• House Budget Committee Spox Response on IPAB posts

    Conor Sweeney, Communications Director of the House Budget Committee that is chaired by Rep. Paul Ryan emailed me the below message (printed verbatim and with his permission) in response to my post last night on the upcoming IPAB hearings. I don’t believe Mr. Sweeney had a chance to see the second post before sending the email based on the timing of the email and the post, but I believe his message to me addresses most of his concerns about what I have written. I appreciate Mr. Sweeney taking the time to contact me. Below his email message I Provide brief responses to his comments.


    Dr. Taylor-

    We appreciate your interest in Paul Ryan and his efforts to advance consumer-directed health care reforms. With respect to your concerns:

    • Congressman Paul Ryan believes in providing greater transparency for consumers, not imposing greater control over their lives. The Patients’ Choice Act includes a transparency initiative that empowers beneficiaries to serve as more powerful consumers.  The President’s approach empowers an unconstitutional board to impose price controls, cut provider reimbursements, or make coverage determinations by fiat.
    • The facts about The Patients’ Choice Act’s Health Care Service Commission:
      • No authority to influence Medicare spending;
      • No decision-making authority with respect to provider reimbursements or availability of beneficiary services;
      • Exists solely for the purpose of encouraging transparency and proper metrics with respect to health care services, which will allow consumers to compare on the basis of cost and quality.
    • As Ryan recently argued: “Our plan is to give seniors the power to deny business to inefficient providers. Their plan is to give government the power to deny care to seniors.”
    • For more on The Patients’ Choice Act, please see page 8 of this Section-by-Section document from Senator Coburn’s office: http://coburn.senate.gov/public/index.cfm?a=Files.Serve&File_id=77b590f2-0686-4904-aef8-0866cc47092d

    Many thanks,



    Greater Transparency: I very much like the PCA notion that guidelines and the like be put into language that is understandable. They clearly wanted the information created by the Commission and the Quality Forum (two boards created by the PCA) to be useable by consumers as well as insurers. It is unclear how that would all have worked.

    Unconstitutional Board: The PCA creates a 5 member board (who must have this be their full time job) that is nominated by the President and confirmed by the Senate. The 5 member board then creates a 15 member board to carry out the details of guidelines, research and the like. The IPAB is a 15 member board that is nominated by the President and confirmed by the Senate (and IPAB must be their full time job). There is a great deal of similarity. The implication of the boards created in both bills/law is that Congress is unable to do much of the hardest work, and they are turning to experts. How can such a board be unconstitutional when in the ACA but fine when proposed in the PCA?

    Price Controls, cut provider reimbursements: IPAB would be required to issue recommendations that would reduce Medicare per capita expenditures if Medicare growth rate targets are not met. This will be done by cutting payments to providers given prohibitions in the ACA against “The proposal shall not include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums under section 1818, 1818A, or 1839, increase Medicare beneficiary costsharing (including deductibles, coinsurance, and copayments), or otherwise restrict benefits or modify eligibility criteria.” ( Quoting the law (Pub. L. 111-148, § 3403) and what IPAB cannot do.

    The worst penalty/impact: I wrote in the previous post that the PCA provisions had more teeth than does the IPAB, and a commenter made a good point that while the ultimate penalty in the PCA as I read it (banning someone from participating in Medicare and Medicaid) is a huge penalty, the IPAB could be expected to have a smaller impact on many more providers through reimbursement cuts. This is a fair point. Another important point is that the PCA was never subjected to a hearing, and certainly wasn’t marked in committee, so it would have been clarified and fleshed out had it been. However, the cosponsors made clear the top penalty that could be imposed by these boards in the PCA was the banning of providers from Medicare and Medicaid and/or a civil penalty (again, as I read it). This would happen if providers didn’t follow the guidelines put forth by the committee created in the PCA. That is quite a penalty imposed by a board in conjunction with the Sec. of HHS.

    Our plan: Here he is referring to Rep. Ryan’s Medicare proposal in his budget. I didn’t post on this, and am not going to get into it here.The blog has had lots on it, mostly written by Austin.

