Even Critics of ObamaCare’s Independent Payment Advisory Board Miss Its Worst Rationing

Recently there has been a fair amount of press coverage of the effort to repeal a central aspect of the Obama Health Care Law—the unelected 18-member Independent Payment Advisory Board given sweeping powers to limit what people are allowed to spend for health care. Strangely, however, most critics focus only on its impact on Medicare spending, and at least one of its defenders appears ignorant of the authority it will exercise to limit Americans’ use of their own private funds.

Democratic representatives are increasingly joining Republicans in co-sponsoring H.R. 452, a bill to repeal the Independent Payment Advisory Board. As noted in an April 19 New York Times article by Robert Pear,

Democrats and Republicans are joining to oppose one of the most important features of President Obama’s new deficit reduction plan, a powerful independent board that could make sweeping cuts in the growth of Medicare spending. Mr. Obama wants to expand the power of the 15-member [sic] panel, which was created by the new health care law, to rein in Medicare costs. But not only do Republicans and some Democrats oppose increasing the power of the board, they also want to eliminate it altogether. Opponents fear that the panel, known as the Independent Payment Advisory Board, would usurp Congressional spending power over one of the government’s most important and expensive social programs. Under the law, spending cuts recommended by the presidentially appointed panel would take effect automatically unless Congress voted to block or change them. In general, federal courts could not review actions to carry out the board’s recommendations.

In an April 21 piece defending the board, Paul Krugman, one of the paper’s op-ed columnists, wrote, “Before you start yelling about ‘rationing’ and ‘death panels,’ bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money. We’re talking only about what will be paid for with taxpayers’ money.”

Yet Krugman’s statement is flatly wrong.

As documented with specific quotes from the legislation at http://bit.ly/itblQZ, the Obama Health Care Law specifically directs the board to make “recommendations to slow the growth in national health expenditures” for private—not just governmentally funded—dollars devoted to health care. These recommendations are supposed to limit what ordinary citizens and their health insurance coverage can pay for medical treatment to force it below the rate of medical inflation.

To implement these recommendations, the federal Department of Health and Human Services is empowered to impose so-called “quality” and “efficiency” measures on health care providers. Doctors who violate a “quality” standard by prescribing more lifesaving medical treatment than it permits will be disqualified from contracting with any of the health insurance plans that individual Americans, under the Obama Health Care Law, will be mandated to purchase. Few doctors would be able to remain in practice if subjected to that penalty.

This means that treatment that a doctor and patient deem advisable to save that patient’s life or preserve or improve the patient’s health, but which exceeds the standard imposed by the government, will be denied even if the patient is willing and able to pay for it.

“It is truly astounding that this extreme form of rationing has gone almost unremarked even by critics of the Independent Payment Advisory Board,” said National Right to Life Executive Director David N. O’Steen, Ph.D. “That means it is up to grassroots pro-lifers to make both their elected representatives and media outlets aware of the facts, and of how important it is that the Independent Payment Advisory Board be repealed.”

More details on the rationing in the Obama Health Care Law are available at http://bit.ly/161yrt.

OBAMA PROPOSES TO LIMIT AMERICANS’ HEALTH CARE EVEN MORE THAN UNDER OBAMACARE

In the much ballyhooed debt-reduction “framework” President Obama revealed this week in a speech at George Washington University, the President proposed a dramatically graver limit on what Americans will be allowed to spend for our own healthcare than that which will be imposed by the Obama Health Care Law if it is not repealed before 2015.

As now enacted, the Obama Health Care Law directs an unelected 18-member panel called the “Independent Payment Advisory Board” to limit what Americans are permitted to spend on health care out of their own, nongovernment, funds to less than enough to keep up with medical inflation. However, Obama is now proposing what the White House framework calls “a more ambitious target of holding . . . cost growth . . . to GDP [gross domestic product] plus 0.5 percent beginning in 2018, through strengthening the Independent Payment Advisory Board (IPAB).”

Suppose this proposal had been in effect in 2009, the most recent year for which statistics are available. In 2009, because of the recession the overall real GDP per capita, as reported by the Bureau of Labor and Statistics, actually shrank by 2.1 percent. If you use President Obama’s formula for that period of time, after adding .5% , Americans would have been forced to decrease what we would be allowed to spend to save our lives and preserve our health by 1.6 percent.

In 2009, the actual rate of medical inflation was 2.7%. Had the Obama Health Care Law (ObamaCare) been in effect, Americans would have been able to increase their medical spending, but not enough to keep up with the 2.7% medical inflation rate.

But under the Obama proposal announced this week, what Americans of all ages would be permitted to spend for health care, taking into account the increased cost of medical goods and services, would in real terms be 3.3% less than in the previous year.

While there has been increasingly widespread opposition to the Independent Medical Payment Advisory Board from physician groups, Republicans, and an increasing number of Democrats, the public focus has been on its mission to make cuts in government Medicare spending. Far too little attention has been given to the rationing it would impose through limits on the resources Americans will be allowed to devote to our own health care.

Under the Obama Health Care Law, these limits will be subject to enforcement by the federal Department of Health and Human Services, which will be empowered to impose so-called “quality” and “efficiency” measures on health care providers. Any doctor who dares to provide life-saving treatment in excess of these limits will be disqualified from contracting with any of the insurance plans which, under the individual mandate, Americans will be required to purchase.

The Obama Health Care Law must be repealed, and his still more draconian proposals defeated. If not, as is now true of Canadians who must often come to the United States to obtain life-saving health care, Americans will increasingly have to find locations abroad if we want to be able to use our own money effectively to save their own lives.

PRESIDENT’S SUPPORT FOR STATE “FLEXIBILITY” IN IMPLEMENTING OBAMA HEALTH CARE LAW WON’T AVOID RATIONING

President Obama made headlines in a speech before the National Governors Association, when he endorsed a Senate bill described as allowing states to seek “waivers” of certain requirements in the Obama Healthcare Law. However, the offer comes with strings, and would do nothing to change the elements of the federal law that will impose rationing of medical treatment if it is not repealed.

There would be no “waiver” from the duty of the Independent Payment Advisory Board to recommend, or the authority of the federal Department of Health and Human Services to impose, so-called “quality” and “efficiency” standards on health care providers designed to limit what Americans will be permitted to spend on life-saving medical care for themselves and their families, forcing it below the rate of medical inflation.

Senate Bill 248, for which the President expressed support, would move from 2017 to 2014 the date when states would be allowed to seek exemptions from certain Obama Health Care Law requirements, such as state insurance exchanges, and the individual and employer mandates. Such a waiver would be granted, however, only if the Administration is convinced that the state’s alternative would 1) make insurance just as "affordable" as under Obamacare (translation: limit what resources people are allowed to devote to their own health care); 2) Cover as many people as Obamacare with health insurance which is as “comprehensive” as Obamacare; and 3) Not increase the federal budget deficit.

