[House Report 112-412]
[From the U.S. Government Publishing Office]


112th Congress                                            Rept. 112-412
                        HOUSE OF REPRESENTATIVES
 2d Session                                                      Part 2

======================================================================



 
             MEDICARE DECISIONS ACCOUNTABILITY ACT OF 2011

                                _______
                                

 March 16, 2012.--Committed to the Committee of the Whole House on the 
              State of the Union and ordered to be printed

                                _______
                                

  Mr. Upton, from the Committee on Energy and Commerce, submitted the 
                               following

                              R E P O R T

                             together with

                            DISSENTING VIEWS

                        [To accompany H.R. 452]

      [Including cost estimate of the Congressional Budget Office]

    The Committee on Energy and Commerce, to whom was referred 
the bill (H.R. 452) to repeal the provisions of the Patient 
Protection and Affordable Care Act providing for the 
Independent Payment Advisory Board, having considered the same, 
report favorably thereon with an amendment and recommend that 
the bill as amended do pass.

                                CONTENTS

                                                                   Page
Amendment........................................................     2
Purpose and Summary..............................................     2
Background and Need for Legislation..............................     2
Hearings.........................................................     4
Committee Consideration..........................................     5
Committee Votes..................................................     5
Committee Oversight Findings.....................................     5
Statement of General Performance Goals and Objectives............     5
New Budget Authority, Entitlement Authority, and Tax Expenditures     5
Earmark..........................................................     6
Committee Cost Estimate..........................................     6
Congressional Budget Office Estimate.............................     6
Federal Mandates Statement.......................................    10
Advisory Committee Statement.....................................    10
Applicability to Legislative Branch..............................    10
Section-by-Section Analysis of the Legislation...................    10
Changes in Existing Law Made by the Bill, as Reported............    10
Dissenting Views.................................................    46

                               Amendment

    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 ``Medicare Decisions Accountability Act 
of 2011''.

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, but excluding 
subsection (d) of section 1899A of the Social Security Act, as added 
and amended 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.

                          Purpose and Summary

    The purpose of H.R. 452, the ``Medicare Decisions 
Accountability Act of 2011'' is to repeal section 3403 and 
section 10320 of the Patient Protection and Affordable Care Act 
(PPACA), which establish the Independent Payment Advisory Board 
(IPAB).

