Impenetrable Care: Parsing the 2446 Pages of “Obamacare.”

Speaker Pelosi signing bill she hasn't read. She wasn't the only one, and not the first, or the last, to do so.

As have many ,I’ve railed against Congress for passing the Patient Protection and Affordable Care act without reading it. The bill famously had to be passed to find out what was in it, as Speaker Pelosi explained.

Since, like many, perhaps millions of Americans, I’m convinced I’m as smart as at least half the folks in Washington, It occurred to me that the time had come to walk the walk.  I’m going to read the whole damn thing – 2464 ages with the reconciliation – with the aim of finishing before the Supremes rule.

What do I bring to the job?  First, time. I’m retired.   This sucker is long!  A

The Emperor Justinian's Corpus Iuris is quite succinct by modern standards.

cursory search indicates that, so far, the Act runs to about 1.1 million words.  The Revised Standard Version(King James ) Bible is something  in excess of 700,000 words.  Justinian’s 7th Century code of Roman law is estimated at between two and three bibles.


I have no legal training, but rigorous high school English, four years of Latin and five of French – for that latinate legal vocabulary – and a master’s in English should help. And I spent many years in a job requiring me to read complex commercial contract language.  I am, I think, better equipped than many citizens for this task. Let’s  see if I’m up to it

 So we begin

“In the Senate of the United States,

December 24, 2009.

Resolved, That the bill from the House of Representatives (H.R. 3590) entitled ‘‘An Act to amend the Internal Revenue Code of 1986 to modify the first-time homebuyers credit in the case of members of the Armed Forces and certain

other Federal employees, and for other purposes.’’, do pass with the following…”

 Huh? Homebuyer’s credit?

“AMENDMENTS:

Strike out all after the enacting clause and insert:

1 SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

2 (a) SHORT TITLE.—This Act may be cited as the ‘‘Patient Protection and Affordable Care Act’’.

Oh,here we are. Congress does work in mysterious ways.

A fifteen page table of contents follows. Then after striking this, that, and the other thing we get to this:

“TITLE I—QUALITY, AFFORDABLE  HEALTH CARE FOR ALL AMERICANS

 Subtitle A—Immediate Improvements in Health Care Coverage  for All Americans”

Section 2711 states that there shall be no benefit limit, either per annum or lifetime. Coverage, which may not be revoked except for fraud.   However, those benefits not considered essential under section 1302 b can be limited. Maybe. I guess we’ll see when we get to 1302(b) . Also referenced are some IRS codes. I’ll never finish this if I go and look them up as I go along.

Providers must cover

evidence-based items or services that have in

effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force.”(page 21)

Huh? Who are they?

…an independent panel of non-Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists who work under the auspices of the Agency for Healthcare Quality and Research.”

Never heard of them either? Me too. They hang out at HHS. Another to add to the collection of alphabet agencies such as BATF, ICE, and so on. I wonder if they have a SWAT tram.

‘‘(2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;”

 So again, a reference to standards to beset by a government agency. At least I’ve heard of these guys, as we all have.

Here is also a philosophical question: what is the meaning of insurance, if we insure ourselves for foreseeable needs, such as childhood immunizations, or Ms. Fluke’s birth control pills? I really don’t remember, but I thin I got my shots at the doctor’s office, and my parent’s paid. In the 50s there was the polio epidemic and I remember getting the vaccine at school.

20 ‘‘(3) with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guide lines supported by the Health Resources and Services evidence -informed preventive care.”

 

I understand every word and semiotic unit in this phrase, yet have no idea what they are talking about.

The process of distilling and disseminating the best available evidence from research, practice and experience and using that evidence to inform and improve public health policy and practice. “

Now I get it. Somebody, or, rather, a whole lot of somebodies, will decide what’s best for younger people, and that’s what they will get. Interesting that the first reference I found was in Canada.

‘‘(4) with respect to women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health Resources and Services Administration for purposes of this paragraph.”(page 21)

Wait a minute. Health Resources and Services Administration? Another bunch?  I scrolled back and checked; Yup, first reference. So who are these folks?

The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. ‘ And..”Comprising six bureaus and ten offices .

Fabulous!

‘‘(c) VALUE-BASED INSURANCE DESIGN.—The Secretary may develop guidelines to permit a group health 7 plan and a health insurance issuer offering group or individual health insurance coverage to utilize value-based insurance designs.”(page 22)

Value based?

“…the idea that consumers’ out-of-pocket medical costs should be based on the value of a service to their health rather than its price.”( From the Washington Post.)

So is that clear? I thought so.

“REGULATIONS.—The Secretary shall promulgate regulations to define the dependents to which coverage shall be made available under subsection (a).”(page 22)


The Slackercare clause


Well, well, well, no wonder insurance companies wanted in on this. This next section smacks of the industrial codes of the New Deals National Reconstruction Act.

‘‘(a) IN GENERAL.—Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to enrollees a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the ‘NAIC’), a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.”


"Your plan for coordination of industry follows precisely our lines of cooperation." Benito Mussolini, speaking in open letter to FDR, 1933.

Pure corporatism, which is a polite way of saying classically fascist: industry, advocates and qualified individuals, all working together to tell us what w e need and what we’ll get. Given current practice, those “advocates” will likely be funded in part by the government, just as the EPA funds NGOs that then sue it.

At least, that’s the way I see it.  I suspect the people who out this together view it as a collaborative effort of the “healthcare community.”

And yet another group involved, without even a name yet, but they will no doubt get plenty of office space and a snazzy web page, funding and per diems.

Pages 25-27 describe benefits summary standards. This seems harmless though rather prescriptive, but it is noteworthy that the sections preempts any state regulation.Is it really harmless? A government controlled consortium of “interestd” parties will define the language in which we describe insurance terms and medical procedures. Will they think out of the box, or box us in?

Also, there is the philosophical question: would not insurance companies that gave out fraudulent or impenetrable benefit summaries suffer in the marketplace? In making such market based objections one is in the position of howling after a train that is disappearing down the track or more accurately left before the passenger arrived,or should this legislation stand, the metaphor would be that the station is closed, and grass has overgrown the rusting rails.

I have barely reached page 30, but have already learned that the Federal government is even  more vast than I knew and is set to be even more so, beyond  imagination as that is.  This act, with its multi-aency involvement, working groups and standard setting, is set to loose great torrents of administrative law that will in time seep into every aspect of our lives  It is classically fascist in that it aims  to shepherd disparate social and economic groups to an ostensibly mutually beneficial agreement under the eye and ultimately enforcement, of the state.

The emperor Diocletian used coercion, micromanagement and a debased currency in trying to halt economic decline. Sound familiar?

The urge to control economic activity is an old one, and the record of failure for such efforts is equally ancient.

  (More to come)

 


 

 

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