Most States are struggling with their health care budgets, and many expect the situation to become worse under the requirements of the Obama health care law. Politico reported, “The move comes as governors, particularly Republican state leaders, say the law is overly burdensome on the already stretched states. Much of the expansive legislation has to be implemented at the state level.”

Were the bill to be enacted, the most likely result would be that proposals threatening the most dangerous rationing would see new life in the states. For example, Vermont officials are pushing hard to secure a waiver to implement their proposed “single-payer” system – under which all Vermont citizens would be forced into a single state government health plan, subject to state budgetary limits, with no opportunity to choose other insurance less likely to ration. Said Senator Bernard Sanders (Socialist-VT), “At a time when 50 million Americans lack health insurance and when the cost of health care continues to soar, it is my strong hope that Vermont will lead the nation in a new direction through a Medicare-for-all, single-payer approach.”

While it is, in theory, possible for states to craft any sort of plan they wish within the requirements, it is difficult to see how the Obama administration might approve ones that did not dramatically curtail what people are allowed to spend for their health care. It is precisely the policy of preventing people from being allowed, if they choose, to use their own funds to keep up with health care inflation that creates the gravest threat of rationing.

The Senate proposal may have a difficult time in the House, where congressional Republicans want states to have much more flexibility. Inside Health Policy wrote that the plan to bump up the waiver dates, “was met with disdain from GOP lawmakers, who said the opt-out criteria are too stringent and called the move a confession that the bill is unworkable in its current form.”

Politico reported, “Mandating many of the same requirements, this plan would treat states as agents of the very law these governors are running away from,” said Michael Steel, spokesman for Speaker John Boehner. “A better approach would be working with reform-minded governors to give states more flexibility . . . . Now that the administration has conceded that Obamacare is unworkable, we hope they will work with us to repeal the law and replace it with common-sense reforms . . . .”

STATE OF THE UNION: HONEYED WORDS HERALD WORSE RATIONING AHEAD

Suppose a government official announced a plan to limit the automobiles you were allowed to buy, so that only the smallest and cheapest would be available. It is likely most Americans would oppose it. Announce a plan limiting what automobile manufacturers can charge you for cars, however, and it would sound appealing to many people. Yet both proposals would amount to the same plan. When the government imposes limits on what people can choose to spend for a product or service, it means that only those items that producers can afford to provide at or below the government limit will be available. Instead of letting consumers balance cost against benefit, and decide what they can afford to and want to spend their own money on, the government takes that choice away from them.

Now consider what President Obama said in his January 25, 2011 State of the Union speech about health care. He said his health care law “prevents the health insurance industry from exploiting patients.” That certainly sounds good: no one wants patients to be “exploited.” But what does it mean? Obama considers it “exploiting” people when they are given the option of paying more to save the lives of their families, through the purchase of unrationed health insurance, than Obama thinks they should be allowed to choose to pay.

There is an old joke about a man being stopped by a thief who points a gun at him and says, “Your money or your life!” The man replies, “Take my life. I’m saving my money for my old age.”

It’s very foolish to pay less than you can afford for health insurance if that means you and your family will be stuck with a cheap “managed care” plan that will use “utilization review” and limited drug “formularies” to limit the treatment or drugs you may need to save your lives. It’s foolish to look only at the price without also considering the quality you will get for that price.

Americans balance quality and price all the time. Of course we look for the “better deal” that will save us money, but we also keep in mind that sometimes paying bottom dollar for shoddy merchandise is no bargain.

In the State of the Union speech, President Obama said of what people are allowed to spend on health care, “The health insurance law we passed last year will slow these rising costs.” And he called for “further reducing health care costs.”

What he didn’t mention was how the Obama health care law will “slow . . . rising costs.” It will do so in large part by forcing doctors and other health care providers to limit care, through “quality and efficiency” standards imposed on them that will establish one uniform national standard of care for what treatment may – and may not – be offered patients. Beginning in 2015, these “quality and efficiency” standards will be drawn from recommendations of an 18-member Independent Payment Advisory Board that is directed to come up with ways to limit what private citizens choose to pay, using their own funds and private insurance, so that they cannot keep up with the rate of medical inflation. (For details and documentation, see http://www.nrlc.org/HealthCareRationing/Index.html .)

If you’re not allowed to keep up with medical inflation, what do you think will happen to the quantity and quality of the health care you can get? It will go into a steady decline.

Yet Obama is not only pledged to veto any repeal of the health care rationing law– he is now threatening to seek unspecified (so far) measures that will limit the resources Americans are allowed to use to save their own lives still further.

Honeyed words – but words that mean one thing: worse and worse health care rationing ahead.

HOUSE TO VOTE ON OBAMA HEALTHCARE LAW REPEAL NEXT WEEK

Last night, H.R. 2, to repeal the Obama Healthcare Law, was introduced in the House of Representatives. The bill is scheduled to come up for a vote on Wednesday, January 12th. Repeal would protect Americans from the rationing that would deny or limit life-saving health care. Unless the Obama Healthcare Law is repealed or dramatically altered, the following will occur:

1. Bureaucrats in Washington (the Department of Health and Human Services, based on recommendations by the Independent Payment Advisory Board) will be able to dictate what treatment your doctor or hospital can – and can’t – give you through so-called “quality and efficiency measures.”

2. As Medicare is slashed by billions of dollars, federal bureaucrats will be empowered to deny or limit older Americans' choice of adding their own money, if they wish, to get unrationed insurance.

3. Consumers will be denied the choice of plans offered by insurers who allow their customers to spend what state bureaucrats deem an “excessive or unjustified” amount for their health insurance.

Full documentation of these and other rationing elements can be found here.

2010 General Session: 2,000 Pages of Really Bad Stuff

Listen to Master of Ceremonies and National Right to Life Executive Director David N. O’Steen give background on how the health care system worked before and will work after Obamacare. Then, Federal Legislative Director Douglas Johnson discusses abortion coverage in the new law. Finally, Burke Balch, J.D. who directs the Powell Center for Medical Ethics discusses rationing components of the law. To download the PowerPoint presentation accompanying the discussion of rationing, click on "Rationing in the Obama Health Care Law, June 26, 2010." To see as well as hear the presentation, view the C-SPAN coverage.

How the new Health Care Law Limits Senior Citizens’ Right to Use Their Own Money to Save Their Own Lives

Section 3209 of the health care bill signed into law on March 23, 2010 effectively allows federal bureaucrats at the Centers for Medicaid and Medicare Services (CMS) of the federal Department of Health and Human Services (HHS) to bar senior citizens from adding their own money, if they choose, to the government contribution in order to get private-fee-for-service Medicare Advantage (MA) plans less likely to ration life-saving treatment.