                  Background and Need for Legislation

    According to PPACA, section 3403 establishes a 15-member 
board to ``reduce the per capita rate of growth in Medicare 
spending.''\1\
---------------------------------------------------------------------------
    \1\Section 3403, Patient Protection and Affordable Care Act (Public 
Law 11-148).
---------------------------------------------------------------------------
    By April 30 of each year, beginning in 2013, the Centers 
for Medicare and Medicaid Services (CMS) Actuary's Office will 
project whether Medicare's per-capita spending growth rate in 
the following two years will exceed a targeted rate. Initially, 
the targeted rate of spending growth will be based on the 
projected five-year average percentage increase in the Consumer 
Price Index for all urban consumers (CPIu) and the Consumer 
Price Index for all urban consumers for medical care (CPIm).
    Beginning with the 2018 Determination Year, the target will 
be set at the nominal gross domestic product per capita, plus 
1.0 percent (President Obama's FY 2013 budget proposes that 
this be changed to GDP plus 0.5%).\2\ If future Medicare 
spending is expected to exceed the targets, the board will 
propose recommendations to Congress and the President to reduce 
the growth rate. The board's first set of recommendations would 
be proposed on January 15, 2014.
---------------------------------------------------------------------------
    \2\FY 2013, Budget in Brief, U.S. Dept. of Health and Human 
Services; p. 55.
---------------------------------------------------------------------------
    By September 1 of each Determination Year, the Board 
submits a draft of its proposal for review to the Secretary of 
the Department of Health and Human Services (Secretary) and to 
Medicare Patient Advisory Commission (MedPAC) for consultation. 
The board transmits its annual proposal to Congress and the 
President on January 15 of each Proposal Year, beginning 2014. 
The proposal is referred to the House Committees on Energy and 
Commerce and Ways and Means and the Senate Finance Committee. 
The committees must report an implementing bill or legislation 
that achieves at least the same level of targeted reductions in 
Medicare spending growth as contained in the IPAB plan. Unless 
both houses of Congress agrees to legislation that achieves the 
same reductions in spending, the Secretary automatically 
implements the board's proposals on August 15 of the Proposal 
Year and the recommendations that relate to payment rate 
changes that take effect on a fiscal year basis take effect on 
October 1 of the Proposal Year. Recommendations relating to 
payment rate changes that take effect on a calendar year basis 
take effect on January 1 of the Implementation Year.
    Spending rate reductions will be established at: 0.5 
percent in 2015; 1.0 percent in 2016; 1.25 percent in 2017; and 
1.5 percent in 2018 and beyond.
    The board will be composed of 15 members appointed by the 
President, with the advice and consent of the Senate. As such, 
the members are officers of the United States under the 
appointments clause of the U.S. Constitution. The Secretary, 
the Administrator of CMS, and the Administrator of the Health 
Resources and Services Administration are ex-officio non-voting 
members. The Chairperson is appointed by the President from 
among the members of the Board. Each appointed member may serve 
two consecutive six-year terms. Appointed members of the board 
will be compensated at a rate equal to Level III of the 
Executive Schedule ($165,300 for 2011), and the Chairperson 
will be compensated at a rate equal to Level II ($179,700 for 
2011).
    At present, the Administration has not made known any 
attempt to nominate any members of the board. If the board does 
not make a recommendation or if the membership of the board is 
not filled, the Secretary is tasked with developing 
recommendations. If Congress is unable to pass legislation 
overturning the Secretary's recommendations, the Secretary must 
implement them.
    The effect of the procedures in the legislation is to favor 
the continuation of the board and its recommendations, even in 
the face of significant opposition in both chambers of 
Congress. Section 3403 establishes a second ``fast track'' 
parliamentary mechanism for consideration of legislation 
discontinuing the automatic implementation process for the 
recommendations of the board. However, in order to qualify for 
consideration under ``fast track'' procedures, the House and 
Senate must adopt a joint resolution discontinuing the process. 
The joint resolution to discontinue the board must be 
introduced by February 1, 2017. If the joint resolution is 
adopted by both houses of Congress, but vetoed by the 
President, overriding the veto would require a super-majority 
vote of two-thirds in both chambers for the measure to become 
law, shifting the balance of power to the President and away 
from Congress.
    The budget for the board for FY 2012 was to be $15 million, 
with annual adjustments based on increases in the CPI. This is 
slightly more than the MedPAC budget. The FY 2012 Consolidated 
Appropriations Bill cut $10 million of the $15 million that 
PPACA appropriated for IPAB for FY 2012. The disposition of the 
remaining $5 million, which was to be appropriated for FY 2012, 
remains unclear. The board is to be funded out of the Medicare 
trust funds--specifically, 60 percent of the board's funds will 
come from the Federal Hospital Insurance Trust Fund and 40 
percent from the Federal Supplementary Medical Insurance Trust 
Fund.
    Some have raised concerns that, in spite of the language in 
the legislation, IPAB will result in ``de facto'' rationing of 
care. According to MedPAC, some Medicare beneficiaries, 
especially those looking for a new primary care physician, are 
already having difficulty finding physicians to see them.\3\ 
The data is clear; faced with substantial fee cuts, such as 
those that are still pending under the Sustainable Growth Rate 
(SGR), most physicians will reduce the number of Medicare 
patients they treat, or stop seeing Medicare patients 
altogether. According to an American Medical Association 
survey, current reimbursement rates have already led 17 percent 
of doctors, including 31 percent of primary care physicians, to 
restrict the number of Medicare patients in their practices.\4\ 
Under the current SGR payment formula, cuts to physician fees 
of over 30 percent are pending for January 2013. Further 
arbitrary cuts under IPAB will only make access problems worse.
---------------------------------------------------------------------------
    \3\MedPAC Report to the Congress, Medicare Payment Policy, March, 
2011; CH. 4, pg. 69, available at: http://www.medpac.gov/chapters/
Mar11_Ch04.pdf
    \4\AMA ONLINE SURVEY OF PHYSICIANS The Impact of Medicare Physician 
Payment on Seniors' Access To Care May 2010, available at: http://
www.ama-assn.org/resources/doc/washington/medicare-survey-results-
0510.pdf.
---------------------------------------------------------------------------
    The CMS actuary has expressed concerns about the power 
given to the board's unelected officials and about the 
detrimental effect that ratcheting down payments could have on 
innovation and in limiting patient access to physicians, 
medicines, and other treatments, stating that the target growth 
rates create a situation in Medicare that is analogous to the 
SGR.\5\
---------------------------------------------------------------------------
    \5\Foster RS. Estimated financial effects of the ``Patient 
Protection and Affordable Care Act,'' as amended. Washington, DC.: 
Centers for Medicare and Medicaid Services, April 22, 2010.
---------------------------------------------------------------------------
    Since hospitals, skilled nursing facilities, long-term care 
hospitals, and other providers are exempt from IPAB cuts 
through 2019, and laboratory services through 2015, physicians 
will be disproportionately affected. Again, there is a valid 
concern that the additional IPAB cuts will cause access 
problems for Medicare beneficiaries.
    In March 2010, the Congressional Budget Office (CBO) 
estimated the cost savings from IPAB at $15.5 billion during 
the 2015 to 2019 period.\6\ In March 2011, CBO changed their 
estimate and projected that, under current law, the IPAB 
mechanism would not affect Medicare spending during the 2011 to 
2021 period.\7\ This meant that repeal of IPAB would not 
require an offset and, in fact, would be a likely cost saver by 
the amount appropriated ($15 million per year, adjusted for 
inflation). Two months later, based on a ``one-sided bet'' 
statistical justification, CBO again rescored the repeal of 
IPAB at the current cost estimate of $2.4 billion. Under the 
``one-sided'' bet theory, IPAB has no cost and can only save 
money. Thus, because H.R. 452 strikes IPAB, and the 
hypothetical savings IPAB promises, CBO determined the bill 
will cost $3.1 billion from 2013 to 2022.
---------------------------------------------------------------------------
    \6\Letter from Douglas W. Elmendorf, Director, Congressional Budget 
Office, to Honorable Nancy Pelosi, Speaker, House of Representatives, 
March 20, 2010, http://www.cbo.gov/ftpdocs/113xx/doc11379/
AmendReconProp.pdf.
    \7\CBO March, 2011 Medicare Baseline, Available at www.cbo.gov/
budget/factsheets/2011b/medicare.pdf.
---------------------------------------------------------------------------

                                Hearings

    On July 13, 2011, the Subcommittee on Health held a hearing 
entitled ``IPAB: The Controversial Consequences for Medicare 
and Seniors.'' At the hearing, the Subcommittee discussed the 
fundamental differences between the Republican and Democratic 
plans for Medicare reform and how IPAB will affect current 
reform efforts, ration health care goods and services, and may 
be unconstitutional.
    The Subcommittee received testimony from: John Cornyn, 
Senator (TX); Allyson Schwartz (PA-13); David P. Roe (TN-01); 
George Miller (CA-07); Kathleen Sebelius, Secretary; Department 
of Health and Human Services; Chris Davis, Legislative Analyst, 
Congressional Research Service; David Newman, Financial 
Analyst, Congressional Research Service; Diane Cohen, Senior 
Attorney, Goldwater Institute; Judy Feder, Senior Fellow, 
Center for American Progress; Avik Roy, Healthcare Analyst, 
Monness, Crespi, Hardt & Co.; Stuart Guterman, Senior Program 
Director, the Commonwealth Fund; Scott Gottlieb, Resident 
Fellow, American Enterprise Institute; Alex Valadka, Chief 
Executive Officer, Seton Brain and Spine Institute; Mary 
Grealey, President, Healthcare Leadership Council.

