Other countries that provide health care for their citizens all use rationing of one sort or another to control costs. In the last 2 years, laws have been passed in this country that greatly expand government’s role in providing health care. Likewise, along with that legislation, agencies have been created to control costs by, in effect, rationing health care.
Several agencies have been charged with this task. Among them are the Institute of Medicine (IOM), the Patient-Centered Outcomes Research Institute (PCORI), the Federal Coordinating Council for Comparative Effectiveness Research (FCCCER) and the Independent Payment Advisory Board (IPAB).
Until recently, these new agencies have escaped public attention and “Death Panel” headlines partly because they are in the beginning stages of formation. However, President Obama called attention to IPAB in his recent budget address saying it was a key component in reigning in the cost of Medicare and bringing down the deficit. Without giving any details, he then called on Congress to ‘strengthen’ the Board’s power.
From the earliest discussions of the health care reform legislation, IPAB was one of the most controversial portions. Democrats as well as Republicans were against this particular part of the Affordable Care Act (ACA) from the start. Earlier this year a prominent Democrat, Rep. Allyson Schwartz (PA), a health care reform champion, co-authored legislation repealing this provision of the health care reform bill. After the president’s speech, she penned a letter to fellow Representatives, asking their support in not strengthening the board, as the President suggested, but getting rid of it altogether.
Someone giving Section 3403 in the ACA a quick scan , however, might judge IPAB relatively harmless. IPAB is a 15 member panel appointed by the President. Its function is to ensure that the Medicare cost growth rate compared to inflation (and later, GDP) doesn’t exceed certain measures. When it does, the Board must propose changes to Congress that will bring those costs in line. However, IPAB is prohibited from:
- · increasing taxes
- · changing benefits
- · increasing premiums
- · increasing cost sharing
- · rationing care
- · changing eligibility
One might stop there, conclude IPAB couldn’t do any damage, and go on to the next section. But wait, there’s more. It’s not explicitly stated, but what the Board can do is reduce reimbursements to medical service providers. Health care and senior advocates are alarmed, fearing this will result in rationing care. This is happening now with Medicaid which pays physicians and hospitals less than what other insurers pay. As a result, doctors are refusing to treat Medicaid patients, resulting in fewer available doctors, longer waits and, often, lesser quality care. Hospital emergency rooms are filled with Medicaid patients unable to see a doctor in a reasonable amount of time. Consequently, frustrated Medicaid patients often forgo medical treatment altogether. Thus, the cascading effect of low payments to health care providers results in rationing. The fear is that this will happen to seniors under Medicare as well. In fact, when called in to review this part of the ACA, the respected Chief Actuary of Medicare, Rick Foster, expressed this very concern.
But wait, there’s more: Normally government agencies make proposals to Congress and Congress, after deliberating, is free to accept or ignore them. IPAB, however, has been given special powers. Congress, if it disagrees with the Board,, must come up with cost cutting plans of their own that meet or exceed those of the Board’s. Not only that, these must pass the Senate by a 3/5 majority. In addition, discussion and voting must be ‘fast-tracked’. This means the legislative process can’t exceed 30 hours. If the House and Senate proposals disagree , they have only another 10 hours to reconcile their differences. Unless Congress can pass countering legislation, the Board’s proposals will be implemented. These conditions make it nearly impossible to challenge any IPAB proposal, effectively making IPAB an autonomous un-elected legislative body and stripping Congress of its authority over Medicare expenses. Incredibly, the ACA also states that the Board’s proposals are exempt from judicial review! Constitutional law experts, as well as members of Congress, see this as an executive branch take-over of congressional and judicial branch functions. Consequently, a lawsuit challenging the constitutionality of IPAB is winding its way now through the federal courts.
And still more: The health care reform law, passed by the 111th Congress, has put unprecedented obstacles to repealing this part of the ACA. Both the House and Senate must pass such a resolution with a 3/5th majority; and no action can be taken before 2017, keeping future Congresses from making any changes.
The problem is IPAB isn’t the only government agency with a rationing function in our future. And while IPAB affects mainly Medicare patients, there are other agencies that will affect us all. We’ll look at these next.