Medicare—the government program that provides health insurance to older people in the United States—faces grave fiscal problems as the baby boom generation ages. Medicare is financed by payroll taxes, which means that those now working are paying for the health care of those now retired. As the baby boom generation moves from middle into old age, the proportion of the retired population will increase, while the proportion of the working population will decrease. The consequence is that the amount of money available for each Medicare beneficiary, when adjusted for health care inflation, will shrink.

In theory, taxes could be increased dramatically to make up the shortfall – an unlikely and politically difficult proposition. The second alternative—to put it bluntly but accurately—is rationing. Less money available per senior citizen would mean less treatment, including less of the treatments necessary to prevent death. For want of treatment, many people whose lives could have been saved by medical treatment would perish against their will. The third alternative is that, as the government contribution decreases, the shortfall could be made up by payments from older people themselves, so that their Medicare health insurance premium could voluntarily be financed partly by the government and partly from their own income and savings.

It is not widely understood that, as a result of legislative changes in 1997 and 2003 undertaken at the behest of the National Right to Life Committee, this third alternative had become law. Under the title of “private fee-for-service plans,” there is an option in Medicare under which senior citizens can choose health insurance whose value, under the law in effect through 2010 [endnote 1], was not limited by what the government may pay toward it. These plans could set premiums and reimbursement rates for providers without upward limits imposed by government regulation.

This means that such plans would not have been forced to limit treatment, as long as senior citizens were left free to choose to pay more for them. Medicare covers everyone of retirement age, regardless of income or assets. Yet, because of budget constraints, the Medicare reimbursement rates for health care providers tend to be below the cost of giving the care—a deficit that can only accelerate as cost pressures on Medicare increase with the retirement of the baby boomers. To cope with this, providers engage in “cost shifting” by using funds they receive in payment for treating privately insured working people to help make up for what the providers lose when treating retirees under Medicare. Thus, comparatively low-income workers often effectively subsidize higher-income retirees.

However, when middle-income retirees are free voluntarily to add their own money on top of the government contribution, through a private fee-for-service plan, they stop being the beneficiaries of cost-shifting and become contributors to it. Thus, preserving this option without premium price controls would not only have allowed retirees who could afford it to reduce the danger of being denied treatment; it also would have resulted in the ability of providers to provide more treatment to those who cannot afford to add additional funds on top of the government contribution. See generally the Powell Center's webinar on affording health care without rationing.

Section 3209 of the new law indirectly amends the section in the Medicare law as it previously existed that allowed private fee-for-service plans to set their premiums without approval by the Center for Medicare and Medicaid Services (CMS) by adding, “Nothing in this section shall be construed as requiring the Secretary to accept any or every bid submitted by an MA organization under this subsection.”[endnote 2] This gives statutorily unlimited discretion to refuse to permit private-fee-for-service plans to charge premiums sufficient to offset the reductions in the Medicare government contribution.

Theoretically, of course, the federal bureaucrats given this new authority could choose not to exercise it. That seems highly unlikely during the Obama Administration, however, since on February 22, 2010 the President specifically proposed that the health bill include a provision under which Medicare Advantage plans (which, as noted, include the private-fee-for-service plans) would explicitly "be prohibited from charging seniors more than they would pay for services delivered under the traditional Medicare program."[endnote 3] While this explicit prohibition was not included in the final law (presumably because rules governing the “reconciliation” procedure did not permit it), it clearly demonstrates the policy stance of the Administration, which under Section 3209 it will now have authority to implement.

TECHNICAL EXPLANATION
Understanding how the health care bill that became law on March 23, 2010 gave power to the federal Department of Health and Human Services (HHS) to limit senior citizens' right to add their own money requires following a complex trail within the bill and existing law to understand the effect of Section 3209. Under pre-existing law [42 U.S.C. § 1395w-24 (a)(6)(B)(i) & (ii)] [endnote 4], the Secretary of Health and Human Services has authority to “negotiate” the premiums to be charged by private Medicare plans (“Medicare Advantage” health insurance plans) – meaning that the Centers for Medicare and Medicaid Services (CMS) in HHS can keep a Medicare Advantage plan from participating unless it agrees to charge a premium acceptable to CMS– , but this authority did not apply to private fee-for-service plans [42 U.S.C. § 1395w-24 (a)(6)(B)(iv)] [endnote 5] – meaning that CMS had no power to impose a premium price control as a condition of participation for private fee-for-service plans, which could be excluded only if they failed to meet other applicable standards.

Section 3209 effectively trumps this crucial exemption by giving CMS the absolute and standardless discretion to reject premium “bids” by any Medicare Advantage plan, including a private fee-for-service plan. Specifically, it would add this subparagraph:

( c) Rejection of Bids.–
( i ) In general.–Nothing in this section shall be construed as requiring the Secretary to accept any or every bid submitted by an MA organization under this subsection.[endnote 6]

This means that the previous law that effectively forbade the Secretary to exclude a private fee-for-service plan on the basis that CMS considered its premiums to be too high has been trumped by the new ability of the Secretary to reject “any or every” premium bid submitted by a private fee-for-service plan.

ENDNOTES

[1] Section 3209 takes effect with regard to plans that will be in operation in 2011. See Section 3209( c).

[2] Section 3209 is found on page 904-905 of the engrossed Senate-passed bill.

[3] The proposal appears under the heading, "Title III . . . Guaranteeing Benefits for Seniors by Ending Overpayments to Insurance Companies."

[4] 42 U.S.C. § 1395w-24 (a)(6)(B) reads, in relevant part (emphasis supplied):

(B) Acceptance and negotiation of bid amounts.
(i) Authority. Subject to clauses (iii) and (iv), the Secretary has the authority to negotiate regarding monthly bid amounts submitted under subparagraph (A) . . . in exercising such authority the Secretary shall have authority similar to the authority of the Director of the Office of Personnel Management with respect to health benefits plans under chapter 89 of title 5, United States Code [5 USCS §§ 8901 et seq.].
(ii) Application of FEHBP standard. Subject to clause (iv), the Secretary may only accept such a bid amount or proportion if the Secretary determines that such amount and proportions are supported by the actuarial bases provided under subparagraph (A) and reasonably and equitably reflects the revenue requirements (as used for purposes of section 1302(8) of the Public Health Service Act [42 USCS § 300e-1(8)] [relating to the standards for setting different rates for individuals and families and for individuals, small groups, and large groups]) of benefits provided under that plan.

[5] 42 U.S.C. § 1395w-24 (a)(6)(B)(iv) provides:

(iv) Exception. In the case of a [private fee-for-service] plan described in section 1851(a)(2)(C) [42 USCS § 1395w-21(a)(2)(C)], the provisions of clauses (i) and (ii) shall not apply and the provisions of paragraph (5)(B), prohibiting the review, approval, or disapproval of amounts described in such paragraph, shall apply to the negotiation and rejection of the monthly bid amounts and the proportions referred to in subparagraph (A).