                        Committee Consideration

    On February 29, 2012, the Subcommittee on Health met in 
open markup session and forwarded H.R. 452, without amendment, 
to the full Committee by a vote of 17 yeas and 5 nays, a quorum 
being present.
    On March 6, 2012, the full Committee met in open markup 
session to consider H.R. 452, the ``Medicare Decisions 
Accountability Act of 2011.'' A motion by Mr. Upton to order 
H.R. 452 reported to the House, as amended, was agreed to by a 
voice vote.

                            Committee Votes

    Clause 3(b) of rule XIII of the Rules of the House of 
Representatives requires the Committee to list the record votes 
on the motion to report legislation and amendments thereto. 
There were no record votes taken in connection with ordering 
H.R. 452 reported.

                      Committee Oversight Findings

    Pursuant to clause 3(c)(1) of rule XIII of the Rules of the 
House of Representatives, the Committee held a hearing and made 
findings that are reflected in this report.

         Statement of General Performance Goals and Objectives

    The goal of H.R. 452 is to protect the future of the 
Medicare program by preserving the right of patients and their 
doctors to make decisions regarding the value of health care 
goods and services and preventing major health reform 
legislation from being implemented without being subjected to 
the usual legislative process.

   New Budget Authority, Entitlement Authority, and Tax Expenditures

    In compliance with clause 3(c)(2) of rule XIII of the Rules 
of the House of Representatives, the Committee finds that H.R. 
452, the ``Medicare Decisions Accountability Act of 2011,'' 
would result in no new or increased budget authority, 
entitlement authority, or tax expenditures or revenues.

                                Earmark

    In compliance with clause 9(e), 9(f), and 9(g) of rule XXI, 
the committee finds that H.R. 452, the ``Medicare Decisions 
Accountability Act of 2011'' contains no earmarks, limited tax 
benefits, or limited tariff benefits.

                        Committee Cost Estimate

    The Committee adopts as its own the cost estimate prepared 
by the Director of the Congressional Budget Office pursuant to 
section 402 of the Congressional Budget Act of 1974.

                  Congressional Budget Office Estimate

    Pursuant to clause 3(c)(3) of rule XIII of the Rules of the 
House of Representatives, the following is the cost estimate 
provided by the Congressional Budget Office pursuant to section 
402 of the Congressional Budget Act of 1974:

                                     U.S. Congress,
                               Congressional Budget Office,
                                     Washington, DC, March 7, 2012.
Hon. Fred Upton,
Chairman, Committee on Energy and Commerce, U.S. House of 
        Representatives, Washington, DC.
    Dear Mr. Chairman: The Congressional Budget Office has 
prepared the enclosed cost estimate for H.R. 452, the Medicare 
Decisions Accountability Act of 2011.
    If you wish further details on this estimate, we will be 
pleased to provide them. The CBO staff contact is Tom Bradley.
            Sincerely,
                                              Douglas W. Elmendorf.
    Enclosure.

H.R. 452--Medicare Decisions Accountability Act of 2011

    Summary: H.R. 452 would repeal the provisions of the 
Affordable Care Act (ACA) that established the Independent 
Payment Advisory Board (IPAB) and created a process by which 
that 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 certain specified 
savings.
    CBO estimates that enacting H.R. 452 would not have any 
budgetary impact in 2012 but would increase direct spending by 
$3.1 billion over the 2013-2022 period. That estimate is 
extremely uncertain because it is not clear whether the 
mechanism for spending reductions under the IPAB authority will 
be triggered under current law over the next 10 years. However, 
it is possible that such authority would be triggered in one or 
more of those years; thus, repealing the IPAB provision of the 
ACA could result in higher spending for the Medicare program 
than would occur under current law. CBO's estimate represents 
the expected value of a broad range of possible effects of 
repealing the provision over that period.
    Pay-as-you-go procedures apply because enacting the 
legislation would affect direct spending. Enacting the bill 
would not affect revenues.
    H.R. 452 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. 452 is shown in the following table. 
The costs of this legislation fall within budget function 570 
(Medicare).

--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              By fiscal year, in millions of dollars --
                                           -------------------------------------------------------------------------------------------------------------
                                             2012    2013    2014    2015    2016    2017    2018    2019    2020    2021    2022   2012-2017  2012-2022
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                               CHANGES IN DIRECT SPENDING

        Estimated Budget Authority               0     -14     -14     -14     -14     -15     475   1,095     384     414     824       -71      3,121
             Estimated Outlays                   0      -6     -10     -14     -14     -15     475   1,095     384     414     824       -59      3,133
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Basis of Estimate: H.R. 452 would repeal the provisions of 
the ACA that created the Independent Payment Advisory Board. 
Assuming enactment near the beginning of fiscal year 2013, CBO 
estimates that the bill would reduce direct spending by $59 
million over the 2013-2017 period, but would increase direct 
spending, on an expected-value basis, after 2017. On balance, 
CBO estimates that enacting H.R. 452 would lead to a net 
increase in direct spending of $3,133 million over the 2013-
2022 period.

