Friday, November 20, 2009

Say Hello to my Little Fed - UPDATE

UPDATE: Ed Morrissey reports the vote to proceed is on for Saturday. Rush reports 97% of bills that succeed in this vote become law.  Call your Senator; tell them to start over.  

Another Saturday health care vote appears to be in the works, this time in the Senate. While the Senate may be may be taking its cue from the "success" of the House in its' Saturday vote, there are a few differences between the two bills that could push any resolution of the health care debate well into next year. Still conventional wisdom has it that if Reid is able to pull together the 60 votes he needs in this important opening vote, some 2000 page piece of legislation will eventually make its'way to the President's desk. Holdouts can be bought and the sky's the limit as far as Democrats are concerned to guarantee passage of their behemoth health care takeover.

Mickey Kaus may have uncovered what may well be the equivalent of the 11th hour reprieve after actually reading a key portion of the monster legislation that threatens to divide the House and Senate before all is said and done.  The Times buried this point of disagreement way at the bottom of their report:
The two chambers also disagree on whether to create an independent commission to help cut the growth of Medicare. Senate Democrats say such a commission could make politically unpopular decisions needed to put Medicare on a sound financial footing. But House leaders say it is the duty of Congress to make such tough decisions.
Kaus wondered whether the Senate bill, which was purported to actually go further than the House bill to contain costs had followed a "Fed" model detailed by Leonhardt in the Times:

A FED FOR HEALTH 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 theFederal 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. Unfortunately, it initially applies to doctors and home health care providers but not hospitals, thanks to a deal between the hospitals and the White House. It expands to include everyone in 2019. The House bill has no such commission.
Whether one ends up in the final bill will be a good test of Mr. Obama’s endgame leadership.
Kaus had assumed the  IMAB,  short for Independent Medical Advisory Board, created in the Senate had been less powerful and threatening after reading Ezra Klein's analysis:
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 he read the bill, or at least the relevant portion found on pages 1000-1053.  Here are the keypoints Kaus found:

--The new 15 member "IMAB" board makes cost-cutting recommendations if Medicare spending exceeds specific targets.
--Congress can disapprove these changes by passing a bill. But like other legislation, the president can veto that bill (and his veto can be overridden).
--The "fast tracking" provisions Klein discusses apply to the bill disapprovingthe changes. That is, they make it easier for opponents of the changes to block them without, say, being filibustered in the Senate. But they also sharply restrict what a "fast-tracked" disapproval can do--for example, it can't block spending cuts if that causes cost-reduction targets to be missed. To this extent it's an "up or down" vote, like a base-closing resolution
--Key point: If Congress doesn't pass the fast-tracked bill, the Secretary of HHS must implement the IMAB panel's recommendations
--And Congress loses even its fast-track disapproval 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.
Though its pretty complicated it looks as though the legislation empowers an unelected body as powerful as the Fed to do some of the dirty work cutting benefits etc that Congress is notoriously reluctant to make. It also makes it much more difficult for Congress to overrule the panel recommendations. Now wipe those two dirty words "death panels" from your mind, we all know how crazy that argument was right?

Still, Kaus wonders what Congress might do if the IMAB decided that the federal government won't pay for mammograms for women under 40? Could they stop it? What if government, as is often the case, is divided? It seems the power is on the side of the "Med" instead of Congress. Yes, there may be means for the Congress to pass a law overthrowing the panel recommendations or eliminating the board altogether. In reality, it is always much more difficult to eliminate or even "audit" such a powerful group once they have been put in action. While we already have one unelected board with power over our money, the Senate bill gives another unelected board power over our health and 1/6th of the economy. What could possibly go wrong?

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