The “provisions of paragraph (5)(B)” incorporated by reference are:

(B) Exception. The Secretary shall not review, approve, or disapprove the amounts submitted under paragraph (3) or, in the case of an MA private fee-for-service plan, subparagraphs (A)(ii) and (B) of paragraph (4).

Paragraph (4), subparagraph (A)(ii) reads "the amount of the Medicare + Choice [now called Medicare Advantage] monthly basic beneficiary premium”; paragraph (4), subparagraph (B) reads “Supplemental benefits. For benefits described in section 1852(a)(3) [42 USCS § 1395w-22(a)(3)], the amount of the Medicare + Choice monthly supplemental beneficiary premium (as defined in subsection (b)(2)(B)). "

[6] The new subparagraph ( C ) has been added to 42 U.S.C. § 1395w-24 (a)(5). Since the language of subparagraph (a)(6)(B) that prevents the Secretary from “negotiating” private fee-for-service plan premiums is based on incorporating by reference subparagraph (a)( 5)(B), as explained in the previous note, and because clause ( i ) of (a)(5)’s new subparagraph ( C ) prevents subparagraph (B) from being construed to limit the Secretary’s authority to reject bids, it effectively makes meaningless the premium negotiation prohibition of subparagraph (a)(6)(B).

REPEALING OBAMA’S DEATH CARE LAW

The health care restructuring bill approved 219 to 212 by the House of Representatives on Sunday, March 21, 2010 and sent for President Obama’s signature (having been adopted by the Senate in December 2009) will, if not repealed before its most dangerous provisions come into effect, result in the rationing denial of lifesaving medical treatment, and consequent premature and involuntary death, of an unknown but immense number of Americans.

Americans will effectively be limited in spending their own money to save their own lives, unless they are able to travel abroad for life-preserving measures which will be denied them in this country.

These effects will occur regardless of whether the separate "reconciliation" bill also approved by the House is passed by the Senate, since its contents will in no way diminish, although they may exacerbate, the rationing in the bill about to be signed.

The Obama Health Care Rationing Law: The Commission That Will Develop Standards the Administration Will Impose to Limit Private Sector Medical Care

An 18-member "Independent Payment Advisory Board" [Sec. 10320(b)] is given the duty, on January 15, 2015 and every two years thereafter, with regard to private health care, to make "recommendations to slow the growth in national health expenditures . . . that the Secretary [of Health and Human Services] or other Federal agencies can implement administratively" [Section 10320(a)(5)(o)(1)(A)]. In turn, the Secretary of Health and Human Services is empowered to impose "quality" AND "efficiency" measures [Section 10304] on health care providers (including hospices, ambulatory surgical centers, rehabilitation facilities, home health agencies, physicians and hospitals) [Section 3014(a) adding Social Security Act Section 1890(b)(7)(B)(I)] which must report on their compliance.

In complex gobbledegook, what this amounts to is that doctors, hospitals, and other health care providers will be told by Washington just what diagnostic tests and medical care is considered to meet "quality" and "efficiency" standards – not only for federally funded health care programs like Medicare, but also for health care paid for by private citizens and their nongovernmental health insurance. And these will be "quality and efficiency" standards specifically designed to limit what ordinary Americans spend on health care. Treatment that a doctor and patient in consultation deem needed or advisable to save that patient’s life or preserve or improve the patient’s health but which the government decides is too costly – even if the patient is willing and able to pay for it – will run afoul of the imposed standards. In effect, there will be one uniform national standard of care, established by Washington bureaucrats and set with a view to limiting what private citizens are allowed to spend on saving their own lives.

Detailed analysis of other provisions that will impose rationing.

The Prospect of Repeal

The silver lining to this very dark cloud is that the most onerous rationing elements of the Obama health care law will not go into effect until 2015– well after the next Presidential election. For repeal to be a realistic prospect, three things are essential:

–The President who takes office in 2013 would have to be someone who would sign a repeal. (Theoretically, a two-thirds majority of both Houses committed to repeal could accomplish it even over a presidential veto, but achieving such numbers would be extremely difficult.)

– As a result of the 2010 and 2012 Congressional elections, a majority of those in the 2013 House of Representatives must support repeal.

– Also as a result of the 2010 and 2012 Congressional elections, the 2013 Senate must have an adequate majority committed to repeal. Full confidence of repeal would come from 60 of the 100 Senators supporting repeal – enough to impose cloture so as to overcome a filibuster. However, it is possible that, if the elections were clearly seen to have been greatly influenced by popular rejection of the Obama Health Care Rationing Law, then even if there were 41 or more Senators who had supported its adoption, some of them might prefer not to obstruct repeal, especially those soon up for re-election. It is also conceivable that the "reconciliation" process used to secure enactment of the health care law could be used by pro-repeal Senators to gut it with 51 votes.

While most observers expect gains by opponents of Obamacare in the election of Senators in 2010, a shift to a majority in support of repeal may not be achieved. However, in 2012, only 10 or 11 opponents of the law will beup for re-election, compared to either 23 or 24 Senators who voted for it standing for re-election. (This number depends on who wins the 2010 special election to fill Secretary of State Hillary Clinton’s New York Senate seat – its winner will have to face the voters again in 2012.) With these odds, the chance for pro-repeal Senators to emerge in control of the Senate in 2013 is a decent one.

In short, horrific as the enactment of the Obama Health Care Rationing Law is, now is not the time to despair. Rather, the pro-life movement must devote itself over these critical years – 2010 through 2012– to ensuring that the American people are given the facts needed to counter the placating misinformation the Obama Administration and its apologists in Congress and the press are already spreading, confident that with a spoon full of sugar we will swallow their deadly recipe. We must maintain and expand the current majority that, according to most public opinion polls, rejects the Obama Health Care Rationing Law.

OBAMA PROPOSAL LIMITS RIGHTS OF AMERICANS OF ALL AGES TO USE THEIR OWN MONEY TO SAVE THEIR OWN LIVES

The February 22, 2010, Obama Administration health care proposal imposes premium price controls on ALL insurance plans, not just those for Medicare-eligible senior citizens. That means that the right of Americans to spend their own money to get insurance plans less likely to deny treatment will be significantly limited. People will not be allowed to spend their own money, if they choose, to improve the chances of saving their own family’s lives.

It is basic economics that price controls force rationing.

Under the President’s proposal, states and the federal government would be empowered to review and reject premiums charged by any health insurance plan, even the supposedly "grandfathered" plans that Americans now have.

Yet the Administration has the temerity, even now, to state, "For Americans with insurance coverage who like what they have, they can keep it. Nothing in this act or anywhere in the bill forces anyone to change insurance they have, period."

It is as though a government, concerned about the high cost of restaurant food, imposed a price limit of $5 per meal, and then asserted that for those who like their restaurant food, nothing will force them to change their eating habits. The reality, of course, is that restaurants would be unable to afford to offer meals at prices below the cost of their ingredients. Consequently, about all restaurant-goers would be able to get would be fast food.

