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Reader questions: No, the health-care bill does not keep you from paying money in exchange for services

Commenter Fast Eddie is concerned:


Do you have enough courage to take on the most controversial part of the whole Obama-Reid-Pelosi agenda?

If they managed to get the Senate bill passed in the House, HOW WOULD THAT EFFECT A MIDDLE CLASS FAMILIES ABILITY TO PRIVATELY CONTRACT WITH THEIR PERSONAL DOCTOR in the event that their healthcare insurance won't cover something?

It wouldn't. There is nothing in either bill that bars you from giving a doctor money in exchange for a service. But my experience with these fears is that they usually come from a very twisted and wrong reading of something that actually exists in the bill. So if this is based on a real provision, let me know where it is and we can go through it in more detail.

By Ezra Klein  |  February 9, 2010; 11:07 AM ET
 
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Comments

Also, Ezra, the death panels. And how if you don't sign on for Obamacare the Democrats will send you to jail. Don't forget that.

Kudos to Ezra for doing something that I have trouble doing. I have a HARD TIME READING posts of anything that USE ALL CAPS FOR EMPHASIS!! Or more than one exclamation point. :)

But then, I use smileys, which other people hate. :(

That being said, almost every piece of legislation has unintended consequences. I can't help but wonder if current HCR, if passed, might have the effect of increasing the amount of fee-for-service physicians and even hospitals. Which is, ironically, the platonic healthcare ideal for many conservatives.

Posted by: Kevin_Willis | February 9, 2010 11:20 AM | Report abuse

If I type IN ALL CAPS, then what Rush told me MUST BE TRUE!

Posted by: AZProgressive | February 9, 2010 11:20 AM | Report abuse

Thanks Ezra for responding. I greatly appreciate you taking the time.

A former head of the AMA named Donald Palmisano(sp?) was on the Wall Street Journal website talking about this.

I emailed him to find a reference in the bill for what he was talking about and I will follow-up with a post of his response.

It was his understanding that the Medicare rules restricting private contracting are in effect and indeed Democrats in committee explicitly voted down an amendment by Rep Foxx that was specifically designed to clear up any possible ambiguity....I will post some info on this as soon as I can.


While it is true that anybody can privately contract with any doctor at any time, I believe it is true that THE DOCTOR WILL BE BANNED FROM PROVIDING ANY SERVICES COVERED IN THE NEW FEDERAL EXCHANGE FOR TWO YEARS.

That sounds pretty much like an end to the status quo to me.

Posted by: FastEddieO007 | February 9, 2010 11:34 AM | Report abuse

PS: Death panels came about based on our President's own words regarding his dying grandmother's hip surgery, saying that it may represent an unsustainable model for government-run healthcare.

Posted by: FastEddieO007 | February 9, 2010 11:35 AM | Report abuse

I APOLOGIZE FOR USING ALL CAPS sometimes. A bad habit I guess.

Posted by: FastEddieO007 | February 9, 2010 11:37 AM | Report abuse

Former AMA Head Donald Palmisano wrote me the following:
_______________

The bills in the senate and house follow the rules of Medicare for
private contracting. You can do private contracting but the physician
has to get out of Medicare for two years.
See the link below regarding Medicare and the summary.

http://www.aafp.org/online/en/home/practicemgt/mcareoptions.html

PRIVATE CONTRACTING
Provisions in the Balanced Budget Act of 1997 give physicians and
their Medicare patients the freedom to privately contract to provide
health care services outside the Medicare system. Private contracting
decisions may not be made on a case-by-case or patient-by-patient
basis, however. Once physicians have opted out of Medicare, they
cannot submit claims to Medicare for any of their patients for a two-
year period.
---------
Those in control of Congress do not want to allow private contracting
other than what exists now as evidence by this amendment offered and
defeated in the House:

Here is the amendment that was offered for the House bill but it was
not allowed by the rules committee:
http://rules-republicans.house.gov/ShortTopics/Read.aspx?id=315
Foxx: To make in order and provide the necessary waivers for amendment
#114 offered by Rep. Price (R-GA), which would add language protecting
the private right to contract between individuals and health care
providers.

