Why Democratic Party Discipline May Be Harmful to the Health of Rhode Islanders

Rhode Island's Republican candidates for Federal office would like to replace the Patient Protection and Affordable Care Act (PPACA, aka Obamacare) with something different. Senate Candidate Barry Hinckley calls for outright repeal on his campaign website; Second District Congressional candidate Michael Riley wants most of it repealed while retaining certain provisions, and First District Congressional candidate Brendan Doherty has said he will support Obamacare repeal if it is coupled with an effective replacement. Rhode Island’s Democratic incumbents feel differently. Senator Sheldon Whitehouse said in his first television advertisement that he is proud of having supported the new healthcare law and First District Congressman David Cicilline has made Doherty's willingness to repeal and replace Obamacare a major part of his TV advertising. Given this range of positions, Rhode Island voters need to give some consideration to the narrow range of healthcare options that the Obamacare structure commits them to.

A central feature of the PPACA is a fifteen-member executive-branch body, all members to be appointed by the President and confirmed by the Senate, called the Independent Payments Advisory Board (IPAB). Under the current law, IPAB proposals can acquire the force of law under certain conditions (and are expressly exempt from judicial review), unless the President and Congress agree upon alternate means for achieving certain fiscal targets. Functionally, IPAB is supposed to be the major cost containment measure in Obamacare, though at this time, according to the direct text of the legislation...

[IPAB proposals] shall 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.

Congressmen Cicilline and James Langevin have actually voted in favor of having an IPAB not just once, but twice. The first time was during the initial passage of Obamacare, when the measure passed with no Republican votes, at around the time the Democratic speaker of the House Nancy Pelosi was telling citizens and legislators alike that "We have to pass the bill so you can find out what is in it". The second time was in March of 2012, when both Congressmen voted against a measure that would specifically repeal IPAB while leaving most of the rest of Obamacare intact. IPAB seems to be central to the Democratic vision of healthcare and not something peripheral, and all four members of Rhode Island’s Federal delegation have expressed support for some form of IPAB.

Though the point of IPAB is to contain costs, influential figures within Democratic policy circles have expressed skepticism that it can do so given the current limits on its mandate. Christina Romer, former Chairwoman of Council of Economic Advisors under President Obama, wrote in the New York Times that "even with the law...more steps to contain costs will have to be taken" and that "once [IPAB] has a track record...perhaps it could be empowered to suggest changes in benefits or in how Medicare services are provided". Steve Rattner, the man selected by President Obama to be his “car czar”, went even further in the Times -- scary further -- writing that IPAB could become an appropriate mechanism for rationing (he explicitly uses that term) because too much money is spent in the United States on end-of-life care. People like Romer and Rattner are not fringe academics; of course, they haven't been elected to office either -- but the whole point of IPAB is to put lawmaking power in the hands of people who haven’t been elected to office.

If IPAB in its current form fails to contain costs -- and there's little reason to believe that Chirstina Romer, Steven Rattner and standard economic theory are all wrong about a program of purchase mandates and government subsidies not being effective means to reduce costs -- representatives of the citizens of Rhode Island will likely be asked in the very near future to decide on a either a Democratic alternative to "enhance" IPAB or a Republican alternative to repeal IPAB and Obamacare-in-general and replace them with something else. Voters should be aware this November when making their choices for Congressman and Senator this November, that candidates who uncritically accept the national Democratic party line on this matter are prepared to lock their constituents into a very narrow range of healthcare choices: living with fantasy economics until fiscal calamity forces a change (always a Rhode Island favorite), or giving IPAB the power to implement rationing, or possibly both, to stay safely within the bounds of their political partisanship.