Coming Full Circle to IMAC

In an attempt to shore up support for healthcare reform legislation, particularly among Blue Dog Democrats who have expressed concern that current draft bills do little to rein in long-term spending, the Obama administration is now proposing the establishment of an Independent Medicare Advisory Council (IMAC), which would be empowered to make recommendations on Medicare payment rates and other reforms.

It is worth recalling that former Senate Majority Leader Tom Daschle, President Obama’s original nominee for both HHS Secretary and Director of the White House Office of Health Reform, had been advocating the creation of a Federal Health Board, modeled on the Federal Reserve Board, with the independence and authority to make decisions about healthcare policy. Dr. Ezekiel Emanuel of the National Institutes of Health, who is the brother of White House Chief of Staff Rahm Emanuel and currently serves as a healthcare advisor to Peter Orszag, the Director of the Office of Management and Budget, has also advocated the creation of a Federal Health Board.

The idea of a Federal Health Board did not appear to have a very promising future, particularly after Mr. Daschle’s departure. After all, even if one concedes that Congressional meddling in Medicare policy has often served narrow political interests rather than the broader goal of high-quality, cost-effective healthcare, removing decisions from the political process and, instead, putting them in the hands of “experts” is inherently undemocratic.

Although the idea of a Federal Health Board appeared to be aborted, Senator Rockefeller proposed elevating the status of MedPAC so that it could play a similar role, an idea that the administration supported, but neither the House bill nor the Senate HELP Committee bill included such a provision.

Now, with the IMAC idea apparently gaining traction, we appear to have come full circle. Changing the name may make the idea more palatable, but the differences with the Federal Health Board idea may not simply be a matter of cosmetics. In contrast to a Federal Health Board, IMAC’s ability to set policy would only partially be insulated from the political process. Peter Orszag described the process in a letter to House Speaker Nancy Pelosi last week:

This proposed legislation would require the President to approve or disapprove each set of the IMAC’s recommendations as a package. If the President accepts the IMAC’s recommendations, Congress would then have 30 days to intervene with a joint resolution before the Secretary of Health and Human Services is authorized to implement them. If either the President disapproves the recommendations of the IMAC or Congress passes such a joint resolution, the recommendations would be null and void, and current law would remain in effect. The review process would permit intervention if the IMAC’s reforms are not in keeping with the goals of Congress or the President, while retaining autonomy for implementing annual payment updates and other Medicare reforms for the IMAC.

Currently, Congress must act if it agrees with MedPAC’s recommendations and wants to implement them as law. By contrast, with IMAC, basically Congress would have to act if it wanted to prevent IMAC’s recommendations from being implemented into law. Given the difficulty Congress has on agreeing to any course of action, that provision alone may effectively insulate IMAC from the political process while, at least on the surface, making IMAC subject to Congressional oversight. We will see if President Obama raises the idea of IMAC in his press conference this evening on healthcare reform.