Defeated

4 to 6*

----

Posted by: FastEddieO007 | February 9, 2010 11:38 AM | Report abuse

FastEddie: I'm not the most knowledgeable person here, so correct me if I'm wrong. But from the link above, the AAFP seems to be talking about changes implemented by the Department of Defense Appropriations Act of 2010, not the health care bills in Congress. And even there, it doesn't imply that the precautions they want their doctors to take are a direct result of the appropriations bill. It seems to be describing what is currently the status quo.

Whether these restrictions actually exist today, or if they're addressed at all in the health care legislation, is beyond me. But the fact that a Republican amendment was defeated on this doesn't prove anything one way or the other. All sorts of amendments are offered for all kinds of different reasons, whether they're based in reality or not, and ~90% are voted on strictly on party lines.

Posted by: dwbh | February 9, 2010 11:56 AM | Report abuse

Did Dr. Palmisano point to a specific provision in any of the bills that support his contention. Given her history, I wouldn't accept an amendment offered by Rep. Foxx as evidence of anything other than paranoia and mendacity.

Posted by: cmccauley60 | February 9, 2010 11:59 AM | Report abuse

This link here is a great article that summarizes the infamous interview that President Obama gave to the NY Times way back in April of last year that gave tremendous insight into Obama's vision for bending the cost curve....this is the interview that gave pause to Sarah Palin who wondered aloud on her Facebook page whether or not Obama viewed providing "hip surgery"-type services to a baby with Downs syndrome that might also die in a few years:

http://www.bloomberg.com/apps/news?pid=20601070&sid=aGrKbfWkzTqc

Posted by: FastEddieO007 | February 9, 2010 12:01 PM | Report abuse

Ezra, hopefully you can comment on Eddie's reply. I'm not sure I understand the detais of the Medicare rules either and what he means by "private contracting".
I assume he means negotioting directly with his doctor on what he will pay for services rendered.

Posted by: truth5 | February 9, 2010 12:02 PM | Report abuse

What I refer to here is the "status quo" for Medicare, but which Pelosi and Reid have apparently extended into their new legislation....voting down Foxx's amendment in committee seems to have confirmed precisely what Dr. Donald Palmisano was saying too.

Posted by: FastEddieO007 | February 9, 2010 12:03 PM | Report abuse

And it gets much worse, since for the moment it'd be reasonable for a Medicare patient to find a doctor willing to leave Medicare for 2 years (i.e. theres still about 50% of business outside of Medicare) when Pelosi & Reid's bill becomes law that will no longer be true.

This makes Obama's cavalier attitude regarding paying out-of-pocket regarding HIS grandmother so repulsive to me....he is a powerful politician capable of finding a doctor in the 5% willing to work outside the federal system. Us in the middle class will not be so fortunate.

Posted by: FastEddieO007 | February 9, 2010 12:06 PM | Report abuse

FastEddie: ok, so if this is the status quo already, then the answer to your original question, "If they managed to get the Senate bill passed in the House, HOW WOULD THAT EFFECT A MIDDLE CLASS FAMILIES ABILITY TO PRIVATELY CONTRACT WITH THEIR PERSONAL DOCTOR in the event that their healthcare insurance won't cover something?" would be that it wouldn't. There would be no effect on the status quo one way or the other. Unless there's something specific in the new legislation that impacts this that you or Palmisano could cite.

Posted by: dwbh | February 9, 2010 12:09 PM | Report abuse

Eddie has it exactly right. The system that is being contemplated will necessarily have an elite track for the president and his family, high level officials, celebrities, and other favored types. The rest of you can go eat dirt.

Posted by: truck1 | February 9, 2010 12:16 PM | Report abuse

Here are pros & cons of the limits on "private contracting" for Medicare

http://www.ncpa.org/commentaries/misplaced-criticisms-of-medicare-private-contracting

http://www.ncpa.org/pub/ba268


I am an honest middle class person who has concerns. I am not picking on this for something to do.

