SENATE BILL 562 (INTRODUCED BY LARA & ATKINS): A PR0P0SAL FOR SINGLE-PAYER THAT INCLUDES PROVISION FOR COLLECTIVE BARGAINING

Senate Bill 562 enjoys the nickname of The Healthy California Act because it is intended to offer comprehensive health-care coverage to all residents of California -- it would be innovative as a single-payer plan for Californians. All the same the California Medical Association (CMA) is opposed.

By contrast the Union of American Physicians and Dentists (UAPD) holds a more guarded position and currently is "watch" on this bill although it is widely thought that the majority of its physicians who are employed or salaried favor SB 562. 

The reasoning goes like this: California already has a state-wide program called Medi-Cal (the stateside version of Medicaid). This program is administered by DHCS (Department of Health Care Services) and is largely governed and funded by the federal program, Medicaid. SB 562 purportedly would expand this program to cover all residents of California. 

The chief argument in favor of SB 562 is that it would cut out the meddlesome middleman, namely, the insurance company. Supposedly so doing would reduce costs; however, there is nothing in the law that mandates passing on these costs reductions to the patient. More likely the savings in costs would find their way into the pockets of the corporate overseers in the form of increased corporate compensation. 

The argument stumbles on, akin to the United States Postal Service whose rates have gone up while its efficiency has not. What is more likely than not is that the single-payer system would simply declare certain expensive services out of bounds as was done in the summer of 2015 when cardiac pacemakers were put on a rationing status by requiring conditions beyond what most cardiologists would require, e.g., Big Gubbamint decided that Mobitz Type II syndrome did not require a pacemaker.

How about rationing? Under the Affordable Care Act (ACA), popularly known as Obamacare, Sections 3403 and 10320 are especially relevant -- these sections set up how a public policy committee will be set up within the ACA to keep costs down. 

The method used for Obamacare was to appoint a committee,  the Independent Payment Advisory Board (IPAB) whose job it would be to decide, once costs got too high, which services should  be curtailed. The IPAB as envisioned in the ACA will not report to Congress. The salary is expected to be about $165,000 each for 15 appointees (none will be elected). 

Trouble is that SB 562 envisions a similar mechanism, namely, "a public advisory committee to advise the board on all matters of policy for the program." The members of this committee would include 4 physicians (one must be a psychiatrist) appointed by the Governor, Senate Rules Committee, and two by the Assembly Speaker. It doesn't get more political than that, does it!?

Two appointees would be registered nurses appointed by the Senate Committee on Rules. One would be a dentist appointed by the Governor. One representative would be from the private hospital sector, also appointed by the Governor. Another appointee would be a representative of the public hospital system, appointed, wouldja' believe, by the Governor. Another would be a representative of an integrated health care delivery system, no surprise by now, also appointed by the Governor. There would also be other representatives appointed by the Governor, the Assembly Speaker, and the Senate Committee on Rules. 

So instead of a science-based advisory board, we'll be offered a "public advisory" board steeped in political intrigue. 

Under Chapter 2, Governance, we learn that there will be "Appointments to the board by the Governor, the Senate Committee on Rules, and the Speaker of the Assembly," to wit 

(A) "At least one representative of a labor organization representing registered nurses,"

(B) "At least one representative of the general public,"

(C) "At least one representative of a labor organization,' 

(D) "At least one representative of the medical provider community."

Does it escape anyone's notice that the first dictum above guarantees appointment of two RNs and that none of the provisions guarantees the appointment of an MD? The closest it comes to that is the statement about someone from "the medical provider community" but not necessarily an MD.

Notice also how the provisions outlined above tilt to labor, e.g., the two RNs are to be from "a labor organization representing registered nurses" AND "at least one representative of a labor organization" which makes at least three appointees from Big Labor. Not, come to think of it, that the insurance companies haven't earned this shift in appointee preference!

In referring to a piece done by the undersigned for the Indiana Daily Journal in 2009 it was mentioned that "the trap to avoid is restrictive utilization review such that we get Rationing Coupons as opposed to access to care." When this comment came to the attention of Stuart A. Bussey, MD, JD, UAPD president, he stated that "we will follow this bill 562 and suggest safeguards to avoid restrictive utilization."

Finally, that brings us to why unions might be interested in SB 562. On page two of the current draft still in committee, we read that "the bill would authorize health care providers, as defined, to collectively negotiate rates of payment for health services." 

We will no doubt continue this discussion as SB 562 walks, runs, or stumbles its way through the legislative process. 

References

"Single-payer health plan has its own disadvantages," Indiana Daily Journal, Franklin, Indiana, August 8-9, 2009

"Medicare versus the Independent Payment Advisory Board (IPAB)," The Weinmann Report, www.politicsofhealthcare.com, June 29, 2015














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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.

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
 

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

OBAMACARE: "DOCTORS ET CETERA" IN THE ACA AND IPAB

DO IT OUR WAY OR DIE

October 29th Update to Politico comment of October 22nd. The above comment is in reference to "Presidential debate: 5 things to watch Monday" by MAGGIE HABERMAN and GLENN THRUSH | 10/22/12 4:23 AM EDT.
Read more: http://www.politico.com/news/stories/1012/82696.html#ixzz2AhZSGXJx

The highwater mark of Obamacare is carried in the bowels of the Independent Payment Advisory Board (IPAB), a level that hasn't yet been reached because the Affordable Care Act (ACA) is still in its infancy. It is the IPAB that will have the authority to declare entire diagnostic and treatment protocols too extravagant not only for Medicare but also for the general public and therefore not covered or payable by the ACA -- that's when Obamacare will become known for its bite.

But that bite won't chomp on President Obama or Congress because both of them are exempt from the ACA. Did you know that? Congress has its own health care plan. The Congressional plan does not include an IPAB to water  down care by restricting access to diagnostic testing and treatment. The current ACA does just that. The IPAB portion of the ACA should be repealed even if we continue to debate the rest of it.

Keep in mind that Congress keeps special healthcare benefits handy for itself including access to treatment at military hospitals.

In the autumn of 2009 President Obama stated "I will ensure that no government bureaucrat gets between you and the care you need." It's probably safe to say he wasn't thinking of the IPAB at the time. President Obama has now promised a minimum of 15 brand new bureaucrats.

In the first debate, President Obama said the IPAB would consist of "doctors et cetera." The fact is that there'll be plenty of "et cetera" but there's no obligation under the ACA that any of the 15 appointees to the IPAB must be a physician.

Governor Romney did no better than the president because he didn't seem to realize that President Obama was winging it when he said "doctors et cetera." What else does Governor Romney not know about the ACA except that he prefers his pals in the insurance industry, the blokes who rescind health care contracts once the subscriber has the temerity to get sick?

For a guy known for his financial expertise, we're surprised that the Governor failed to mention that each one of the 15 appointees to the IPAB will be paid $165,000 annually for a total annual budget of $2,475,000 just for the 15 appointees -- staff and resource time will get counted later, right?

The IPAB can be repealed without repealing the entire bill. The mechanism would be to rescind Sections 3403 and 10320. The current stand-off means that one side won't improve what's wrong with the ACA and the other side would repeal all of it to bring back the greed-soaked insurance companies.

See also our October 4th blog; use the glossary to find more articles about the IPAB, the ACA, and related topics.