Administrative costs

    The Congress appropriated $15 million for the IPAB in the 
ACA for fiscal year 2012, along with a formula for increasing 
that amount in subsequent years by the percentage increase in 
the consumer price index for all urban consumers (CPI-U). 
(However, $10 million of the $15 million provided for 2012 was 
subsequently rescinded.) Funds appropriated in authorizing 
legislation are considered direct spending, because the 
availability of those funds is not contingent on future 
appropriation acts.
    CBO estimates that net funding for IPAB administrative 
costs will total $149 million over the 2013-2022 period, and 
that outlays will total $137 million through 2022. Those 
amounts take into account that about 10 percent of the funds 
provided for the IPAB will be offset by changes in receipts 
from Medicare Part 13 premiums. For example, the estimated 
gross funding for 2013 under current law is $15 million, and 
about $1 million in additional Part B premiums will be 
collected, resulting in an estimated net change in budget 
authority of $14 million for next year.
    In total, CBO estimates that enacting H.R. 452 would reduce 
net direct spending for administrative costs by $137 million 
over the 2013-2022 period.

Net spending for Medicare benefits

    Under current law, the Independent Payment Advisory Board 
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 that is based on inflation (for 2015 to 2019) or 
growth in the economy (for 2020 and subsequent years). Each 
year, beginning in the spring of 2013, 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 http://www.bls.gov/cpi/cpifact4.htm).
---------------------------------------------------------------------------
    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.
    CBO's current estimates of Medicare spending and its 
current economic projections result in an IPAB spending measure 
that is below the economic measure in each target year through 
2022 (that is, in the last year of each five-year period):

----------------------------------------------------------------------------------------------------------------
                                    2015      2016      2017      2018      2019      2020      2021      2022
----------------------------------------------------------------------------------------------------------------
Spending Measure................      1.7%      1.7%      1.5%      2.7%      3.1%      3.6%      3.9%      4.2%
Economic Measure................      2.8%      2.8%      2.9%      3.0%      3.2%      5.2%      4.9%      4.7%
                                 -------------------------------------------------------------------------------
    Difference..................     -1.1%     -1.1%     -1.4%     -0.3%     -0.1%     -1.6%     -1.0%     -0.5%
----------------------------------------------------------------------------------------------------------------

    The point estimates in CBO's baseline projections, 
therefore, result in a projected savings target of zero in 
every year through 2022.
    The IPAB mechanism, however, is essentially a one-sided 
bet: The resulting target can be only zero or savings; the IPAB 
cannot be instructed to increase spending. So, variations in 
those measures might lead to additional savings but could not 
lead to added costs.\2\
---------------------------------------------------------------------------
    \2\For a discussion of CBO's longstanding approach to estimating 
one-sided bets, see http://www.cbo.gov/sites/default/files/cbofiles/
ftpdocs/15xx/doc1589/onesided.pdf.
---------------------------------------------------------------------------
    In fact, the difference between the spending measure and 
the economic measure in each year that the Chief Actuary makes 
an IPAB determination will probably not be equal to the 
difference that CBO currently projects. If the Chief Actuary 
ends up projecting some combination of a higher spending 
measure or a lower economic measure than CBO currently 
projects, the savings target for the IPAB mechanism could 
exceed zero.
    Because of the one-sided nature of the budgetary impact of 
variations in the spending and economic measures that determine 
IPAB's savings target, it is important to consider the 
probabilities associated with such variations when assessing 
the effects of possible changes in law. To assess the 
probability of the IPAB mechanism being triggered, CBO analyzed 
the technical component of changes in its recent baseline 
projections of Medicare spending.\3\ We concluded that there is 
a roughly two-thirds chance that the amount of spending in five 
years will differ from the agency's current projection by less 
than 2 percent as a result of technical factors.\4\ (Thus, 
there is a one-third chance that the amount of spending in five 
years would differ by more than 2 percent as a result of such 
factors.) The uncertainty regarding the five-year moving 
average of the rate of growth in net Medicare spending per 
beneficiary is approximately one-fifth of the uncertainty 
concerning the amount of Medicare spending in the fifth year.
---------------------------------------------------------------------------
    \3\CBO characterizes the components of changes in baseline 
projections as technical, economic, and legislative. This analysis of 
variability in projections focuses on the technical component--which 
largely represents unanticipated changes in the utilization of health 
care services--because the economic component is expected to have 
similar, and largely offsetting, effects on the spending and economic 
measures whose difference determines the IPAB's savings targets. The 
analysis excludes the legislative component of changes in CBO's 
baseline projections because the baseline reflects current law and does 
not anticipate future legislative changes.
    \4\The total uncertainty around CBO's projections of Medicare 
spending--taking into account the economic and legislative components 
of changes in those projections--would be considerably larger.
---------------------------------------------------------------------------
    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 the IPAB's savings target under 
both current law and with the proposed change in law. 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.
    The use of probability-based estimates for changes to the 
IPAB mechanism does not affect the presentation of the effects 
of that mechanism in CBO's baseline. The baseline reflects the 
agency's current best judgment of the likely level of spending 
under current law; if the IPAB mechanism is triggered, that 
outcome probably will result from spending that exceeds CBO's 
current projections.
    Following the above logic, repeal of the IPAB mechanism 
would have a budgetary cost. After application of the de 
minimis rule (for estimated effects that round to 0.0 percent), 
the expected value of the IPAB's savings target would be zero 
in 2015, 2016, 2017, 2020, and 2021 (but not in 2018, 2019, and 
2022, when the expected value of the savings target would be 
between 0.1 percent and 0.2 percent of projected net Medicare 
spending). In addition, CBO anticipates that, if the IPAB 
mechanism was triggered, some of the savings in the target year 
would compound and produce savings in subsequent years. As a 
result, CBO estimates that repealing the IPAB mechanism would 
increase expected Medicare spending each year from 2018 through 
2022, with the expected value of the net increase in Medicare 
spending for benefits totaling about $3.3 billion over that 
five-year 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. 452 would not affect revenues.)

