It's no secret that the Republicans are intent on defunding and dismantling, piece by piece, the Affordable Care Act. The latest portion of ACA to come under fire - somewhat obscured by the wrangling over the country's debt ceiling - is a cornerstone of the law meant to keep Medicare spending in the check, the Independent Payment Advisory Board (IPAB).
Some have likened IPAB to the Base Realignment and Closure Commission, an independent panel created in the late 1980s under the Reagan Administration tasked with making the hard recommendations to Congress on which military bases should be closed. It's a simple idea that is meant to remove political pandering and bickering from the process and allow an independent panel to make specific cost control recommendations to Congress. It would seem IPAB would be something most politicians would favor, as it provides one of Washington's most prized commodities: political cover.
But little comes easy inside the beltway these days, and opposition to IPAB has been mounting, not just from Congressional leaders, but also from a host of organizations in the medical community.
"The AMA opposes any provision that would empower an independent commission, such as the IPAB, to mandate payment cuts for physicians. Physicians are already subject to an expenditure target and other potential payment reductions as the result of the Medicare physician payment formula," wrote AMA President Cecil Wilson in a January 2010 letter to Senate Majority Leader Harry, two months before the ACA became law.
While it's easy to understand AMA's reluctance to be subjected to yet another strict payment cap given the ongoing SGR payment formula debacle, it is equally curious it should tout Congress as the ultimate arbiter - the same Congress that for more than a decade has shrunk from the challenge of fixing the SGR and in the process contributed to the ballooning Medicare budget.
What really scares many in the medical community though, is that IPAB - unlike the Medicare Payment Advisory Commission (MedPAC) whose recommendations Congress routinely ignores - will have real power in shaping Medicare payment policy. If Congress doesn't act on its recommendations, it would be up to HHS to implement them.
In recent testimony before the Energy & Commerce Subcommittee on Health, Mary Grealy, president of the Healthcare Leadership Council argued that IPAB would create healthcare access problems for seniors and would provide the 15-member panel with far too much power in setting Medicare policy.
"Medicare beneficiaries, providers and advocates should have the opportunity to have their voices heard, to be able to have meaningful input on program changes," Grealy testified. "That opportunity would be removed if Medicare decisions are being made by an unelected board that need not be responsive to the public, and can make recommendations that do not require the affirmative approval of Congress."
HHS Secretary Kathleen Sebelius, though, defended IPAB and downplayed the assertion that power was being taken away from Congress to craft Medicare payment policy. "It's up to Congress to decide whether to accept the recommendations or to come up with recommendations of its own to Medicare spending on a stable sustainable path," she said during her testimony. "In other words the IPAB recommendations are only implemented when excessive spending is not addressed and not other actions are taken to bring spending in line."
With the House expected to begin action after the August recess on an IPAB repeal bill sponsored by Rep. Phil Roe (R-Tenn.), opponents to IPAB will need to walk a fine line between arguing that IPAB will have too much power (a contention some Democrats agree with) and the broader contention that IPAB's recommendations will have the ultimate affect of rationing care to seniors (without once again raising the specter of "death panels") for the measure have any chance of passing both chambers.