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.

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

OBAMACARE IN THE STATE OF THE UNION ; WRONGFUL DENIALS OF CARE IN CALIFORNIA

WILL PRESIDENT OBAMA'S STATE OF THE UNION MESSAGE CONTAIN MEANINGFUL COMMENT RE THE AFFORDABLE CARE ACT?

"I will ensure that no government bureaucrat gets between you and the care you need." These words tumbled effortlessly from a confident President Obama in the autumn of 2009 but were immediately set aside in favor of more bureaucracy than healthcare has ever known. Healthcare pundits know that Obamacare as currently written allows for regulation of healthcare by non-physicians through a mechanism known as the Independent Payment Advisory Board (IPAB) whose concern is fiscal health as opposed to the health of patients. The Affordable Care Act (ACA)  also has a built-in mechanism starting in 2014 that will require $1.5 trillion in costs for families and businesses according to Stephen Frank, publisher & editor, California Political News and Views, 9/21/11. This dire prediction for the ACA worries fiscal conservatives. If the estimate is accurate it should worry everyone. We'll wait for President Obama to set our concerns aside before we comment further on Obamacare's managerial accounting.

Remember: the IPAB was once known as the IMAB or Independent Medicare Advisory Board. When the nation's Medicare patients realized they were being targeted for denial of care and supervision of allowable care as a form of  rationing, they raised a hue and cry. The IMAB was brought down. When the storm subsided, it was resurrected as the IPAB.

In the second debate with Governor Romney the president was asked about the make-up of the IPAB. He said it would be "doctors et cetera." There is nothing in the language creating the ACA that requires even one physician to be appointed to the IPAB. That's because, although expanded medical care was the ostensible reason for the ACA,  fiscal control has always trumped medical excellence in its design. The provision of the latest and best in medical care is spoken about but the IPAB is there to restrict what's actually offered. Congress itself wants none of it and opted out of the ACA.  Nonetheless, it's likely that at least one physician who is cooperative enough with the administration will be appointed to the IPAB. During the debate when the president said "doctors et cetera" he gave a false assurance that Governor Romney didn't recognize as such and let pass. We hope the the president will do better in the state of the union speech.

HOW ABOUT CALIFORNIA?

WILL CALIFORNIA  STOP DENIALS OF CARE BY IMR DOCTORS WHOSE NAMES ARE KEPT SECRET OR WHO ARE NOT  LICENSED TO PRACTICE IN CALIFORNIA?  

WILL INSURANCE COMPANIES IN CALIFORNIA BE ALLOWED TO CONTINUE TO RETAIN UR PHYSICIANS WITHOUT CALIFORNIA LICENSES?

We await legislation to abolish secret review of utilization review (UR) denials by so-called Independent Medical Review (IMR) physicians whose names will be concealed by law as mandated by SB 863. We await restoration of the WCAB's ability  to overrule wrong and harmful decisions that deny medical care to injured workers. We also still await law that requires physicians who do Utilization Review and Independent Medical Review to be licensed in California. As matters stand now, doctors not licensed in California can do UR and IMR reviews and deny care to injured workers in California. As the law stands now, the non-California-licensed physician cannot be disciplined in California even for the stupidest and most harmful denials of care since these doctors aren't subject to the medical board of this state. The doctor may be licensed in other states but those other states don't have jurisdiction in California. The time to correct this travesty is overdue. Labor unions and legislators should  revisit SB 863.

As matters stand now, a company named Maximus from Maryland is seeking doctors to do Medical Necessity Reviews for $150 to $200 per review. We do not have reliable information at this time as to what percentage of cases reviewed by Maximus end up in denial of care for injured workers. We don't know how much Maximus will actually pay for each review or how the money will be divided up -- we do know that the doctors are being offered a small enough percentage so that the deal remains attractive in terms of corporate compensation. We presume that the labor unions around the state would be interested in the details. Do we guess wrong? Tell us where we may've gone astray, please!

We will be adding to these comments on Obamacare, SB 863 in California, and wrongful denials of care  over the next few days. Stay tuned. These issues are hot potatoes.

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.

Users Guide to Affordable Care Act (Obamacare and IPAB)

Transcript of above:

#76

Jun. 26, 2012 - 3:00 PM EST

The Independent Payment Advisory Board (IPAB) provision of the Affordable Care Act (ACA), Section 10320, deserves special scrutiny. This provision is the one that opens the door to rationing. It does so by appointing a board that does not report either to Congress or to the public. The IPAB is essentially a protected bureaucracy that will have the power to rule that selected diagnostic tests and treatments do not qualify for coverage under the ACA. It amounts to a covert rationing scheme that will hogtie the hands of treating physicians while also tying the hands of sick and injured patients. In California we see an equivalent in the use of so-called Utilization Review (UR) by doctors retained by insurance companies or their surrogates. These doctors do not speak to or examine the patients for whom they issue denials of care. The IPAB is the ACA equivalent of California's UR. The difference is that the UR people are doctors: the onerous requirement to be a  bona fide physician will not be imposed on the IPAB's unelected elite. Doctors should be worried. Patients should be worried. Insurance companies should be grateful. The increased number of patients the ACA creates will be offset somewhat by allowing denials of selected diagnostic tests and treatment. Congress shouldn't be worried. Congress was smart enough to exempt itself from the ACA from the very start. Watch for this item when SCOTUS rules on the ACA.

Robert L. Weinmann, MD, Editor, http://www.politicsofhealthcare.com/

The point is we're being distracted with dissertations on The Commerce Clause, issues of penalty versus taxation, even some psychoanalysis of Chief Justice Roberts, everything but how access to health care is being reconstructed and even restricted.  Here are some of the issues:

1) ACA makes no restriction on how high insurance premiums can be raised,

2) The IPAB provision derived from Section 10320 of the ACA allows entire treatment protocols to  be disqualified from coverage to maximize cost savings. Physicians and their patients will need to fight if they want to have anything significant to say about this process.