          CBO ESTIMATE OF PAY-AS-YOU-GO EFFECTS FOR H.R. 452, AS ORDERED REPORTED BY THE HOUSE COMMITTEE ON ENERGY AND COMMERCE ON MARCH 6, 2012
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                              By fiscal year, in millions of dollars--
                                           -------------------------------------------------------------------------------------------------------------
                                             2012    2013    2014    2015    2016    2017    2018    2019    2020    2021    2022   2012-2017  2012-2022
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                       NET INCREASE OR DECREASE (-) IN THE DEFICIT

Statutory Pay-As-You-Go Impact............       0      -6     -10     -14     -14     -15     475   1,095     384     414     824       -59      3,133
--------------------------------------------------------------------------------------------------------------------------------------------------------

    Intergovernmental and private-sector impact: H.R. 452 
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: Tom Bradley; Impact on 
State, Local, and Tribal Governments: Lisa Ramirez-Branum; 
Impact on the Private Sector: Jimmy Jin.
    Estimate approved by: Holly Harvey, Deputy Assistant 
Director for Budget Analysis.

                       Federal Mandates Statement

    The Committee adopts as its own the estimate of Federal 
mandates prepared by the Director of the Congressional Budget 
Office pursuant to section 423 of the Unfunded Mandates Reform 
Act.

                      Advisory Committee Statement

    No advisory committees within the meaning of section 5(b) 
of the Federal Advisory Committee Act were created by this H.R. 
452, the ``Medicare Decisions Accountability Act of 2011.''

                  Applicability to Legislative Branch

    The Committee finds that H.R. 452, the ``Medicare Decisions 
Accountability Act of 2011'' does not relate to the terms and 
conditions of employment or access to public services or 
accommodations within the meaning of section 102(b)(3) of the 
Congressional Accountability Act.

             Section-by-Section Analysis of the Legislation

    Section 1. Short Title: the ``Medicare Decisions and 
Accountability Act of 2011.''
    Section 2. This section repeals section 3403 and section 
10320 of the Patient Protection and Affordable Care Act (Public 
Law 111-148), effective as of the enactment of the same and any 
provision of law amended by such sections is restored as if 
such sections had not been enacted into law.

         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).
          [``(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).
                          [``(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.
                  [``(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; and
                          [``(vi) consider the unique needs of 
                        Medicare beneficiaries who are dually 
                        eligible for Medicare and the Medicaid 
                        program under title XIX.
                  [``(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) Transmission of board proposal to president.--
                  [``(A) In general.--
                          [``(i) In general.--Except as 
                        provided in clause (ii) and subsection 
                        (f)(3)(B), the Board shall transmit a 
                        proposal under this section to 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;
                                  [``(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; or
                                  [``(III) for proposal year 
                                2019 and subsequent proposal 
                                years, a year in which the 
                                Chief Actuary of the Centers 
                                for Medicare & Medicaid 
                                Services makes a determination 
                                in the determination year that 
                                the growth rate described in 
                                paragraph (8) exceeds the 
                                growth rate described in 
                                paragraph (6)(A)(i).
                          [``(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 Board under paragraph 
        (3)(A)(i) or the Secretary under paragraph (5), the 
        President shall immediately submit such proposal to 
        Congress.
          [``(5) Contingent secretarial development of 
        proposal.--If, with respect to a proposal year, the 
        Board is required, to but fails, to submit a proposal 
        to 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 
                        per unduplicated enrollee.
                          [``(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.]

           *       *       *       *       *       *       *

  [``(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 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) Exception.--The Secretary shall not be 
        required to implement the recommendations contained in 
        a proposal submitted in a proposal year by the 
        President to Congress pursuant to this section if--
                  [``(A) 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
                  [``(B) 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.
          [``(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 or advisory reports to Congress under 
                this section 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.''.
          [(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 ``Exceptions.--
                  [``(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).]

           *       *       *       *       *       *       *

                              ----------                              


                          SOCIAL SECURITY ACT




           *       *       *       *       *       *       *
TITLE XVIII--HEALTH INSURANCE FOR THE AGED AND DISABLED

           *       *       *       *       *       *       *



                  MEDICARE PAYMENT ADVISORY COMMISSION

  Sec. 1805. (a) * * *
  (b) Duties.--
          (1) * * *

           *       *       *       *       *       *       *

          [(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.]
          [(5)] (4) Agenda and additional reviews.--The 
        Commission shall consult periodically with the chairmen 
        and ranking minority members of the appropriate 
        committees of Congress regarding the Commission's 
        agenda and progress towards achieving the agenda. The 
        Commission may conduct additional reviews, and submit 
        additional reports to the appropriate committees of 
        Congress, from time to time on such topics relating to 
        the program under this title as may be requested by 
        such chairmen and members and as the Commission deems 
        appropriate.
          [(6)] (5) Availability of reports.--The Commission 
        shall transmit to the Secretary a copy of each report 
        submitted under this subsection and shall make such 
        reports available to the public.
          [(7)] (6) Appropriate committees of congress.--For 
        purposes of this section, the term ``appropriate 
        committees of Congress'' means the Committees on Ways 
        and Means and Commerce of the House of Representatives 
        and the Committee on Finance of the Senate.
          [(8)] (7) Voting and reporting requirements.--With 
        respect to each recommendation contained in a report 
        submitted under paragraph (1), each member of the 
        Commission shall vote on the recommendation, and the 
        Commission shall include, by member, the results of 
        that vote in the report containing the recommendation.
          [(9)] (8) Examination of budget consequences.--Before 
        making any recommendations, the Commission shall 
        examine the budget consequences of such 
        recommendations, directly or through consultation with 
        appropriate expert entities.

