Joe Biden’s Obamacare Gaffe Points to a Larger Truth

In Iowa just before the New Year, former Vice President Joe Biden had an interesting response to a voter’s concerns about Obamacare. The voter said his father had lost his coverage when the law’s major provisions took effect in 2014, and the “replacement” plans proved far more expensive. Asked to apologize for what PolitiFact dubbed its “Lie of the Year” for 2013—that “If you like your plan, you can keep it”—Biden demurred by claiming the following:

There’s two ways people know when something is important. One, when it’s so clear when it’s passed that everybody understands it. And no one did understand Obamacare, including the way it was rolled out. And the gentleman’s right—he said you could keep your doctor if you wanted to, and you couldn’t keep your doctor if you wanted to, necessarily. He’s dead right about that.

On its face, Biden’s comments initially resemble House Speaker Nancy Pelosi’s “We have to pass the bill so that you can find out what is in it” gaffe. But in reality, they hint at a larger truth: the federal government has gotten so big and sprawling, nobody really understands it.

Pelosi’s ‘Kinsley Gaffe’

Just before Obamacare’s passage in March 2010, Pelosi made comments that conservatives have parodied for most of the ten years since:

Upon closer inspection, though, her comments centered on the political messaging about the law, rather than the underlying policy. She prefaced her infamous quote by noting that “You’ve heard about the controversies within the bill, the process about the bill.”

But in Pelosi’s view, the American people had not heard about the substance of the bill itself: “I don’t know if you have heard that it is legislation for the future.” She went on to talk a bit about preventive care measures contained in Obamacare, which in her view would lower health-care costs. She then gave her infamous quote about passing the bill “so that you can find out what is in it, away from the fog of the controversy.”

Pelosi’s statement still seems extraordinary. She admitted that, even with Barack Obama—who won the presidency in fair measure through his rhetoric—in the White House, more than 250 Democrats in the House, and 60 Democrats in the Senate, Obamacare had proven a political failure. Democrats had lost the messaging battle in 2009 and 2010, and could only hope that enacting the legislation and allowing Americans to see its purported benefits could turn the dynamic around.

But Pelosi’s comments said “we have to pass the bill so that you can find out what is in it”—emphasis on the second person. She still claimed to know the contents of the legislation, contra the recent claims of the vice president at the time.

So Much for ‘Experts’

On one level, Biden’s comments echoed Pelosi’s. He talked about “the way it was rolled out”—a likely reference to the messaging battles of 2009-10, the “debacle” of the exchange launch in late 2013, or a combination of the two.

But unlike Pelosi—who said the public didn’t understand Obamacare—Biden said that “no one did understand Obamacare.” One wonders whether the statement meant to inoculate Obama from accepting blame for his “like your plan” rhetoric, even though Obama himself apologized for misleading the public on the issue in late 2013.

Regardless, Biden’s rhetoric echoes the example of Max Baucus, at the time the chairman of the Senate Finance Committee. Asked shortly after the legislation passed whether he had read Obamacare prior to its enactment, he responded that “I don’t think you want me to waste my time to read every single word of that health care bill,” because “we hire experts” who are the only people who “know what the heck it is:”

Except that four years later, one of those “experts” who worked on Baucus’ staff at the time, Yvette Fontenot, admitted that when drafting Obamacare’s employer mandate, “We didn’t have a very good handle on how difficult operationalizing the provision would be at that time.” So, to borrow Baucus’ own phrase, even one of his self-appointed “experts” didn’t “know what the heck it is” either.

Why Expand a Government You Can’t Even Understand?

Biden’s comments once again reveal that the federal government has become too big and sprawling for anyone to understand. Yet he and his Democratic colleagues continue to push massive, multi-trillion-dollar expansions of government as part of their presidential campaigns. Sen. Elizabeth Warren goes so far as to claim that “experts” can fix just about everything that’s wrong with the world, even though Biden’s admission shows that they need to start by fixing the problems they caused.

As the old saying goes, when you’re in a hole, stop digging. That axiom applies equally to Biden’s propensity to put his foot in his mouth and Democrats’ desire to expand a government they do not understand.

This post was originally published at The Federalist.

The Bad, The Ugly, and The Good of Liberal Entitlement Proposals

The New England Journal of Medicine yesterday published two new papers on entitlement reform and controlling health costs.  The first, by AEI’s Joe Antos and several co-authors, highlights several market-based mechanisms to slow the growth of costs.  The second, published by a group of liberal academics convened by the Center for American Progress, includes proposals that can be described as “The Bad, The Ugly, and The Good.”

