IPAB is a four letter word
The House is taking up a bill to remove Medicare’s independent payment advisory board (IPAB) from the Affordable Care Act. Opponents of IPAB call it a death panel and claim it will ration care. That’s nonesense, and flies in the face of the legislation that created the IPAB, which prohitits it from ratioining anything. In fact, the law goes so far to anticiate critics’ concerns, real and imagined, that the board is prohibited from almost anything. It can’t change benefits, increase the eligibility age for Medicare, increase beneficiary premiums or cost sharing, tamper with eligibility rules, raise revenues in any way, or reduce payments to hsoitpals and hospices until fiscal 2020. What’s left is to recommend pay cuts for doctors, other providers, Medicare Advantage and Part D drug plans. The IPAB requirement to recommend cost reductions is triggered when Medicare costs exceed a pre-set limit. IPAB preserves what we love most about the sustainable growth rate formula (SGR), the automitic trigger that imposes physician fee cuts, but extends the reach to more providers and to Medicare health plans. It is unreasonable to expect that IPAB recommendatioins will meet a better fate than the SGR. While the ACA ostensibly makes IPAB cuts automatic unless Congress finds a better way to make the same cuts, in practice Congress can always vote to suspend the IPAB recommendation just as it suspends the SGR cuts.
Of course, the ACA didn’t eliminate the SGR, so now we have the SGR plus the IPAB. When Congress suspends an SGR cut, it increases the likelihood that it will be facing an IPAB mandate. So it will get to repeat the SGR drama twice each year.
The IPAB exists because Congress doesn’t trust itself to make rational decisions where Medicare is concerned. IPAB is often compared to the base realignment and closing (BRAC) process, which isolates individual members of Congress from accountability for military base closings that hurt their own districs. But BRAC recommendations only touch a few districts, and there are winners as well as losers among the districts affected. IPAB will adversly affect seniors and providers in all districts. So suspending IPAB recommendations will likely become must-pass legislation, even more so that suspending the SGR cuts. And must-pass legislation becomes the vehicle for more bickering, posturing, brinksmanship, and all the things that have earned Congress such contempt.
For its own good, Congress should repeal the IPAB. Not becasue it’s going to ration care, but because it will inevitably confront Congress with yet another policy on auto-pilot. An auto-pilot that, by design, will keep trying to fly Medicare into a cliff.