           *       *       *       *       *       *       *


Part E--Miscellaneous Provisions

           *       *       *       *       *       *       *



                  [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.]

           *       *       *       *       *       *       *

  [(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.]

           *       *       *       *       *       *       *

                              ----------                              


              SECTION 207 OF TITLE 18, UNITED STATES CODE


Sec. 207. Restrictions on former officers, employees, and elected 
                    officials of the executive and legislative branches

  (a) * * *

           *       *       *       *       *       *       *

  (c) One-Year Restrictions on Certain Senior Personnel of the 
Executive Branch and Independent Agencies.--
          (1) * * *

           *       *       *       *       *       *       *

          [(3) Members of the Independent Payment Advisory 
        Board.--
                  [(A) In general.--Paragraph (1) shall apply 
                to a member of the Independent Payment 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 
                Payment 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.]

           *       *       *       *       *       *       *


                            DISSENTING VIEWS

    H.R. 452, the ``Medicare Decisions Accountability Act of 
2011,'' introduced by Congressman Phil Roe, would repeal, 
effective as of the enactment of the Patient Protection and 
Affordable Care Act (ACA), sections 3403 and 10320. These 
repealed sections pertain to the Independent Payment Advisory 
Board (IPAB) and subsequent amendments to the IPAB. This 
legislation should be rejected because it furthers the anti-
Medicare agenda of the Republican majority in the House.
    The Affordable Care Act created the IPAB to provide a 
backup cost control option in case the other delivery system 
reforms in the legislation did not adequately slow the growth 
in health care spending. The ACA was the largest deficit 
reducing bill passed in the last decade, saving taxpayers $210 
billion over the next decade and $1.2 trillion in the second 
decade.\1\ In addition to contributing to deficit reduction, 
the bill was also the most significant improvement to Medicare 
passed in years, and it reduced Medicare cost growth per 
beneficiary from an average of 7.8% to just less than 3%.\2\
---------------------------------------------------------------------------
    \1\Letter from Douglas W. Elmendorf, Director, Congressional Budget 
Office, to Speaker John Boehner, U.S. House of Representatives (Jan. 6, 
2011) (online at http://www.cbo.gov/sites/default/files/cbofiles/
ftpdocs/120xx/doc12040/01-06-ppaca_repeal.pdf).
    \2\Center on Budget and Policy Priorities, Statement: Robert 
Greenstein, President, on the 2011 Medicare Trustees' Report (May 13, 
2011) (online at http://www.cbpp.org/cms/index.cfm?fa=view&id=3494).
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    Repealing the IPAB would add more than $3 billion to the 
cost of Medicare over the next decade. Rather than addressing 
the need to manage Medicare responsibly, this legislation would 
simply add more costs on to the program. IPAB is intended to be 
a moderate, evidence-based, consumer oriented panel that would 
protect Medicare benefits and beneficiary costs. The Republican 
alternative to IPAB is to eliminate Medicare's benefit 
guarantee and shift more costs on to patients.
    House Republicans have made every effort to dismantle the 
health reform law by any means possible. Fortunately, their 
efforts to enact wholesale repeal have been rejected.\3\ As a 
result, they are now attempting to repeal the law piece by 
piece.\4\ The IPAB repeal bill is nothing more than yet another 
assault on the health reform law, which has to date provided 
benefits to tens of millions of Americans.
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    \3\Although the House of Representatives has passed a bill to 
repeal the ACA (H.R. 2), that legislation will not become law since the 
Senate has defeated the proposal. (H.R. 2 passed the House on January 
22, 2011 (Congressional Record, H322-323). The Senate defeated a 
similar proposal the following month on February 2, 2011 (Congressional 
Record S475)). In any case, President Obama has made clear that he will 
veto any such legislation. (Executive Office of the President, Office 
of Management and Budget, Statement of Administration Policy: H.R. 2--
Repealing the Affordable Care Act (Jan. 6, 2011) (online at http://
www.whitehouse.gov/sites/default/files/omb/legislative/sap/112/
saphr2r_20110106.pdf)).
    \4\Efforts in the House of Representatives to repeal or otherwise 
destroy individual parts of the ACA include: H.R. 1173, Fiscal 
Responsibility and Retirement Security Act of 2011 (passed the House on 
Feb. 1, 2012 (Congressional Record, H322-354); H.R. 358, Protect Life 
Act (passed the House on Oct. 13, 2011 (Congressional Record, H6885-
6903)); H.R. 1214, To Repeal Mandatory Funding for School-Based Health 
Center Construction (passed the House on May 4, 2011(Congressional 
Record H2969-2977)); H.R. 1216, To Convert Funding for Graduate Medical 
Education in Qualified Teaching Centers from Direct Appropriations to 
an Authorization of Appropriations (passed the House on May 25, 2011 
(Congressional Record H3361-3388; H3396-3401; H3430-3434)); and H.R. 
1217, To Repeal the Prevention and Public Health Fund) (passed the 
House on Apr. 13, 2011 (Congressional Record H2633-2647)). To date, 
none of these bills has been considered by the Senate.
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IPAB in Context
    It is important to consider the IPAB in the context of the 
entire Affordable Care Act. The law included a variety of 
innovative programs that protected Medicare's guarantee for 
seniors and people with disabilities while at the same time 
driving the program toward better value and quality for 
patients. These include linking hospital payments to rates of 
readmission; value-based purchasing for fee-for-service (FFS) 
providers and Medicare Advantage plans; attention to patient 
safety; disclosure of financial relationships between 
manufacturers and physicians; and research on the comparative 
effectiveness of different clinical interventions.\5\ In 
addition, the new Center for Medicare & Medicaid Innovation, 
