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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]