If I can become convinced that Democrats aren't attempting to limit my freedom at handling my medical options I will drop it.

Newt Gingrich also addressed this topic....

http://www.usnews.com/articles/opinion/2009/01/27/the-market-can-fix-the-healthcare-problem.html%20?PageNr=1


I look forward to hearing more on this....

Honestly if Democrats want bipartisan solutions they may have to go out of their way and explicitly address these types of "misreadings" (if that is what they are) through the adoption of amendments like Foxx's in order to calm the fears of people like me. (IMHO)

Posted by: FastEddieO007 | February 9, 2010 12:17 PM | Report abuse

One reason Medicare is going broke is that it basically pays for everything. Most of health care spending comes in the last year or so of life.

Conservatives and many others want to curb Medicare spending. There are only two ways to curb Medicare spending: continue to pay for everything but at lower rates (doctors and hospitals and their allies will object) or pay at current rates but don't pay for everything, especially not treatments unlikely to have much effect towards the end of life (to the extent that can be predicted).

But the minute that is suggested we are on the slippery slope to death panels. That's why this is such a hard conversation to have. It seems that conseratives who favor cost cutting fall back on rationing by income as being ok but not rationing by effectiveness or utility, not if government reimbursement guidelines are the criteria. Many liberals think rationing by income is immoral.

How to resolve this?

Posted by: Mimikatz | February 9, 2010 12:17 PM | Report abuse

"my experience with these fears is that they usually come from a very twisted and wrong reading of something that actually exists in the bill."

My experience with such "very twisted and wrong readings of something in the bill" is that whenever Senate Republicans introduced an amendment to firmly resolve such ambiguities in the bill, Democrats would shoot it down, replacing it with some non-binding "Sense of the Senate" resolution or similar toothless nonsense.

The loopholes are there because Dems intend for them to be used.

Posted by: cpurick | February 9, 2010 12:21 PM | Report abuse

Newt Gingrich:
"Ask government-run healthcare advocates if they would ban all private contracting, which would make it illegal for you to purchase any healthcare service also covered by the government. Instead, you would have to wait in line for care--the length of that line and quality of that care notwithstanding. Horrifying, yes. But that was Canadian law until a 2005 decision by even its left-wing Supreme Court found that "access to a waiting list is not access to healthcare." If those advocates answer no, then they are allowing for what they claim to oppose--two-tiered healthcare where the rich use their money and connections to access one system, leaving everyone else to use the lower-quality, government-run one."

Posted by: FastEddieO007 | February 9, 2010 12:23 PM | Report abuse

Mimikatz,

You wrote:
It seems that conseratives who favor cost cutting fall back on rationing by income as being ok but not rationing by effectiveness or utility, not if government reimbursement guidelines are the criteria. Many liberals think rationing by income is immoral.

Rationing by income will still happen----its a question of which side of that line do middle class families find themselves on? Under Obama & Pelosi's plan, the middle class is effectively shifted into government-run Medicaid with no way out other than to buy lottery tickets and "hope" to win your freedom back.

Posted by: FastEddieO007 | February 9, 2010 12:29 PM | Report abuse

Well, if you want to blame anyone for this Medicare restriction, I would blame the Republican congress of 1997 (along with the Democratic president) that passed this restriction into law (according to your NCPA link). But arguing that Obama, Reid, and Pelosi are somehow responsible for it is as unfair and nonsensical as blaming Obama for the Civil War.

Now, you can advocate for them to remove this restriction from Medicare. Lord knows that there are a lot of problems in the Senate bill left unfixed. But you and Palmisano seem to be arguing that this restriction expands beyond healthcare into the national insurance exchange or some other non-Medicare entity. This is what we need to see proof of to evaluate.

Posted by: dwbh | February 9, 2010 12:35 PM | Report abuse

FastEddie, you should be a little more skeptical of what Newt Gingrich -- not an honest broker by any means -- is telling you, rather than swallowing it whole.

