- TXT
-
PDF
(PDF provides a complete and accurate display of this text.)
Tip
?
115th Congress } { Rept. 115-373
HOUSE OF REPRESENTATIVES
1st Session } { Part 1
======================================================================
PROTECTING SENIORS ACCESS TO MEDICARE ACT
_______
October 31, 2017.--Committed to the Committee of the Whole House on the
State of the Union and ordered to be printed
_______
Mr. Brady of Texas, from the Committee on Ways and Means, submitted the
following
R E P O R T
together with
ADDITIONAL VIEWS
[To accompany H.R. 849]
[Including cost estimate of the Congressional Budget Office]
The Committee on Ways and Means, to whom was referred the
bill (H.R. 849) to repeal the provisions of the Patient
Protection and Affordable Care Act providing for the
Independent Payment Advisory Board, having considered the same,
reports favorably thereon with an amendment and recommends that
the bill as amended do pass.
CONTENTS
Page
I. SUMMARY AND BACKGROUND...........................................2
A. Purpose and Summary................................. 2
B. Background and Need for Legislation................. 2
C. Legislative History................................. 2
II. EXPLANATION OF THE BILL..........................................3
A. Protecting Seniors' Access to Medicare Act of 2017.. 3
III. VOTES OF THE COMMITTEE...........................................6
IV. BUDGET EFFECTS OF THE BILL.......................................8
A. Committee Estimate of Budgetary Effects............. 8
B. Statement Regarding New Budget Authority and Tax
Expenditures Budget Authority...................... 8
C. Cost Estimate Prepared by the Congressional Budget
Office............................................. 8
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE......11
A. Committee Oversight Findings and Recommendations.... 11
B. Statement of General Performance Goals and
Objectives......................................... 11
C. Information Relating to Unfunded Mandates........... 12
D. Congressional Earmarks, Limited Tax Benefits, and
Limited Tariff Benefits............................ 12
E. Duplication of Federal Programs..................... 12
F. Disclosure of Directed Rule Makings................. 12
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED...........12
VII. ADDITIONAL VIEWS................................................38
The amendment is as follows:
Strike all after the enacting clause and insert the
following:
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Protecting Seniors Access to Medicare
Act''.
SEC. 2. REPEAL OF THE INDEPENDENT PAYMENT ADVISORY BOARD.
Effective as of the enactment of the Patient Protection and
Affordable Care Act (Public Law 111-148), sections 3403 and 10320 of
such Act (including the amendments made by such sections) are repealed,
and any provision of law amended by such sections is hereby restored as
if such sections had not been enacted into law.
I. SUMMARY AND BACKGROUND
A. Purpose and Summary
The bill, H.R. 849, as ordered by the Committee on Ways and
Means on October 4, 2017, would repeal Medicare's Independent
Payment Advisory Board (``IPAB''), section 3403 and 10320 of
the Patient Protection and Affordable Care Act (``ACA''; P.L.
111-148).
B. Background and Need for Legislation
On February 3, 2017, Representative David P. Roe (R-TN) and
Representative Raul Ruiz introduced H.R. 849, a bill to repeal
provisions of the ACA providing for IPAB. The Committee on Ways
and Means received primary referral for the bill because the
bill includes Medicare provisions that fall within the
jurisdiction of the Committee, including relevant provisions of
the Social Security Act (SSA). The Committee has multiple
concerns about IPAB, including: IPAB will consist of unelected
officials whose primary responsibility will be to cut Medicare
spending which could result in restricting access to health
care services and/or rationing of care; IPAB will not be
accountable to patients, providers, or Congress as it is
allowed to operate in private; IPAB is free from judicial
review; and IPAB delegates too much power to the Executive
Branch.
C. Legislative History
BACKGROUND
H.R. 849 was introduced on February 3, 2017, and was
referred to the Committee on Ways and Means, and additionally
to the Committee on Energy and Commerce and the Committee on
Rules.
COMMITTEE HEARINGS
On June 8, 2017, the Committee held a hearing on the
Department of Health and Human Services' (HHS) Fiscal Year 2018
Budget Proposal with Secretary Price, in which IPAB was
discussed.
On February 10, 2016, the Committee held a hearing on the
HHS Fiscal Year 2017 Budget Proposal with Secretary Burwell, in
which IPAB was discussed.
On June 10, 2015, the Committee held a hearing on the
Implementation of the Affordable Care Act with Secretary
Burwell, in which IPAB was discussed.
On March 12, 2014, the Committee held a hearing on the HHS
Fiscal Year 2015 Budget Proposal with Secretary Sebelius, in
which IPAB was discussed.
On March 6, 2012, the Subcommittee on Health held a hearing
to specifically examine how IPAB will impact the Medicare
program, its beneficiaries, and health care providers.
On June 22, 2011, the Subcommittee held a hearing on the
2011 Medicare Trustees Report, in which IPAB was discussed.
On February 28, 2012, the Committee held a hearing on the
HHS Fiscal Year 2013 Budget Proposal with Secretary Sebelius,
in which IPAB was discussed.
On February 10, 2011, the Committee held a hearing on the
ACA's impact on Medicare and its beneficiaries.
On January 26, 2011, the Committee held a hearing on the
ACA's impact on jobs, employers, and the economy.
COMMITTEE ACTION
The Committee on Ways and Means marked up H.R. 849, the
Protecting Seniors' Access to Medicare Act of 2017, on October
4, 2017, and ordered the bill, as amended, favorably reported
(with a quorum being present).
II. EXPLANATION OF THE BILL
A. Protecting Seniors' Access to Medicare Act of 2017
PRESENT LAW
IPAB was created by Sections 3403 and 10320 of the ACA
(P.L. 111-148). Beginning in 2014, IPAB is tasked with making
recommendations to cut per capita Medicare spending if such
spending exceeds certain economic growth targets. No board
members have been selected to date.
By April 30, 2013, and each subsequent year, the Chief
Actuary at the Centers for Medicare and Medicaid Services (CMS)
is required to calculate whether the projected growth in
average per beneficiary Medicare spending over a five-year
period (beginning two years before the year in which the
calculation is being made and ending two years after) exceeds
projected Medicare spending targets. From 2015-2019, the
Medicare spending growth targets will be the projected 5-year
increase in the average of the urban consumer price index (CPI-
U) and medical inflation (CPI-M). Beginning in 2020, the
Medicare spending growth target will be GDP + 1 percent.
If the Chief Actuary determines that projected Medicare
spending growth exceeds the projected spending growth targets,
then the Chief Actuary must establish a savings target to rein
in Medicare spending in the last year of the five-year period
being examined. Savings targets are capped at the lesser of a
pre-determined percentage (which increases from 0.5 percent of
total Medicare spending in 2015 to 1.5 percent in 2018 and
beyond) or the actual difference between estimated Medicare
spending growth and the spending growth target.
If Medicare per capita spending is projected to outpace the
target, IPAB would then recommend Medicare cuts that, if
enacted, would meet or exceed the savings target identified by
the CMS Chief Actuary. IPAB is prohibited from recommending
policies that would ration care (although ``ration'' is not
defined in law), raise beneficiary premiums, increase cost
sharing, or otherwise restrict benefits or eligibility.
Due to the projected growth in Medicare spending, the
Trustees currently predict that IPAB will be triggered as soon
as 2021, compared to the 2016 report that predicted a 2017
trigger date. The Trustees estimate that IPAB will reduce
Medicare growth rates for the first time in 2023, by 0.002
percent. In addition, the Trustees project that growth rates
will be reduced by similarly small amounts in 2026, 2027, 2028,
2030, 2033, and 2035. However, they project that ``IPAB is not
triggered beyond 2035 in current law, mostly due to the
assumptions about long-range health care cost growth, which is
lower than GDP growth.''
IPAB operating funds are drawn from the Medicare trust
funds. IPAB was scheduled to receive $15 million in FY2012
(indexed to inflation in future years). Congress has repeatedly
rescinded its funding (FY2012-FY2017), rescinding $15 million
in the Consolidated Appropriations Act of 2017, which policy
was most recently retained in the three-month continuing
resolution (The Continuing Appropriations Act, 2018 and
Supplemental Appropriations for Disaster Relief Requirements
Act of 2017).
IPAB's recommendations are due to the President and
Congress by January 15 following the year in which the Chief
Actuary sets the savings target. IPAB was prohibited from
making its first recommendations before January 15, 2014, and
IPAB-related spending reductions could not be implemented
before August 15, 2014. If IPAB does not submit recommendations
(e.g., a majority of IPAB members do not vote in favor of a
final package to send to Congress and the President that meets
the targeted savings), the HHS Secretary would draft a proposal
to achieve the necessary cuts (due by January 25 to the
President, who would then send the proposal to Congress).
Similarly, if the Senate fails to confirm the President's IPAB
appointees, the HHS Secretary would be solely responsible for
developing the legislation to cut Medicare to achieve the
savings target and for submitting that plan to the President.
The President would then have two days to submit that plan to
Congress.
IPAB's recommendations are afforded expedited procedures
for consideration by the House and Senate. In years in which
IPAB makes recommendations, the Committees of jurisdiction
would have until April 1 to report legislation that complies
with the spending cuts (either by adopting the IPAB's
recommendations in whole or in part) or the IPAB
recommendations would be discharged to floor. Congress would
have until August 15 to pass such legislation. Congress can
change the specific policy recommended by IPAB, but the savings
targets must be met.
If Congress does not pass legislation that meets IPAB's
savings requirements, the HHS Secretary would implement IPAB's
recommendations beginning August 15 of the year in which the
IPAB issued such recommendations. If Congress' response to IPAB
recommendations is to pass a different collection of Medicare
cuts, the President can issue a veto (which requires the
standard two-thirds vote to override).
In 2017, Congress could have discontinued IPAB via a joint
resolution which receives ``fast track'' treatment in the
Senate, so long as the resolution had been introduced before
February 1 and contained specific language outlined in the
Democrats' health care overhaul. Such a repeal would have
required a three-fifths supermajority vote in both the House
and Senate. Repeal efforts in other years will not enjoy these
special Senate floor procedures.
IPAB will consist of 15 members appointed by the President
and confirmed by the Senate. The President is to ``consult''
with the Senate Majority and Minority Leaders and with the
Speaker and House Minority Leader on 12 of the 15 members (3
per each leader). IPAB members are to have expertise in health
finance, actuarial science, health plans, or integrated
delivery systems and would consist of physicians or other
health professionals, academics, economists, and experts in
urban/rural, consumer, and seniors' interests. However, the
majority of IPAB members cannot be health care providers. IPAB
members could generally serve a maximum of two, six-year terms.
The HHS Secretary, CMS Administrator, and the Health Resources
and Services Administration (HRSA) Administrator will serve as
non-voting IPAB members. IPAB receives its operational funding
from the Medicare trust funds.
Special exemptions from IPAB-recommended cuts were granted
to those providers who, in the ACA, received a cut to their
annual base Medicare payment adjustment and a ``productivity
adjustment'' cut. Specifically, providers cannot be cut by the
IPAB in years in which they are subject to the productivity
cuts and a cut to their payment update. As such, the hospital
and hospice industries are exempt from IPAB cuts until 2019,
while clinical laboratories were exempt from IPAB cuts through
2015. Given that a significant sector of the health care
industry is exempt from cuts (representing 37 percent of
Medicare benefit payments in 2009), other providers such as
physicians, nursing homes, home health agencies, Medicare
Advantage, and Part D plans would likely bear the brunt of any
cuts, at least until 2019.