    Sen. Coburn document: The document linked is a summary of the Patients’ Choice Act. As always, the best thing is for you to read the relevant sections of the Patients’ Choice Act for yourself, p. 206-215 are the key sections. You can read the relevant sections of the actual bill in 5 minutes.

    Rationing: Not sure where to start. The word rationing has been rendered devoid of meaning by our political discourse. Not rationing is unlimited supply. This is impossible now, and always will be impossible. It is a matter of how, not if.  Watching the morning hearing on IPAB reaffirmed for me a bipartisan blind spot: reducing costs over what they would be by default (and on a per capita basis) can only occur by providing less care and/or paying less for that same care. You can call it what you want, I call it math. It will be hard as hell, but we have no choice but to try. Both sides assume the best for their favorite policy, and the worst for the other guys. Rationing is what ‘they’ (the other side wants); ‘We’ (our side) wants to improve quality, save money and increase value. The country has got to grow up and face limits. We have no hope of doing so if our leaders simply bicker with and talk past one another as they did in this hearing.



    • What is both interesting and disturbing Don, having listened passively to the hearing is:

      1) Unlike recent hearings, with the backdrop of the debt talks, this one had a renewed zeal (having Ryan there was a boost). You got a better sense of the direction public messaging will move if healthcare slides into the public domain, front and center once again. We are a few steps away from new and improved death panel-oid slogans that encapsulate the notion of rationing. It will be interesting to see how the left and right will organize their memorable sound bites, and how they play offense and defense to sway public opinion. I enjoy watching many of these hearings, and by far, rationing invokes the most emotion, and has the most traction. This is the one to watch to move opinion.

      2) I assumed the ACA will/would survive, but if it failed, would die by a thousand cuts. Given the negotiations now, its hard to imagine how you envision a plan–as piecemeal as this one was–and suddenly negotiate separate deals–massive ones–and drop them into it. Its like telling the architect you want a ranch, after designing your split level–the day you break ground.

      How do you expect to trim sensibly, imparting the least possible harm if huge swaths of cash evaporate…from which initiatives depended and pivoted. Want to move folks out of institutions? Cut a few billion here and there from programs intent to make it happen. Hell, I would take a a job in the private sector.

      3) We all know things change, deals evolve, but if I was a monied interest (AHIP, AMA, AARP), I would dig my heels in and simply resist.any future changes or less than appealing offers. The whole Beltway lot has proven totally unreliable (as opposed to just unreliable). The old saying, fool me once, shame on you, fool me twice, shame on me is front and center. Again, this is politics and its hard ball, but with this political climate, who would shake hands with anyone. Deals mean nothing. Note to the GOP if they win in 2012.


    • Ok, I read pages 206-215 again. It certainly sounds a lot more intrusive than just encouraging transparency. The appointed board seems no more, or less, unconstitutional that that of the IPAB. I find Mr. Sweeney’s response a bit insulting. It is the kind of thing he should write to the general public. For those who read health policy, it makes no sense. As a physician, taxpayer and voter, I wish they would give up these attempts to spin things into what they aren’t.

      As an aside, I had forgotten that the PCA also supports ACOs. More and more I am convinced that the universe of ideas for reforming health care is relatively small. Ideas declared as intolerable when presented by one party are acceptable when presented by one’s own ideological brethren.


    • @steve
      The ACA and the PCA are cousins for sure. I assure you that Repub staffers were thrilled when I drew the parallels in this two years ago
      The country desperately needs a political deal that makes health reform a bipartisan activity so that all the carping can stop and we get down to working on the policy. Given it takes 218 votes in house, 60 in senate and 1 in white house, the ACA is the only vehicle we have

    • Regarding the phenomenon of “talking past each other” at the hearing: this is intentional. The purpose of these hearings (like all hearings) is theater, not policy. The only goal (on both sides) is to influence the public perception of the debate. I know this is a cynical perspective, but it is amply supported by many years of evidence.

      • @David
        yes, lots of evidence with you. Ala, if I was going to watch 2 hours of TV on Tuesday, I think the Tour de France would have been a more interesting choice