First, the bad.  The CAP paper claims that “the only sustainable solution [to entitlements] is to control overall growth in costs.”  The problem is that, as we previously noted, over the next 25 years, demographics count for at least half – and as much as three-quarters – of projected increases in spending on Medicare, Medicaid, Social Security, and Obamacare insurance subsidies.  These demographic changes make existing entitlements untenable over the long term.  Yet by putting forth a half-solution focused solely on containing health costs, the CAP paper presumes a status quo of existing entitlement structures that is fundamentally unsustainable.

Next, the ugly.  In order to contain costs, the CAP paper proposes a system of supposed “self-regulation” that amounts to Obamacare’s Independent Payment Advisory Board on steroids:

Under a model of self-regulation, public and private payers would negotiate payment rates with providers, and these rates would be binding on all payers and providers in a state….The privately negotiated rates would have to adhere to a global spending target for both public and private payers in the state.  After a transition, this target should limit growth in health spending per capita to the average growth in wages, which would combat wage stagnation and resonate with the public.  We recommend that an independent council composed of providers, payers, businesses, consumers, and economists set and enforce the spending target.

In other words, CAP proposes that a board of “experts” can set spending levels for the entire health care system, and enforce this spending cap through “self-regulation.”  Many may believe that this system of “self-regulation” wouldn’t last long, because the fundamentally arrogant premise that a group of “experts” can micro-manage the health care decisions of the entire country (or even entire states) would soon be revealed for the folly it is.  The ultimate result would be a(nother) government takeover – this one of the supposed “voluntary” boards – and a federally-imposed system of “rationing with our eyes open” previously advanced by one of the paper’s authors, Donald Berwick.

Fortunately, however, even the CAP paper focuses on some good policy.  The discussion of competitive bidding features the rare admission from a group of liberals that market-based solutions can work in health care:

Instead of the government setting prices, market forces should be used to allow manufacturers and suppliers to compete to offer the lowest price.  In 2011, such competitive bidding reduced Medicare spending on medical equipment such as wheelchairs by more than 42%….We suggest that Medicare immediately expand the current program nationwide.  As soon as possible, Medicare should extend competitive bidding to medical devices, laboratory tests, radiologic diagnostic services, and all other commodities.

Given that strong endorsement of competitive bidding for some of Medicare, the real question is why the authors don’t believe in competitive bidding for all of Medicare.  CAP said as recently as this week that private insurance plans can’t price their coverage options below traditional Medicare – meaning traditional Medicare wouldn’t lose market share under a competitive bidding plan – so what are the authors of the paper afraid of?

Some may believe the reason why liberals are afraid to let traditional Medicare compete is the same reason why liberals won’t admit Medicare’s significant demographic problems: A desire to cling to the shibboleth that government-run Medicare represents the epitome of progressivism, and must remain unchanged and inviolate in perpetuity.  For all the demographic and other reasons we’ve outlined previously and above, that’s simply not going to happen, no matter how hard the left tries to (over-)regulate the health sector.  Stein’s Law guarantees that the demographic problems constituting more than half of Medicare’s increase in spending will not go unaddressed.

So the real question for the left is when liberals will admit that traditional Medicare cannot survive unchanged, or with mere tweaks at the margins, and needs fundamental structural reform.  Perhaps at that point the left will recognize that the competitive bidding structure they have promoted for parts of the Medicare program is best served to change the entire program.  Now THAT would be a change we could all believe in.

Obamacare and Judicial Activism

Writing in the Wall Street Journal this morning, columnist Alan Blinder repeated familiar Democrat talking points about the Supreme Court and judicial activism.  Discussing the interplay between Obamacare’s individual mandate and the insurance “reforms” included in the law, Blinder asked “what happens if the justices void the mandate but leave the insurance reforms in place?  The answer is: We get incoherence.  Which, of course, is why you don’t want judges making economic policy.”

On this point, Blinder is half-right at least.  Judges should NOT make economic policy.  But the “solution” to the problem of judges not making economic policy should not involve blithe acceptance of a new and unprecedented mandate for individuals to buy a product as a condition of their existence, merely because Congress said the mandate was “essential” to make the law’s otherwise unsustainable new regulations work.

Rather, the position that does not involve judges making economic policy was one adopted by Republican senators in an amicus brief to the Court – namely, that if the Court strikes down the individual mandate, all of Obamacare must necessarily fall.  In the absence of such a ruling from the Court, the alternatives have ranged from the speculative – i.e., what parts of the law would be fiscally sustainable without the mandate? – to the seemingly absurd – Justice Breyer’s self-described “pipe dream” attempting to have lawyers argue what parts of Obamacare’s 2700-page Humpty Dumpty could be put back together again. (Because really, do we need MORE backroom deals involving Obamacare…?)