REASONS FOR CHANGE
The Committee believes that appointing an unelected and
unaccountable board to cut Medicare spending will harm
beneficiary access to care and force health care providers to
limit the number of beneficiaries they will treat or even stop
participating in Medicare altogether.
While the statute suggests that IPAB will be prohibited
from recommending policies that ration health care, the term
``ration'' is not defined in the statute, meaning its
definition and application would be determined by IPAB members.
Further, nothing would preclude IPAB from rationing care by way
of driving down reimbursements for treatments and procedures to
levels where no provider would provide the care.
The Committee also has significant concerns about the
degree of institutional power that will be taken from Congress
and provided to IPAB and the Executive Branch. The President
controls IPAB appointments, whether considered by Congress or
recess appointed. If IPAB is unable to submit a proposal to cut
Medicare to Congress, the HHS Secretary submits a proposal
instead. Congress has limited ability to override the Medicare
cuts proposed by IPAB and HHS, and any override could be vetoed
by the President, ensuring that the President's IPAB or HHS
proposal becomes law.
The Committee objects to IPAB's ability to conduct its
proceedings outside of the public domain, as well as its
exemption from judicial review. Such authority hinders
consideration of beneficiary and provider input while robbing
them of any recourse through the judicial system or appeal of
IPAB decisions.
EXPLANATION OF PROVISIONS
H.R. 849, as amended, would repeal section 3403 and 10320
of the ACA, including the amendments made by these sections.
Beginning in 2014, the IPAB is tasked with making
recommendations to cut per capita Medicare spending if such
spending exceeds certain economic growth targets. The Secretary
of HHS is directed to implement the Board's proposals
automatically unless Congress affirmatively acts to alter the
Board's proposals or to discontinue the automatic
implementation of such proposals. Under the proposed
legislation, the IPAB would be repealed.
EFFECTIVE DATE
H.R. 849 would become effective on the date of its
enactment.
III. VOTES OF THE COMMITTEE
In compliance with clause 3(b) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the vote of the Committee on Ways and Means in its
consideration of H.R. 849, the Protecting Seniors' Access to
Medicare Act of 2017, on October 4, 2017.
The Chairman's amendment in the nature of a substitute was
adopted by a voice vote (with a quorum being present).
The vote on Mr. Reichert's motion to table Mr. Doggett's
appeal of the ruling of the Chair was agreed to by a roll call
vote of 22 yeas to 15 nays (with a quorum being present). The
vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Brady...................... X ........ ......... Mr. Neal......... ........ X .........
Mr. Johnson.................... X ........ ......... Mr. Levin........ ........ X .........
Mr. Nunes...................... X ........ ......... Mr. Lewis........ ........ X .........
Mr. Tiberi..................... X ........ ......... Mr. Doggett...... ........ X .........
Mr. Reichert................... X ........ ......... Mr. Thompson..... ........ X .........
Mr. Roskam..................... X ........ ......... Mr. Larson....... ........ X .........
Mr. Buchanan................... X ........ ......... Mr. Blumenauer... ........ X .........
Mr. Smith (NE)................. X ........ ......... Mr. Kind......... ........ X .........
Ms. Jenkins.................... X ........ ......... Mr. Pascrell..... ........ X .........
Mr. Paulsen.................... X ........ ......... Mr. Crowley...... ........ X .........
Mr. Marchant................... X ........ ......... Mr. Davis........ ........ ........ .........
Ms. Black...................... X ........ ......... Ms. Sanchez...... ........ X .........
Mr. Reed....................... ........ ........ ......... Mr. Higgins...... ........ X .........
Mr. Kelly...................... X ........ ......... Ms. Sewell....... ........ X .........
Mr. Renacci.................... X ........ ......... Ms. DelBene...... ........ X .........
Mr. Meehan..................... X ........ ......... Ms. Chu.......... ........ X .........
Ms. Noem....................... X ........ .........
Mr. Holding.................... X ........ .........
Mr. Smith (MO)................. ........ ........ .........
Mr. Rice....................... X ........ .........
Mr. Schweikert................. X ........ .........
Ms. Walorski................... X ........ .........
Mr. Curbelo.................... X ........ .........
Mr. Bishop..................... X ........ .........
----------------------------------------------------------------------------------------------------------------
The vote on the amendment offered by Mr. Doggett to the
amendment in the nature of a substitute to H.R. 849, which
would prevent the repeal of the Independent Payment Advisory
Board if CMS found that Medicare prescription drug spending was
growing faster than the rate of inflation, was not agreed to by
a roll call vote of 22 nays to 15 yeas (with a quorum being
present). The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Brady...................... ........ X ......... Mr. Neal......... X ........ .........
Mr. Johnson.................... ........ X ......... Mr. Levin........ X ........ .........
Mr. Nunes...................... ........ X ......... Mr. Lewis........ X ........ .........
Mr. Tiberi..................... ........ X ......... Mr. Doggett...... X ........ .........
Mr. Reichert................... ........ X ......... Mr. Thompson..... X ........ .........
Mr. Roskam..................... ........ X ......... Mr. Larson....... X ........ .........
Mr. Buchanan................... ........ X ......... Mr. Blumenauer... X ........ .........
Mr. Smith (NE)................. ........ X ......... Mr. Kind......... X ........ .........
Ms. Jenkins.................... ........ X ......... Mr. Pascrell..... X ........ .........
Mr. Paulsen.................... ........ X ......... Mr. Crowley...... X ........ .........
Mr. Marchant................... ........ X ......... Mr. Davis........ ........ ........ .........
Ms. Black...................... ........ X ......... Ms. Sanchez...... X ........ .........
Mr. Reed....................... ........ ........ ......... Mr. Higgins...... X ........ .........
Mr. Kelly...................... ........ X ......... Ms. Sewell....... X ........ .........
Mr. Renacci.................... ........ X ......... Ms. DelBene...... X ........ .........
Mr. Meehan..................... ........ X ......... Ms. Chu.......... X ........ .........
Ms. Noem....................... ........ X .........
Mr. Holding.................... ........ X .........
Mr. Smith (MO)................. ........ ........ .........
Mr. Rice....................... ........ X .........
Mr. Schweikert................. ........ X .........
Ms. Walorski................... ........ X .........
Mr. Curbelo.................... ........ X .........
Mr. Bishop..................... ........ X .........
----------------------------------------------------------------------------------------------------------------
H.R. 849 was ordered favorably reported to the House of
Representatives as amended by a roll call vote of 24 yeas to 13
nays (with a quorum being present). The vote was as follows:
----------------------------------------------------------------------------------------------------------------
Representative Yea Nay Present Representative Yea Nay Present
----------------------------------------------------------------------------------------------------------------
Mr. Brady...................... X ........ ......... Mr. Neal......... ........ X .........
Mr. Johnson.................... X ........ ......... Mr. Levin........ ........ X .........
Mr. Nunes...................... X ........ ......... Mr. Lewis........ ........ X .........
Mr. Tiberi..................... X ........ ......... Mr. Doggett...... ........ X .........
Mr. Reichert................... X ........ ......... Mr. Thompson..... ........ X .........
Mr. Roskam..................... X ........ ......... Mr. Larson....... ........ X .........
Mr. Buchanan................... X ........ ......... Mr. Blumenauer... ........ X .........
Mr. Smith (NE)................. X ........ ......... Mr. Kind......... ........ X .........
Ms. Jenkins.................... X ........ ......... Mr. Pascrell..... X ........ .........
Mr. Paulsen.................... X ........ ......... Mr. Crowley...... ........ X .........
Mr. Marchant................... X ........ ......... Mr. Davis........ ........ ........ .........
Ms. Black...................... X ........ ......... Ms. Sanchez...... X ........ .........
Mr. Reed....................... ........ ........ ......... Mr. Higgins...... ........ X .........
Mr. Kelly...................... X ........ ......... Ms. Sewell....... ........ X .........
Mr. Renacci.................... X ........ ......... Ms. DelBene...... ........ X .........
Mr. Meehan..................... X ........ ......... Ms. Chu.......... ........ X .........
Ms. Noem....................... X ........ .........
Mr. Holding.................... X ........ .........
Mr. Smith (MO)................. ........ ........ .........
Mr. Rice....................... X ........ .........
Mr. Schweikert................. X ........ .........
Ms. Walorski................... X ........ .........
Mr. Curbelo.................... X ........ .........
Mr. Bishop..................... X ........ .........
----------------------------------------------------------------------------------------------------------------
IV. BUDGET EFFECTS OF THE BILL
A. Committee Estimate of Budgetary Effects
In compliance with clause 3(d) of rule XIII of the Rules of
the House of Representatives, the following statement is made
concerning the effects on the budget of the bill, H.R. 849, as
reported. The Committee agrees with the estimate prepared by
the Congressional Budget Office (CBO), which is included below.
B. Statement Regarding New Budget Authority and Tax Expenditures Budget
Authority
In compliance with clause 3(c)(2) of rule XIII of the Rules
of the House of Representatives, the Committee states that H.R.
849, as reported, would increase direct spending by $17.5
billion over the 2017-2026 period. The Committee states further
that the bill involves no new or increased tax expenditures.
C. Cost Estimate Prepared by the Congressional Budget Office
In compliance with clause 3(c)(3) of rule XIII of the Rules
of the House of Representatives, requiring a cost estimate
prepared by the CBO, the following statement by CBO is
provided.
U.S. Congress,
Congessional Budget Office,
Washington, DC, October 27, 2017.
Hon. Kevin Brady,
Chairman, Committee on Ways and Means,
House of Representatives, Washington, DC.
Dear Mr. Chairman: The Congressional Budget Office has
prepared the enclosed cost estimate for H.R. 849, the
Protecting Seniors' Access to Medicare Act.
If you wish further details on this estimate, we will be
pleased to provide them. The CBO staff contact is Lori Housman.
Sincerely,
Keith Hall
Director.
Enclosure.
H.R. 849--Protecting Seniors' Access to Medicare Act
Summary: H.R. 849 would repeal the provisions of the
Affordable Care Act (ACA) that established the Independent
Payment Advisory Board (IPAB) and that created a process by
which the Board (or the Secretary of the Department of Health
and Human Services) would be required under certain
circumstances to modify the Medicare program to achieve
specified savings.
CBO estimates that enacting H.R. 849 would increase direct
spending by $17.5 billion over the 2018-2027 period. That
estimate is extremely uncertain because it is not clear whether
the mechanism for spending reductions under the IPAB authority
will be invoked under current law for most of the next ten
years. Under CBO's current baseline projections such authority
is projected to be invoked in 2023, 2025, and 2027. However,
given the uncertainty that surrounds those projections, it is
possible that such authority would be invoked in other years.
Taking into account that possibility, CBO estimates that
repealing the IPAB provision of the ACA would probably result
in higher spending for the Medicare program over the 2022
through 2027 period than would occur under current law. CBO's
estimate represents the expected value of a broad range of
possible effects from repealing IPAB provisions.
Pay-as-you-go procedures apply because enacting the
legislation would affect direct spending. Enacting the bill
would not affect revenues.
CBO estimates that enacting H.R. 849 would increase net
direct spending and on-budget deficits by more than $5 billion
in one or more of the four consecutive 10-year periods
beginning in 2028.
