In attack on health reform, Republicans target Medicare advisory board

WASHINGTON--When it comes to political targets, the Independent Payment Advisory Board has a lot to offer.

Sure, it might sound like a benign, obscure federal panel, a backwater of health care reform that almost no one has heard of.

But it's bureaucratic. It's unelected. And it has a lot of power-or it will, anyway, when its members are actually appointed and it gets up and running.

In the meantime, it's become a prime target in the Republican effort to unravel the Democrats' health care reform overhaul.

This week, a half-dozen House Republicans unveiled a one-paragraph piece of legislation to dismantle the IPAB, well before it ever gets going. And unlike most other Republican repeal initiatives, this GOP effort might attract some Democratic company.

"I don't like IPAB. I never did," said Rep. Joe Courtney, D-2nd District, who helped shape some provisions of the health care reform law but tried, unsuccessfully, to nix this one.

The advisory board was created, in large part, to do what some politicians are afraid of: make hard decisions about Medicare costs.

Sen. Jay Rockefeller, D-W. Va., was a key author and promoter of the board, one of several elements in the health reform law that seeks to contain health care costs in general and Medicare in particular.

As evidenced by the perennial congressional battle over Medicare payments to doctors, lawmakers have been reluctant to do anything that would curtail the elderly's access to that government health insurance program.

Rockefeller argued that politics needed to be taken out of the equation when it comes to setting Medicare payments to providers. So he and others proposed a 15-member board of health care experts, appointed by the President for six-year terms, which is required to recommend Medicare spending reductions if costs exceed fiscal targets set out in the health care reform law. Its first report to Congress is due in 2014.

The Department of Health and Human Services will have to automatically put all the recommendations into practice, unless Congress comes up with an alternative package that achieves the same level of savings. It would be the first time Medicare has been subject to any spending caps.

"Everyone says they're in favor of controlling Medicare costs, but it seems like when you get right down to it, they're not, because one person's cost is another person's income," said Timothy Jost, a law professor and health care expert at Washington and Lee University.

"There are a lot of interest groups invested in keeping Medicare spending a lot of money," he said. To boot, "there are a lot of beneficiaries who are dependent on Medicare for health care. So whenever you really start talking about cutting Medicare costs, people start getting really nervous."

That is the problem the IAPB was created to solve, Jost said. It has the added benefit of bringing the opinions of top national experts to bear on such decisions.

Rockefeller says it's the only way to save the cherished program, which serves millions of Americans aged 65 and older.

"The IPAB is one of the best parts of the health care reform law to reduce the budget deficit and improve care, while protecting seniors and persons with disabilities from any cuts in benefits," Rockefeller said.

He said it would look at "evidence-based reforms that protect Medicare beneficiaries, improve the quality of care, and re-align payment structures for all health care providers throughout the Medicare program - without undue interference from special interests and lobbyists."

But Republicans say it's a Communist-style proposal that will end up rationing care.

"I take you back to the old Soviet Union," Rep. John Fleming, R-La., said at a news conference this week unveiling the GOP's bill to repeal the IPAB. "That's the way they did things--a central planning committee would set prices, they would control costs--and of course their economy failed."

He noted that President Barack Obama, in his State of the Union address on Tuesday, invited Republicans to offer ideas about how to improve the health reform law.

"One great step in doing that is removing these awful bureaucrats that are going to be overly-paid in order to determine what goods and services people are going to get in the health care system," Fleming said.

Rep. Phil Roe, R-Tenn., the lead sponsor of the IPAB repeal bill, compared the board to entities that exist in other countries that have national health care.

"In England, their board is called NICE," he said, referring to the National Institute for Health and Clinical Excellence. "What a nasty word... to ration care," Roe said, adding that the U.S. version will allow "a bunch of bureaucrats" to decide who gets care and who doesn't.

The health care law specifically forbids the IPAB from offering any proposals that would ration care, reduce Medicare benefits, or tweak eligibility rules. All the same, it was lumped into the "death panel" debate by GOP critics as it moved through Congress.

"It's only in Washington, D.C., that a board created to help address our long-term fiscal imbalance while boosting quality in health care and that is specifically by law prohibited from rationing care could be called a death panel," Peter Orszag, then-director of the Office of Management and Budget, said of the proposal.

Courtney doesn't use such red-flag language to describe the IPAB. And he questions the GOP's rationale for trying to do away with it.

But he also takes issue with the need for such a board, and he worries about its eventual impact.

"What kind of irks me is this attitude like Congress is incapable of controlling costs in the system," he said, when in fact the health reform law implemented several significant containment measures.
The reform law, for example, will significantly reduce hospital reimbursement rates for Medicare and it slices into subsidies for private insurers who cover Medicare beneficiaries.

"Those were really hard political choices, but we did it," Courtney said, noting that the law will cut the rate of growth in health care costs from a projected 8 percent to 6 percent.

He said the IPAB is an abdication of Congress's responsibility to shape Medicare policies--and then face the voters in the next election.

He also said he's concerned that the IPAB will make decisions on Medicare payments that don't take into account issues unique to Connecticut. He was among those signing a letter to House Speaker Nancy Pelosi in December 2009, a key moment in the health reform debate, urging her to fight any such board in the law.

"To create an unelected, unaccountable Medicare commission... would end Congress's ability to shape Medicare to provide the best policies for beneficiaries in our communities around the country," the letter read.

On Thursday, Courtney said he and other New England lawmakers were particularly concerned--and still are--that "we're going to get swept up in decisions that don't fairly adjust for factors that people don't have any control over," such as higher labor or energy costs in Connecticut and other states.

But even as he considers joining Republicans in voting to repeal the IPAB, Courtney said he doesn't think they have the best motives in mind.

He pointed to recent comments by GOP leaders saying they would like to turn Medicare into a voucher program, a proposal Republicans may include in their budget for the coming fiscal year.

Any recommendations by the IPAB, Courtney said, would pale in comparison to such a move to essentially privatize Medicare.

"It's like, make up your mind," Courtney says of seemingly contradictory GOP proposals. "Do you want to protect fee-for-service Medicare or convert it to vouchers?... Who cares about the IPAB if the whole system is just getting transferred to insurance companies?"

Roe and other GOP lawmakers at this week's news conference said they weren't sure what the Republican alternative to controlling Medicare costs would look like. They said that will come later, as they work through the regular committee process to craft replacement legislation.

Judith Stein, executive director of the Center for Medicare Advocacy, said that even though she wouldn't mind seeing the IPAB die an early death, she's wary of the GOP's plan.

"I have grave concerns about this being the first of many efforts to peel off separate sections of the health reform. We very much want health reform to go forward," she said. "It's just such a slippery slope right now."

She said one possible solution is that Congress tweaks the IPAB, so that lawmakers can accept some of its recommendations and reject others. Congress already has such an advisory board, called MedPAC, which Rockefeller says is toothless and ineffective.

But Stein said lawmakers should not be able to punt all these decisions to someone else.

"Even though Congress may be reluctant to make hard decisions, that's why they are there," she said.