To Democrats mortified at the prospect of the Court striking down all of Obamacare, we can offer three helpful hints:

  1. If you want portions of the law to be severed if struck down, include a severability clause.  Democrats had every chance to do so – the House version of Obamacare included such language – but didn’t.  Liberals have absolutely no right to blame the Supreme Court if the Court decides to strike down the entire law, rather than trying to pick and choose which provisions to keep, in what would likely be a futile attempt to try and “fix” the mess Democrats themselves created.
  2. Read the bill.  While judges should in no event make economic policy, it’s somewhat difficult to argue that Congress is better placed to do so when multiple Members state publicly that reading the bill is a waste of time, because “we have to make judgments very fast,” and because “we hire experts” to read the bill instead.  Reading the bill is also helpful in ascertaining prior to passage whether a severability clause may be needed.  (See point #1 above.)
  3. If you ever again get tempted to pass a 2700-page bill the American people don’t support, just.  Don’t.  Thankfully, some Members of Congress may have already learned that lesson – the hard way.

Obama Abandons Medicare

President Obama and Democrats claim to be committed to “protecting” seniors.  But their policies fail to protect the essential Medicare program.  It is yet another broken promise by the president.  Once again this week, President Obama ignored a legal requirement to produce a plan to strengthen Medicare – the fourth straight year he has failed to put a plan forward.  And reports indicate Democrats in the Senate have no plans to strengthen Medicare because it would be “giving away the biggest [political] advantage” Democrats have had “in some time.”
The failure of the President’s health care law to strengthen Medicare is a prime example of Democratic hypocrisy.  A close look at provisions in the law reveal how it’s fiscal gimmicks and centralized control undermine the Medicare program, harming seniors in the process.
Millions Lose Their Current Coverage

The Congressional Budget Office (CBO) estimates that the president’s health care law will cut a total of $202.3 billion from Medicare Advantage plans.  These plans deliver a range of health care options to more than 12 million seniors, one-quarter of those enrolled in the Medicare program.  One recent study demonstrated that the law will cause Medicare Advantage plan enrollment to be cut in half by 2017.  In addition to enrollment being cut, seniors’ choice of health care plans will be cut by two-thirds

The Health Care Law Hurts Medicare’s Long-Term Solvency

Obama Administration actuaries have confirmed that the president’s health care law will increase overall health spending by $311 billion.  The increased spending further exacerbates the long-term trends that have placed the Medicare program in financial trouble.

The president’s health care law uses Medicare savings not to strengthen Medicare, but to fund new entitlements.  The CBO stated the law “would not enhance the ability of the government to pay for future Medicare benefits.”  The non-partisan Medicare actuary confirmed that Medicare reductions in the law “cannot be simultaneously used to finance other federal outlays and to extend the [Medicare] trust fund.”  Even Speaker Pelosi admitted this problem in November, when she said in an interview that “we took half a trillion dollars out of Medicare in…the health care bill,” to pay for other program spending.
Unsustainable Payment Cuts Would Drive Hospitals Out of Business

Medicare payment reductions in the Obama health care law will not improve the solvency of the program.  CBO concluded that the reductions are phantom savings.  They say the largest Medicare reductions—permanent reductions in payments to hospitals and other Part A medical providers—will be “difficult to sustain for a long period.”  The non-partisan Medicare actuary also found that provisions in the health care law “are unlikely to be sustainable on a permanent annual basis.”

 
One analysis conducted by the Medicare actuary found that over the long term, Medicare would pay hospitals only about one-third the rate paid by private health insurance.  These reductions would cause up to 40 percent of hospitals to become unprofitable—meaning medical providers would likely have to stop treating Medicare patients to remain in business, and thus jeopardizing beneficiaries’ access to care. 
Cuts to Doctors Would Lead to Higher Premiums

The president’s health care law did not fix the Medicare formula for physician reimbursement levels.  As a result, physicians will receive a 32 percent cut in payment levels beginning in January 2013 and further reductions thereafter while health costs continue to rise.  The president’s FY 2013 budget does not fix the funding shortfall either – it ignores the $429 billion cost for the fix.  If the president’s proposals become law, seniors would pay higher Part B premiums—more than $100 billion.