Doctors in Canada have always made a thriving living by accepting private payments from patients. What was illegal in Canada was private insurance that competed with their single payer plan. Countries like France and the Netherlands, meanwhile, have the two insurance plans coexist, and now Canada is migrating to that kind of system.

Posted by: constans | February 9, 2010 12:38 PM | Report abuse

Fast Eddie, you're not a regular middle class citizen. You're an intern at some right-wing or republican organization trolling around with your stupid talking points.

Your argument is the old "two-tiered" system argument. There will be two tiers of care: one for the rich who can afford insurance, and one for the poor (or middle class) who can't and are on government run insurance or have none at all .

Hmm, kinda sounds like the system we have now, the one people like you (and Dr. Palmisano) want to preserve. You probably would agree with this statement:

"Privately insured Americans would get higher quality health care, but because the market for medical innovation would be smaller, everybody will get worse care than they would otherwise have received had most health care not been nationalized." (http://www.reason.com/news/show/134016.html)

There are a lot of assumtions in that statement, but quite a bit or fear mongering. Tell me, how would Rep. Ryan's plan square with your concerns? Too bad the voucher won't pay for that chemo you might need. Good luck bargaining with that onclologist...

Posted by: nickthap | February 9, 2010 12:42 PM | Report abuse

Forgive the sloppy cut & paste...This is from House bill on pages 222-223.


(c) PAYMENT TERMS FOR PROVIDERS.—
8 (1) PHYSICIANS.—The Secretary shall provide
9 for the annual participation of physicians under the
10 public health insurance option, for which payment
11 may be made for services furnished during the year,
12 in one of 2 classes:
13 (A) PREFERRED PHYSICIANS.—Those phy14
sicians who agree to accept the payment under
15 section 323 (without regard to cost-sharing) as
16 the payment in full.
17 (B) PARTICIPATING, NON-PREFERRED
18 PHYSICIANS.—Those physicians who agree not
19 to impose charges (in relation to the payment
20 described in section 323 for such physicians)
21 that exceed the sum of the in-network cost22
sharing plus 15 percent of the total payment
23 for each item and service. The Secretary shall
24 reduce the payment described in section 323 for
25 such physicians.
VerDate Nov 24 2008 10:05 Oct 29, 2009 Jkt 000000 PO 00000 Frm 00222
Fmt 6652 Sfmt 6201 C:\TEMP\AHCAA_001.XML HOLCPC
October 29, 2009 (10:05 a.m.)
F:\P11\NHI\TRICOMM\AHCAA_001.XML
f:\VHLC\102909\102909.022.xml (453769|4)
223
1 (2) OTHER PROVIDERS.—The Secretary shall
2 provide for the participation (on an annual or other
3 basis specified by the Secretary) of health care pro4
viders (other than physicians) under the public
5 health insurance option under which payment shall
6 only be available if the provider agrees to accept the
7 payment under section 323 (without regard to cost sharing) as the payment in full.
9 (d) EXCLUSION OF CERTAIN PROVIDERS.—The Secretary shall exclude from participation under the public health insurance option a health care provider that is excluded from participation in a Federal health care program (as defined in section 1128B(f) of the Social Security Act).

Posted by: FastEddieO007 | February 9, 2010 1:01 PM | Report abuse

Kevin Willis, I'm with you. Down with all caps, up with smileys! :)

Posted by: madjoy | February 9, 2010 1:31 PM | Report abuse

FastEddie: the portion of the bill you cited talks about restrictions for the public health insurance option, or the "public option". The public option has been off the table for some time now, and it won't be part of the final legislation. So any restrictions on the public option are obviously moot.

Posted by: dwbh | February 9, 2010 1:31 PM | Report abuse

"Rationing by income will still happen----its a question of which side of that line do middle class families find themselves on? Under Obama & Pelosi's plan, the middle class is effectively shifted into government-run Medicaid with no way out other than to buy lottery tickets and "hope" to win your freedom back."