H.R. 849 contains no intergovernmental or private-sector
mandates as defined in the Unfunded Mandates Reform Act (UMRA).
Estimated cost to the Federal Government: The estimated
budgetary impact of H.R. 849 is shown in the following table.
The costs of this legislation fall within budget function 570
(Medicare).
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
CHANGES IN DIRECT SPENDING
1Estimated Budget Authority............................. 0 0 0 0 800 220 5,160 1,560 6,600 3,150 800 17,490
Estimated Outlays....................................... 0 0 0 0 800 220 5,160 1,560 6,600 3,150 800 17,490
--------------------------------------------------------------------------------------------------------------------------------------------------------
Basis of estimate: H.R. 849 would repeal the provisions of
the ACA that created IPAB. CBO estimates that enacting the bill
would lead to a net increase in direct spending of $17.5
billion over the 2018-2027 period.
Background
Under current law, IPAB has the obligation to reduce
Medicare spending--beginning in 2015--relative to what
otherwise would occur if the rate of growth in spending per
beneficiary is projected to exceed a target rate. For 2015
through 2019, that target rate is based on inflation; for 2020
and subsequent years, it is based on growth in the economy.
Each year, the law requires the Chief Actuary of the Centers
for Medicare and Medicaid Services (CMS) to project two
numbers, each of which is a five-year moving average for the
period ending two years in the future:
The rate of change in net Medicare spending
per beneficiary (that is, gross Medicare spending less
enrollees' payments for premiums); and
The rate of change in an economic measure--
which is the average of the CPI-U and CPI-M\1\ for
five-year periods ending in 2015 through 2019, and GDP
per capita plus 1 percentage point for five-year
periods ending in 2020 and subsequent years.
---------------------------------------------------------------------------
\1\The CPI-U is the consumer price index for all urban consumers
and the CPI-M is the medical care category of the CPI-U. The medical
care category is one of eight major expenditure groups that make up the
CPI-U (see www.bls.gov/cpi/questions-and-answers.htm#Question_7).
---------------------------------------------------------------------------
In general, the Chief Actuary of CMS will compare those two
values, and if the spending measure is larger than the economic
measure, the difference will be used to determine the IPAB's
savings target for the last year of the five-year period.
However, current law prohibits modifications designed to
achieve the savings target in two consecutive years if the
Chief Actuary determines that the rate of growth in Medicare
spending per beneficiary is below the rate of growth in
national health expenditures per capita. In general, CBO
expects that modifications designed to achieve the savings
target would not be implemented in consecutive years.
CBO's current estimates of Medicare spending and its
current economic projections result in an estimated IPAB
spending measure that is above the economic measure in 2023 and
each subsequent year through 2027. However, because of the
limitation on making modifications in consecutive years, CBO's
baseline projections include the assumption that modifications
to the Medicare program designed to achieve the savings target
would be implemented in 2023, 2025, and 2027. In addition, CBO
anticipates that some of the savings from program modifications
made to hit the savings target generated by the IPAB mechanism
will compound and produce savings in subsequent years. Under
current law, CBO projects that actions taken to achieve the
IPAB spending target will reduce Medicare spending by $15
billion over the 2018-2027 period.\2\
---------------------------------------------------------------------------
\2\CBO's baseline projections result in a projected savings target
of 0.1 percent for 2019. However, the 2017 Annual Report of the Boards
of Trustees of the Federal Hospital Insurance and Federal Supplementary
Medical Insurance Trust Funds (Trustees Report) determined that the
target growth rate will not be exceeded for 2019. CBO views the
Trustees Report as a final action that sets the savings target for 2019
to zero.
---------------------------------------------------------------------------
Estimated effects of H.R. 849 over the 2018-2027 period
The IPAB mechanism is essentially a one-sided bet: either
modifications to achieve a savings target are required
(resulting in savings) or they are not (resulting in no
change).\3\ IPAB cannot be instructed to increase spending. So,
variations in those measures might lead to additional savings
but could not lead to added costs. Because of the one-sided
nature of the budgetary impact of variations in the spending
and economic measures that determine IPAB's savings target, CBO
must consider the probabilities associated with such variations
when assessing the budgetary effects of possible changes in
law.
---------------------------------------------------------------------------
\3\For a discussion of CBO's longstanding approach to estimating
one-sided bets, see www.cbo.gov/sites/default/files/cbofiles/ftpdocs/
15xx/doc1589/onesided.pdf.
---------------------------------------------------------------------------
To produce estimates for proposed legislative changes to
the IPAB mechanism that take into account the probabilities of
variations in the relevant measures, CBO applies that
probability distribution to its point estimates of the five-
year moving average of net Medicare spending per beneficiary to
calculate an expected value for IPAB's savings target under
both current law and under the proposal. CBO applies a de
minimis rule that the target will be zero if the expected value
of the savings target is less than 0.05 percent.\4\
---------------------------------------------------------------------------
\4\A further discussion of this methodology can be found in CBO's
estimate for H.R. 452, the Medicare Decisions Accountability Act of
2011, www.cbo.gov/sites/default/files/112th-congress-2011-2012/
costestimate/hr45220120.pdf.
---------------------------------------------------------------------------
Under that probability-based approach, and after applying
the de minimis rule (for estimated effects that round to 0.0
percent), CBO estimates that the expected value of IPAB's
savings target would be zero for 2018 through 2021. For 2022
through 2028, the expected value of the savings target would be
between 0.1 percent and 0.7 percent of projected net Medicare
spending. As a result, CBO estimates that repealing the IPAB
mechanism would increase expected Medicare spending each year
from 2022 through 2027, with the expected value of the net
increase in Medicare spending for benefits totaling $17.5
billion over that period.
Pay-As-You-Go considerations: The Statutory Pay-As-You-Go
Act of 2010 establishes budget-reporting and enforcement
procedures for legislation affecting direct spending or
revenues. The net changes in outlays that are subject to those
pay-as-you-go procedures are shown in the following table.
Enacting H.R. 849 would not affect revenues.
--------------------------------------------------------------------------------------------------------------------------------------------------------
By fiscal year, in millions of dollars--
-----------------------------------------------------------------------------------------------------
2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2018-2022 2018-2027
--------------------------------------------------------------------------------------------------------------------------------------------------------
NET INCREASE OR DECREASE (-) IN THE DEFICIT
Statutory Pay-As-You-Go
Impact............................................ 0 0 0 0 800 220 5,160 1,560 6,600 3,150 800 17,490
--------------------------------------------------------------------------------------------------------------------------------------------------------
Increase in long-term direct spending and deficits: CBO
estimates that enacting H.R. 849 would increase net direct
spending and on-budget deficits by more than $5 billion in one
or more of the four consecutive 10-year periods beginning in
2028.
Intergovernmental and private-sector impact S: H.R. 849
contains no intergovernmental or private-sector mandates as
defined in UMRA and would impose no costs on state, local, or
tribal governments.
Estimate prepared by: Federal costs: Lori Housman; Impact
on State, local, and tribal governments: Amy Petz; Impact on
the private sector: Amy Petz.
Estimate approved by: Holly Harvey: Deputy Assistant
Director for Budget Analysis.
V. OTHER MATTERS TO BE DISCUSSED UNDER THE RULES OF THE HOUSE
A. Committee Oversight Findings and Recommendations
With respect to clause 3(c)(1) of rule XIII of the Rules of
the House of Representatives, the Committee made findings and
recommendations that are reflected in this report.
B. Statement of General Performance Goals and Objectives
With respect to clause 3(c)(4) of rule XIII of the Rules of
the House of Representatives, the Committee advises that the
bill does not authorize funding, so no statement of general
performance goals and objectives is required.
C. Information Relating to Unfunded Mandates
This information is provided in accordance with section 423
of the Unfunded Mandates Reform Act of 1995 (Pub. L. No. 104-
4).
The Committee has determined that the bill does not contain
Federal mandates on the private sector. The Committee has
determined that the bill does not impose a Federal
intergovernmental mandate on State, local, or tribal
governments.
D. Congressional Earmarks, Limited Tax Benefits, and Limited Tariff
Benefits
With respect to clause 9 of rule XXI of the Rules of the
House of Representatives, the Committee has carefully reviewed
the provisions of the bill, and states that the provisions of
the bill do not contain any congressional earmarks, limited tax
benefits, or limited tariff benefits within the meaning of the
rule.
E. Duplication of Federal Programs
In compliance with clause 3(c)(5) of rule XIII of the Rules
of the House of Representatives, the Committee states that no
provision of the bill establishes or reauthorizes: (1) a
program of the Federal Government known to be duplicative of
another Federal program; (2) a program included in any report
from the Government Accountability Office to Congress pursuant
to section 21 of Public Law 111-139; or (3) a program related
to a program identified in the most recent Catalog of Federal
Domestic Assistance, published pursuant to the Federal Program
Information Act (Pub. L. No. 95-220, as amended by Pub. L. No.
98-169).
F. Disclosure of Directed Rule Makings
In compliance with Sec. 3(i) of H. Res. 5 (115th Congress),
the following statement is made concerning directed rule
makings:
The Committee advises that the bill requires no directed
rulemakings within the meaning of such section.
VI. CHANGES IN EXISTING LAW MADE BY THE BILL, AS REPORTED
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets, new
matter is printed in italic, and existing law in which no
change is proposed is shown in roman):
Changes in Existing Law Made by the Bill, as Reported
In compliance with clause 3(e) of rule XIII of the Rules of
the House of Representatives, changes in existing law made by
the bill, as reported, are shown as follows (existing law
proposed to be omitted is enclosed in black brackets and
existing law in which no change is proposed is shown in roman):
PATIENT PROTECTION AND AFFORDABLE CARE ACT
* * * * * * *
TITLE III--IMPROVING THE QUALITY AND EFFICIENCY OF HEALTH CARE
* * * * * * *
Subtitle E--Ensuring Medicare Sustainability
* * * * * * *
[SEC. 3403. INDEPENDENT MEDICARE ADVISORY BOARD.
[(a) Board.--
[(1) In general.--Title XVIII of the Social Security
Act (42 U.S.C. 1395 et seq.), as amended by section
3022, is amended by adding at the end the following new
section:
[``INDEPENDENT MEDICARE ADVISORY BOARD
[``Sec. 1899A. (a) Establishment.--There is established an
independent board to be known as the `Independent Medicare
Advisory Board'.
[``(b) Purpose.--It is the purpose of this section to, in
accordance with the following provisions of this section,
reduce the per capita rate of growth in Medicare spending--
[``(1) by requiring the Chief Actuary of the Centers
for Medicare & Medicaid Services to determine in each
year to which this section applies (in this section
referred to as `a determination year') the projected
per capita growth rate under Medicare for the second
year following the determination year (in this section
referred to as `an implementation year');
[``(2) if the projection for the implementation year
exceeds the target growth rate for that year, by
requiring the Board to develop and submit during the
first year following the determination year (in this
section referred to as `a proposal year') a proposal
containing recommendations to reduce the Medicare per
capita growth rate to the extent required by this
section; and
[``(3) by requiring the Secretary to implement such
proposals unless Congress enacts legislation pursuant
to this section.
[``(c) Board Proposals.--
[``(1) Development.--
[``(A) In general.--The Board shall develop
detailed and specific proposals related to the
Medicare program in accordance with the
succeeding provisions of this section.
