Joe Wilson: Healthcare Hypocrite

Two words -- You Lie! -- have brought Representative Joe Wilson greater national scrutiny than anything he has previously said or done. Wilson, a South Carolina Republican, shouted disagreement with President Obama during his recent speech to Congress regarding healthcare reform.



Healthcare Hypocrisy: Wilson's Contradictory Stances on Governmental Health Plans

The most intriguing and relevant news regarding Wilson surrounds his hypocritical stances on "government-run" healthcare. Wilson argues that "[a] government-controlled system would limit choice and quality by letting politicians and bureaucrats determine your level of care in order to bring down costs. That is unnecessary and unacceptable."



In July 2009, however, Wilson spoke very glowingly and intimately about TRICARE, the government-administered and funded health plan for military personnel, veterans and their dependants:

As a 31-year Army Guard and Reserve veteran, I know the importance of TRICARE. I know it is important for the military personnel and families at the bases I represent . . . .I am grateful to have four sons now serving in the military, and I know that their families appreciate the availability of TRICARE.



Currently, TRICARE provides world class health care to 9.4 million beneficiaries. . . .TRICARE. . .is a low cost, comprehensive health plan. . . .[I]n 2008 TRICARE was rated the best health care insurer in the nation according to the Wilson Health Information survey of customer satisfaction. TRICARE also received stellar marks on the 2007 annual federal government report from the 2007 American Customer Satisfaction Index. . . .



I believe that TRICARE is one part of our health care system that’s working. . . . I believe that our military personnel and their families. . .like what they have. . . .

As a veteran, Wilson qualifies for TRICARE. According to his own words, his four sons and their families and many of his constituents rely upon TRICARE. Although Wilson offers high praise for TRICARE, he argues that allowing "politicians and bureaucrats" to determine the level of care in order to lower costs is "unnecessary and unacceptable." Politicians and bureaucrats, however, administer TRICARE and determine the level of care for participants. Also, federal law makes cost-effectiveness a primary goal of TRICARE administration.



Earth to Wilson: TRICARE = Public Plan = Government-Run Health Program = Government-Sponsored Health Plan

Congress created and funds TRICARE. The Secretary of Defense administers TRICARE. Although Congress has mandated that TRICARE cover certain broad categories of medical services, the Secretary of Defense issues the specific plan materials, which establish covered and excluded treatments under the various available plans as well as the obligations of participants. Like all other federal regulations, TRICARE policies are contained in the Code of Federal Regulations (or CFR).



Because the government has the exclusive authority to determine the treatments covered by TRICARE:



Unless TRICARE participants have other health plans or the money to self-pay, then the scope of their allowable medical treatment is determined by "politicians and bureaucrats" -- not by doctors and patients. The government does not mandate that individuals participate in TRICARE, but if they do, they can only receive services authorized by the federal government (unless they have another plan or elect to self-pay).



Government health plans, however, are typically very comprehensive and usually less expensive than private insurance plans. Wilson does not explain why only military personnel (or seniors) should benefit from comprehensive and relatively inexpensive medical services.



TRICARE "Death Panels" and "Interference With the Doctor and Patient" Relationship

The CFR contains TRICARE plan materials. A review of the regulations demonstrates the close involvement of the federal government in the medical services of plan participants. The discussion below provides examples of some areas of covered and excluded services.



1. Federal regulations allow reimbursement of costs associated with the provision of counseling to terminally ill patients, including counseling "for the purpose of helping the individual and those caring for him or her to adjust to the individual's approaching death" (see pg. 137).



2. Federal regulations, however, disallow reimbursement for "unnecessary diagnostic tests," which the government defines as "X-ray, laboratory, and pathological services and machine diagnostic tests [except for certain cancer screenings] not related to a specific illness or injury or a definitive set of symptoms."



3. Federal regulations do not permit reimbursement for "unnecessary postpartum inpatient" treatment of a mother or newborn -- when only one of the two needs extended hospitalization (e.g., will not pay for mom to stay in hospital when newborn needs hospitalization). This includes stays to allow the mother to breastfeed the infant (see pg. 147).



4. Federal law does not permit TRICARE to pay for the use of an "unproven" "drug, device, or medical treatment or procedure." This prohibition covers any drug or device that lacks FDA approval or clearance (see pg. 148) and any treatment or procedure that has not been subjected to a sufficient number of well controlled clinical studies (see pg. 149).



The multiple-page partial list of excluded drugs, devices, procedures and treatments includes in utro fetal surgery, treatment of chronic fatigue syndrome, gastric wrapping/banding, intestinal bypass, and "high dose chemotherapy with stem cell rescue" to treat breast cancer (with limited exceptions), ovarian cancer, or testicular cancer (see pp. 149-151).



5. Federal regulations provide that "[TRICARE] benefits for rare diseases are reviewed on a case-by-case basis" (see pg. 149).



6. Federal law requires participating medical providers to accept as full payment for TRICARE-covered services the co-pay and/or deductible, plus the amount that the government establishes an allowable expense for the particular service category (see pg. 167).



This short list represents just a few ways in which the government shapes the terms of the doctor-patient relationship for people who choose TRICARE as a service payer. For example, doctors cannot cannot collect more than the allowed amount for any services. Also, psatients cannot elect to undergo excluded services -- unless of course the individual has supplemental coverage or can self-pay.



Furthermore, as the statute and administering regulations state, cost-effectiveness is a central goal of the program. Conservatives, however, argue that cost-effectiveness is impossible without compromising care. If that is the case, then to the extent that TRICARE is cost-effective, it does so by compromising the care of participants.



Finally, the Democrats' reform proposals would not curtail services covered in private health insurance policies. Instead, the proposals would augment the rights of policyholders by prohibiting denial of coverage for preexisting conditions, the cessation of coverage after the insured has reached a lifetime maximum level of benefits, and the canelation of policies if individuals develop a particular illness. The government would determine the specifics of a public plan option, but Medicare and TRICARE demonstrate that the government can perform this function and maintain comprehensive coverage. If Wilson wants to challenge liars, he can start at home.