[ Update: This post has been corrected. New text has been underlined. ***]
David Leonhardt, complaining that the House health care bill doesn't do enough to control costs , touts a particular model for imposing parsimonious changes on the nation's health care delivery system:
Twice a year, an outside advisory board sends Congress a list of suggestions for Medicare payment rates, based on the available evidence. Congress generally ignores them, in deference to the various industry groups that oppose any cuts to their payments.
We already have a wonderful model for how to avoid such interference. It’s called the Federal Reserve . The Fed is charged with setting interest rates based on economic conditions, not politics. The Senate bill would create such a commission for Medicare.
But does the Senate bill really have a cost-cutting commission that's like the Fed ? The Fed is a highly independent agency whose actions take effect without approval from Congress. Maybe Congress could overturn a Fed action, but it would require a new piece of legislation, passed by both houses and signed by the president. In contrast, the current cost-cutting "MedPAC" panel submits proposals that then have to be passed as new laws by Congress or else they don't take effect (which, as Leonhardt notes, is usually what happens).
The logical middle ground would be to have an independent panel whose recommendations take effect unless they are somehow vetoed by Congress without presidential involvement,** or whose recommendations must be affirmatively passed by Congress but get the benefit of a streamlined, limited-amendment up-or-down fast-track "base closing" type of legislative process.
I assumed that the second of these obvious middle ground alternatives--rather than a "Fed" approach--had been taken when I read this description of the Reid Senate bill on Ezra Klein's blog :
The idea isn't simply that a panel of experts gets to dream up interesting reforms to try out in Medicare. It's that they are charged with making sure that Medicare hits certain growth targets, and their package of reforms has to achieve that goal. Those reforms are then sent to Congress, where Senate debate is limited to 30 hours, and amendments must be both budget neutral and "germane." This report, in other words, is exempt from the filibuster. So far as anything is ever easy to pass, this is easy to pass.
Then I read the bill. As far as I can see, it's actually a whole lot closer to Leonhardt's "Fed" model than I'd thought . In general, there is an independent panel ("IMAB"), and if Congress does nothing, its cost-cutting rules take effect. What's more, the "fast track" process described by Klein would not allow Congress to simply stop the board's rules, only to substitute its own plan to save the same amount of money . This would be a very powerful unelected board. David Broder may explode .
You can read the law yourself--the relevant provision (Sec. 3403) runs from page 1000 to page 1053 here . But what it seems to say, specifically, is:
--The new 15 member "IMAB" board makes cost-cutting recommendations if Medicare spending exceeds specific targets.
--Congress then 'considers' these changes in bill form . But like other legislation, the president can veto this bill (and his veto can be overridden).
--The "fast tracking" provisions Klein discusses apply to this bill. But they also sharply restrict what the 'fast track' bill can do. Congress can't, under the fast track, just block the IMAB board's decrees. It can change them, but if it changes them it has to meet the cost-reduction targets in some other way. It's not allowed to not save money, apparently (though the Senate is allowed to do some unspecified things by 2/3 vote that I don't quite understand). In other words, the 'fast track' isn't designed to enable Congress to swiftly pass the new IMAB board's rules. The IMAB board doesn't need Congress' OK (see next paragraph). The fast track is designed to allow Congress to tinker with the IMAB board's rules as long as it reaches the same result. In this sense, the Reid fast track isn't like base closing , where Congress votes a package of cuts up or down in a special procedure. Voting down is not an option here.
-- Key point: If Congress doesn' t pass the fast-tracked 'tinkering' bill, the Secretary of HHS must implement the IMAB panel's recommendations.
--And Congress loses even its fast-track tinkering power after 2020, unless, by a 60% supermajority, during a specific window in the first half of 2017, while standing on one leg and humming Battle Hymn of the Republic , it passes a joint resolution discontinuing the whole process. Correction: The part about standing on one leg and humming doesn't seem to be in the final bill.
Complicated! (If I got it wrong, let me know.) The most obvious flaw seems to be this: Under the Reid bill, the way Congress react to the "IMAB" board's rules is by passing a law, subject to presidential veto, on a carefully-circumscribed "fast track." But Congress can pass a new law, subject to veto, anytime it wants on any subject, using its traditional "slow track" (or any faster track it feels like creating). The Reid bill can't stop future Congresses from doing that--passing a law simply throwing out an IMAB board recommendation , for example, without offering an alternative way to save money. Or killing the IMAB board completely (whether or not it passes this law in the first half of 2017). All the Reid reform can hope to do is prevent Congress from doing this via the specified "fast track." A meddling Congress, faced with constituents angry at Medicare cuts, might well say, in effect, 'take your fast track and shove it--we'll show you fast'.
Suppose, say, the "expert" IMAB board decrees that the feds won't pay for routine mammograms for women in their forties . How do you think Congress would react? ...
**--Several readers suggest that this "legislative veto" middle ground would be unconstitutional under the principles of INS v. Chadha . They may be right--which could be why the Reid bill envisions a fast-track legislative process that requires the President's signature, as with any regular law. But the Reid bill appears to rely on a legislative veto of its own--allowing Congress, by joint resolution, without the President's approval, to terminate the whole IMAB board in 2017. Why would it be unconstitutional to let Congress, acting alone, kill the IMAB board's rules, but not unconstitutional to let it kill the IMAB board? ... Paranoid thought: It's a trap. Proponents of a strong, Fed-like panel would love to sucker opponents into attacking it via a "joint resolution" mechanism that's later held unconstitutional and void. ...
***-- Correction: Underlined words and sentences reflect a second, and I hope more accurate, reading of the bill. The "fast track" resolution is not designed to let Congress nix the board's rules, as I initially thought. It apparently only lets Congress substitute other ways to save the same amount of money. All the more reason Congress is likely to simply skip the 'fast track' entirely.
Cynical view: This entire "Fed for Medicare" provision, with its nanny-like restrictions on what Congress can do on the 'fast track,' isn't going to pass, and if it passes it won't last. It's mainly Kabuki designed to convince the CBO to "score" the whole health bill as a deficit-reducer. ... 10:40 P.M.
Murder in the White House: I've read the Lloyd Grove's account and Steve Clemons' account and Elizabeth Drew's account --and I still don't have a clue as to why Greg Craig was forced out as White House Counsel--just that it was a bad, bad thing and was done by leaks. ... If you could force someone out merely by leaks, wouldn't Rahm Emanuel have been forced out of the Clinton White House in 1993 ? ... There's something here we don't know, no? Someone Craig pissed off, maybe. Someone unfireable from Chicago? (I'm just speculating, but that is the sort of thing that would fill the role of ninth planet here.) ...
Update : Time 's account fills much of the void, portraying Craig as a politically tone-deaf civil liberties purist . Maybe there is another side to the story. But if Craig really did want to release photos of detainee abuse, that's enough for me. ... 11:49 P.M.