[``(B) Advisory reports.--Beginning January
15, 2014, the Board may develop and submit to
Congress advisory reports on matters related to
the Medicare program, regardless of whether or
not the Board submitted a proposal for such
year. Such a report may, for years prior to
2020, include recommendations regarding
improvements to payment systems for providers
of services and suppliers who are not otherwise
subject to the scope of the Board's
recommendations in a proposal under this
section. Any advisory report submitted under
this subparagraph shall not be subject to the
rules for congressional consideration under
subsection (d). In any year (beginning with
2014) that the Board is not required to submit
a proposal under this section, the Board shall
submit to Congress an advisory report on
matters related to the Medicare program.
[``(2) Proposals.--
[``(A) Requirements.--Each proposal submitted
under this section in a proposal year shall
meet each of the following requirements:
[``(i) If the Chief Actuary of the
Centers for Medicare & Medicaid
Services has made a determination under
paragraph (7)(A) in the determination
year, the proposal shall include
recommendations so that the proposal as
a whole (after taking into account
recommendations under clause (v)) will
result in a net reduction in total
Medicare program spending in the
implementation year that is at least
equal to the applicable savings target
established under paragraph (7)(B) for
such implementation year. In
determining whether a proposal meets
the requirement of the preceding
sentence, reductions in Medicare
program spending during the 3-month
period immediately preceding the
implementation year shall be counted to
the extent that such reductions are a
result of the implementation of
recommendations contained in the
proposal for a change in the payment
rate for an item or service that was
effective during such period pursuant
to subsection (e)(2)(A).
[``(ii) The proposal shall not
include any recommendation to ration
health care, raise revenues or Medicare
beneficiary premiums under section
1818, 1818A, or 1839, increase Medicare
beneficiary cost-sharing (including
deductibles, coinsurance, and
copayments), or otherwise restrict
benefits or modify eligibility
criteria.
[``(iii) In the case of proposals
submitted prior to December 31, 2018,
the proposal shall not include any
recommendation that would reduce
payment rates for items and services
furnished, prior to December 31, 2019,
by providers of services (as defined in
section 1861(u)) and suppliers (as
defined in section 1861(d)) scheduled,
pursuant to the amendments made by
section 3401 of the Patient Protection
and Affordable Care Act, to receive a
reduction to the inflationary payment
updates of such providers of services
and suppliers in excess of a reduction
due to productivity in a year in which
such recommendations would take effect.
[``(iv) As appropriate, the proposal
shall include recommendations to reduce
Medicare payments under parts C and D,
such as reductions in direct subsidy
payments to Medicare Advantage and
prescription drug plans specified under
paragraph (1) and (2) of section 1860D-
15(a) that are related to
administrative expenses (including
profits) for basic coverage, denying
high bids or removing high bids for
prescription drug coverage from the
calculation of the national average
monthly bid amount under section 1860D-
13(a)(4), and reductions in payments to
Medicare Advantage plans under clauses
(i) and (ii) of section 1853(a)(1)(B)
that are related to administrative
expenses (including profits) and
performance bonuses for Medicare
Advantage plans under section 1853(n).
Any such recommendation shall not
affect the base beneficiary premium
percentage specified under 1860D-13(a)
or the full premium subsidy under
section 1860D-14(a).
[``(v) The proposal shall include
recommendations with respect to
administrative funding for the
Secretary to carry out the
recommendations contained in the
proposal.
[``(vi) The proposal shall only
include recommendations related to the
Medicare program.
[``(vii) If the Chief Actuary of the
Centers for Medicare & Medicaid
Services has made a determination
described in subsection
(e)(3)(B)(i)(II) in the determination
year, the proposal shall be designed to
help reduce the growth rate described
in paragraph (8) while maintaining or
enhancing beneficiary access to quality
care under this title.
[``(B) Additional considerations.--In
developing and submitting each proposal under
this section in a proposal year, the Board
shall, to the extent feasible--
[``(i) give priority to
recommendations that extend Medicare
solvency;
[``(ii) include recommendations
that--
[``(I) improve the health
care delivery system and health
outcomes, including by
promoting integrated care, care
coordination, prevention and
wellness, and quality and
efficiency improvement; and
[``(II) protect and improve
Medicare beneficiaries' access
to necessary and evidence-based
items and services, including
in rural and frontier areas;
[``(iii) include recommendations that
target reductions in Medicare program
spending to sources of excess cost
growth;
[``(iv) consider the effects on
Medicare beneficiaries of changes in
payments to providers of services (as
defined in section 1861(u)) and
suppliers (as defined in section
1861(d));
[``(v) consider the effects of the
recommendations on providers of
services and suppliers with actual or
projected negative cost margins or
payment updates;
[``(vi) consider the unique needs of
Medicare beneficiaries who are dually
eligible for Medicare and the Medicaid
program under title XIX; and
[``(vii) take into account the data
and findings contained in the annual
reports under subsection (n) in order
to develop proposals that can most
effectively promote the delivery of
efficient, high quality care to
Medicare beneficiaries.
[``(C) No increase in total Medicare program
spending.--Each proposal submitted under this
section shall be designed in such a manner that
implementation of the recommendations contained
in the proposal would not be expected to
result, over the 10-year period starting with
the implementation year, in any increase in the
total amount of net Medicare program spending
relative to the total amount of net Medicare
program spending that would have occurred
absent such implementation.
[``(D) Consultation with MedPAC.--The Board
shall submit a draft copy of each proposal to
be submitted under this section to the Medicare
Payment Advisory Commission established under
section 1805 for its review. The Board shall
submit such draft copy by not later than
September 1 of the determination year.
[``(E) Review and comment by the Secretary.--
The Board shall submit a draft copy of each
proposal to be submitted to Congress under this
section to the Secretary for the Secretary's
review and comment. The Board shall submit such
draft copy by not later than September 1 of the
determination year. Not later than March 1 of
the submission year, the Secretary shall submit
a report to Congress on the results of such
review, unless the Secretary submits a proposal
under paragraph (5)(A) in that year.
[``(F) Consultations.--In carrying out its
duties under this section, the Board shall
engage in regular consultations with the
Medicaid and CHIP Payment and Access Commission
under section 1900.
[``(3) Submission of Board proposal to Congress and
the President.--
[``(A) In general.--
[``(i) In general.--Except as
provided in clause (ii) and subsection
(f)(3)(B), the Board shall submit a
proposal under this section to Congress
and the President on January 15 of each
year (beginning with 2014).
[``(ii) Exception.--The Board shall
not submit a proposal under clause (i)
in a proposal year if the year is--
[``(I) a year for which the
Chief Actuary of the Centers
for Medicare & Medicaid
Services makes a determination
in the determination year under
paragraph (6)(A) that the
growth rate described in clause
(i) of such paragraph does not
exceed the growth rate
described in clause (ii) of
such paragraph; or
[``(II) a year in which the
Chief Actuary of the Centers
for Medicare & Medicaid
Services makes a determination
in the determination year that
the projected percentage
increase (if any) for the
medical care expenditure
category of the Consumer Price
Index for All Urban Consumers
(United States city average)
for the implementation year is
less than the projected
percentage increase (if any) in
the Consumer Price Index for
All Urban Consumers (all items;
United States city average) for
such implementation year.
[``(iii) Start-up period.--The Board
may not submit a proposal under clause
(i) prior to January 15, 2014.
[``(B) Required information.--Each proposal
submitted by the Board under subparagraph
(A)(i) shall include--
[``(i) the recommendations described
in paragraph (2)(A)(i);
[``(ii) an explanation of each
recommendation contained in the
proposal and the reasons for including
such recommendation;
[``(iii) an actuarial opinion by the
Chief Actuary of the Centers for
Medicare & Medicaid Services certifying
that the proposal meets the
requirements of subparagraphs (A)(i)
and (C) of paragraph (2);
[``(iv) a legislative proposal that
implements the recommendations; and
[``(v) other information determined
appropriate by the Board.
[``(4) Presidential submission to Congress.--Upon
receiving a proposal from the Secretary under paragraph
(5), the President shall within 2 days submit such
proposal to Congress.
[``(5) Contingent secretarial development of
proposal.--If, with respect to a proposal year, the
Board is required, but fails, to submit a proposal to
Congress and the President by the deadline applicable
under paragraph (3)(A)(i), the Secretary shall develop
a detailed and specific proposal that satisfies the
requirements of subparagraphs (A) and (C) (and, to the
extent feasible, subparagraph (B)) of paragraph (2) and
contains the information required paragraph (3)(B)). By
not later than January 25 of the year, the Secretary
shall transmit--
[``(A) such proposal to the President; and
[``(B) a copy of such proposal to the
Medicare Payment Advisory Commission for its
review.
[``(6) Per capita growth rate projections by chief
actuary.--
[``(A) In general.--Subject to subsection
(f)(3)(A), not later than April 30, 2013, and
annually thereafter, the Chief Actuary of the
Centers for Medicare & Medicaid Services shall
determine in each such year whether--
[``(i) the projected Medicare per
capita growth rate for the
implementation year (as determined
under subparagraph (B)); exceeds
[``(ii) the projected Medicare per
capita target growth rate for the
implementation year (as determined
under subparagraph (C)).
[``(B) Medicare per capita growth rate.--
[``(i) In general.--For purposes of
this section, the Medicare per capita
growth rate for an implementation year
shall be calculated as the projected 5-
year average (ending with such year) of
the growth in Medicare program spending
(calculated as the sum of per capita
spending under each of parts A, B, and
D).
[``(ii) Requirement.--The projection
under clause (i) shall--
[``(I) to the extent that
there is projected to be a
negative update to the single
conversion factor applicable to
payments for physicians'
services under section 1848(d)
furnished in the proposal year
or the implementation year,
assume that such update for
such services is 0 percent
rather than the negative
percent that would otherwise
apply; and
[``(II) take into account any
delivery system reforms or
other payment changes that have
been enacted or published in
final rules but not yet
implemented as of the making of
such calculation.
[``(C) Medicare per capita target growth
rate.--For purposes of this section, the
Medicare per capita target growth rate for an
implementation year shall be calculated as the
projected 5-year average (ending with such
year) percentage increase in--
[``(i) with respect to a
determination year that is prior to
2018, the average of the projected
percentage increase (if any) in--
[``(I) the Consumer Price
Index for All Urban Consumers
(all items; United States city
average); and
[``(II) the medical care
expenditure category of the
Consumer Price Index for All
Urban Consumers (United States
city average); and
[``(ii) with respect to a
determination year that is after 2017,
the nominal gross domestic product per
capita plus 1.0 percentage point.
[``(7) Savings requirement.--
[``(A) In general.--If, with respect to a
determination year, the Chief Actuary of the
Centers for Medicare & Medicaid Services makes
a determination under paragraph (6)(A) that the
growth rate described in clause (i) of such
paragraph exceeds the growth rate described in
clause (ii) of such paragraph, the Chief
Actuary shall establish an applicable savings
target for the implementation year.
[``(B) Applicable savings target.--For
purposes of this section, the applicable
savings target for an implementation year shall
be an amount equal to the product of--
[``(i) the total amount of projected
Medicare program spending for the
proposal year; and
[``(ii) the applicable percent for
the implementation year.
