MEDICARE A COVERT TARGET IN HEALTH BILL

Sam Smith - Less than 24 hours ago, your editor reluctantly expressed the view that bad as the healthcare bill was, it would help enough people to justify its passage. I had forgotten something I had written earlier: "There are few things worse for politicians than for it to be discovered that they voted for some bad policy they didn't even know they were approving. In 2010 and 2012, the healthcare bill could easily be as risky as a highway around Baghdad."

I have just hit one of those landmines. A reader sent along a Kaus Files report on an undebated provision of the measure that is dangerous and dishonest enough to cause me to think now that the whole measure should be put on hold. Buried in the legislation is a way that the establishment, as it has long wanted, can do severe damage to Medicare with Congress having little power to resist. If Obama and the rest of the Democratic leadership are willing to be so corrupt and covert about this part of healthcare, what do they have in mind for the rest?

Basically, Obama will have achieved some of what Clinton did with social welfare, although at least Clinton was more open about it. In both cases the victim is a major legacy of the Democratic Party from a time when it still had a soul.

Further, this is just the beginning; the same crowd has its eye on Social Security.

This provision is despicable as are those who slipped it in and it should either be removed or the measure killed.


Kaus Files - David Leonhardt, complaining that the House health care bill doesn't do enough to control costs, touts a particular model for imposing parsimonious changes on the nation's health care delivery system:

"Twice a year, an outside advisory board sends Congress a list of suggestions for Medicare payment rates, based on the available evidence. Congress generally ignores them, in deference to the various industry groups that oppose any cuts to their payments.

"We already have a wonderful model for how to avoid such interference. It’s called the Federal Reserve. The Fed is charged with setting interest rates based on economic conditions, not politics. The Senate bill would create such a commission for Medicare."

But does the Senate bill really have a cost-cutting commission that's like the Fed? The Fed is a highly independent agency whose actions take effect without approval from Congress. Maybe Congress could overturn a Fed action, but it would require a new piece of legislation, passed by both houses and signed by the president. In contrast, the current cost-cutting "MedPAC" panel submits proposals that then have to be passed as new laws by Congress or else they don't take effect (which, as Leonhardt notes, is usually what happens).

The logical middle ground would be to have an independent panel whose recommendations take effect unless they are somehow vetoed by Congress without presidential involvement, or whose recommendations must be affirmatively passed by Congress but get the benefit of a streamlined, limited-amendment up-or-down fast-track "base closing" type of legislative process.

I assumed that the second of these obvious middle ground alternatives--rather than a "Fed" approach--had been taken when I read this description of the Reid Senate bill on Ezra Klein's blog:

"The idea isn't simply that a panel of experts gets to dream up interesting reforms to try out in Medicare. It's that they are charged with making sure that Medicare hits certain growth targets, and their package of reforms has to achieve that goal. Those reforms are then sent to Congress, where Senate debate is limited to 30 hours, and amendments must be both budget neutral and 'germane.' This report, in other words, is exempt from the filibuster. So far as anything is ever easy to pass, this is easy to pass."

Then I read the bill. As far as I can see, it's actually a whole lot closer to Leonhardt's Fed model than I'd thought. In general, there is an independent panel (IMAB), and if Congress does nothing, its cost-cutting rules take effect. What's more, the "fast track" process described by Klein would not allow Congress to simply stop the board's rules, only to substitute its own plan to save the same amount of money. This would be a very powerful unelected board. . . .

What it seems to say, specifically, is:

--The new 15 member "IMAB" board makes cost-cutting recommendations if Medicare spending exceeds specific targets.

--Congress then 'considers' these changes in bill form. But like other legislation, the president can veto this bill (and his veto can be overridden).

--The "fast tracking" provisions Klein discusses apply to this bill. But they also sharply restrict what the 'fast track' bill can do. Congress can't, under the fast track, just block the IMAB board's decrees. It can change them, but if it changes them it has to meet the cost-reduction targets in some other way. It's not allowed to not save money, apparently (though the Senate is allowed to do some unspecified things by 2/3 vote that I don't quite understand). In other words, the 'fast track' isn't designed to enable Congress to swiftly pass the new IMAB board's rules. The IMAB board doesn't need Congress' OK. The fast track is designed to allow Congress to tinker with the IMAB board's rules as long as it reaches the same result. In this sense, the Reid fast track isn't like base closing, where Congress votes a package of cuts up or down in a special procedure. Voting down is not an option here.

--Key point: If Congress doesn't pass the fast-tracked 'tinkering' bill, the Secretary of HHS must implement the IMAB panel's recommendations.

--And Congress loses even its fast-track tinkering power after 2020, unless, by a 60% supermajority, during a specific window in the first half of 2017, while standing on one leg and humming Battle Hymn of the Republic, it passes a joint resolution discontinuing the whole process. Correction: The part about standing on one leg and humming doesn't seem to be in the final bill.