Most Seniors Will Pay More
In order to give a select group of beneficiaries richer coverage, the president’s health care law raises seniors’ Part D premiums  CBO estimated that “the law would lead to an average increase in premiums for Part D beneficiaries of about four percent in 2011, rising to about nine percent in 2019.”  That means 17 million seniors enrolled in Part D plans are paying higher premiums so that about 400,000 beneficiaries passing through the so-called “doughnut hole” can receive the full benefit of the law’s drug discount.  Many of these beneficiaries are low-income seniors whose additional costs were already covered before the President’s health care law.
The Law Puts Washington Bureaucrats in Control 
The president’s health care law establishes a new board of 15 unelected, unaccountable bureaucrats empowered to make decisions with the force of law on reductions within Medicare.  Each of these officials, whose salaries will be paid by the federal government, could be in power for well over a decade.  The law mandates that a majority of board members must consist of economists and other similar “experts,” NOT practicing doctors, nurses, or other medical providers.  Its members will make rulings to reduce Medicare spending, and these rulings will be binding unless overturned by a supermajority of both houses of Congress.  Medicare beneficiaries who are harmed by this unaccountable board will have no recourse to appeal its decisions, as the law prohibits both judicial and administrative review of the board’s decisions.  Patients should be concerned that the law inserts bureaucrats between patients and doctors.
Medicare must be strengthened.  CBO projects that the Medicare trust fund will run deficits in the tens of billions of dollars forever.   The president’s former Chief of Staff, Bill Daley, said in July that the program “will run out of money in five years if we don’t do something.”  The president himself acknowledged that “if you look at the numbers, then Medicare in particular will run out of money and we will not be able to sustain that program no matter how much taxes go up.  I mean, it’s not an option for us to just sit by and do nothing.”
Unfortunately, the president’s health care law fails a Medicare program in need of strengthening.  The law imposes budget gimmicks that divert Medicare savings to pay for new programs, and assumes payment reductions that will have to be overridden for seniors to have access to care.  Moreover, the law centralizes control within a government-run system, eliminating choices in Medicare Advantage and ceding massive power to a board of unelected and unaccountable bureaucrats.  While Democrats claim that Republicans want to destroy Medicare, it is Democrats who radically altered the program for the worse as part of President Obama’s massive 2700-page health law.

The Economic Cost of Medicare’s Inefficiencies

Amidst the debate about raising the debt limit and entitlement reform, it’s worth highlighting an article released earlier this week by two commissioners of the Medicare Payment Advisory Commission (MedPAC), which forms the basis for the board of “experts” included in Obamacare.  Both Kate Baicker and Michael Chernew conclude that Medicare is both fiscally and economically unsustainable in its current form and needs a fundamental restructuring:

The public financing of Medicare has particular implications for the economy.  Specifically, raising taxes to pay for public insurance exerts a structural drag on the economy even if the revenue is spent on care; the same is not true of unsubsidized, privately purchased care or insurance.  The net size and timing of the economic consequences depend on how the taxes are raised and how the revenue is spent.  Deficit spending on health care also carries an economic cost: taxes are required to pay back any borrowed money (with interest), and rising debt-to-GDP ratios may have calamitous effects on the country’s future ability to borrow….

An analysis performed by the Congressional Budget Office (CBO) before [Obamacare] was passed suggested that income tax rates would have to increase by more than 70% to finance health care spending that grew just 1 percentage point faster than the GDP — and by more than 160% to finance growth at the historical rate of 2.5 percentage points faster than GDP growth, increasing the income tax rate in the top bracket, for example, to 92% from 35%….

Medicare’s design generates inefficient utilization, which imposes broad indirect costs on all patients.  For example, fee-for-service payment discourages coordinated care, and if Medicare benefit or payment design encourages investment in inefficient resources or inefficient care patterns, that can also drive higher and inefficient private spending….

Even if [Obamacare] achieves its ambitious goals, Medicare would still need extra resources to solve this demographic problem [i.e., the retirement of the Baby Boom generation].  Although some additional resources could come from reducing waste in the system, no industrialized country has ever achieved sustained growth rates of health care spending below that of the GDP, so it seems unlikely that Medicare’s growth could be reduced below the projected [Obamacare] trajectory.

They conclude that Medicare’s current structure raises costs, kills jobs, and CANNOT be solved by tax increases.  Or, in other words, we don’t have a taxing problem – we have a spending problem.

What have Democrats suggested to solve this looming crisis?  Not much.  President Obama made vague paeans to additional entitlement means testing at his press conference this morning, but he has yet to issue ANY specific proposals for reform, despite being required by law to do soWhen will the President and Democrats finally bring forth a Medicare reform plan?

Questions for Secretary Sebelius on IPAB

Today begins a double-header of IPAB-related hearings in the House; Secretary Sebelius will be testifying before the House Budget Committee this morning, and before the Energy and Commerce Committee tomorrow morning.  In advance of these hearings, we’ve prepared a list of possible questions surrounding IPAB – Obamacare’s board of unelected bureaucrats – that the Secretary’s testimony may help resolve:

Fiscal Impact

  1. Both the Congressional Budget Office and the Medicare trustees agree that the Medicare program is running permanent deficits and will never come into balance absent reform.  Given this dire fiscal situation, exactly how long will IPAB extend the solvency of the Medicare program?