3) Doctors will be advised to see more patients faster to make up in volume for reduced remuneration to accommodate the  huge anticipated increases in eligible recipients. Physicians will have to learn to stand their ground when it comes to deciding length of hospital stays and time allotted to patients.

4) Patients who can afford it may use the coverage that's allowed under ACA and step outside the system for whatever ACA doesn't cover,

5) The IPAB will become the Controller of health care because it will make the rules and regulations that decide what qualifies as allowable care under the ACA.  The IPAB is a federalized version of California's Utilization Review in Workers' Compensation. Decision-making authority will be in the hands of unelected politicians appointed to the IPAB by other politicians. As the Romans used to say, Cave Canem (Beware of the Dog).

AFFORDABLE CARE ACT AND THE IPAB: whose sails should be trimmed?

THE INDEPENDENT PAYMENT ADVISORY BOARD (IPAB) of the Affordable Care Act (ACA) was written into the ACA to control costs. It is a regulatory mechanism included in the ACA to regulate the commerce that the ACA creates. Congress cannot reasonably argue that the ACA doesn't create commerce while at the same time inserting into the ACA a mechanism to regulate newly created commerce. The argument comes down to this point: either Congress has the right to create commerce or it does not.

As a regulatory mechanism, the IPAB will have the authority to deny access to care to methods of diagnosis and treatment prescribed by licensed physicians. The IPAB will not report to Congress nor to the population at large. As a politically appointed board the IPAB will report to the political persons who appointed them.

The Supreme Court of the United States (SCOTUS) could invalidate some but not all parts of the ACA which was characterized in court as consisting of over 2,000 pages which many members of Congress haven't read and don't understand. On the other hand, everyone understands that insurance companies, left to their own devices, have often arbitrarily denied forms of treatment or engaged in retroactive denials of care and coverage. Nobody trusts the insurance companies to do the right thing, least of all Congress which exempted itself from the ACA. A modest proposal would be to preclude retroactive denials of coverage and arbitrary utilization review by doctors who haven't interviewed and examined the patients for whom specific diagnostic and treatment protocols have been prescribed. Another modest proposal would be to repeal the IPAB.

The more radical proposals are to do away with the entire ACA which would strip away protection from denials of care based on pre-existing conditions, e.g., life, and which could also pave the way for wrongful denials of care especially to the poor and elederly and to Medicaid and Medicare in particular.

Both sides have in common a distrust of the insurance companies; however, the Justices are supposed to deal with issues of law, not justice. It is strange then, isn't it, that we already know how at least four of the justices will rule. We don't need law degrees to know that. Neither do the justices need medical degrees to know the consequences of their decisions about the accessibility of medical care.

References

See The Weinmann Report on POLITICO Forums, POLITICO.com, 3/28/2012, Reply # 43, http://dyn.politico.com/members/forums/thread.cfm?catid=1&su ...

CAN CONGRESS CREATE COMMERCE? That's the question that was asked today in the United States Supreme Court with reference to the Affordable Care Act.

While it was acknowledged that Congress can regulate commerce, it was not accepted that Congress can create commerce. The basic question is whether or not the creation of the Individual Mandate creates commerce. It is this concept, requiring persons to purchase a product, that opponents argue is a step too far. Can government require the purchase of specific products on the grounds that they're good for us, e.g., the now famous broccoli argument, or exercise. What would prevent government from requiring the purchase of this or that vegetable if it were deemed good for the general health? Why not require everyone to buy a gym membership and then police the purchasers to be sure they exercise? The argument is that so doing would be an unconstitutional extension of federal authority even if the argument that "it's good for you" is correct.

WHAT IF THE LAW IS STRUCK DOWN? Will we then get return to policies that allow disqualification from health insurance because of pre-existing conditions?

WHAT IF THE LAW IS UPHELD BUT THEN WE TURN OUT TO HAVE A SHORTAGE OF DOCTORS? A shortage of 20,000 primary care doctors is predicted over the next few years. To this question we have an answer, i.e., government will allow non-physicians to practice medicine by setting up alternative credentialing processes that will allow persons with "alternative credentials" to practice (after all, in stiff white laboratory coats don't they all look alike anyway?).

WHAT ABOUT PIECEMEAL DISMANTLING OR ENABLEMENT OF THE ACA? The court could rule in such a way that insurance companies are precluded from denying insurance to persons with pre-existing conditions. The court could throw out the Independent Payment Advisory Board (IPAB) which many of us see as a thinly veiled ruse to deny access to care without invoking formal rationing (see our previous columns wherein the IPAB as a cost-control mechanism is discussed).

SOME PUNDITS THINK THAT BOTH OBAMA AND ROMNEY ARE ON THE ROPES, Obama because the ACA is largely his doing, Romney because he developed a similar plan in Massachusetts. Although Romney is campaigning against the ACA on a federal level, he avers that so doing within individual states is a matter of states rights, not unlike mandatory automobile insurance. On the other hand, Obama has let several of his health-care promises slip away, e.g., "I will ensure that no government bureaucrat gets between you and the care you need."

The IPAB was inserted into the ACA for cost control, in short, to stand "between you and the care you need." But for now, the ringing question is whether or not cramming mandatory health insurance down our throats is a wise extension of government policy or an unconstitutional creation of commerce as opposed to a regulation of commerce. Stay tuned.

Reference

"What Obama should've said about health reform," Robert L. Weinmann, MD, THE HILL NEWSPAPER, Washington, DC, 16 September 2009