along with the new office of Medicare-Medicaid Coordination 
Office, is tasked with researching new ways of paying for and 
delivering care that will reduce costs and increase quality. 
Together, these initiatives encourage providers to focus on the 
outcomes that are important to patients and to taxpayers.
---------------------------------------------------------------------------
    \5\D. Cutler, et al., The Impact of Health Reform on Health System 
Spending, The Commonwealth Fund (May 2010) (online at http://
www.commonwealthfund.org//media/Files/Publications/Issue%20Brief/2010/
May/1405_Cutler_impact_hlt_reform_on_hlt_sys_spending_ib_v4.pdf).
---------------------------------------------------------------------------
    In addition to delivery system reforms that will drive down 
costs, the ACA made significant strides in rooting out waste 
and overpayments in the traditional Medicare program. For 
example, overpayments to Medicare Advantage plans were reduced, 
and payments to providers were aligned to encourage 
improvements in health care productivity. The Centers for 
Medicare & Medicaid Services (CMS), the Department of Health 
and Human Services Inspector General, and the Justice 
Department were given more tools and more resources to find and 
prevent fraud in Medicare and Medicaid. In February 2012, the 
Justice Department and the Department of Health and Human 
Services announced record-breaking health care fraud recoveries 
for the preceding year of $4.1 billion--the highest annual 
amount ever recovered from individuals and companies who 
attempted to defraud seniors and taxpayers or who sought 
payments to which they were not entitled.\6\
---------------------------------------------------------------------------
    \6\U.S. Department of Justice, Health Care Fraud Prevention and 
Enforcement Efforts Result in Record-Breaking Recoveries Totaling 
Nearly $4.1 Billion, (Feb. 14, 2012) (online at www.justice.gov/opa/pr/
2012/February/12-ag-213.html).
---------------------------------------------------------------------------
    The net effect of all of these system improvements--which 
will benefit patients directly through lower out of pocket 
costs and improved care--is a dramatic slowdown in projected 
Medicare spending. Over the 25 years from 1985 to 2009, 
Medicare per capita spending growth averaged 6.7%; over the 
next 10 years, the Medicare Trustees project that Medicare per 
capita spending will grow by just 3% on average.\7\ The long-
run actuarial deficit in Part A, hospital insurance, was 
reduced by more than 80%, contributing to a significant 
extension in the solvency of the Trust Fund.
---------------------------------------------------------------------------
    \7\J. Ebeler et al., The Independent Payment Advisory Board: A New 
Approach to Controlling Medicare Spending, The Kaiser Family Foundation 
(Apr. 2011) (online at http://www.kff.org/medicare/upload/8150.pdf); 
see also Center on Budget and Policy Priorities, Statement: Robert 
Greenstein, President, on the 2011 Medicare Trustees' Report (May 13, 
2011) (online at http://www.cbpp.org/cms/index.cfm?fa=view&id=3494).
---------------------------------------------------------------------------
    Savings estimated to arise from IPAB-directed payment 
changes were just 4% of the overall savings in the ACA. 
Nevertheless, the IPAB was included in the legislation as a 
back stop. While we have seen cost growth slow significantly, 
and anticipate the Affordable Care Act's reforms further 
contributing to moderating health care cost growth, in the 
event that the cost trends change, the IPAB remains as a 
patient-oriented, evidence-based approach to addressing 
spending challenges--without sacrificing coverage, quality, or 
access to care.
    IPAB is not perfect; even IPAB supporters have advocated 
for changes in the IPAB statute. But it is far preferable to 
wholesale repeal, particularly in the face of the Republican 
alternative to the IPAB's patient-focused approach.
    In contrast to the IPAB, which kicks in only if spending 
targets are exceeded and which explicitly cannot recommend 
changes that would affect a beneficiary's costs, benefits, or 
access, the Republican proposals for Medicare, as outlined in 
the Ryan budget, would increase beneficiary costs starting in 
2013. These costs increases rise dramatically in 2022, when the 
Republican plan would end the Medicare program and replace it 
with a voucher.
    Below are a few examples of how the Republican alternative 
would adversely affect seniors. In contrast, with the IPAB, 
these important areas would be harmed under the Republican 
plan:
    Prevention and wellness. The Republican plan for Medicare 
would impose cost sharing of 20% or more on those services.
    In contrast, under the ACA, the average Medicare 
beneficiary will save $4,200 between 2011 and 2021 in out of 
pocket costs. Already, from January through November 2011, 24.2 
million individuals enrolled in traditional Medicare (or 69.5% 
of those enrolled in the program) received one or more free 
preventive services. In addition, 1.9 million individuals 
enrolled in traditional Medicare took advantage of the new free 
Annual Wellness Visit.\8\
---------------------------------------------------------------------------
    \8\ Office of the Assistant Secretary for Planning and Evaluation, 
ASPE Issue Brief: Medicare Beneficiary Savings And the Affordable Care 
Act (Feb. 2, 2012) (online at http://aspe.hhs.gov/health/reports/2012/
MedicareBeneficiarySavings/ib.pdf).
---------------------------------------------------------------------------
    Savings on drug costs. The Republican plan for Medicare 
would put an end to the savings on prescription drug costs 
provided to people with Medicare under the ACA and would 
instead increase seniors' costs for these medicines.
    In contrast, under the ACA, seniors benefit from a drug 
discount program for beneficiaries in the ``donut hole.'' These 
discounts stared in 2010, and they will phase out the donut 
hole by 2020. During 2011, 3.6 million people with Medicare 
saved $2.1 billion on their prescription drugs due to the 
Affordable Care Act. These individuals who hit the donut hole 
saved an average of $604 on the cost of their prescription 
drugs.\9\
---------------------------------------------------------------------------
    \9\Id.
---------------------------------------------------------------------------
