It's hard to make the big changes needed in Medicare when so much favors the status quo. As we told you yesterday, President Obama in his health reform letter to Senators Baucus and Kennedy broached the possibilty of granting more power to a revamped MedPAC, which would diminish some of Congress' authority to preserve the status quo over spending and benefits.  He wrote:

To identify and achieve additional savings, I am also open to your ideas about giving special consideration to the recommendations of the Medicare Payment Advisory Commission (MedPAC), a commission created by a Republican Congress. Under this approach, MedPAC's recommendations on cost reductions would be adopted unless opposed by a joint resolution of the Congress. This is similar to a process that has been used effectively by a commission charged with closing military bases, and could be a valuable tool to help achieve health care reform in a fiscally responsible way.

This idea is similar (though not identical) to a bill introduced by Senator Jay Rockefeller in late May that would increase the power of MedPAC. (It's been dubbed the "MedPAC on steroids" option). Right now MedPAC is a legislative advisory body; Rockefeller would move it to the executive branch and expand its powers. The commission would be given the authority to make reimbursement decisions—and implement them. Rockefeller argues that this would protect Medicare policy from the whims of Members of Congress, who can be more susceptible to special interest money and niche constituencies they represent—or even to local sob stories, when a patient or family is convinced that a treatment or drug or procedure should be covered, even when the evidence suggests that it should not.

Rockefeller's idea is among one of several that have circulated about giving MedPAC more oomph—and insulating decisions from politics. As Len Nichols, director of New America's Health Policy Program told the Washington Post, "The thing I'd say about the whole genre of proposals in this area is that it's really about empowering information and science and evidence over lobbying. Everyting else is a device to make that happen."

Len, Robert Berenson of the Urban Insitute and I co-authored a paper in March about Medicare governance. The idea was that either a revved up MedPAC or a new board (in that paper we called them the Medicare "Guardians" as in Plato's guardians in The Republic) would be an independent agency, somewhat like the Fed. (If we understand Rockefeller's vision, MedPAC wold be in the executive branch and thus would ultimately answer to the president.)

In the scenario we outlined, board members would be nominated by the president, confirmed by the Senate, and serve staggered six-year terms, renewable once. Like the current MedPAC members, they would be highly qualified health care experts and represent the broad spectrum of stakeholders. But unlike MedPAC commissioners today, they would serve full-time and have a larger staff. Members would be split among the political parties, as in the FCC and FEC. We won't go into every detail here (you can read the paper, starting on page 44, or the summary), but the main point is that Congress would still have oversight and pass "big picture" legislation on financing and eligibility. The board and CMS would have authority over myriad smaller coverage and payment decisions, walled off from politics. The goal is more accountability to beneficiaries and taxpayers, and less to special interests and officials.

All that said, we heartily applaud President Obama and Senator Rockefeller for moving ahead the discussion about a more sensible and accountable way to run Medicare. We hope that this opens up a dialogue on the often overlooked area of governance within health care policy.