 December 2013. He was told that the plan he liked and had intended to keep was not compliant with the Affordable Care Act, that his new premium for a plan he didn't want would be increased by 40%,  that his deductibles would go up by 12.5%, and that his co-pays after the deductible was met would, in Joe's own words, "skyrocket."

Next Joe B  checked out CoveredCA. Too bad for Joe B, because CoveredCA did not offer him any HSA compliant plans. Joe B's conclusion, sadly on target, is that "the lies which were told that both got the law passed and got many elected or re-elected (Obama) are insidious and cause for great concern for our country."

Next, Joe B learned about the IPAB (Independent Payment Advisory Board) from our blog and finds that  provision of the ACA "cause for great additional concern."

Joe B's conclusion: "Stealthily setting up a plan to redistribute income through the healthcare system is what is resulting, and it's just not right."

Our conclusion: if the president wants to ease into a more socialized system, or a single-payer model, he should have the intestinal fortitude to tell that to the voting public.  What he is doing now is an attempt to deceive the public and re-write history. It is likely that the computer glitches in the sign-up process will eventually be fixed, but Joe B has just found out that the HSA compliant health care plan that he liked and was told he could keep is out the window -- that, my friends, is not a computer glitch. It was false when the promise that Joe B could keep his health care plan was initially floated and remains so today -- a sad commentary and severe blow to our ability to trust our president's promises on healthcare or anything else.




 

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

CONGRESS KEEPS ITS SUBSIDIES

Dateline, Washington, DC, 2 AM, 1 October 2013 -- In our earlier blog on 9/30/13, we mentioned Rep. Langford's last ditch effort to scuttle subsidies and create an even playing field for Obamacare. The idea, to impose a one year delay in the requirement of the Affordable Care Act that individuals buy health insurance, was also supposed to deny federal subsidies to MOCs (Members of Congress), to staff employees of Congressional offices, to members of the Executive Branch, to White House staff, and to both the president and vice president for the same length of time. It turns out that that was a "No Fly Zone." When asked about it, Speaker Boehner said the Constitution mandates that Congress be paid. Yes, maybe so, but there's nothing in the Constitution that says MOCs and their Capitol Hill staffers must have subsidies in addition to salaries. In a masterpiece of hypocrisy, both sides of the aisle have managed to cause a shutdown. Military is excluded and will be funded but not necessarily all of their civilian counterparts at the Pentagon. We will want to stay tuned: today's fight isn't over and the debt ceiling conflict is just around the corner.

Dateline, Washington, D.C. 3:50 PM, 9/30/2013 MOC James Langford now wants to pull all individual exemptions in Obamacare while leaving intact current business exemptions. He points out how at first Congressional exemptions were proposed and then replaced by mandatory participation and then in turn how subsidies snuck into the game with the result that individual exemptions blossomed for the favored few on both sides of the political aisle leaving the befuddled middle class out in the proverbial cold. At this writing there's still 8 hours to go to shutdown.

OBAMACARE: separating fact from fiction in the Affordable Care Act (ACA)

