‘Nuclear Option’ Revives a Big, Controversial Part of Obamacare

Obama can now fill a cost-cutting board that Republicans want to repeal.

PANORAMA CITY, CA - JANUARY 28: Dr. Jason Greenspan (L) and emergency room nurse Junizar Manansala care for a patient in the ER of Mission Community Hospital where doctors held a press conference outside on a class action lawsuit against the state of California by a coalition of emergency room physicians claiming that without additional funding, the entire emergency healthcare system is on the verge of collapse on January 28, 2009 in Panorama City, California. According to the coalition, the cost of providing emergency room treatment has nearly doubled over the past decade and patient load increased by more than 28 percent while Medi-Cal reimbursements have remained largely unchanged. During that time, 85 California hospitals in California have closed and an additional 55 facilities have shut down their emergency rooms. California now reportedly ranks worst in the nation for access emergency care and last in emergency rooms per capita. California has seven emergency rooms per million people while the national average is 20 emergency rooms per million people. 
National Journal
Sam Baker
Nov. 21, 2013, 11:24 a.m.

The Sen­ate’s de­cision to go “nuc­le­ar” breathes new life in­to a dormant but ex­tremely con­tro­ver­sial part of Obama­care.

The Sen­ate’s rules change will likely make it much easi­er for Pres­id­ent Obama to fill the In­de­pend­ent Pay­ment Ad­vis­ory Board, or IPAB — a 15-mem­ber pan­el tasked with slow­ing the growth in Medi­care spend­ing. The IPAB is a po­lar­iz­ing piece of the Af­ford­able Care Act: It’s been a fea­ture of GOP cam­paign ads, and the House has voted to re­peal it.

The IPAB is tech­nic­ally sup­posed to sub­mit its first pro­posed cuts in Janu­ary, but Obama hasn’t even nom­in­ated any­one to the board yet. Nom­in­ees have to be con­firmed by the Sen­ate, which un­til today re­quired 60 votes — and Re­pub­lic­ans were highly un­likely to help con­firm any­one to the board.

But now that the Sen­ate has moved to a 51-vote threshold for ex­ec­ut­ive ap­point­ments, Obama will likely be able to fill the board and move ahead with one of the most sig­ni­fic­ant cost-con­trol meas­ures in his sig­na­ture health care law — if he wants to.

A GOP Sen­ate aide con­firmed that the rules change will ap­ply to IPAB nom­in­ees; spokespeople for Ma­jor­ity Lead­er Harry Re­id, D-Nev., and the White House did not re­spond to ques­tions about the rules change and the health care board.

Obama might not want to ap­point any­one to the IPAB be­fore next year’s midterms, even if he could get them con­firmed more eas­ily. The nom­in­a­tions would cer­tainly trig­ger a fresh de­bate over his health care law and its cuts in Medi­care spend­ing.

Plus, Medi­care’s trust­ees say the pro­gram’s costs are grow­ing so slowly on their own that the IPAB wouldn’t even be triggered un­til at least 2015. The IPAB’s charge, un­der the Af­ford­able Care Act, is to make tar­geted cuts in Medi­care’s pay­ments to doc­tors and health care pro­viders if the pro­gram’s over­all costs grow faster than a cer­tain rate.

Tech­nic­ally, the board only re­com­mends cuts to Con­gress, but the pro­cess is struc­tured so that its cuts are highly likely to take ef­fect. Con­gress has to pro­act­ively block the IPAB’s re­com­mend­a­tions and come up with equi­val­ent sav­ings some­where else in the budget.

GOP crit­ics op­pose the IPAB largely be­cause it puts the power to set Medi­care pay­ments in the hands of un­elec­ted ex­perts. Sup­port­ers say that’s ex­actly the point: Con­gress lacks the polit­ic­al will to ac­tu­ally make mean­ing­ful cuts to doc­tors, hos­pit­als, and oth­er pro­viders, so an ad­min­is­trat­ive pan­el is the only way to con­trol Medi­care’s costs.

Re­pub­lic­ans are also afraid that the IPAB will “ra­tion” care. The law pro­hib­its the board from “ra­tion­ing,” and it is not al­lowed to cut seni­ors’ be­ne­fits — only pro­viders’ pay­ments. But crit­ics say the board will drive pay­ments so low that doc­tors in cer­tain fields will quit ac­cept­ing Medi­care pay­ments.

The policy is pop­u­lar with a large num­ber of aca­dem­ics and health care wonks — it was the pet pro­ject of Peter Or­sz­ag, who led the White House budget of­fice dur­ing the health care de­bate. But doc­tors, phar­ma­ceut­ic­al com­pan­ies, and oth­er health care pro­viders strongly sup­port re­peal­ing the board.

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