This is a bullseye. Virtually everyone in America knows the best schools are private schools. This bill is the healthcare equivalent of telling everybody they'd rather be in public schools. The hell we would. Do you want your private healthcare to be a privelege accessible only to the wealthy, while we're all relegate to an expanded version of Medicaid?

This is about forcing everyone into a lower standard of care because it's become politically incorrect for only those who don't pay to do with less. Now everyone should do with less -- except the politically connected, of course.

Posted by: cpurick | February 9, 2010 1:35 PM | Report abuse

a respectful suggestion:

How about if we all hold off on further postings until Ezra has had a chance to review and respond to FastEddieO007's citations?

Just so this thing does not veer off topic (since it is an interesting topic).

Posted by: Patrick_M | February 9, 2010 1:55 PM | Report abuse

cpurick, I think the Republican view (which you state) could be more appealing if it had something of any sort that seemed like it would actually (in actual practice) significantly improve access to health care for that 30 million or so who would like to buy insurance, but cannot.

Not a fake ideas, like people in Texas should be able to buy insurance from Minnesota (as if that would help someone with a preexisting condition!).

Republicans are very near, or completely at, the following analogy:

People on a lifeboat say "no, do not throw any of our excess, but limited life vests overboard to those people stuggling and drowning nearby in the water, because that would slightly reduce our own resources -- we don't know 100% for sure that we ourselves might want those extra later. Better to let those people drown, and keep our excess life vests handy just in case we want them later for ourselves. So we'll just float here on our lifeboat with the extra life vests, while they drown. And meanwhile, we will throw overboard a few empty drinking bottles, which could indeed be used as tiny floaties, to give them a sop of help."

Posted by: HalHorvath | February 9, 2010 2:02 PM | Report abuse

The provision FastEddie cites is from the House bill -- not the House bill as passed, but a previous version. If you go to Thomas (http://thomas.loc.gov/) and pull up the bill (HR 3962, the engrossed or House-passed version) the language he cites is on pp. 228-230.

It should be obvious, but the Senate bill (HR 3590) contains no similar language.

Posted by: Policywonky | February 9, 2010 2:06 PM | Report abuse

Oh good, let's turn Ezra's blog into an ongoing response to every batsh*t accusation that comes out of the bloated corpse of the GOP. Let's continue to pretend that they're good faith actors providing valuable input as representatives of a large number of Americans. If only we can respond to their madness with clear, concise, factual rebuttals, we will have an informed citizenry ready to reject these extremists. Americans will suddenly realize the depth of their obstruction and they'll be forced to participate constructively in our democracy.

Bwahahaha!

Posted by: BigTunaTim | February 9, 2010 2:10 PM | Report abuse

It sounds like the trolls are dragging out 90s-era talking points talking about the fears of "a government takeover of health care!" and things. The public *option* was just that-- an option. Those of us with our own insurance wouldn't find a difference.

It is a bit ironic that as the HCR bill has become more conservative, the rhetoric against the bill has attacked it as being more and more "socialist." The more conservative the bill becomes, the greater number of restrictions and greater the extend of government control conservatives claim it has.

Posted by: constans | February 9, 2010 2:11 PM | Report abuse

By the way, there are many important and legitimate criticisms that can be levied against these bills, To pick this one is ludicrous, IMHO.

For those criticizing the bills (and I am one), it helps if you cite the correct bill version (i.e., the bill text as passed, not as introduced) and have a good understanding of the context of the language in the bill as well as how the specific provision would alter our health insurance and healthcare system as a whole.

Posted by: Policywonky | February 9, 2010 2:12 PM | Report abuse

@constans: "The more conservative the bill becomes, the greater number of restrictions and greater the extend of government control conservatives claim it has."