Similarly, when every premium increase is subject to veto by government officials, it means that instead of Americans making their own choices balancing the cost against the benefit in evaluating competing insurance plans, that decision will be taken out of their hands by bureaucrats whose principal duty is to hold health care spending down. Denial of lifesaving diagnostic tests and treatment would surely follow. This is rationing, pure and simple.

OBAMA PROPOSAL THREATENS TO DENY SENIOR CITIZENS ABILITY TO USE OWN MONEY TO SAVE THEIR OWN LIVES

The Obama health care proposal issued this morning would take away from America’s senior citizens their current right to add their own money on top of the government Medicare contribution to get health insurance less likely to deny treatment through tightly controlled managed care. (See http://www.nrlc.org/MedEthics/PLPositionMedicare.html ). It would do so even as it cuts the government contribution to Medicare by hundreds of billions of dollars.

Under "Title III . . . Guaranteeing Benefits for Seniors by Ending Overpayments to Insurance Companies," the Obama proposal states that Medicare Advantage plans – the alternative that now allows older Americans, if they wish, to pay more to get insurance less likely to ration treatment– will "be prohibited from charging seniors more than they would pay for services delivered under the traditional Medicare program."

Thus, older Americans would be prohibited by law from making up the Medicare shortfall by using their own money to save their own lives. (See http://www.nrlc.org/MedEthics/JusticeArgument.html )
This means that, even as more and more doctors and other health care providers are leaving the Medicare program because of low government reimbursement rates – rates that under the Obama bill will decline still more in comparison to medical inflation– senior citizens will have nowhere to turn. Their only option will be tightly managed plans that provide less and less treatment.

In a case of genuine chutzpah, the Obama proposal then goes on to claim that "all ideas that ration care . . . will be banned" – even as it imposes what will be ever-increasing rationing on senior citizens.

NRLC PRESS CONFERENCE 1/21/2010 STATEMENT ON HEALTH CARE RATIONING

STATEMENT BY BURKE J. BALCH, J.D.
DIRECTOR, ROBERT POWELL CENTER FOR MEDICAL ETHICS
National Right to Life Committee Press Conference
Zenger Room, National Press Building, Washington, D.C.
January 21, 2010
　
Since its inception, the pro-life movement has been just as concerned with protecting the lives of people with disabilities and older people from euthanasia as it has been with protecting unborn children from abortion, and we have regarded government-imposed rationing of lifesaving medical treatment, food and fluids as an unacceptable form of involuntary euthanasia.

Therefore, the pro-life movement has grave concerns about rationing elements in the pending health care legislation. This morning’s Washington Post quotes Harvard health policy professor Robert Blendon as saying that what Massachusetts voters heard was now Senator-elect Scott Brown’s message that the national health care bills would require Medicare cuts. Indeed, a great deal of the backlash, not just in Massachusetts but also nationally, comes from those with insurance realizing that their health care will be endangered if the proposed legislation is enacted.

That legislation is based upon a widely held but fundamentally fallacious assumption – that it is necessary to "bend the cost curve" of health care spending because America cannot afford to continue to increase health care spending in the future as it has in the past.

As it happens, foremost among the economists who have debunked this fallacy is the Obama Administration’s nominee for Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services, Columbia University health care economist Sherry Glied, in her 1997 book "Chronic Condition: Why Health Reform Fails." The first two of these charts are based on data from that book, updated.

The percent of the average family budget devoted to health care (including what employers pay for employees’ health insurance) has steadily grown from 3% in 1940 to 17% in 2006. This trend, and fear that it will continue unless "the cost curve is bent," lies behind the increasingly widespread view that rationing, however unpalatable, is essential. But as Glied’s book demonstrates, the trend must be seen in context.

During that same period, the percent of the average family budget devoted to food declined from almost 30% to under 15%, because of ever-increasing improvements in agricultural productivity. We can look further at the three essentials of food, clothing, and shelter combined. From 1940 to 2006, the percent of the average family budget devoted to these necessities fell from about 53% to about 33%. Consequently, the percent for health care plus food, clothing, and shelter actually dropped from 56% in 1940 to 50% in 2006. Productivity improvements in such areas as agriculture, transportation, and the assembly of clothing freed up resources enabling Americans, on average, to put significantly more resources into obtaining better health care.
While we are presently coping with severe economic downturn, research by health care economists across the ideological spectrum, from David Cutler[1] to Robert Hall and Charles Jones, shows that there is no reason, so long as productivity growth continues, why we cannot indefinitely continue to increase the proportion of our incomes that is spent to keep us alive and healthy.

The pending health legislation contains numerous mechanisms to hold down the amount of their funds Americans are allowed to use to save their own lives. As documented on our website, both the House and Senate bills would not just limit government health care spending; they would empower bureaucrats to limit what private citizens can spend to get unrationed health insurance. Senior citizens, faced with massive Medicare cuts, could be prevented by the federal Centers for Medicare and Medicaid Services from exercising the choice current law allows them to add their own money on top of the diminishing government Medicare contribution in order to get Medicare Advantage private fee-for-service plans less likely to deny treatments and diagnostic tests. Those participating in the health insurance exchanges could see their insurance choices limited to those plans most likely to deny care if government bureaucrats exclude plans less likely to ration care on the claim that they cost too much.

Under the Senate bill, an almost omnipotent commission would be directed not only to hold Medicare increases below the rate of medical inflation, but also to recommend to the HHS Secretary measures to keep increases private health care spending below medical inflation as well. The HHS Secretary would be empowered to impose so-called "quality" and "efficiency" standards on ALL health care providers governing the health care they provide not only under government programs but also under private insurance.

We don’t need this U.K.-style rationing, and the National Right to Life Committee will be working to prevent or repeal it. Last night, in an interview with George Stephanopoulos, the President suggested the possibility of a stripped-down bill, but one of the three items he mentioned as being in such a bill was "cost-containment." We will be carefully watching any such stripped-down measure to determine whether it includes provisions that, like the pending bills, would ration health care, and will be quick to publicize and oppose them.

[1] David M Cutler, Your Money or Your Life: Strong Medicine for America's Healthcare System (Oxford: Oxford University Press, 2004).

NYDN REPORTS PELOSI WILL SEEK RECONCILIATION

Late this afternoon, it was reported by the New York Daily News that Nancy Pelosi is set to announce that the House is going to use the Reconciliation Process to try and pass health care reform. The Reconciliation Process only requires a simple majority to pass a bill. In terms of the Senate, the critical ability of the Senate to filibuster is gone, and only 51 votes would be needed to pass the bill.

The Reconciliation Process is complex and difficult to navigate. Very basically, each of the committees with jurisdiction over Healthcare would need to pass bills, and then the House Budget Committee would merge these into a reconciliation bill and report it to the House floor – needing 218 votes to pass.