[``(C) Applicable percent.--For purposes of
subparagraph (B), the applicable percent for an
implementation year is the lesser of--
[``(i) in the case of--
[``(I) implementation year
2015, 0.5 percent;
[``(II) implementation year
2016, 1.0 percent;
[``(III) implementation year
2017, 1.25 percent; and
[``(IV) implementation year
2018 or any subsequent
implementation year, 1.5
percent; and
[``(ii) the projected excess for the
implementation year (expressed as a
percent) determined under subparagraph
(A).
[``(8) Per capita rate of growth in national health
expenditures.--In each determination year (beginning in
2018), the Chief Actuary of the Centers for Medicare &
Medicaid Services shall project the per capita rate of
growth in national health expenditures for the
implementation year. Such rate of growth for an
implementation year shall be calculated as the
projected 5-year average (ending with such year)
percentage increase in national health care
expenditures.
[``(d) Congressional Consideration.--
[``(1) Introduction.--
[``(A) In general.--On the day on which a
proposal is submitted by the Board or the
President to the House of Representatives and
the Senate under subsection (c)(3)(A)(i) or
subsection (c)(4), the legislative proposal
(described in subsection (c)(3)(B)(iv))
contained in the proposal shall be introduced
(by request) in the Senate by the majority
leader of the Senate or by Members of the
Senate designated by the majority leader of the
Senate and shall be introduced (by request) in
the House by the majority leader of the House
or by Members of the House designated by the
majority leader of the House.
[``(B) Not in session.--If either House is
not in session on the day on which such
legislative proposal is submitted, the
legislative proposal shall be introduced in
that House, as provided in subparagraph (A), on
the first day thereafter on which that House is
in session.
[``(C) Any Member.--If the legislative
proposal is not introduced in either House
within 5 days on which that House is in session
after the day on which the legislative proposal
is submitted, then any Member of that House may
introduce the legislative proposal.
[``(D) Referral.--The legislation introduced
under this paragraph shall be referred by the
Presiding Officers of the respective Houses to
the Committee on Finance in the Senate and to
the Committee on Energy and Commerce and the
Committee on Ways and Means in the House of
Representatives.
[``(2) Committee consideration of proposal.--
[``(A) Reporting bill.--Not later than April
1 of any proposal year in which a proposal is
submitted by the Board or the President to
Congress under this section, the Committee on
Ways and Means and the Committee on Energy and
Commerce of the House of Representatives and
the Committee on Finance of the Senate may
report the bill referred to the Committee under
paragraph (1)(D) with committee amendments
related to the Medicare program.
[``(B) Calculations.--In determining whether
a committee amendment meets the requirement of
subparagraph (A), the reductions in Medicare
program spending during the 3-month period
immediately preceding the implementation year
shall be counted to the extent that such
reductions are a result of the implementation
provisions in the committee amendment for a
change in the payment rate for an item or
service that was effective during such period
pursuant to such amendment.
[``(C) Committee jurisdiction.--
Notwithstanding rule XV of the Standing Rules
of the Senate, a committee amendment described
in subparagraph (A) may include matter not
within the jurisdiction of the Committee on
Finance if that matter is relevant to a
proposal contained in the bill submitted under
subsection (c)(3).
[``(D) Discharge.--If, with respect to the
House involved, the committee has not reported
the bill by the date required by subparagraph
(A), the committee shall be discharged from
further consideration of the proposal.
[``(3) Limitation on changes to the Board
recommendations.--
[``(A) In general.--It shall not be in order
in the Senate or the House of Representatives
to consider any bill, resolution, or amendment,
pursuant to this subsection or conference
report thereon, that fails to satisfy the
requirements of subparagraphs (A)(i) and (C) of
subsection (c)(2).
[``(B) Limitation on changes to the Board
recommendations in other legislation.--It shall
not be in order in the Senate or the House of
Representatives to consider any bill,
resolution, amendment, or conference report
(other than pursuant to this section) that
would repeal or otherwise change the
recommendations of the Board if that change
would fail to satisfy the requirements of
subparagraphs (A)(i) and (C) of subsection
(c)(2).
[``(C) Limitation on changes to this
subsection.--It shall not be in order in the
Senate or the House of Representatives to
consider any bill, resolution, amendment, or
conference report that would repeal or
otherwise change this subsection.
[``(D) Waiver.--This paragraph may be waived
or suspended in the Senate only by the
affirmative vote of three-fifths of the
Members, duly chosen and sworn.
[``(E) Appeals.--An affirmative vote of
three-fifths of the Members of the Senate, duly
chosen and sworn, shall be required in the
Senate to sustain an appeal of the ruling of
the Chair on a point of order raised under this
paragraph.
[``(4) Expedited procedure.--
[``(A) Consideration.--A motion to proceed to
the consideration of the bill in the Senate is
not debatable.
[``(B) Amendment.--
[``(i) Time limitation.--Debate in
the Senate on any amendment to a bill
under this section shall be limited to
1 hour, to be equally divided between,
and controlled by, the mover and the
manager of the bill, and debate on any
amendment to an amendment, debatable
motion, or appeal shall be limited to
30 minutes, to be equally divided
between, and controlled by, the mover
and the manager of the bill, except
that in the event the manager of the
bill is in favor of any such amendment,
motion, or appeal, the time in
opposition thereto shall be controlled
by the minority leader or such leader's
designee.
[``(ii) Germane.--No amendment that
is not germane to the provisions of
such bill shall be received.
[``(iii) Additional time.--The
leaders, or either of them, may, from
the time under their control on the
passage of the bill, allot additional
time to any Senator during the
consideration of any amendment,
debatable motion, or appeal.
[``(iv) Amendment not in order.--It
shall not be in order to consider an
amendment that would cause the bill to
result in a net reduction in total
Medicare program spending in the
implementation year that is less than
the applicable savings target
established under subsection (c)(7)(B)
for such implementation year.
[``(v) Waiver and appeals.--This
paragraph may be waived or suspended in
the Senate only by the affirmative vote
of three-fifths of the Members, duly
chosen and sworn. An affirmative vote
of three-fifths of the Members of the
Senate, duly chosen and sworn, shall be
required in the Senate to sustain an
appeal of the ruling of the Chair on a
point of order raised under this
section.
[``(C) Consideration by the other House.--
[``(i) In general.--The expedited
procedures provided in this subsection
for the consideration of a bill
introduced pursuant to paragraph (1)
shall not apply to such a bill that is
received by one House from the other
House if such a bill was not introduced
in the receiving House.
[``(ii) Before passage.--If a bill
that is introduced pursuant to
paragraph (1) is received by one House
from the other House, after
introduction but before disposition of
such a bill in the receiving House,
then the following shall apply:
[``(I) The receiving House
shall consider the bill
introduced in that House
through all stages of
consideration up to, but not
including, passage.
[``(II) The question on
passage shall be put on the
bill of the other House as
amended by the language of the
receiving House.
[``(iii) After passage.--If a bill
introduced pursuant to paragraph (1) is
received by one House from the other
House, after such a bill is passed by
the receiving House, then the vote on
passage of the bill that originates in
the receiving House shall be considered
to be the vote on passage of the bill
received from the other House as
amended by the language of the
receiving House.
[``(iv) Disposition.--Upon
disposition of a bill introduced
pursuant to paragraph (1) that is
received by one House from the other
House, it shall no longer be in order
to consider the bill that originates in
the receiving House.
[``(v) Limitation.--Clauses (ii),
(iii), and (iv) shall apply only to a
bill received by one House from the
other House if the bill--
[``(I) is related only to the
program under this title; and
[``(II) satisfies the
requirements of subparagraphs
(A)(i) and (C) of subsection
(c)(2).
[``(D) Senate limits on debate.--
[``(i) In general.--In the Senate,
consideration of the bill and on all
debatable motions and appeals in
connection therewith shall not exceed a
total of 30 hours, which shall be
divided equally between the majority
and minority leaders or their
designees.
[``(ii) Motion to further limit
debate.--A motion to further limit
debate on the bill is in order and is
not debatable.
[``(iii) Motion or appeal.--Any
debatable motion or appeal is debatable
for not to exceed 1 hour, to be divided
equally between those favoring and
those opposing the motion or appeal.
[``(iv) Final disposition.--After 30
hours of consideration, the Senate
shall proceed, without any further
debate on any question, to vote on the
final disposition thereof to the
exclusion of all amendments not then
pending before the Senate at that time
and to the exclusion of all motions,
except a motion to table, or to
reconsider and one quorum call on
demand to establish the presence of a
quorum (and motions required to
establish a quorum) immediately before
the final vote begins.
[``(E) Consideration in conference.--
[``(i) In general.--Consideration in
the Senate and the House of
Representatives on the conference
report or any messages between Houses
shall be limited to 10 hours, equally
divided and controlled by the majority
and minority leaders of the Senate or
their designees and the Speaker of the
House of Representatives and the
minority leader of the House of
Representatives or their designees.
[``(ii) Time limitation.--Debate in
the Senate on any amendment under this
subparagraph shall be limited to 1
hour, to be equally divided between,
and controlled by, the mover and the
manager of the bill, and debate on any
amendment to an amendment, debatable
motion, or appeal shall be limited to
30 minutes, to be equally divided
between, and controlled by, the mover
and the manager of the bill, except
that in the event the manager of the
bill is in favor of any such amendment,
motion, or appeal, the time in
opposition thereto shall be controlled
by the minority leader or such leader's
designee.
[``(iii) Final disposition.--After 10
hours of consideration, the Senate
shall proceed, without any further
debate on any question, to vote on the
final disposition thereof to the
exclusion of all motions not then
pending before the Senate at that time
or necessary to resolve the differences
between the Houses and to the exclusion
of all other motions, except a motion
to table, or to reconsider and one
quorum call on demand to establish the
presence of a quorum (and motions
required to establish a quorum)
immediately before the final vote
begins.
[``(iv) Limitation.--Clauses (i)
through (iii) shall only apply to a
conference report, message or the
amendments thereto if the conference
report, message, or an amendment
thereto--
[``(I) is related only to the
program under this title; and
[``(II) satisfies the
requirements of subparagraphs
(A)(i) and (C) of subsection
(c)(2).
[``(F) Veto.--If the President vetoes the
bill debate on a veto message in the Senate
under this subsection shall be 1 hour equally
divided between the majority and minority
leaders or their designees.
[``(5) Rules of the Senate and House of
Representatives.--This subsection and subsection (f)(2)
are enacted by Congress--
[``(A) as an exercise of the rulemaking power
of the Senate and the House of Representatives,
respectively, and is deemed to be part of the
rules of each House, respectively, but
applicable only with respect to the procedure
to be followed in that House in the case of
bill under this section, and it supersedes
other rules only to the extent that it is
inconsistent with such rules; and
[``(B) with full recognition of the
constitutional right of either House to change
the rules (so far as they relate to the
procedure of that House) at any time, in the
same manner, and to the same extent as in the
case of any other rule of that House.
[``(e) Implementation of Proposal.--
[``(1) In general.--Notwithstanding any other
provision of law, the Secretary shall, except as
provided in paragraph (3), implement the
recommendations contained in a proposal submitted by
the Board or the President to Congress pursuant to this
section on August 15 of the year in which the proposal
is so submitted.
