Tuesday, February 8, 2011

IPAB and Ryan

Austin Frakt with a post following up Ezra Klein's comments on similarities between the Affordable Care Act (ACA) and Paul Ryan's Roadmap in terms of addressing cost inflation in Medicare. Part of Klein's point was to ask why Ryan thinks Congresses of the future would do his preferred hard things, when he has been saying Congress will not do hard things to implement the ACA. I have also written about this.

Austin today notes that Ryan's Roadmap health policy plans empowers the Sec of HHS to enforce future Medicare growth rates, while Austin thinks an IPAB has a better chance of doing a better job and wonders why Ryan would prefer one political appointee for this important task as compared to a broad based board such as IPAB doing it. The answer I think is that an independent board such as the IPAB is a classic example of an idea that once had bipartisan policy support, but which become politically partisan once it appeared in the ACA.

On May 20, 2009, Rep. Ryan (along with co-sponors Nunes in the House and Coburn and Burr in the Senate) introduced the Patients' Choice Act. It contained two boards that would apply cost effectiveness research and the like in an effort to improve quality and reduce spending (Title VIII of the PCA). Thus, Rep. Ryan proposed a more robust version of the IPAB, about a month before the first House Committee reported out HR 3200.

This is just one of many examples of Republicans vehemently opposing ideas in the ACA that they once supported, and in this case, even proposed.


  1. if you had a world where ryan's legislation occurred, where everybody where medicare provided vouchers with which seniors bought insurance, you could have something like IPAB but it wouldn't actually need teeth. It would conduct effectiveness research and issue recommendations. Insureres would use those recommendations as a CYA against potential litigation. The same net result but you don't have to monkey around with congress or HHS (my understanding was that with IPAB as conceived under PPACA IPAB would submit a list of recommendations which congress would vote on in their entirety on an up or down basis- please correct me if I am wrong).

  2. The IPAB that actually passed is fairly limited; it cannot make coverage decisions, for example. It is less expansive than the IMAC proposed in the Patients' Choice Act.

    If you had a ramped up IPAB, then I follow your logic. I see an IPAB approach as an alternative to Ryan. Both have a goal of slowing federal spending, which means less care must be delivered one way or another. Ryan would reduce govt spending on health by moving Medicare to defined contribution, which would buy less insurance than what Medicare now covers, which means you ration on price (those with lots of money will be able to buy). IPAB is really expert driven rationing, basically by asking the questions does it improve quality of life and/or extend life. There is no easy way to reduce health spending compared to what it will be under the default.