Similarly, in the Senate, the Finance and HELP committees would need to report bills that the Budget committee would meld together and then report that product to the Senate floor. Only 51 votes would be needed to begin consideration of it. Debate is limited to 20 hours. Amendments are unlimited but must be germane to the bill.

As long as the bill has been drafted not to violate the budget resolution the Senate can pass the bill with a simple majority. This rule is very difficult to adhere to and would eliminate huge and key elements present in the current reform bills. After the Senate passes their reconciliation bill, they work out differences with the House, if any.

If the reports are true, then we can fully expect a bill – one potentially wrought with rationing concerns. President Obama, speaking to ABC news last night said, “We know that we have to have some form of cost containment because if we don't then our budgets are going to blow up." It is precisely these cost-containment measures that raise rationing concerns. Continue checking back often, since health reform is far from dead.

NEW YORK TIMES STORY SHOWS HOW HEALTH BILL'S EFFORTS TO CUT DOWN WHAT HEALTH CARE PROVIDERS ARE ALLOWED TO DO CAN RESULT IN LIVES LOST

December 22. The health care bill which the Senate is about to adopt authorizes the Secretary of Health and Human Services to impose "efficiency" measures on doctors and hospitals throughout the country, [1] and it changes the way health care providers treating senior citizens under Medicare will be paid – instead of getting a set amount for each test or procedure, their reimbursement will be changed depending on what "value" the government believes will come from it.

However, an article in this morning’s New York Times challenges the idea that this approach will save money without denying needed and effective lifesaving care.

The Obama Administration’s director of the Office of Management and Budget, Peter Orzag, has attacked the fact that the Ronald Reagan University of California at Los Angelos [UCLA] Medical Center spends more than Rochester, Minnesota's Mayo Clinic. "One of them costs twice as much as the other, and I can tell you that we have no idea what we’re getting in exchange for the extra $25,000 a year at U.C.L.A. Medical. We can no longer afford an overall health care system in which the thought is more is always better, because it’s not."

But the Times article cites recent research showing that "[T]he hospital that spent the most on heart failure patients had one-third fewer deaths after six months of an initial hospital stay."

The Times reports:

Take the case of Salah Putrus, who at age 71 had a long history of heart failure After repeated visits to his local hospital near Burbank, Calif., Mr. Putrus was referred to U.C.L.A. this year to be evaluated for a heart transplant.

Some other medical centers might have considered Mr. Putrus too old for the surgery. But U.C.L.A.’s attitude was "let’s see what we can do for
him," said his physician there, Dr. Tamara Horwich.

Indeed, Mr. Putrus recalled, Dr. Horwich and her colleagues "did every test." They changed his medicines to reduce the amount of water he was retaining. They even removed some teeth that could be a potential source of infection.

His condition improved so much that more than six months later, Mr. Putrus has remained out of the hospital and is no longer considered in active need of a transplant.

The Obama Administration and Congressional architects of the health care bill have relied heavily on a series of studies by researchers at Dartmouth which seem to show that the greater amounts of money spent on health care in some regions of the country don’t produce better outcomes and hence are wasted. This conclusion is the basis for much of the health care bill’s efforts to use the power of the federal government to force doctors and hospitals to spend less per patient.

But, as the Times story points out, "Because Dartmouth’s analysis focuses solely on patients who have died, a case like Mr. Putrus’s would not show up in its data. That is why critics say Dartmouth’s approach takes an overly pessimistic view of medicine: if you consider only the patients who die, there is really no way to know whether it makes sense to spend more on one case than another."
　

Dr.[J. Thomas] Rosenthal [, chief medical officer of the U.C.L.A. Health System,] and his U.C.L.A. colleagues . . . say that unless the distinction can be clearly drawn between excellence and excess in medical care, efforts to cut wasteful spending could be little more than blunt rationing.

"There’s a real risk of doing harm here — real harm," he said.

NRLC WRITES SENATORS LISTING ABORTION, RATIONING ELEMENTS OF SENATE HEALTH BILL

The National Right to Life Committee has sent a letter to Senators setting forth the abortion and summarizing the rationing elements in the Senate health care restructuring bill, avaliable here.

MANAGER’S AMENDMENT INTENSIFIES RATIONING

The Manager’s Amendment to the Senate health care restructuring bill offered by Majority Leader Harry Reid (D-NV) on December 19 contains two provisions that intensify the rationing already present in the Reid Substitute.

– Taking a significant step closer to the powerful Federal-Reserve-Board-like Federal Health Board envisioned by former Senator Tom Daschle, Obama’s original nominee for health czar, the Manager’s Amendment renames and expands the authority of what the Reid Substitute called the "Independent Medicare Advisory Board." Its new title is the "Independent Payment Advisory Board" [Section 10320(b), p. 189] and it is directed to make recommendations to "slow the growth" in PRIVATE (non-federal) "health expenditures . . . that the Secretary [of Health and Human Services] or other Federal agencies can implement administratively." Section 10320(a)(5), adding Section 1899A (o)(1)(A) of the Social Security Act, p. 188. To the extent these are effective, they will limit the ability of private citizens to spend their own money to protect their own lives, by obtaining health care or health insurance that is not rationed.

– Section 10304 (p. 152) empowers the Secretary of Health and Human Services to impose "efficiency measures," in addition to the "quality measures" already provided for under the Reid Substitute, on health care providers. Much of the professional literature advocates the use of "quality of life" standards that devalue the lives of older people and people with disabilities in such measures. While there are limits on the use of comparative effectiveness research to justify denial of treatment based on quality of life criteria under Section 6301( c) of the Reid Substitute, the quality and efficiency measures are not made subject to these critically important anti-discrimination protections.

A more detailed analysis of these rationing-promoting elements of the Manager’s Amendment follows:

INDEPENDENT PAYMENT ADVISORY BOARD AUTHORITY TO RECOMMEND, AND HHS SECRETARY TO LIMIT, RIGHT TO USE ONE’S OWN MONEY TO SAVE ONE’S OWN LIFE

Under the Reid Substitute’s Section 3403 (pp. 1000- 1053) as modified by the Manager’s Amendment Section 10320 (pp. 180-90), the "Independent Payment Advisory Board" will have sweeping powers.

As originally set forth in the Reid Substitute, the Board was called the "Medicare" Advisory Board, and its mission was focused on cutting Medicare reimbursement rates (see below) – a duty it retains. However, the Manager’s Amendment dramatically expands its authority, so as to work to limit nonfederal health care spending, as well. Starting in 2014, "and at least once every two years thereafter," the Board is to make recommendations "to slow the growth in national health expenditures" other than Federal health care programs – recommendations "that the Secretary or other Federal agencies can implement administratively," as well as recommendations for legislative action. To the extent these are effective, they will limit the ability of private citizens to spend their own money to protect their own lives, by obtaining health care, or health insurance, that is not rationed.