Transparency

  1. You recently wrote in a Politico op-ed that “contrary to critics’ contentions, the board’s work will be transparent, independent, and accountable to Congress and the President.”  Where in the statute is the requirement that IPAB’s bureaucrats conduct a public process, and solicit public comment, prior to issuing its recommendations?  Put another way, is there anything prohibiting IPAB members from negotiating backroom deals regarding their recommendations, similar to the “rock-solid deal” the Administration struck behind closed doors with Big Pharma?
  2. In May the Administration proposed requiring state Medicaid programs to obtain public comments before reducing provider reimbursement levels.  Why is the Obama Administration imposing public comment requirements on state Medicaid programs, but not imposing a similar requirement on its controversial IPAB?

Membership

  1. Your Politico op-ed notes that “economists” will comprise some of the “health experts” appointed to IPAB.  Why do you believe economists are qualified to pass judgment on health care treatments?
  2. According to the statute, a majority of IPAB members must not be “individuals who are directly involved in the provision” of health care services.  Do you believe it’s appropriate that a majority of IPAB’s members must be bureaucrats rather than doctors and nurses who treat patients firsthand?
  3. Why hasn’t the President nominated his appointees to IPAB yet?  The statute gives the board $15 million in mandatory funding, beginning in October.  If the President believes IPAB is such a good thing, why hasn’t he nominated members promptly, so the board can be up and running in short order?

Rationing

  1. You have claimed that IPAB “is expressly prohibited from making recommendations that ration care.”  Where exactly in the statute is the term “rationing” defined?
  2. Where in the statute is there a prohibition on IPAB making recommendations that could reduce access to breast cancer treatments – say, mammograms?  What about diabetes treatment and prostate cancer screenings – are there any provisions in the law that explicitly state IPAB cannot reduce access to those treatments?
  3. Last week the New York Times editorial board wrote that “A prime driver of our escalating health care costs is the advance of medical technology and the understandable desire of patients and doctors to adopt the latest treatment.  Sooner or later, as the nation struggles to contain health care spending, we may need to devise measures to determine whether very high-priced drugs provide enough medical benefit to warrant paying the bill.”  Do you agree?

Judicial Review

  1. If someone believes that IPAB has in fact rationed care, what redress does that person have to challenge the board’s decisions, seeing as how the board’s recommendations are exempt from judicial or administrative review?
  2. For nine years you served as Executive Director of the Kansas Association of Trial Lawyers, whose mission statement is “to uphold and advocate for the right of the individual for redress of grievances and access to the courts.”  How is your support for IPAB – which blocks access to the courts for any beneficiaries harmed by the board’s recommendations – consistent with the mission statement of the organization you headed for nearly a decade?
  3. In 2009 President Obama stated that he was “not advocating caps on malpractice awards…which I personally believe can be unfair to people who’ve been wrongfully harmed.”  If that’s still the President’s position, why does IPAB cap damages for people wrongfully harmed at ZERO – by never allowing them to file legal action at all?
  4. If the IPAB will not harm seniors and Medicare beneficiaries, why does the statute prohibit lawsuits against its recommendations in the first place?
  5. Would the Administration support repealing the provision prohibiting judicial review of IPAB’s recommendations?  Why or why not?

Other “Expert” Recommendations

  1. Your Administration has defended the IPAB on the grounds that independent experts should be called upon to make recommendations “to help Medicare provide better care at lower costs.”  The Medicare Payment Advisory Commission – a panel of experts similar to IPAB – recently came out in support of requiring co-pays for home health visits, on the grounds that a modest co-pay would encourage appropriate use of home health care.  Does the Administration agree with the recommendations of the MedPAC “experts?”
  2. Likewise, the President’s own Fiscal Commission supported restructuring Medigap insurance to “constrain over-utilization and reduce overall spending.”  Does the Administration agree with this recommendation of the “expert” panel the President himself appointed?

Broader Applicability

  1. Do you believe Members of Congress should follow, and/or be subject to, IPAB’s recommendations?  Will you do so yourself?
  2. Do you believe IPAB supporters who claim to support “experts” making health care choices should use their own independent resources to buy out of a rationing regime if IPAB restricts access to needed services and treatments?
  3. Does the Administration plan on running ads featuring Andy Griffith informing Medicare beneficiaries that their health care will be determined in part on the recommendations of a board of unelected bureaucrats?  If not, why not?

House Republican Budget

  1. You recently received Three Pinocchios from the Washington Post for making “outrageous” assertions and “ present[ing] a highly inflammable comment as a statement of fact” about the House-passed budget, comments for which the Post said you “should be ashamed.”  Do you agree with the Post’s characterization of your allegation that “there’s no question” patients would “die sooner” under the House-passed budget?  If not, why not?  Do you still stand by your original comments?
  2. You’ve previously testified before Congress that you have in fact read all of Obamacare.  Therefore, can you please explain the language on page 111 of the statute regarding the inflation adjustment mechanism for Obamacare premium subsidies in the years after 2018, and explain how exactly this inflation adjustment mechanism differs from the inflation adjustment mechanism for Medicare premium support payments included in the House-passed budget, which you said would cause seniors to “die sooner?”