[``(2) Application.--
[``(A) In general.--A recommendation
described in paragraph (1) shall apply as
follows:
[``(i) In the case of a
recommendation that is a change in the
payment rate for an item or service
under Medicare in which payment rates
change on a fiscal year basis (or a
cost reporting period basis that
relates to a fiscal year), on a
calendar year basis (or a cost
reporting period basis that relates to
a calendar year), or on a rate year
basis (or a cost reporting period basis
that relates to a rate year), such
recommendation shall apply to items and
services furnished on the first day of
the first fiscal year, calendar year,
or rate year (as the case may be) that
begins after such August 15.
[``(ii) In the case of a
recommendation relating to payments to
plans under parts C and D, such
recommendation shall apply to plan
years beginning on the first day of the
first calendar year that begins after
such August 15.
[``(iii) In the case of any other
recommendation, such recommendation
shall be addressed in the regular
regulatory process timeframe and shall
apply as soon as practicable.
[``(B) Interim final rulemaking.--The
Secretary may use interim final rulemaking to
implement any recommendation described in
paragraph (1).
[``(3) Exceptions.--
[``(A) In general.--The Secretary shall not
implement the recommendations contained in a
proposal submitted in a proposal year by the
Board or the President to Congress pursuant to
this section if--
[``(i) prior to August 15 of the
proposal year, Federal legislation is
enacted that includes the following
provision: `This Act supercedes the
recommendations of the Board contained
in the proposal submitted, in the year
which includes the date of enactment of
this Act, to Congress under section
1899A of the Social Security Act.'; and
[``(ii) in the case of implementation
year 2020 and subsequent implementation
years, a joint resolution described in
subsection (f)(1) is enacted not later
than August 15, 2017.
[``(B) Limited additional exception.--
[``(i) In general.--Subject to clause
(ii), the Secretary shall not implement
the recommendations contained in a
proposal submitted by the Board or the
President to Congress pursuant to this
section in a proposal year (beginning
with proposal year 2019) if--
[``(I) the Board was required
to submit a proposal to
Congress under this section in
the year preceding the proposal
year; and
[``(II) the Chief Actuary of
the Centers for Medicare &
Medicaid Services makes a
determination in the
determination year that the
growth rate described in
subsection (c)(8) exceeds the
growth rate described in
subsection (c)(6)(A)(i).
[``(ii) Limited additional exception
may not be applied in two consecutive
years.--This subparagraph shall not
apply if the recommendations contained
in a proposal submitted by the Board or
the President to Congress pursuant to
this section in the year preceding the
proposal year were not required to be
implemented by reason of this
subparagraph.
[``(iii) No affect on requirement to
submit proposals or for congressional
consideration of proposals.--Clause (i)
and (ii) shall not affect--
[``(I) the requirement of the
Board or the President to
submit a proposal to Congress
in a proposal year in
accordance with the provisions
of this section; or
[``(II) Congressional
consideration of a legislative
proposal (described in
subsection (c)(3)(B)(iv))
contained such a proposal in
accordance with subsection (d).
[``(4) No affect on authority to implement certain
provisions.--Nothing in paragraph (3) shall be
construed to affect the authority of the Secretary to
implement any recommendation contained in a proposal or
advisory report under this section to the extent that
the Secretary otherwise has the authority to implement
such recommendation administratively.
[``(5) Limitation on review.--There shall be no
administrative or judicial review under section 1869,
section 1878, or otherwise of the implementation by the
Secretary under this subsection of the recommendations
contained in a proposal.
[``(f) Joint resolution Required To Discontinue the Board.--
[``(1) In general.--For purposes of subsection
(e)(3)(B), a joint resolution described in this
paragraph means only a joint resolution--
[``(A) that is introduced in 2017 by not
later than February 1 of such year;
[``(B) which does not have a preamble;
[``(C) the title of which is as follows:
`Joint resolution approving the discontinuation
of the process for consideration and automatic
implementation of the annual proposal of the
Independent Medicare Advisory Board under
section 1899A of the Social Security Act'; and
[``(D) the matter after the resolving clause
of which is as follows: `That Congress approves
the discontinuation of the process for
consideration and automatic implementation of
the annual proposal of the Independent Medicare
Advisory Board under section 1899A of the
Social Security Act.'.
[``(2) Procedure.--
[``(A) Referral.--A joint resolution
described in paragraph (1) shall be referred to
the Committee on Ways and Means and the
Committee on Energy and Commerce of the House
of Representatives and the Committee on Finance
of the Senate.
[``(B) Discharge.--In the Senate, if the
committee to which is referred a joint
resolution described in paragraph (1) has not
reported such joint resolution (or an identical
joint resolution) at the end of 20 days after
the joint resolution described in paragraph (1)
is introduced, such committee may be discharged
from further consideration of such joint
resolution upon a petition supported in writing
by 30 Members of the Senate, and such joint
resolution shall be placed on the calendar.
[``(C) Consideration.--
[``(i) In general.--In the Senate,
when the committee to which a joint
resolution is referred has reported, or
when a committee is discharged (under
subparagraph (C)) from further
consideration of a joint resolution
described in paragraph (1), it is at
any time thereafter in order (even
though a previous motion to the same
effect has been disagreed to) for a
motion to proceed to the consideration
of the joint resolution to be made, and
all points of order against the joint
resolution (and against consideration
of the joint resolution) are waived,
except for points of order under the
Congressional Budget act of 1974 or
under budget resolutions pursuant to
that Act. The motion is not debatable.
A motion to reconsider the vote by
which the motion is agreed to or
disagreed to shall not be in order. If
a motion to proceed to the
consideration of the joint resolution
is agreed to, the joint resolution
shall remain the unfinished business of
the Senate until disposed of.
[``(ii) Debate limitation.--In the
Senate, consideration of the joint
resolution, and on all debatable
motions and appeals in connection
therewith, shall be limited to not more
than 10 hours, which shall be divided
equally between the majority leader and
the minority leader, or their
designees. A motion further to limit
debate is in order and not debatable.
An amendment to, or a motion to
postpone, or a motion to proceed to the
consideration of other business, or a
motion to recommit the joint resolution
is not in order.
[``(iii) Passage.--In the Senate,
immediately following the conclusion of
the debate on a joint resolution
described in paragraph (1), and a
single quorum call at the conclusion of
the debate if requested in accordance
with the rules of the Senate, the vote
on passage of the joint resolution
shall occur.
[``(iv) Appeals.--Appeals from the
decisions of the Chair relating to the
application of the rules of the Senate
to the procedure relating to a joint
resolution described in paragraph (1)
shall be decided without debate.
[``(D) Other House acts first.--If, before
the passage by 1 House of a joint resolution of
that House described in paragraph (1), that
House receives from the other House a joint
resolution described in paragraph (1), then the
following procedures shall apply:
[``(i) The joint resolution of the
other House shall not be referred to a
committee.
[``(ii) With respect to a joint
resolution described in paragraph (1)
of the House receiving the joint
resolution--
[``(I) the procedure in that
House shall be the same as if
no joint resolution had been
received from the other House;
but
[``(II) the vote on final
passage shall be on the joint
resolution of the other House.
[``(E) Excluded days.--For purposes of
determining the period specified in
subparagraph (B), there shall be excluded any
days either House of Congress is adjourned for
more than 3 days during a session of Congress.
[``(F) Majority required for adoption.--A
joint resolution considered under this
subsection shall require an affirmative vote of
three-fifths of the Members, duly chosen and
sworn, for adoption.
[``(3) Termination.--If a joint resolution described
in paragraph (1) is enacted not later than August 15,
2017--
[``(A) the Chief Actuary of the Medicare &
Medicaid Services shall not--
[``(i) make any determinations under
subsection (c)(6) after May 1, 2017; or
[``(ii) provide any opinion pursuant
to subsection (c)(3)(B)(iii) after
January 16, 2018;
[``(B) the Board shall not submit any
proposals, advisory reports, or advisory
recommendations under this section or produce
the public report under subsection (n) after
January 16, 2018; and
[``(C) the Board and the consumer advisory
council under subsection (k) shall terminate on
August 16, 2018.
[``(g) Board Membership; Terms of Office; Chairperson;
Removal.--
[``(1) Membership.--
[``(A) In general.--The Board shall be
composed of--
[``(i) 15 members appointed by the
President, by and with the advice and
consent of the Senate; and
[``(ii) the Secretary, the
Administrator of the Center for
Medicare & Medicaid Services, and the
Administrator of the Health Resources
and Services Administration, all of
whom shall serve ex officio as
nonvoting members of the Board.
[``(B) Qualifications.--
[``(i) In general.--The appointed
membership of the Board shall include
individuals with national recognition
for their expertise in health finance
and economics, actuarial science,
health facility management, health
plans and integrated delivery systems,
reimbursement of health facilities,
allopathic and osteopathic physicians,
and other providers of health services,
and other related fields, who provide a
mix of different professionals, broad
geographic representation, and a
balance between urban and rural
representatives.
[``(ii) Inclusion.--The appointed
membership of the Board shall include
(but not be limited to) physicians and
other health professionals, experts in
the area of pharmaco-economics or
prescription drug benefit programs,
employers, third-party payers,
individuals skilled in the conduct and
interpretation of biomedical, health
services, and health economics research
and expertise in outcomes and
effectiveness research and technology
assessment. Such membership shall also
include representatives of consumers
and the elderly.
[``(iii) Majority nonproviders.--
Individuals who are directly involved
in the provision or management of the
delivery of items and services covered
under this title shall not constitute a
majority of the appointed membership of
the Board.
[``(C) Ethical disclosure.--The President
shall establish a system for public disclosure
by appointed members of the Board of financial
and other potential conflicts of interest
relating to such members. Appointed members of
the Board shall be treated as officers in the
executive branch for purposes of applying title
I of the Ethics in Government Act of 1978
(Public Law 95-521).
[``(D) Conflicts of interest.--No individual
may serve as an appointed member if that
individual engages in any other business,
vocation, or employment.
[``(E) Consultation with congress.--In
selecting individuals for nominations for
appointments to the Board, the President shall
consult with--
[``(i) the majority leader of the
Senate concerning the appointment of 3
members;
[``(ii) the Speaker of the House of
Representatives concerning the
appointment of 3 members;
[``(iii) the minority leader of the
Senate concerning the appointment of 3
members; and
[``(iv) the minority leader of the
House of Representatives concerning the
appointment of 3 members.
[``(2) Term of office.--Each appointed member shall
hold office for a term of 6 years except that--
[``(A) a member may not serve more than 2
full consecutive terms (but may be reappointed
to 2 full consecutive terms after being
appointed to fill a vacancy on the Board);
[``(B) a member appointed to fill a vacancy
occurring prior to the expiration of the term
for which that member's predecessor was
appointed shall be appointed for the remainder
of such term;
[``(C) a member may continue to serve after
the expiration of the member's term until a
successor has taken office; and
[``(D) of the members first appointed under
this section, 5 shall be appointed for a term
of 1 year, 5 shall be appointed for a term of 3
years, and 5 shall be appointed for a term of 6
years, the term of each to be designated by the
President at the time of nomination.
[``(3) Chairperson.--
[``(A) In general.--The Chairperson shall be
appointed by the President, by and with the
advice and consent of the Senate, from among
the members of the Board.