    Individuals who are dually eligible for Medicare and 
Medicaid. The Republican plan for Medicare would slash the 
Medicaid program beginning in 2013, leading states ``to reduce 
payments to providers, curtail eligibility for Medicaid, 
provide less extensive coverage to beneficiaries, or pay more 
themselves than would be the case under current law,'' 
according to the CBO.\10\
---------------------------------------------------------------------------
    \10\ Letter from Douglas W. Elmendorf, Director, Congressional 
Budget Office, to Rep. Paul Ryan, U.S. House of Representatives (Apr. 
5, 2011) (online at http://www.cbo.gov/sites/default/files/cbofiles/
ftpdocs/121xx/doc12128/04-05-ryan_letter.pdf).
---------------------------------------------------------------------------
    Medicaid is the largest payer for long-term care services, 
and helps 9 million Medicare beneficiaries fill in the cost 
sharing, premiums, and other benefits Medicare does not cover. 
The Affordable Care Act not only protected coverage for these 
individuals but also increased benefits and boosted provider 
payments to ensure access to care.
    In all, the Republican plan would end the Medicare program 
in 2022 and replace it with a voucher. Most dramatically, the 
Republican plan would increase overall Medicare costs for new 
beneficiaries by more than $6,000 per person per year, starting 
in 2022, and would compound those costs indefinitely. Total 
cuts to the Medicare program would reach $20 trillion by 2050.
    Far from promoting efficiency, as the IPAB would do, the 
Republican proposal is actually estimated to increase health 
care costs overall by requiring seniors to buy coverage from 
inefficient private plans. CBO said:
        A typical beneficiary would spend more for health care 
        under the proposal than under CBO's long-term scenarios 
        for several reasons. First, private plans would cost 
        more than traditional Medicare because of the net 
        effect of differences in payment rates for providers, 
        administrative costs, and utilization of health care 
        services . . . Second, the government's contribution 
        would grow more slowly than health care costs, leaving 
        more for beneficiaries to pay.\11\
---------------------------------------------------------------------------
    \11\Id.
---------------------------------------------------------------------------
IPAB Operations
    The Independent Payment Advisory Board is an expert panel 
composed of 15 Presidentially appointed and Senate-confirmed 
individuals.\12\ The IPAB is designed to be a fallback option 
for cost control, not a primary option. Only if Medicare 
spending growth is not brought lower than the statutory targets 
are binding IPAB recommendations issued.
---------------------------------------------------------------------------
    \12\The Affordable Care Act, Section 3403. For a comprehensive 
summary of the IPAB's statutory design, see David Newman and 
Christopher Davis, The Independent Payment Advisory Board, 
Congressional Research Service (online at http://www.crs.gov/pages/
Reports.aspx?PRODCODE=R41511&Source=search); see also J. Ebeler et al., 
The Independent Payment Advisory Board: A New Approach to Controlling 
Medicare Spending, The Kaiser Family Foundation (Apr. 2011) (online at 
http://www.kff.org/medicare/upload/8150.pdf).
---------------------------------------------------------------------------
    IPAB not likely to be triggered. The ACA reduced projected 
Medicare spending growth to historically low levels; 
accordingly, CBO has judged that IPAB is not likely to make 
binding recommendations at any point in the next decade. Only 
if CBO is incorrect, and Medicare spending growth exceeds 
projections, will IPAB be empowered to make binding 
recommendations to the Congress.
    IPAB is statutorily prohibited from rationing, raising 
costs on seniors, or cutting benefits. The statute is explicit 
in stating that IPAB recommendations may not involve rationing 
care, increasing cost sharing, premiums, or taxes, or reducing 
benefits. The statute provides expressly that IPAB's 
recommendations may not ``include any recommendation to ration 
health care, raise revenues or Medicare beneficiary premiums . 
. . increase Medicare beneficiary cost-sharing (including 
deductibles, coinsurance, and copayments), or otherwise 
restrict benefits or modify eligibility criteria.''\13\
---------------------------------------------------------------------------
    \13\Section 1899A(c)(2)(ii) of the Social Security Act (P.L. 74-
271) added by Section 3403 of the ACA. The board is required to 
consider giving priority to recommendations that increase Medicare's 
solvency, protect and improve access to care, and consider targeting 
recommendations on sources of excess growth in Medicare.
---------------------------------------------------------------------------
    IPAB does not usurp congressional authority. Once the IPAB 
recommendations are submitted to the Congress, they may be 
modified by committees of jurisdiction and 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).
    IPAB savings are moderate, based on evidence, and intended 
as a backstop to advise the Congress. Spending reductions 
recommended by the IPAB may not exceed 0.5% of Medicare 
spending in 2015, phasing up to 1.5% in 2018 and beyond. If the 
spending growth targets are not exceeded, the IPAB may still 
make recommendations to reduce spending in Medicare, but those 
recommendations are not automatically implemented and are not 
given fast track procedures in Congress.
    If the IPAB is not able to produce recommendations that 
meet the requirements in statute, the Secretary of HHS is 
required to submit recommendations to Congress that meet those 
requirements. The Secretary's recommendations would then be 
referred to committees for the same consideration received by 
IPAB recommendations.
    In conclusion, H.R. 452 is simply another attempt on the 
part of the Republicans to repeal the Affordable Care Act by 
any means possible, with no alternative to address America's 
health care needs other than a draconian plan to destroy 
Medicare, shifting more costs on to individuals who need health 
care in their time of need. That is why this bill should be 
rejected on the House floor.

                                                   Henry A. Waxman.

                                  