A Modest Proposal for IPAB’s Defenders

Several months ago I began experiencing problems walking on my left foot.*  I was born with deformed bones in my left foot, and the pressure from walking on this abnormal foot structure for more than 30 years began to take its toll.  I visited several podiatric and orthopedic specialists to evaluate my options; non-invasive methods like orthotics and therapy helped, but it became apparent to me that they weren’t really solving the problem, as opposed to delaying the inevitable.  So I consulted with a surgeon, and he arrived at a plan of action – fusions, grafts, and a tendon lengthening – which should significantly alleviate my pain and improve my gait.  Feeling comfortable with the surgeon’s level of expertise and with his recommended treatment plan, I scheduled surgery for a few weeks from now.

However, the recent debate over the IPAB – Obamacare’s body of unelected bureaucrats who will control Medicare spending – has prompted me to reconsider my decision.  After all, who am I to decide how my own health care should be handled?

  • Paul Krugman has taught me that “Patients are Not Consumers” and that “making [health care] decisions intelligently requires a vast amount of specialized knowledge”;
  • The Center for American Progress, in making “The Case for Bureaucrats in Health Care,” has taught me that health care is different from buying shoes;
  • Ezra Klein has taught me that “consumer-directed health care is a silly idea” because “patients are not qualified to evaluate good care”; and
  • CMS Administrator Donald Berwick has taught me that “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care.  That is for leaders to do.”

These statements have left me in a serious conundrum, and forced me to reconsider my thinking.  After all, I’m not an expert on health care – I’m not even close:

  • I don’t have a PhD in economics, which, as Secretary Sebelius recently pointed out, qualifies individuals as “experts” in how to run a health care system;
  • Neither I nor my surgeon graduated from an Ivy League school; and
  • I don’t even know all the words to Fair Harvard.

I do however now recognize that I am not only clearly incapable of making my own health care choices, but also that my health – and our entire country – would be better off leaving those choices to “experts” who are my intellectual superiors.  After all, President Obama promised that the stimulus would prevent unemployment from rising above 8 percent – and who thinks joblessness is still a major problem more than two years later?  And just look at how Obamacare has already delivered the $2,500 reduction in premiums that candidate Obama repeatedly promised.

So all I need now is to find a suitable “expert” to tell me whether I should have the surgery or take the painkiller.  Therein lies my open request to IPAB’s defenders, to provide me with the enlightened knowledge of my own medical condition that I so clearly lack:

  • Peter Orszag – supporter of IPAB as a way “to improve Medicare’s cost-effectiveness” – can tell me whether my surgery will cost too much;
  • Zeke Emanuel can tell me where my procedure fits on his chart for the allocation of scarce medical resources; and
  • Dr. Berwick can tell me if I’m one of those cases where “Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been available for centuries.”

I do hope that one of these individuals – or indeed other political commentators who have supported IPAB in recent weeks – can tell me how I should proceed when it comes to my foot.  After all, I now realize that my surgeon could be recommending an operation just for the reimbursement check – because most medical professionals base their decision-making processes on whether they will obtain a $50,000 payday (as opposed to Obamacare’s “experts,” whose decisions will be based on the fact that “the social budget is limited – we have a limited resource pool”).

There is a catch however:  While I will defer my own opinion to those of the “experts,” I do expect that any individual who passes judgment on my case will assume full financial and legal liability for same.  That may be a problem for some of IPAB’s defenders.  After all, Section 3403 of the statute exempts the IPAB and its members from ANY legal liability associated with its decisions.

And therein lies the point of this proposal, and this story:  If the IPAB’s defenders – and its so-called “experts” – aren’t willing to put their own money where their mouths are, then how good will this board of unaccountable bureaucrats be?

 

* And just in case you were wondering, the facts of this story are real, as is the sarcasm…

Who Am I To Decide How My Own Health Care Should Be Handled?

Several months ago I began experiencing problems walking. I was born with deformed bones in my left foot, and the pressure from walking on this abnormal foot structure for more than 30 years has begun to take its toll. I visited several podiatric and orthopedic specialists to evaluate my options. Non-invasive methods like orthotics and therapy helped, but it became apparent to me that they weren’t really solving the problem; they were just delaying the inevitable. So I consulted with a surgeon, and he arrived at a plan of action — fusions, grafts and a tendon lengthening — which should significantly alleviate my pain and improve my gait. Feeling comfortable with the surgeon’s level of expertise and with his recommended treatment plan, I scheduled surgery for a few weeks from now.