[``(B) Duties.--The Chairperson shall be the
principal executive officer of the Board, and
shall exercise all of the executive and
administrative functions of the Board,
including functions of the Board with respect
to--
[``(i) the appointment and
supervision of personnel employed by
the Board;
[``(ii) the distribution of business
among personnel appointed and
supervised by the Chairperson and among
administrative units of the Board; and
[``(iii) the use and expenditure of
funds.
[``(C) Governance.--In carrying out any of
the functions under subparagraph (B), the
Chairperson shall be governed by the general
policies established by the Board and by the
decisions, findings, and determinations the
Board shall by law be authorized to make.
[``(D) Requests for appropriations.--Requests
or estimates for regular, supplemental, or
deficiency appropriations on behalf of the
Board may not be submitted by the Chairperson
without the prior approval of a majority vote
of the Board.
[``(4) Removal.--Any appointed member may be removed
by the President for neglect of duty or malfeasance in
office, but for no other cause.
[``(h) Vacancies; Quorum; Seal; Vice Chairperson; Voting on
Reports.--
[``(1) Vacancies.--No vacancy on the Board shall
impair the right of the remaining members to exercise
all the powers of the Board.
[``(2) Quorum.--A majority of the appointed members
of the Board shall constitute a quorum for the
transaction of business, but a lesser number of members
may hold hearings.
[``(3) Seal.--The Board shall have an official seal,
of which judicial notice shall be taken.
[``(4) Vice Chairperson.--The Board shall annually
elect a Vice Chairperson to act in the absence or
disability of the Chairperson or in case of a vacancy
in the office of the Chairperson.
[``(5) Voting on proposals.--Any proposal of the
Board must be approved by the majority of appointed
members present.
[``(i) Powers of the Board.--
[``(1) Hearings.--The Board may hold such hearings,
sit and act at such times and places, take such
testimony, and receive such evidence as the Board
considers advisable to carry out this section.
[``(2) Authority to inform research priorities for
data collection.--The Board may advise the Secretary on
priorities for health services research, particularly
as such priorities pertain to necessary changes and
issues regarding payment reforms under Medicare.
[``(3) Obtaining official data.--The Board may secure
directly from any department or agency of the United
States information necessary to enable it to carry out
this section. Upon request of the Chairperson, the head
of that department or agency shall furnish that
information to the Board on an agreed upon schedule.
[``(4) Postal services.--The Board may use the United
States mails in the same manner and under the same
conditions as other departments and agencies of the
Federal Government.
[``(5) Gifts.--The Board may accept, use, and dispose
of gifts or donations of services or property.
[``(6) Offices.--The Board shall maintain a principal
office and such field offices as it determines
necessary, and may meet and exercise any of its powers
at any other place.
[``(j) Personnel Matters.--
[``(1) Compensation of members and chairperson.--Each
appointed member, other than the Chairperson, shall be
compensated at a rate equal to the annual rate of basic
pay prescribed for level III of the Executive Schedule
under section 5315 of title 5, United States Code. The
Chairperson shall be compensated at a rate equal to the
daily equivalent of the annual rate of basic pay
prescribed for level II of the Executive Schedule under
section 5315 of title 5, United States Code.
[``(2) Travel expenses.--The appointed members shall
be allowed travel expenses, including per diem in lieu
of subsistence, at rates authorized for employees of
agencies under subchapter I of chapter 57 of title 5,
United States Code, while away from their homes or
regular places of business in the performance of
services for the Board.
[``(3) Staff.--
[``(A) In general.--The Chairperson may,
without regard to the civil service laws and
regulations, appoint and terminate an executive
director and such other additional personnel as
may be necessary to enable the Board to perform
its duties. The employment of an executive
director shall be subject to confirmation by
the Board.
[``(B) Compensation.--The Chairperson may fix
the compensation of the executive director and
other personnel without regard to chapter 51
and subchapter III of chapter 53 of title 5,
United States Code, relating to classification
of positions and General Schedule pay rates,
except that the rate of pay for the executive
director and other personnel may not exceed the
rate payable for level V of the Executive
Schedule under section 5316 of such title.
[``(4) Detail of government employees.--Any Federal
Government employee may be detailed to the Board
without reimbursement, and such detail shall be without
interruption or loss of civil service status or
privilege.
[``(5) Procurement of temporary and intermittent
services.--The Chairperson may procure temporary and
intermittent services under section 3109(b) of title 5,
United States Code, at rates for individuals which do
not exceed the daily equivalent of the annual rate of
basic pay prescribed for level V of the Executive
Schedule under section 5316 of such title.
[``(k) Consumer Advisory Council.--
[``(1) In general.--There is established a consumer
advisory council to advise the Board on the impact of
payment policies under this title on consumers.
[``(2) Membership.--
[``(A) Number and appointment.--The consumer
advisory council shall be composed of 10
consumer representatives appointed by the
Comptroller General of the United States, 1
from among each of the 10 regions established
by the Secretary as of the date of enactment of
this section.
[``(B) Qualifications.--The membership of the
council shall represent the interests of
consumers and particular communities.
[``(3) Duties.--The consumer advisory council shall,
subject to the call of the Board, meet not less
frequently than 2 times each year in the District of
Columbia.
[``(4) Open meetings.--Meetings of the consumer
advisory council shall be open to the public.
[``(5) Election of officers.--Members of the consumer
advisory council shall elect their own officers.
[``(6) Application of FACA.--The Federal Advisory
Committee Act (5 U.S.C. App.) shall apply to the
consumer advisory council except that section 14 of
such Act shall not apply.
[``(l) Definitions.--In this section:
[``(1) Board; Chairperson; Member.--The terms
`Board', `Chairperson', and `Member' mean the
Independent Medicare Advisory Board established under
subsection (a) and the Chairperson and any Member
thereof, respectively.
[``(2) Medicare.--The term `Medicare' means the
program established under this title, including parts
A, B, C, and D.
[``(3) Medicare beneficiary.--The term `Medicare
beneficiary' means an individual who is entitled to, or
enrolled for, benefits under part A or enrolled for
benefits under part B.
[``(4) Medicare program spending.--The term `Medicare
program spending' means program spending under parts A,
B, and D net of premiums.
[``(m) Funding.--
[``(1) In general.--There are appropriated to the
Board to carry out its duties and functions--
[``(A) for fiscal year 2012, $15,000,000; and
[``(B) for each subsequent fiscal year, the
amount appropriated under this paragraph for
the previous fiscal year increased by the
annual percentage increase in the Consumer
Price Index for All Urban Consumers (all items;
United States city average) as of June of the
previous fiscal year.
[``(2) From trust funds.--Sixty percent of amounts
appropriated under paragraph (1) shall be derived by
transfer from the Federal Hospital Insurance Trust Fund
under section 1817 and 40 percent of amounts
appropriated under such paragraph shall be derived by
transfer from the Federal Supplementary Medical
Insurance Trust Fund under section 1841.
[``(n) Annual Public Report.--
[``(1) In general.--Not later than July 1, 2014, and
annually thereafter, the Board shall produce a public
report containing standardized information on system-
wide health care costs, patient access to care,
utilization, and quality-of-care that allows for
comparison by region, types of services, types of
providers, and both private payers and the program
under this title.
[``(2) Requirements.--Each report produced pursuant
to paragraph (1) shall include information with respect
to the following areas:
[``(A) The quality and costs of care for the
population at the most local level determined
practical by the Board (with quality and costs
compared to national benchmarks and reflecting
rates of change, taking into account quality
measures described in section 1890(b)(7)(B)).
[``(B) Beneficiary and consumer access to
care, patient and caregiver experience of care,
and the cost-sharing or out-of-pocket burden on
patients.
[``(C) Epidemiological shifts and demographic
changes.
[``(D) The proliferation, effectiveness, and
utilization of health care technologies,
including variation in provider practice
patterns and costs.
[``(E) Any other areas that the Board
determines affect overall spending and quality
of care in the private sector.
[``(o) Advisory Recommendations for Non-Federal Health Care
Programs.--
[``(1) In general.--Not later than January 15, 2015,
and at least once every two years thereafter, the Board
shall submit to Congress and the President
recommendations to slow the growth in national health
expenditures (excluding expenditures under this title
and in other Federal health care programs) while
preserving or enhancing quality of care, such as
recommendations--
[``(A) that the Secretary or other Federal
agencies can implement administratively;
[``(B) that may require legislation to be
enacted by Congress in order to be implemented;
[``(C) that may require legislation to be
enacted by State or local governments in order
to be implemented;
[``(D) that private sector entities can
voluntarily implement; and
[``(E) with respect to other areas determined
appropriate by the Board.
[``(2) Coordination.--In making recommendations under
paragraph (1), the Board shall coordinate such
recommendations with recommendations contained in
proposals and advisory reports produced by the Board
under subsection (c).
[``(3) Available to public.--The Board shall make
recommendations submitted to Congress and the President
under this subsection available to the public.''.
[(2) Lobbying cooling-off period for members of the
Independent Medicare Advisory Board.--Section 207(c) of
title 18, United States Code, is amended by inserting
at the end the following:
[``(3) Members of the Independent Medicare Advisory
Board.--
[``(A) In general.--Paragraph (1) shall apply
to a member of the Independent Medicare
Advisory Board under section 1899A.
[``(B) Agencies and Congress.--For purposes
of paragraph (1), the agency in which the
individual described in subparagraph (A) served
shall be considered to be the Independent
Medicare Advisory Board, the Department of
Health and Human Services, and the relevant
committees of jurisdiction of Congress,
including the Committee on Ways and Means and
the Committee on Energy and Commerce of the
House of Representatives and the Committee on
Finance of the Senate.''.
[(b) GAO Study and Report on Determination and Implementation
of Payment and Coverage Policies Under the Medicare Program.--
[(1) Initial study and report.--
[(A) Study.--The Comptroller General of the
United States (in this section referred to as
the ``Comptroller General'') shall conduct a
study on changes to payment policies,
methodologies, and rates and coverage policies
and methodologies under the Medicare program
under title XVIII of the Social Security Act as
a result of the recommendations contained in
the proposals made by the Independent Medicare
Advisory Board under section 1899A of such Act
(as added by subsection (a)), including an
analysis of the effect of such recommendations
on--
[(i) Medicare beneficiary access to
providers and items and services;
[(ii) the affordability of Medicare
premiums and cost-sharing (including
deductibles, coinsurance, and
copayments);
[(iii) the potential impact of
changes on other government or private-
sector purchasers and payers of care;
and
[(iv) quality of patient care,
including patient experience, outcomes,
and other measures of care.
[(B) Report.--Not later than July 1, 2015,
the Comptroller General shall submit to
Congress a report containing the results of the
study conducted under subparagraph (A),
together with recommendations for such
legislation and administrative action as the
Comptroller General determines appropriate.
[(2) Subsequent studies and reports.--The Comptroller
General shall periodically conduct such additional
studies and submit reports to Congress on changes to
Medicare payments policies, methodologies, and rates
and coverage policies and methodologies as the
Comptroller General determines appropriate, in
consultation with the Committee on Ways and Means and
the Committee on Energy and Commerce of the House of
Representatives and the Committee on Finance of the
Senate.
