Senator Baucus’s proposal for health care reform passed muster from the CBO. From the story:

A compromise health care proposal widely seen as having the best chance to win Democratic and Republican support would cost $829 billion over the next 10 years, nonpartisan budget analysts concluded Wednesday. It also would reduce the federal deficit by more than $80 billion, according to a report from the Congressional Budget Office.

That and six bits will buy you a cup of coffee: First, these things are never as cheap as they promise. Just look at Medicare and Medicaid. Second, this would include cutting hundreds of billions out of Medicare. Good luck with that. Third, it does not include what the bureaucrats would put in–that’s where the real mischief will be done.  Fourth, the public option is out, an approach the Democratic Left promises to vote down. So, this seems like O’Hare Airport to me–you can get in, but you can’t get out. But that’s okay for Obamacare supporters. The point of this Kabuki Theater is to get this to the floor, after which most of the changes making it affordable will soon become non operable.

But even if I am being overly cynical about the Baucus bill, I fear we will still have the cost/benefit/best practices–rationing–boards that will apply to the private plans.  Federal money will help pay for abortion, which hasn’t been done in years, through the vouchers the lower income will receive to help pay premiums.  That could kill the bill.  And why tax good policies, while limiting the amount of money that consumers can pay out of pocket for care, e.g. deductibles and copays.  But that will tax the non-rich, violating an Obama promise, while making it harder to reduce the cost of plans.  Finally, it requires all of us to buy insurance–or else. I understand the point in terms of spreading the risk, but is it constitutional?

What a mess.  And the reason is because Obamacare is not reform, it is a remaking.  In other words, it does much more than is needed to fix the problems we have.

This is what will happen if we permit government cost/benefit boards to decide on what treatments–and patients–are worth spending money on–and which aren’t.  The Province of Ontario, Canada, has limited life extending treatment for terminal colon cancer patients to save $9 million. From the story:

Opponents of the public option maintain that Canadian-style health care would entail rationing, caps on care, bureaucratic interference in medical decision-making and even “death panels” deciding when the ill become too expensive to save. Most Canadians believe this is a gross exaggeration of reality. But then how to characterize Ontario’s decision to cut off funding for colorectal cancer patients taking a life-prolonging drug, in order to save $9-million a year?

Andre Marin, the province’s plain-speaking ombudsman, said the decision “verges on cruelty.” Marin said the “arbitrary” limit on the number of cycles of the drug Avastin that Ontario will fund forces patients to pay out of their own pockets or abandon treatment. Avastin does not cure cancer, but prolongs life when taken in conjunction with chemotherapy treatment, adding, on average, nine months of survival. “For patients whose cancer has already metastasized, it stops their tumours from growing and prolongs their lives, at least for a while. It is, without exaggeration, their lifeline,” Mr. Marin said.

Ontario Health Minister David Caplan rejected the suggestion that the cap on treatment was a financial decision alone, arguing it was based on clinical evidence. But it’s easy to reach the conclusion that the province decided nine extra months of life for a dying patient wasn’t worth the money. Which is pretty much the kind of decision a “death panel” would be confronted with.

This is precisely the “evidence based” kind of decision making, linked with quality of life judgmentalism, that Obamacare would impose to cut costs.  And, it is precisely what Oregon did to Barbara Wagner and Randy Stroup under its rationed Medicaid system–with the exception that a compassionate bureaucrat offered to pay for their assisted suicides.

Death panel?  You be the judge.

Most of the focus in the Obamacare debate has been on HB 3200. But Senator Max Baucus (D-MT) has been trying to forge a compromise package. Instead, he has upset both sides, the Left because it has no public option and the Right because it too contains provisions that would, in the name of cost cutting, put the expensive for whom to care at great medical hazard.

A Washington Times editorial points out one provision that I have been meaning to address.  It seems that physicians who spend the top 10% in caring for patients each year will see their compensation reduced–no matter the cause!  From the editorial:

Yes, there are death panels. Its members won’t even know whose deaths they are causing. But under the health care bill sponsored by Senate Finance Committee Chairman Max Baucus, Montana Democrat, death panels will indeed exist – oh so cleverly disguised as accountants. The offending provision is on Pages 80-81 of the unamended Baucus bill, hidden amid a lot of similar legislative mumbo-jumbo about Medicare payments to doctors. The key sentence: “Beginning in 2015, payment would be reduced by five percent if an aggregation of the physician’s resource use is at or above the 90th percentile of national utilization.” Translated into plain English, it means that in any year in which a particular doctor’s average per-patient Medicare costs are in the top 10 percent in the nation, the feds will cut the doctor’s payments by 5 percent.

Forget results. This provision makes no account for the results of care, its quality or even its efficiency. It just says that if a doctor authorizes expensive care, no matter how successfully, the government will punish him by scrimping on what already is a low reimbursement rate for treating Medicare patients. The incentive, therefore, is for the doctor always to provide less care for his patients for fear of having his payments docked. And because no doctor will know who falls in the top 10 percent until year’s end, or what total average costs will break the 10 percent threshold, the pressure will be intense to withhold care, and withhold care again, and then withhold it some more. Or at least to prescribe cheaper care, no matter how much less effective, in order to avoid the penalties.

This is simply unacceptable.  It places doctors in a direct financial conflict of interest with their own patients, further undermining Hippocratic values, already under intense assault by the bioethics movement’s promotion of a quality of life ethic.

Time to steer a different course.  Rather than try to remake everything, let’s focus on the cost of insurance and access to those with pre existing conditions.  That can be done faster, cheaper,  and without policies that undercut the equal moral value of all human life.