However, the recent debate over the Independent Payment Advisory Board (IPAB) — Obamacare’s body of unelected bureaucrats who will control Medicare spending — has prompted me to reconsider my decision. After all, who am I to decide how my own health care should be handled?

  • Paul Krugman has taught me that “patients are not consumers” and that “making [health care] decisions intelligently requires a vast amount of specialized knowledge”;
  • The Center for American Progress, in making “The Case for Bureaucrats in Health Care,” has taught me that health care is different from buying shoes;
  • Ezra Klein has taught me that “consumer-directed health care is a silly idea” because “patients are not qualified to evaluate good care”; and
  • CMS Administrator Donald Berwick has taught me that “I cannot believe that the individual health care consumer can enforce through choice the proper configurations of a system as massive and complex as health care. That is for leaders to do.”

These statements have left me in a serious conundrum, and forced me to reconsider my thinking. After all, I’m not an expert on health care — I’m not even close:

  • I don’t have a PhD in economics, which, as Health and Human Services Secretary Kathleen Sebelius recently pointed out, qualifies individuals as “experts” in how to run a health care system;
  • Neither I nor my surgeon graduated from an Ivy League school; and

I do, however, now recognize that I am not only clearly incapable of making my own health care choices, but also that my health — and our entire country — would be better off leaving those choices to “experts” who are my intellectual superiors. After all, President Obama promised that the stimulus would prevent unemployment from rising above 8 percent, and who thinks joblessness is still a major problem more than two years later? And just look at how Obamacare has already delivered the $2,500 reduction in premiums that candidate Obama repeatedly promised.

So all I need now is to find a suitable “expert” to tell me whether I should have the surgery or take the painkiller. Therein lies my open request to IPAB’s defenders, to provide me with the enlightened knowledge of my own medical condition that I so clearly lack:

  • Peter Orszag, who supports IPAB as a way “to improve Medicare’s cost-effectiveness,” can tell me whether my surgery will cost too much;
  • Dr. Berwick can tell me if I’m one of those cases where “Most people who have serious pain do not need advanced methods; they just need the morphine and counseling that have been available for centuries.”

I do hope that one of these individuals — or indeed other political commentators who have supported IPAB in recent weeks — can tell me how I should proceed when it comes to my foot. After all, I now realize that my surgeon could be recommending an operation just for the reimbursement check, because most medical professionals base their decision-making processes on whether they will obtain a $50,000 payday (as opposed to Obamacare’s “experts,” whose decisions will be based on the fact that “the social budget is limited — we have a limited resource pool”).

There is a catch, however: While I will defer my own opinion to those of the “experts,” I do expect that any individual who passes judgment on my case will assume full financial and legal liability for same. That may be a problem for some of IPAB’s defenders. After all, Section 3403 of the statute exempts the IPAB and its members from ANY legal liability associated with its decisions.

And therein lies the point of this proposal, and this story: If the IPAB’s defenders — and its so-called “experts” — aren’t willing to put their own money where their mouths are, then how good will this board of unaccountable bureaucrats be?

This post was originally published at The Daily Caller.

The Facts about IPAB’s Road to Rationing

Secretary Sebelius has an op-ed in Politico this morning regarding Obamacare’s Independent Payment Advisory Board, a 15 member board that will recommend ways to reduce Medicare spending.  Several specific assertions in the article merit comment and rebuttal:

  • The Secretary notes that the board will be “made up of 15 health experts,” including “economists.”  This admission – coupled with the statutory requirement that a majority of IPAB members NOT be practicing medical providers – effectively means that many of the members of the board will be proverbial bean-counters, focusing on bottom-line ways to contain costs rather than ways to improve care.
  • The Secretary states that “contrary to critics’ contentions, the board’s work will be transparent, independent, and accountable to Congress and the President.”  That’s an interesting assertion, seeing as how Section 3403 of the statute (which established IPAB) includes NO requirement for public comment prior to IPAB issuing its recommendations.  Specifically, 42 USC 1395kkk(i)(1), as created by the law, indicates that IPAB “may hold such hearings…take such testimony, and receive such evidence as the Board considers advisable.”  The statutory language provides about as firm a commitment to transparency as the President’s promise to televise all health care negotiations on C-SPAN.
  • The Secretary notes that IPAB’s “recommendations must improve care and help control costs.”  In other words, if a treatment, method, or process would save or extend a million lives, but cost Medicare a million dollars, the IPAB is prohibited from recommending that particular therapy.  How will this constraint help patients?
  • The Secretary claims that “the claims that the board will ration care are simply false.”  But the Medicare actuary – and others – have noted that the kind of payment reductions contemplated by IPAB amount to de facto rationing by reducing access to care.  The actuary has stated that the payment reductions in the law could “jeopardize[e] access to care for beneficiaries,” and that the IPAB reductions in particular would be “difficult to achieve in practice,” because of the access-related harm to seniors that would result.
  • The Secretary alleges that the health care law “extended the solvency of the Medicare Trust Fund.”  That statement lies in direct contrast to President Obama himself, who in an interview with Fox News last year admitted that “You can’t say that you are saving on Medicare and then spending the money twice” – once to extend Medicare’s solvency, and a second time to fund new entitlements for other Americans.
  • The Secretary alleges that “economists and the Congressional Budget Office believe this approach [i.e., IPAB] will work.”  On the latter point, the Secretary is making a demonstrably false statement.  Just this Wednesday, the CBO’s latest version of the long-term budget outlook EXCLUDED savings from the IPAB in calculating its alternative fiscal scenario, because it believes the IPAB payment reductions will be “difficult to sustain.”