For 2015, unless Medicare spending is projected NOT to keep up with the rate of medical inflation (specifically, unless it is projected to come in at or below a "target" set at the midway point between medical inflation and the average inflation rate for all goods and services , the "Consumer Price Index-Urban"), the Board is to specify how to cut Medicare payments by either the difference from the target or half a percent, whichever is less.

For 2016, the Board is to specify how to cut Medicare by the lesser of the difference from the target for that year or 1 percent, and for 2017 by the lesser of the difference from the target for that year or 1.25 percent.

For 2018 and subsequent years, the target shifts to the growth in Gross Domestic Product (GDP) per capita, and the Board must specify how to cut Medicare payments by the lesser of the difference from that target and 1.5 percent.

Each year, the Secretary of Health and Human Services must implement the Board’s directives unless Congress, within a given deadline, legislates an alternative set of restrictions to accomplish the same result. However, Congress could not reduce the net of the targeted cuts unless three-fifths of both chambers voted to do so. The bill goes so far as to forbid a future Congress from repealing these provisions, except for a one-time opportunity in 2017! Section 3403, adding Social Security Act Section 1899A(d)(3)( C), p. 1020.

How is the Board to bring about these Medicare reductions? On its face the bill instructs the Board not "to ration health care, raise revenues or Medicare beneficiary premiums . . . , increase Medicare beneficiary cost-sharing . . . , or otherwise restrict benefits or modify eligibility criteria." Section 3403, creating Social Security Act Section 1899A(c)(2)(A)(ii) , p. 1004. Predominately, the reductions will have to come in reimbursement rates for health care providers.

This is likely to have either – or, more likely, both– of two rationing effects. First, an increasing number of Medicare providers, being paid further and further below their costs of providing care, would stop accepting new Medicare patients. Second, the Board could change the way reimbursement rates are structured, away from a fee-for-service model toward a "capitated" model, for example, under which practitioners are paid a set annual amount per patient, or toward an "episode" model somewhat similar to the DRG payment system for hospitals, under which a set amount is paid per illness or injury. In either of these cases, the physician or other health care provider would have a strong financial incentive to limit treatment, especially if it is costly. So, in compliance with the statute, the Board itself would not be "rationing" treatment – instead, it would be compelling health care providers to do so.

"EFFICIENCY" MEASURES THAT MAY LEAD TO DISCRIMINATORY DENIAL OF TREATMENT BASED ON DISABILITY, AGE, AND OTHER QUALITY OF LIFE CRITERIA

Section 10304 (p. 152) empowers the Secretary of Health and Human Services to impose "efficiency measures," in addition to the "quality measures" provided for under the Reid Substitute, on health care providers. These measures are to be incorporated "in workforce programs, training curricula, and any other means of dissemination determined appropriate by the Secretary." Section 3014(b) adding Social Security Act Section 1890A(b)(1)(A) (p. 709). They are to be used in the calculation of value-based purchasing from hospitals, and renal dialysis services must abide by them or be penalized. Health care providers, including hospices, ambulatory surgical centers, rehabilitation facilities, home health agencies, physicians and hospitals must provide reports, generally made publicly available, based on these measures. Consequently, they exercise considerable influence on how health care providers practice medicine, and consequently on what treatment patients do – and do not – receive.
In the medical and bioethical literature, quality and efficiency measures are often based on "quality of life" standards that discriminate on the basis of age and disability.

Accordingly, during the period when the group of six Senators were negotiating in an attempt to achieve a bipartisan health care bill, agreement was reached to make anti-discrimination language applicable to the results of comparative effectiveness research. See note 1. This language remains in the Reid Substitute, Section 6301( c), adding Social Security Act Section 1182 ( c), (d) and (e) , pp. 1685-87. However, the quality and efficiency measures are NOT made subject to the same limits on employment of quality of life criteria that are applied to the use of comparative effectiveness research under Section 6301( c) of the Reid Substitute. Consequently, the Secretary is free to formulate such measures in a way that has the effect of rationing treatment on the basis of disability, age, or other "quality of life" criteria, as advocated by many mainstream bioethicists.

RATIONING IN SENATE BILL LIKELY TO INTENSIFY

An amendment likely to be added to the Senate health care restructuring bill by Majority Leader Harry Reid would empower federal bureaucrats to impose requirements on private insurance plans with the explicit intent of limiting Americans’ right to spend their own money, if they choose, to save their own lives.

On Wednesday, Senators Jay Rockefeller (D-WV), Joseph Lieberman (I-Ct.), and Sheldon Whitehouse (D-RI) introduced an amendment (# 3240) to the Senate health care restructuring bill, which it is widely reported Senate Majority Leader Reid (D-NV) will include in the mammoth “Manager’s Amendment” he will introduce just in advance of the key “cloture” votes designed to end debate preparatory to adopting the bill. Amendment 3240, which the sponsors went to the Senate floor Thursday to advocate, expands the powers of the Independent Medicare Advisory Board (the Board) so that it will cover not only Medicare, but also all the private insurance plans in the “exchanges” the bill establishes for people annually to choose their health insurance.

The Board would be directed to make recommendations that the Secretary of Health and Human Services could then impose that, in the sweeping and vague language of the amendment, would in their opinion promote “integrated care, care coordination, prevention and wellness, and quality and efficiency[,] ... decrease health care spending, and [bring about] other appropriate improvements.” In addition to the elements characteristic of managed care plans that would be required, note the explicit directive to “decrease health care spending.” All of the requirements presumably are aimed at forcing the privately insured to spend less on healthcare, and the list of requirements is open-ended. Plans deemed to spend too much money on health care would be evicted from the exchange.

Instead of allowing Americans themselves to balance cost, benefits, and quality when choosing among competing health plans in the exchanges, their choice would be subject to potentially drastic restrictions. Americans’ choice to spend their own money for health insurance they judge will be less likely to deny treatments and otherwise ration care would be limited.

“COST CONTAINMENT” AMENDMENT WOULD AUTHORIZE HHS SECRETARY TO REQUIRE HEALTH CARE PROVIDERS TO ABIDE BY “EFFICIENCY” STANDARDS

A cost-containment amendment drafted by freshman Democratic Senators Mark Udall, Tom Udall, Jeanne Shaheen, Mark Warner, Kay Hagan , Jeff Merkley, Mark Begich, Roland Burris, Ted Kaufman, Michael Bennet, Al Franken, and Paul Kirk (see prior blog posting) would expand the authority the health care restructuring bill would give to require doctors, hospitals, and other health care providers to abide by "quality measures" so that the Secretary could also impose "efficiency" measures.

