As the GOP steps up its attacks against the Independent Payment Advisory Board (IPAB) — a 15 panel commission that would make recommendations for lowering Medicare spending to Congress — Matt Yglesias suggests that the very same Republicans who argue the IPAB would ration care are “the very same members of congress who voted this month to privatize Medicare in 2022 and enact draconian cuts throughout the 2020s and 2030s are here in town right now defending health care providers’ right to charge the government high prices for services that don’t work.” But now, some Democrats are also distancing themselves from the IPAB, arguing that the board’s structure — its cuts would go into effect unless Congress acts — usurps Congressional authority. Jonathan Cohn has those details:

But now some Democrats are joining the calls for repeal, as Jennifer Haberkorn first reported in Politico last week and as Robert Pear notes today in the New York Times. The IPAB was never particularly popular with more liberal House Democrats, who didn’t want to cede power over Medicare to another authority. But, at least for the moment, opposition is coming from a different part of the caucus. The Democrat leading the charge against the IPAB right now, for example, is Allyson Schwartz, a self-proclaimed New Democrat who represents the northeastern Philadelphia and the nearby suburbs.

Why does Schwartz want to get rid of IPAB? In a letter announcing her intentions, Schwartz said it was undemocratic to hand over that authority to a commission. And that’s a legitimate (if, in my view, unpersuasive) argument.

So Republicans are claiming that the board will ration — even kill — seniors, while Democrats are suggesting that Congress can do a better in controlling health care spending. I would argue that both are wrong. As to the GOP’s argument, the board kicks in if health care spending increases beyond a specific threshold and is specifically prohibited from rationing. The IPAB’s recommendations cannot “include any recommendation to ration health care, raise revenues or Medicare beneficiary premiums…increase Medicare beneficiary cost- sharing (including deductibles, coinsurance, and co- payments), or otherwise restrict benefits or modify eligibility criteria,” Section 3403 (page 409) of the Affordable Care Act stipulates.

As to the Democratic criticism, I would argue that it’s far better to have representatives of the various stakeholders in health care — drug companies, hospitals, doctors, patients — (all of whom are nominated by the president and confirmed by the Senate) making these decisions in a transparent, public, and accountable manner and then submitting their plan to Congress for a vote, than resting the cost-cutting powers in the hands of politicians and lobbyists who will undoubtedly reach their decisions without any kind of public input.

The Boston Globe’s Christopher Rowland looks at why Mississippi Governor and potential presidential candidate Haley Barbour (R) is so vigorously opposed to expanding the state’s Medicaid program, which could result in “new Medicaid benefits flowing to 300,000 to 400,000 Mississippi residents.” In a phone interview with the paper, Barbour made it clear that he doesn’t believe that the state — which has an 18 percent uninsurance rate, 28 percent poverty rate and suffers from very high instances of obesity and chronic diseases — is experiencing a health access problem. Residents just need to eat better and exercise, he maintains:

“There’s nobody in Mississippi who does not have access to health care.” … Hospitals and doctors in the state routinely provide charitable care, he said. Residents also can get care from clinics such as the one by the side of Route 49 in Yazoo City, as well as larger and better-equipped community clinics scattered around the state. And Barbour pointed to his efforts in the Mississippi Legislature, unsuccessful so far, to win passage of a voluntary insurance exchange where small businesses and individuals could shop for insurance at discount rates. [...]

“Most of the health disparities in Mississippi are not because of the inability to get access or afford health care,’’ said Barbour. “They are because of diet, alcohol, because of drugs, the very high incidence of illegitimacy that leads to high incidence of low-birth weight children.

“I grew up in a society where if it wasn’t fried you were asking, ‘Why not?’ If it was good you would make it even better with a lot of sugar and butter on it.’’

He added that substance-abuse prevention and encouraging healthier diets do not require a massive expansion of Medicaid.

An ounce of prevention is worth a pound of cure, but expanding access to coverage would actually improve access to preventive services and help tackle the high instances of chronic conditions in the states. In fact, the health law actually provides enhanced Federal Medicaid matching funds to States that offer evidence-based prevention services.

What baffles providers in the state is why Barbour is turning down a deal under which the federal government — because of the expansion to Medicaid under the Affordable Care Act — “will pick up 100 percent of the cost of the Medicaid expansion from 2014 to 2016 and 90 percent of the cost after 2020.” It’s true that the state will have to spend extra dollars to cover the expanded population, but those services are worth paying for in a state where many people “earn too much to qualify for Medicaid but not nearly enough to purchase private insurance” and go without needed medical care. Barbour estimates that the state’s share of expanding the Medicaid eligibility umbrella, “while starting at zero, could climb to as much as $237 million a year by 2020 — when the state would have to start picking up 10 percent of the cost.” That’s a good investment — a tiny share of the total price tag — and well worth it for the benefit of expanding access to care for hundreds of thousands of residents and reducing the heavy costs of uncompensated care that hospitals and doctors now have to provide.

In fact, it’s far more sensible than the current system in which every resident of Mississippi has access to care in the emergency room. Barbour is right on that point, but he can’t possibly think that having uninsured individuals flock to the emergency room for something that could have been handled in a primary care setting or addressed through preventive care is a smart or efficient use of taxpayer dollars.

At least two Republicans are on record condemning the Medicare reforms in Rep. Paul Ryan’s (R-WI) proposal and now former Wisconsin Governor and Health and Human Services Secretary Tommy Thompson is also weighing in against the GOP’s plan to voucherize the program. In an op-ed for the Huffington Post, Thompson writes that while encouraging seniors to have “more skin in the game” should be part of the dialogue, policy makers need to focus on changing the incentives in the system to encourage providers to deliver care more efficiently rather than simply cutting the program:

The good news is that we don’t have to wait to begin to realign physician incentives. The Affordable Care Act gives great discretion to the CMS Administrator to experiment with alternative payment systems. CMS has created an “innovation center” and is looking for ideas. I believe the administration should use its discretion to begin to experiment with capitated payment, where one fee is paid for a patient episode of care, regardless of how many procedures are performed. [...] House Budget Chairman Paul Ryan (R-WI) is leading an important conversation about how to develop a system that would encourage consumers to put some skin in the game. [...]

Simply cutting Medicare isn’t the answer by any means. Instead, let’s focus on the most effective fiscal path forward with the least amount of impact on millions of seniors, their families and our broader economy. In other words, reform Medicare, don’t cut it.

Ryan has taken a lot of heat for failing to find health care savings from within the health care system and instead slashing the federal contribution to the program and shifting the extra costs onto seniors. The Congressional Research Service (CRS) reports that it’s unclear if Ryan budget would protect the parts of the law that Thompson is trumpeting, those “that would test various patient care models including accountable care organizations,” but Republicans have previously voted to repeal those provisions.

This isn’t the first time Thompson — who Sen. John McCain (R-AZ) has dubbed “the smartest guy on health care” — has broken with traditional GOP orthodoxy. In November 2010, Thompson said Republicans shouldn’t repeal the entire Affordable Care Act. “When it’s all said and done, you’re not going to be able to repeal health care because President Obama is not going to sign it,” he said. “[T]he overall health care is going to have take a wait-and-see attitude before all the rules are done and drafted.”