Democrats and the Administration continue to assert that the IPAB approach will help, not harm, patients.  If that’s the case:

  • Why did the statute not require IPAB to take comments from the public before making its recommendations?  Just last month the Administration proposed requiring state Medicaid programs to obtain public comments before reducing provider reimbursement levels.  Why is the Obama Administration imposing public comment requirements on state Medicaid programs, but not imposing a similar requirement on its controversial IPAB?
  • Why is the IPAB exempt from administrative and judicial review?  If no patients will be harmed by IPAB’s recommendations, then why are Medicare beneficiaries prohibited from taking legal action against it?
  • Will Secretary Sebelius commit to following IPAB’s recommendations herself?  Or will Democrats and others who claim they support “experts” making health care choices use their own resources to buy themselves out of a rationing regime if IPAB restricts access to services and treatments they need?

Liberals Defend RationCare

In the past several days, various liberal bloggers have come out to defend the RationCare program promoted by the Administration in the form of the Independent Payment Advisory Board.  The Center for American Progress blog makes “The Case for Bureaucrats in Health Care” by arguing that “there should be no question that if you give 15 bureaucrats in Washington a budget with which to run Medicare, that they’ll deliver health care services inside the budget cap.”  The problem is the access problems for seniors that will result from these arbitrary payment reductions to remain under the cap – the Medicare actuary said that the IPAB cuts would be “difficult to achieve in practice,” not least because other provisions in the law could result in 40 percent of providers becoming unprofitable over the long term.

Of course, the Center for American Progress (CAP) also proposed applying the IPAB’s RationCare scheme to the ENTIRE health care sector, which would subject ALL health care expenditures to a spending target – and could make individuals spending their own health care dollars above that target ILLEGAL.  CAP has yet exactly to explain how this provision would work:

  • Would individuals be subject to fines or taxes for daring to buy health care that bureaucrats did not approve?
  • What if someone wanted to fly overseas to obtain health care elsewhere – would they be permitted to leave the country?
  • Could individuals be jailed for having the audacity to pursue health care spending not approved by a bureaucrat?
  • Would doctors be subject to fines, taxes, or criminal penalties for treating their patients even though national spending levels exceeded the bureaucrat-determined cap?
  • CAP believes that women have a constitutional right to abortion.  How exactly does CAP propose to reconcile this purported “constitutional right” with the statutory spending targets it wants to place on ALL health spending?  Is CAP saying that women will always be able to obtain their “constitutional right” to an abortion, but may not be able to obtain pre-natal care if bureaucrats determine the spending target has been exceeded?

Separately, the Economist also expresses its support for having “experts” make health care spending decisions for all Americans, arguing that patients are unable to make these decisions for themselves because “health care is different:”

Patients aren’t going to experience a loss of freedom or satisfaction because an expert reviewer at the Independant [sic] Payment Advisory Board makes the call as to whether a procedure is medically beneficial, rather than the corresponding bureaucrat at their insurance provider or at the for-profit clinic they’re attending.  Health care is different from buying shoes.  Which is why it wouldn’t be at all surprising if a board of 15 experts could play a major role in reducing expenses and improving care outcomes in the American medical industry.

This argument TOTALLY misses the point.  If an insurance company “bureaucrat” makes an incorrect decision regarding a medical procedure, a senior can always go to another insurer and obtain coverage – but if government bureaucrats make such a decision, individuals likely won’t be able to obtain other insurance (not least because of Obamacare’s cuts to Medicare Advantage).

The fact that even Democrats are moving away from RationCare shows how unpopular the idea of having a board of unelected, unaccountable bureaucrats is to most Americans – even if liberal elitists continue to believe that “experts” should determine what type of health care all Americans receive.