A much better way of putting it than my admittedly juvenile rant above. The reality of the GOP's tactics is so self-evident that it's really frustrating to see Charlie Brown - err I mean the Democrats - get suckered over, and over, and over... The GOP is running in pure 100% obstruction mode because it works in the short term. Trying to meet them in the middle is a fool's errand - they'll just keep pulling ever further rightward. The Blue Dog Dems are doing the right's job for them while they sit it out. The right isn't interested in negotiating anything, unless you give them what they want up front as a condition for talks. What is the bombshell revelation in this elementary scenario that Democrats can't understand? Why must the party that represents the people's interests be perpetually dysfunctional?

Posted by: BigTunaTim | February 9, 2010 2:39 PM | Report abuse

Nice lifeboat analogy, Hal, because it's rare to see the bill's supporters admit that it really does attempt to redistribute care from those who pay for it to those who do not.

Along those lines, the problem is that some people cannot afford care, and therefore the solution is to make less expensive care legal for those who can't afford the deluxe package which is the minimum legal standard of care.

Likewise, a rational benchmark for success is not how much we can subsidize poor people's top-tier care, but rather how cheap we can make care so that less wealthy people can once again afford to purchase it.

The political left misreads the public's concern with rising health insurance premiums as a mandate to cover the uninsured. In fact, those are conflicting goals.

Extending coverage to millions and millions of more people for the same price is impossible. It will cost more or the quality for everyone else will decline -- probably both. If you're not among the 47 million uninsured, the odds are that you're quite satisfied with your care. It is right to oppose this legislation which will gut it.

Posted by: cpurick | February 9, 2010 3:56 PM | Report abuse

@constans: "The public *option* was just that-- an option."

Like with Social Security Reform. Keeping a small portion of your Social Security taxes in an account that was specifically yours was just an option. ;)

"It is a bit ironic that as the HCR bill has become more conservative, the rhetoric against the bill has attacked it as being more and more 'socialist.'"

Poll-tested, Tea Party approved. That being said, I agree 100% that the Republicans have no interest in hammering out any kind of compromise legislation that can give Obama any credit. And now that he's blinked, I think they are going to make it that much harder. Unless he's pulling some rope-a-dope, this whole "let's work this thing out, fellas" approach is going to backfire.

While one could argue that the concessions don't go far enough or are too watered down to really replace their conservative equivalents, there's no doubt big things have been pulled out of the legislation to mollify conservatives, and it hasn't worked.

But stop for a moment and ponder how the Republicans would approach Medicare Part D, if it had not been done and was being proposed now as a stand-alone initiative from the Obama administration. "It'll be too costly! There's a huge donut hole in the middle where middle class families will be left out in the cold!" Etc.

Posted by: Kevin_Willis | February 9, 2010 4:02 PM | Report abuse

Eddie, you posted a section of the House bill which was referring to the Public option. Get a clue man, that was never in the Senate bill, and has been off the table for several months now. As someone else said, lets let Ezra research this (that's what he's paid to do) and get back with his opinions.

Posted by: truth5 | February 9, 2010 4:15 PM | Report abuse

See, what FastEddie is doing is runign a disinformation operation. And he made it into one of Ezra's posts. Clever.

Anyway, cpuprick, the point is that the number of uninsured is going to KEEP RISING unless something is done. Which means costs will keep rising (rising # of uninsured=rising costs=DUH).

Anthem of California is raising rates for the individually insured 30-39% this year. This will surely drive healthy people off the roles, ensuring another rate hike (because only those with existing conditiions MUST STAY in the plan--they won't be able to get any other coverage).

So, while you have insurance now (assuming you have health insurance now), there's a fair chance that in ten years you won't, because your employer will have stopped providing it (too expensive), or if you're self-employed you've developed some health problem and have been denied coverage (having dropped the unbelievably expensive coverage you had 'cuz you couldn't afford it).

Have you even thought of the possibility of what would happen if you lost your coverage? And if, because of a pre-existing condition you couldn't get coverage OR care?

Seriously dude, everything's just great 'til it isn't.

Posted by: nickthap | February 9, 2010 6:05 PM | Report abuse

Don't look at me, nick. I'm the one who wants to lower costs.

Posted by: cpurick | February 9, 2010 7:09 PM | Report abuse

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