This seemingly small provision, in section 10007 on page 13 of the amendment, would have dramatic consequences. It would give authority to the federal government to regulate the "efficiency" of health care providers throughout the country. It takes little imagination to recognize that denial of treatment whose cost is deemed – by federal bureaucrats – to exceed its benefit could thus be imposed by administrative ruling on all patients– in short, government-imposed rationing.

REVEALING NEW REPORT EXPOSES DANGERS OF MEDICARE RATIONING

An article from today’s Washington Post, titled “Report: Bill would reduce senior care” details a new report which warns that Medicare cuts approved by House Health Restructuring bill are not only insufficient to provide needed funding for reform, but also may affect access to health care providers. The full Washington Post article is available here. The CMS report is available here.

The article (in part) explains, “A plan to slash more than $500 billion from future Medicare spending -- one of the biggest sources of funding for President Obama's proposed overhaul of the nation's health-care system -- would sharply reduce benefits for some senior citizens and could jeopardize access to care for millions of others, according to a government evaluation released Saturday.

The report, requested by House Republicans, found that Medicare cuts contained in the health package approved by the House on Nov. 7 are likely to prove so costly to hospitals and nursing homes that they could stop taking Medicare altogether. Congress could intervene to avoid such an outcome, but "so doing would likely result in significantly smaller actual savings" than is currently projected, according to the analysis by the chief actuary for the agency that administers Medicare and Medicaid. That would wipe out a big chunk of the financing for the health-care reform package, which is projected to cost $1.05 trillion over the next decade....

The report offers the clearest and most authoritative assessment to date of the effect that Democratic health reform proposals would have on Medicare and Medicaid, the nation's largest public health programs. It analyzes the House bill, but the Senate is also expected to rely on hundreds of billions of dollars in Medicare cuts to finance the package that Majority Leader Harry M. Reid (D-Nev.) hopes to take to the floor this week.”

------
This report makes clear what many predict - that the insufficient funding of the proposals under consideration will lead to rationing. A substantial part of health care subsidies, under any current proposal, would be paid for by “robbing Peter to pay Paul” – reducing Medicare funding for older people in order to cover the uninsured. Over-promising while under-funding health insurance for the uninsured will almost surely lead to rationing.

ALL COMMITTEES HAVE REPORTED BILLS WITH RATIONING CONCERNS - NEGOTIATIONS NOW MOVE BEHIND CLOSED DOORS

Health care restructuring cleared another hurdle when it was voted favorably out of the Senate Finance Committee 14-9 this afternoon. Republican Olympia Snowe (ME) along with every Democrat, voted to move the bill forward. Sen. Snowe, while maintaining that “My vote today is my vote today. It does not predict my vote tomorrow,” ultimately concluded that inaction was riskier than the “imperfect bill.” Several Republican senators continued to warn of the dangers of rationing – with Senator Roberts(KS) in particular noting that the bill contains “robust tools to ration your healthcare.” A good deal of time was spent in committee today by Democrats criticizing an industry-commissioned report by PriceWaterhouseCoopers that found health insurance premiums would increase faster under the Senate's bill than they would without it. Also, Sen. Rockefeller (D-WV) again lamented the lack of inclusion of end-of-life planning. The Senator will likely offer a related amendment on the Senate floor. For more on similar end-of-life planning provisions in the house bill see here.

The Finance committee product contains 1. cuts to Medicare, 2. the dangerous "Death Spiral" provision, 3. a grant of nearly unlimited power to the Medicare Commission to reduce Medicare payments to fit with the limits on growth, and 4. verbal promises to consider price controls.

Negotiations will now shift into a closed-door setting. After today’s vote, Sen. Baucus (D-MT), majority leader Reid (D-NV), and Sen. Dodd (D-CT), along with and a handful of top White House officials, will meet to meld the Finance bill alternative bill that Dodd led through the HELP committee in July.

Leaders in the House have been meeting over the past months in an effort to merge three bills passed out of committees and to bring down projected costs. House Speaker Pelosi (D-CA), has said she expects a final version for consideration by the full chamber soon, although she has not provided a specific timetable. While attempting to shave their $1.2 trillion plan down to $900 billion, the final bill is likely to reduce subsidies, place more people into state Medicaid programs, and employ several of the taxes raised in the Senate Finance Committee. However, House leaders have rejected the Senate Finance plan’s tax on high-value plans – the one financing mechanism that would keep pace with the rising resources devoted to health care would be the 40% levy on health insurance premiums. For more on this see here. House leaders are instead relying on a modified version of their original plan to impose a surcharge on higher income Americans.

It has also been reported today by the Washington Post that in order to come in under $900 billion dollars, House Democrats will cut out a provision that ensures that doctors receive their Medicare payment update formula. This would then be addressed in an expensive stand-alone bill. In the Senate version, the billions required to stop those same scheduled cuts in Medicare payments to physicians is only addressed for one year (then docs take a drastic 25% pay cut if no other action is taken). Not addressing this very integral and expensive aspect of healthcare in these comprehensive bills can give the incorrect appearance that the bills are able to be paid for - when that is not the case. And when inadequate financing is present, coupled with the dangerous mechanisms, rationing becomes a very real threat.

How soon floor action will occur in either chamber is unclear- though leadership insists that they mean to act soon.

PRICE CONTROLS REAR THEIR UGLY HEAD

October 1, 2009. The ability of Americans to choose to use their own money to obtain insurance policies less likely to ration in the exchanges to be set up by the health restructuring bill may be in danger. Originally, state-based "exchanges" were designed to allow comparison shopping among all insurance plans that provided the basic benefits. Now, however, a proposal is afoot to authorize states to limit the value of the insurance policies all Americans using the exchanges may purchase, by allowing them to exclude policies government authorities believe "do not offer good value and cost-effectiveness." This would effectively allow the imposition of price controls, limiting consumers’ access to adequate and unrationed health care. People would be limited in their ability to use their own money to save their own lives.

As the Senate Finance Committee consideration of amendments to its health care restructuring bill drew to a close this evening, Senators Jay Rockefeller (D-WV) and Kent Conrad (D-ND) got a commitment from Chairman Max Baucus (D-MT) to attempt to add such a to the bill, as it is melded with the version reported from the Senate Health, Education, Labor and Pensions Committee in July before the product goes to the Senate floor to a vote.

In a similar vein, Senator Maria Cantwell's (D-WA) amendment narrowly passsed earlier in the day. Agreed to by a vote of 12 -11 (with Sen. Blanche Lincoln (D-AR) joining Republicans), Sen. Cantwell's amendment allows states to establish insurance plans and negotiate rates for people earning between 133 to 200 percent of the federal poverty level- removing them from the exchange.

Sen. Cantwell claimed that 75 percent of the uninsured fall into that range. However, the concern is that "government negotiation" is not really negotiation, but in practice, has been shown to be price control. When there is only one buyer, they can set a price much lower than in a competitive market. Many of the details of the Cantwell Amendment are unclear, but it is one example of how people's access to unrationed care will be limited under this bill.