The UK continues to provide us with a vivid and terrifying education about the dangers of health care rationing. The UK”s central planners have urged that doctors make no efforts to save prematurely born babies under 22 weeks.  This don’t treat decree (because that is what “guidelines” become in practice) is based on evidence measuring overall outcomes.  Almost all such babies either die or have very serious disabilities (or to put it bluntly, if they live, their lives are deemed not worth living).

What this means, is that members of categories are not treated like individuals and rendered care in certain circumstances based on their individual situation. This seems to have happened to a baby born a few days before the cutoff date and, hence, allowed to just die.  From the story “Doctors Told Me It Was Against the Rules to Save My Premature Baby:”

Doctors left a premature baby to die because he was born two days too early, his devastated mother claimed yesterday. Sarah Capewell begged them to save her tiny son, who was born just 21 weeks and five days into her pregnancy  -  almost four months early. They ignored her pleas and allegedly told her they were following national guidelines that babies born before 22 weeks should not be given medical treatment.  Miss Capewell, 23, said doctors refused to even see her son Jayden, who lived for almost two hours without any medical support. She said he was breathing unaided, had a strong heartbeat and was even moving his arms and legs, but medics refused to admit him to a special care baby unit.

If that is true, it is a profound abandonment. Moreover, it illustrates the consequences of treating individuals as mere category members for treatment decisions. For example, in the UK, an older person will be denied a hip replacement based on age, regardless of whether the surgery would benefit the patient and restore the ability to live a vital life.

Some will say the baby wouldn’t have lived.  Even if that is very probable–very little in medicine is certain–that’s not the point. Centralized bureaucratic boards such as the UK’s NICE–which Tom Daschle, who the NYT called the most influential person in the current health care debate, wants us to emulate–means the end of medicine as a profession, and of Hippocratic values as the guiding ethic of health care.  And don’t forget, under Obamacare these centralized boards would establish the rules of care for both private and publicly funded care.

When doctors abide by bureaucratic rules in deciding the treatment to offer or withhold from patients, rather than treat patients as individuals, oppression and neglect will invariably follow.  (Here’s another UK case, a stroke patient purportedly forced onto the Liverpool Care Pathway and sedated and denied fluids.)  Health care rationing isn’t about what is rationed–Obama’s dumb red pill versus blue pill metaphor–it is about who is rationed.  This is precisely what the majority of the American people are trying to prevent as we resist the imposition of utilitarian medical ethics under Obamacare.

I was unaware of this case, but it falls squarely into the debate about Obamacare. A cerebral palsy patient on Medicaid will have to fight in court to receive the level of care prescribed by her physician.  From Jeff Emanuel’s blog entry at CBS.Com:

In 2007, citing a disagreement with Callie’s attending physician over just how much care she needed, the state cut the portion of Callie’s care it was willing to pay for by 15%, to 84 hours a week, over the objections of her doctor. Callie’s mother filed suit, arguing the state had no right to contradict the orders of Callie’s personal physician and limit her treatment. However, Georgia officials argued Callie’s care was subject to rationing, as the state bureaucrats’ need to ensure Medicaid resources were allocated “fairly” superseded her doctor’s care prescription or her personal medical needs.

Callie’s mother won. The state appealed.

The thrust of the states’ argument in Moore was summed up in a brief written by the attorneys representing the state of Florida. “Treating physicians,” they wrote, “cannot be trusted with this sort of decision. When left to their own devices, they advocate for their patients” – something state governments resent due to its interference in the execution of their cost-effectiveness analyses – “and deem all manner of unproven, dangerous, ineffective, cosmetic, unnecessary, bizarre and controversial treatments as ‘medically necessary.’”

While bureaucrats “will consider doctors’ determinations,” said attorney Robert Highsmith in oral arguments on March 24, the “final arbiter” of medical decisions is and should be “the state.” The panel of the 11th Circuit agreed.

I daresay, that if this had been an HMO, the Left would be screaming, and I don’t think the decision would be the same.

I looked up the case. It is unpublished, meaning it is not precedent.  But it states quite starkly that doctors are not the only ones who can determine proper levels of care in a state-funded system. From the court’s decision:

While it is true that, after the 1989 amendments to the Medicaid Act, the state must fund any medically necessary treatment that Anna C. Moore requires [citation omitted] it does not follow that the state is wholly excluded from the process of determining what treatment is necessary. Instead, both the state and Moore’s physician have roles in determining what medical measures are necessary to “correct or ameliorate” Moore’s medical conditions. [Citation omitted] The agency may place appropriate limits on a service based on such criteria as medical necessity or on utilization control procedures. [Citation omitted] A private physician’s word on medical necessity is not dispositive.

The  ruling means that the state and the mother will duke it out in trial over whether the extent of care the doctor prescribed is appropriate in a state-funded system.

The real point Emanuel is making here–and I think it is a good one–is that the court’s and state’s thinking about this bely all the president’s promises about levels of care not changing under Obamacare. Pointing to the UK’s list of horrors (search SHS under “NHS Meltdown” for scores of examples), Emanuel makes a vivid argument:

Government is a jealous mistress. What simply appears to be an issue of who pays for a few extra hours of in-home care today could very well turn into a get-half-coverage-or-none-at-all situation here, like it is in Britain, before too long.

Obamacare will be rationed care, controlled by bureaucrats and utilitarian bioethicists who would man the cost/benefit boards and make the treatment coverage decisions. This is an important case, even if it is not binding, that–along with the Oregon travesty to Barbara Wagner and Randy Stroup, who were offered assisted suicide in place of chemotherapy–gives us a glimpse of a disturbing future–unless we push back Obamacare with its public option and centralized control boards and move in a different direction.