Winners and Losers in the Great IPAB Debate

When the Republican Party reclaimed the House majority after the 2010 elections, one of its first acts was to repeal the entire Patient Protection and Affordable Care Act. The bill was sent to Democratic-majority Senate, where it still sits with no action planned.

House Republicans then decided to aim their healthcare reform ire at the Independent Payment Advisory Board (IPAB). Over the course of just a few months, IPAB shifted from a little-known board tucked somewhere away somewhere in the behemoth PPACA to a household word.

Last week, after six hours of debate and two hours of procedural rulings, the House voted, more or less along party lines, to eliminate the IPAB. As with most political issues, there are winners and losers in the great IPAB debate. Here's a look:

Toss-up (but leaning loser): Independent Advisory Payment Board
Although the Senate is not expected to follow House action and vote to eliminate the IPAB, some damage has been done. Yes, IPAB will remain the law of the land, but recruiting 15 members for the board just got a lot more difficult. The original idea was that the great minds of healthcare will come together and, if needed, make the tough financial decisions required to strengthen Medicare. To remain unencumbered by outside influences, board members will be required to forgo research projects, consulting, and the Washington party circuit to devote themselves to the task at hand. Even if PPACA survives the current Supreme Court challenge, it's likely that IPAB will remain a sore point and could be under constant pressure to be eliminated or changed.

Toss-up: Medicare
It's great that Medicare sustainability is being talked about and ideas are being put on the table. But does anyone really think that Congress is ready to act? IPAB is a backstop in case Medicare costs get out of hand. Our elected officials can't continue to fret about Medicare's future while they decline to implement any reimbursement reductions. As it stands now, the sustainable growth rate (SGR) formula remains in place and there doesn't seem to be any agreement in Congress about what to do next. The IPAB, if it survives, will force Congress to act—although even that decision is years away.

Winner: Republicans
Republicans in the House effectively framed the IPAB debate as their effort to defend seniors from a rationing board. This presents a strong campaign opportunity to appeal to Medicare beneficiaries, and it will be top of mind for senior voters. Did I mention that Republicans equate IPAB with a rationing board? That's their story and they're sticking to it.

Loser: Democrats
The Democrats simply cannot cook their arguments down to simple sound bites. Much of the IPAB debate has consisted of Republicans using the term "rationing board" and the Democrats providing long-winded explanations of why IPAB is not a rationing board. Of course, Democrats used the term "rationing board" multiple times in the process.

Loser: Bipartisanship
The original effort to repeal the section of PPACA that creates IPAB had 232 co-sponsors, including 17 Democrats. Much was made of this wonderful bipartisan effort until House Republicans unexpectedly decided to link medical malpractice and IPAB into a single bill. That caused problems for Democrats, who typically oppose tort reform. In the final vote, only seven Democrats actually supported the combined bill. Political pundits have suggested that Republicans never really wanted Democrats to vote with them because they see IPAB as an important GOP campaign issue that would be muddied by Democratic support.

Loser: Rep. Allyson Schwartz (D-PA)
Rep. Schwartz is a Democrat from a relatively safe district in Pennsylvania. She supported PPACA but was one of the first Democrats to support the elimination of IPAB from the bill. She has been very vocal in her support for the Republican position, speaking against IPAB in various House committee meetings, and even penning an opposition op-ed for USA Today.

Still, she has her limits. When House Republicans added med-mal to the IPAB bill, Rep. Schwartz put her foot down and issued a statement asking them to "set aside political showmanship and bring a clean bill to repeal IPAB to the floor for a vote … Linking this bill to tort reform—an unrelated, divisive, and partisan issue—is bringing what was once a bipartisan effort to a screeching halt. I urge the Rules Committee to reject this offset." That didn't happen, and Schwartz cast her vote against the IPAB repeal.

Winner: The American Medical Association
The AMA scored a twofer, with the House voting its way on medical malpractice as well as IPAB. In a press release touting the vote, the AMA echoed the common complaint that the IPAB panel "would have too little accountability and the power to make indiscriminate cuts that adversely affect access to healthcare for patients." But the AMA still gives PPACA a thumbs up. The group was an early supporter of PPACA, just not for the parts that involve cuts to the physician payment formula.

Winner: 60 Plus Association
Billing itself as the "conservative alternative" to the AARP, 60 Plus earmarked $3.5 million for anti-IPAB media buys in five states where Democratic senators are vulnerable. Pat Boone, the aging crooner and the group's national spokesperson, tied each senator to IPAB—no small feat since the actual repeal vote was in the House—and asked residents to urge the senators to "support real Medicare reform and protect our seniors." The ad will probably help put IPAB in play for the upcoming election season and increases the media profile of the 60 Plus Association.