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

GOVERNOR BROWN SIGNS INTERPRETER BILL (AB 1376)

AB 1376 got the support from Governor Brown it deserved when he signed it into law on the last day available to him -- we did not feel the bill needed to have been the cliffhanger that it turned out to be but, in the words of the bard, "all's well that ends well." Kudos go to many supporters who worked on the bill and to the sponsors of this legislation, particularly Jesse Ceniceros, Board Chair, Voters Injured at Work (VIAW). VIAW was the chief sponsor of this legislation that will enable injured workers to have access to interpreters during medical visits. The bill was one of equity, allowing the deadline for certification of interpreters to be extended to 1 March 2014. Why a bill that passed the last legislative step without opposition in the legislature and clearly had bipartisan support had to wait until the last day of the session for the Governor to sign it intrigues political pundits -- was it just political theater or was there serious backroom efforts to get a veto? It intrigues us. We'll be getting back to SB 863 soon, too -- that's the bill that enables Independent Medical Review to be done by doctors who aren't licensed in California, just like Utilization Review doctors. That's the bill that promised injured workers more than it delivered and embarrassed the California Labor Federation. That's the bill that Senator Beall sought to revise this year via SB 626 which got pulled midway through the session. We'll be poised to pounce if SB 626 comes back in January for the 2014 legislative session. Our editorial from this past summer remains available (see references below).

References

SB 626 (Beall) Tackles SB 863 (Deleon), www.politicsofhealthcare.com, 4/15/13

SB 626 (Beall) Restores Equity and Balance, ibid,  2/24/13

SB 626 Alert, ibid, 2/23/13

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.

AB 1376 DESERVES SUPPORT ...

This bill is intended to make sure that the California workers' comp system continues to have enough interpreters to enable access to care for injured workers who are obliged to rely on interpreters to explain the details of their injuries, how they were incurred, what impairments have been caused, and what level of disability is being experienced. It seems like an easy call -- vote for the bill. In fact, the California legislature did vote for the bill. It passed handily without significant opposition. Now it sits on the Governor's desk as an item of enrolled but not signed legislation. We recommend that Governor Brown sign AB 1376.

Nurse practitioner bill, SB 491 (Hernandez), is down but not out

In part because of its own hypocrisy, the nurse practitioner bill has for the present taken an inglorious swan dive. Nonetheless, we believe it'll come to the surface again. But first, let's get to the juicy hypocrisy.

 

Political readers on healthcare will no doubt recall the nurses' efforts this summer to stop schools from allowing teachers and parents to administer insulin injections to diabetic students. The argument the nurses used was that teachers and parents weren't educated and trained to recognize when insulin injections should be given, what harm might occur were such injections not timely given or withheld, and what adverse side-effects might be expected, let alone treated.  It was a "safety" issue, nothing to do with job preservation.

Physicians identified with these arguments because these arguments were the same that the physicians' lobbies were using to fend off passage of SB 491 (Hernandez).  That the nurse practitioner lobby let itself use these arguments on one hand while arguing against them on the other hand turned out to be the very essence of poor political timing. We doubt they'll repeat the mistake when the bill resurfaces which, in due course, we think it will. So the word we issue to the CMA and its allies is CAVE CANEM (beware of the dog, the sign that was found in the Roman rubble of an ancient eruption of Mt. Vesuvius).

 

In essence, relying on the idea that Obamacare will cause a shortage of physicians, emboldened by Senator Hernandez' willingness to take on the traditional physicians' organizations, the nurse practitioners (NPs) sought the right to practice at levels beyond their education and training and to do so without physician supervision. One argument the NPs used was the shortage of sophisticated medical care in rural  areas. What they didn't say was that the NPs would actually populate these areas and stay there. They  didn't promise to accept lower pay, either. In fact, why  should they?  If the NPs are licensed to practice medicine as physicians, shouldn't they then be entitled to equivalent remuneration? That, we say, would be the logical next step for the nursing lobby. But first it was necessary to get SB 491 passed and signed into law. That is why it's inevitable that the NPs will try again sooner or later.

 

The California Medical Association (CMA) successfully argued that quality and safety in medical care was dependent upon proper education and training. Physicians well know that it's hard enough  to make diagnoses and render treatment even with 12 to 15 years of college, medical school, and advanced internship and residency training.

 

The Union of American Physicians and Dentists (UAPD) weighed in heavily on the side of the CMA. The UAPD  and the CMA acknowledged the importance of nurse practitioners but stopped short of allowing their level of education and training to be legislated as equivalent to physicians' level of education and training. Both organizations argued that the right way to fix anticipated physician shortage problems would be to expand post-graduate residency training positions for newly minted physicians and to expand the number of medical schools. The key  is to provide "properly trained individuals," not simply to invoke a "quick fix" by giving higher priority to the number of licensed professionals as opposed to the quality of the education and training of those professionals.   

 

Other organizations that helped to  oppose SB 491 included the California Neurology Society (CNS), California Academy of Family Physicians, Diabetes Coalition of California, California Society of Anesthesiologists, Blind Children's Center, California Academy of Eye Physicians and Surgeons, American Society of Ophthalmic Plastic and Reconstructive Surgery, Latino Physicians of California, Chinese Medical Dental Association, Let's Face it Together, Minority Health Institute, Dream Machine Foundation, Canvasback Missions, Lighthouse Mission, Time for Change Foundation, Here 4 Them, Osteopathic Physicians and Surgeons, etc (if we've left out your organization, just let us know).

 

References

 

See our blog of 6 August 2013 and references

 

The Daily Journal, San Mateo County, "A Slipper (sic) Slope Indeed," Robert L. Weinmann, MD, 8/13/13

Sacramento Bee, "Expanding role of nurses a recipe for malpractice lawsuits," Robert L. Weinmann, MD, 4/24/13