[(c) Conforming Amendments.--Section 1805(b) of the Social
Security Act (42 U.S.C. 1395b-6(b)) is amended--
[(1) by redesignating paragraphs (4) through (8) as
paragraphs (5) through (9), respectively; and
[(2) by inserting after paragraph (3) the following:
[``(4) Review and comment on the Independent Medicare
Advisory Board or secretarial proposal.--If the
Independent Medicare Advisory Board (as established
under subsection (a) of section 1899A) or the Secretary
submits a proposal to the Commission under such section
in a year, the Commission shall review the proposal
and, not later than March 1 of that year, submit to the
Committee on Ways and Means and the Committee on Energy
and Commerce of the House of Representatives and the
Committee on Finance of the Senate written comments on
such proposal. Such comments may include such
recommendations as the Commission deems
appropriate.''.]
* * * * * * *
TITLE X--STRENGTHENING QUALITY, AFFORDABLE HEALTH CARE FOR ALL
AMERICANS
* * * * * * *
Subtitle C--Provisions Relating to Title III
* * * * * * *
[SEC. 10320. EXPANSION OF THE SCOPE OF, AND ADDITIONAL IMPROVEMENTS TO,
THE INDEPENDENT MEDICARE ADVISORY BOARD.
[(a) In general.--Section 1899A of the Social Security Act,
as added by section 3403, is amended--
[(1) in subsection (c)--
[(A) in paragraph (1)(B), by adding at the
end the following new sentence: ``In any year
(beginning with 2014) that the Board is not
required to submit a proposal under this
section, the Board shall submit to Congress an
advisory report on matters related to the
Medicare program.'';
[(B) in paragraph (2)(A)--
[(i) in clause (iv), by inserting
``or the full premium subsidy under
section 1860D-14(a)'' before the period
at the end of the last sentence; and
[(ii) by adding at the end the
following new clause:
[``(vii) If the Chief Actuary of the
Centers for Medicare & Medicaid
Services has made a determination
described in subsection
(e)(3)(B)(i)(II) in the determination
year, the proposal shall be designed to
help reduce the growth rate described
in paragraph (8) while maintaining or
enhancing beneficiary access to quality
care under this title.'';
[(C) in paragraph (2)(B)--
[(i) in clause (v), by striking
``and'' at the end;
[(ii) in clause (vi), by striking the
period at the end and inserting ``;
and''; and
[(iii) by adding at the end the
following new clause:
[``(vii) take into account the data
and findings contained in the annual
reports under subsection (n) in order
to develop proposals that can most
effectively promote the delivery of
efficient, high quality care to
Medicare beneficiaries.'';
[(D) in paragraph (3)--
[(i) in the heading, by striking
``Transmission of board proposal to
president'' and inserting ``Submission
of board proposal to congress and the
president'';
[(ii) in subparagraph (A)(i), by
striking ``transmit a proposal under
this section to the President'' and
insert ``submit a proposal under this
section to Congress and the
President''; and
[(iii) in subparagraph (A)(ii)--
[(I) in subclause (I), by
inserting ``or'' at the end;
[(II) in subclause (II), by
striking ``; or'' and inserting
a period; and
[(III) by striking subclause
(III);
[(E) in paragraph (4)--
[(i) by striking ``the Board under
paragraph (3)(A)(i) or''; and
[(ii) by striking ``immediately'' and
inserting ``within 2 days'';
[(F) in paragraph (5)--
[(i) by striking ``to but'' and
inserting ``but''; and
[(ii) by inserting ``Congress and''
after ``submit a proposal to''; and
[(G) in paragraph (6)(B)(i), by striking
``per unduplicated enrollee'' and inserting
``(calculated as the sum of per capita spending
under each of parts A, B, and D)'';
[(2) in subsection (d)--
[(A) in paragraph (1)(A)--
[(i) by inserting ``the Board or''
after ``a proposal is submitted by'';
and
[(ii) by inserting ``subsection
(c)(3)(A)(i) or'' after ``the Senate
under''; and
[(B) in paragraph (2)(A), by inserting ``the
Board or'' after ``a proposal is submitted
by'';
[(3) in subsection (e)--
[(A) in paragraph (1), by inserting ``the
Board or'' after ``a proposal submitted by'';
and
[(B) in paragraph (3)--
[(i) By striking ``Exception.--The
Secretary shall not be required to
implement the recommendations contained
in a proposal submitted in a proposal
year by'' and inserting
[``(A) In general.--The Secretary shall not
implement the recommendations contained in a
proposal submitted in a proposal year by the
Board or'';
[(ii) by redesignating subparagraphs
(A) and (B) as clauses (i) and (ii),
respectively, and indenting
appropriately; and
[(iii) by adding at the end the
following new subparagraph:
[``(B) Limited additional exception.--
[``(i) In general.--Subject to clause
(ii), the Secretary shall not implement
the recommendations contained in a
proposal submitted by the Board or the
President to Congress pursuant to this
section in a proposal year (beginning
with proposal year 2019) if--
[``(I) the Board was required
to submit a proposal to
Congress under this section in
the year preceding the proposal
year; and
[``(II) the Chief Actuary of
the Centers for Medicare &
Medicaid Services makes a
determination in the
determination year that the
growth rate described in
subsection (c)(8) exceeds the
growth rate described in
subsection (c)(6)(A)(i).
[``(ii) Limited additional exception
may not be applied in two consecutive
years.--This subparagraph shall not
apply if the recommendations contained
in a proposal submitted by the Board or
the President to Congress pursuant to
this section in the year preceding the
proposal year were not required to be
implemented by reason of this
subparagraph.
[``(iii) No affect on requirement to
submit proposals or for congressional
consideration of proposals.--Clause (i)
and (ii) shall not affect--
[``(I) the requirement of the
Board or the President to
submit a proposal to Congress
in a proposal year in
accordance with the provisions
of this section; or
[``(II) Congressional
consideration of a legislative
proposal (described in
subsection (c)(3)(B)(iv))
contained such a proposal in
accordance with subsection
(d).'';
[(4) in subsection (f)(3)(B)--
[(A) by striking ``or advisory reports to
Congress'' and inserting ``, advisory reports,
or advisory recommendations''; and
[(B) by inserting ``or produce the public
report under subsection (n)'' after ``this
section''; and
[(5) by adding at the end the following new
subsections:
[``(n) Annual Public Report.--
[``(1) In general.--Not later than July 1, 2014, and
annually thereafter, the Board shall produce a public
report containing standardized information on system-
wide health care costs, patient access to care,
utilization, and quality-of-care that allows for
comparison by region, types of services, types of
providers, and both private payers and the program
under this title.
[``(2) Requirements.--Each report produced pursuant
to paragraph (1) shall include information with respect
to the following areas:
[``(A) The quality and costs of care for the
population at the most local level determined
practical by the Board (with quality and costs
compared to national benchmarks and reflecting
rates of change, taking into account quality
measures described in section 1890(b)(7)(B)).
[``(B) Beneficiary and consumer access to
care, patient and caregiver experience of care,
and the cost-sharing or out-of-pocket burden on
patients.
[``(C) Epidemiological shifts and demographic
changes.
[``(D) The proliferation, effectiveness, and
utilization of health care technologies,
including variation in provider practice
patterns and costs.
[``(E) Any other areas that the Board
determines affect overall spending and quality
of care in the private sector.
[``(o) Advisory Recommendations for Non-Federal Health Care
Programs.--
[``(1) In general.--Not later than January 15, 2015,
and at least once every two years thereafter, the Board
shall submit to Congress and the President
recommendations to slow the growth in national health
expenditures (excluding expenditures under this title
and in other Federal health care programs) while
preserving or enhancing quality of care, such as
recommendations--
[``(A) that the Secretary or other Federal
agencies can implement administratively;
[``(B) that may require legislation to be
enacted by Congress in order to be implemented;
[``(C) that may require legislation to be
enacted by State or local governments in order
to be implemented;
[``(D) that private sector entities can
voluntarily implement; and
[``(E) with respect to other areas determined
appropriate by the Board.
[``(2) Coordination.--In making recommendations under
paragraph (1), the Board shall coordinate such
recommendations with recommendations contained in
proposals and advisory reports produced by the Board
under subsection (c).
[``(3) Available to public.--The Board shall make
recommendations submitted to Congress and the President
under this subsection available to the public.''.
[(b) Name Change.--Any reference in the provisions of, or
amendments made by, section 3403 to the ``Independent Medicare
Advisory Board'' shall be deemed to be a reference to the
``Independent Payment Advisory Board''.
[(c) Rule of Construction.--Nothing in the amendments made by
this section shall preclude the Independent Medicare Advisory
Board, as established under section 1899A of the Social
Security Act (as added by section 3403), from solely using data
from public or private sources to carry out the amendments made
by subsection (a)(4).]
* * * * * * *
VII. ADDITIONAL VIEWS
Under current law, the Independent Payment Advisory Board
(IPAB) is intended to be a back stop mechanism to address
health care costs, in the event the other delivery system
reforms of the Affordable Care Act (ACA) did not yield
anticipated outcomes in improving care and lowering costs. To
date, however, the new delivery reform initiatives in the ACA
have brought success. Medicare spending growth has slowed and
as a result, the Congressional Budget Office currently
estimates that the Independent Payment Advisory Board (IPAB)
mechanism will not even be triggered until after 2021.
While some Democrats support the repeal of the IPAB because
it may be viewed as an infringement on Congressional authority,
given IPAB isn't expected to be triggered for some years, the
need for immediate action is not at all clear.
As Republican efforts to repeal the Affordable Care Act
failed earlier this year, the timing of this IPAB effort
appears to be a return to the Republicans' piecemeal attempt to
dismantle the health reform. The Affordable Care Act, which
slowed Medicare spending growth, extended solvency, and lowered
beneficiary cost-sharing, all while improving benefits, should
be improved upon by Congress, not torn down piece by piece
through bills such as H.R. 849.
It is also important, regardless of how IPAB is viewed, to
set the record straight on what IPAB does and does not do. It
is not a ``rationing board'' as Republicans have claimed. The
statute specifically prohibits sending recommendations to
Congress that would harm seniors by increasing their out-of-
pocket costs or cutting their benefits. In fact, it is the
Republican ACA repeal efforts that would have cut nearly a
trillion dollars from Medicaid and Medicare, which would have
truly led to rationing in the country.
During the markup Democrats raised questions about how
Republicans propose to offset the cost of this bill. While CBO
estimates that IPAB's mechanism will not be triggered until
after 2021, due to the vagaries of CBO scoring, they estimate
the ten-year cost of repeal at over $17.5 billion.
Democrats are concerned that Republicans would offset the
$17.5 billion cost of IPAB repeal with actual and immediate
cuts to Medicare benefits, increased costs for Medicare
beneficiaries, or cuts to other health priorities that would
cause coverage loss.
Despite assertions otherwise, the IPAB appointees must have
no conflict of interest helping ensure that sound policy not
special interests are guiding recommendations. Once the IPAB
recommendations are submitted to the Congress, the Committees
of jurisdiction, including the Committee on Ways and Means, may
modify the recommendations as may the full House and full
Senate under fast-track procedures, so long as the spending
targets themselves are not breached. (The House or Senate could
also reject the spending targets, but would face additional
procedural hurdles to do so.) The IPAB's recommendations are
limited to matters affecting Medicare and IPAB is prohibited
from making recommendations that ration care; change
eligibility; increase cost-sharing, premiums, or taxes; or
reduce benefits.
In conclusion, we are concerned with the process, lack of
transparency on offsets, and rhetoric surrounding this
legislation.
Richard E. Neal,
Ranking Member.
[all]