On 20 September 2013, President Obama stated that Obamacare would enable millions of Americans who were locked out of the system to get quality health care. He did not mention Section 10320 of the Affordable Care Act (ACA) that can be implemented when the government feels that costs are getting too high -- at this point the Indpendent Payment Advisory Board (IPAB) is enabled by law to bypass Congress and simply eliminate or disqualify specific services from coverage. While we understand the fiscal imperatives of this Section of the ACA we also feel that the public should be properly advised how such a provision might work, for instance, insulin injections for patients over 80 years of age could be denied payment, so could dialysis coverage for patients over 75 years old, or surgery for brainstem tumors in children. When push comes to shove, it will be of interest to notice if there's equity in denials of care, for instance, will Congressional representatives and staff be subject to the same denials of coverage that will be imposed on rank and file citizens? These questions have come to the surface since our original posting. The ACA under the IPAB Section is empowered to delete coverage under the act, not to tell citizens they can't pay independently for care denied coverage under the ACA. For many patients denial of coverage is tantamount to denial of care. Previously, we've touched upon whether or not Obamacare (ACA) exempts Congress and staff from the full effect of the law as Representative Jim Jordan, R-Ohio, claimed in his August 8th statement which asserted that Congress was getting "special treatment." Jordan stated that Obamacare "exempted Congress and their staff from the full effect of the law." True or not? The Office of Personnel Management says that the federal government usually pays around 75% of employees' health insurance premiums. Newly issued rules regarding payment of employees' health plans bought on the exchange won't be more than the government's contribution for other federally insured workers. Congressional representatives will decide who is employed by the "official office" as opposed to Congressional committees -- the former will be obliged to buy insurance from the exchanges whereas staffers retained by committees will not be obligated to buy from the exchanges. The group hired directly by a Congressional office will be eligible for up to 75% reimbursement or contribution to premium costs. The fact is that "all full-time and part-time employees employed by the official office of a Member of Congress" will be obliged to buy insurance through the exchanges. These employees are eligible for the Congressional co-pay which the Office of Personnel Management says is between 72 and 75% of its employees' health insurance premiums. So what's the uproar about? It is clear that there is a difference in how Congressional employees get treated under the ACA. A large part of the credit or blame for this difference goes to Senator Grassley's amendment to the ACA: it was Senator Grassley whose amendment specified that Congressional staffers "fully participate in the exchange by picking a plan, paying for it on their own, and perhaps qualifying for subsidies (italics added)." This reference to "subsidies" bothers Jordan and others who believe that the ACA is not equitable. The fact is that others besides Congressional employees will also be entitled to subsidies. Hence, the ACA is equitable although it may be more expensive than had been originally envisioned. It is also doubtful that Congressional persons will ever suffer from arbitrary decisions by the IPAB. In a nutshell, Congress and staff are not exempt from the ACA. Co-pays and subsidies are allowed but are not limited to Congress and staff.

My opinion: Grassley intended his amendment to be a poison pill that Democrats wouldn't swallow. He was wrong. The Democrats gulped it down and then shoved it down Republican throats. The real problems will be access to coverage for care. The ACA creates employment worries about full-time versus part-time employment, secretive denials of care by the IPAB under the guise of fiscal restraint whereby specific services are denied or made subject to increasingly onerous rules and regulations. Rising private insurance coverage costs with increasingly higher required deductibles are expected, e.g., middle America will find itself trapped between policies that cover too little and adequate private coverage that costs too much and requires high deductibles. In this scenario, the only winners are the insurance companies.

Credits: Paige Robbins was Chief Research Associate for this piece.

References: The Plain Dealer, PolitiFact.com; News release, Jim Jordan, 8/08/13; Lima News, "Jordan said challenging Obamacare is his top priority," 8/14/13; Office of Personnel Management press release, 8/07/13; News release, Sen. Charles Grassley, "Grassley amendment makes Congress obtain coverage from health care plan established in reform bill," 9/30/09.

IF THE WORK IS EQUAL, SHOULDN'T THE PAY BE EQUAL?

Senate Bills 491, 492, and 493 (Hernandez) would allow RNs with advanced training, optometrists, and pharmacists to practice medical care without the pesky obligation of going to medical school, doing internships, or submitting to residency programs under the supervision of faculty. Indeed, most surgery would remain out ot bounds (not all surgery, mind you!).  The nurses, optometrists, and pharmacists would be allowed to undertake primary care. The RNs with advanced training would be qualified as Nurse Practitioners.  Proponents argue that this largesse will reduce medical costs because lower-cost workers would take over some of the tasks done by physicians. Just where to draw the line is one of the problems. For instance, how does one "draw the line" when the differential diagnosis of, say, "numbness" is the chief complaint?  Should an evaluation  for multiple sclerosis be considered? The patient who is misdirected to the lower level diagnostician will find out the hard way.

The San Jose Mercury News, in an editorial on April 12, 2013, said "these bills ... would allow nurse practitioners to establish indpendent practices and deliver limited care without a doctor's oversight." It has also been argued that the lesser-level practitioner would be paid less. Herein lies a problem: if the NP, optometrist, or pharmacist is delivering medical care equal to or on a par with physicians, shouldn't the lesser level practitioners be paid at the same level?

The Affordable Care Act is supposed to expand access to care, not to water it down.

Recently, we learned that the Union of American Physicians and Dentists negotiated a raise for physicians by showing that a  group of nurses was being paid more than their physician counterparts. The opportunities in Hernandez's  legislation make it worthwhile for physicians, nurses, optometrists, and pharmacists to organize into collective bargaining units lest the Hernandez package be used to create equal work with unequal pay. 

If the Hernandez  package is passed,  the nurses' unions would be asleep at the switch if they did not seek equal pay for equal work.