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Want to know the third biggest reason the national debt is mushrooming and scaring the daylights out of people? 

The core debt issue

If you want to know the third biggest reason the national debt is mushrooming and scaring the daylights out of people, you need look no further than the week's news, particularly a bipartisan effort to undo a critical part of the health-insurance reform law.

Oh, the biggest reasons for the recent additions to the debt load are the Bush tax cuts and the recession, but even they fade over the long haul in comparison with Congress's inability or refusal — you choose the word — to do anything about health-care inflation.

Everyone, including both major parties, has sworn to do something about it for much of the past two decades — make that since Richard Nixon and even further into the mists — but the Patient Protection and Affordable Care Act was the first act of Congress that set out seriously to check health-care costs. The Republicans, of course, want to scrap the whole law and its big cost-containment tools, notably the Independent Payment Advisory Board. But quite a few Democrats also want to cancel the board or else eviscerate its power.

The Democrats say it is because the board would usurp congressional authority, but the real reason is the same one that has kept Congress at bay for 25 years. Powerful medical interests — medical specialists, pharmaceutical companies — resist any steps that would stem rising health-care costs.

In 1985, a Harvard economist named William Hsiao developed a scale measuring the relative value of every medical procedure known to man. A brain surgeon's work was far more valuable than a pediatrician's or general practitioner's. A hysterectomy required 3.8 times more mental effort and 4.47 times more skill than a psychotherapy session. The American Medical Association embraced the plan, Ronald Reagan's Medicare administration adopted it, and all the private insurance companies followed. Family doctors were at the bottom of the scale and their work was to be the least compensated.

You know what happened. Every doctor wanted to be a specialist and now there is a huge shortage of primary-care doctors. Reimbursement for specialists and highly technical procedures took off, and it was indexed annually. If you are on Medicare or private insurance and have a long-term infirmity like liver or heart disease, you'll get ultra sound, MRIs and other high-tech diagnostic procedures whether there is any sign you need them.

Doctor groups say the real driving force behind the overuse of the procedures is not making money but to protect against malpractice lawsuits. Defensive medicine, they call it. But they don't protect against liability. It's the money.

Congress has been unable — unwilling — to call a halt. Oh, the Republicans made a stab at it in the 2003 Medicare drug law, the one that sent Medicare costs, insurance and drug company profits soaring. It called for future reductions in physician reimbursement, its single feint at cost control. But every year Congress, with both parties collaborating, overrides the reduction because the AMA and the specialists would revolt. The doctors say they might stop seeing Medicare patients if their reimbursement was cut.

Then comes the Patient Protection and Affordable Care Act. It created either as policy or as pilot projects just about every cost-control theory in existence, but the big one was the Payment Advisory Board, a 15-member commission appointed by the president and made up of doctors, patient advocates and people independent of the medical professions and interests. It will recommend steps to stop waste and control costs, including coordinating care, finding ways to reduce the vast overuse of expensive technical procedures like MRIs, ultra sound and the like, and raising the priority of primary care.

To avoid the political traps of the past, the board's recommendations would go into effect automatically unless a big majority of Congress voted to stop it.

The panel could not ration care, increase Medicare premiums or cost sharing, raise taxes, restrict benefits or change who is eligible for Medicare, but the precise wording of the law didn't stop the Republicans — their new spokesman Paul Ryan or any of his minions, including his Arkansas cast of Tim Griffin, Rick Crawford and Steve Womack — from saying the panel would start rationing. Rationing is the poll-tested word that they must bring into any debate on health care.

Actually, the Republicans are proposing the only rationing. The Ryan budget plan, approved by the House of Representatives on a near party-line vote, would turn decisions about what kind of care people could get and who would get it to insurance companies in 2021. That year, Medicare would be effectively ended for new enrollees. Everyone would be required to buy a health insurance plan from an insurance company and would be given a government voucher of declining value to help them buy it. Insurance companies, seeking to preserve profits with diminishing government support, would ration procedures, raise premiums and shift rising costs to patients.

President Obama (so far) is standing firm against diluting the Payment Advisory Board or any of the cost-control options in the new law, but in the end — either with his defeat or changes in Congress, which in modern times cannot stand up to economic power — none of those steps will be carried out. It's impossible to be too pessimistic about that.

The deficit? Attack the other causes. Taxes, military spending — easy ones like that.

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