NEJM Perspective: Politics are still entrenched in health care policy, Oberlander says

June 05, 2013
Dr. Oberlander

Dr. Oberlander

The Independent Payment Advisory Board (IPAB), an entity empowered by The Affordable Care Act to recommend changes to Medicare if projected spending is not adequately moderated, seems to be “stuck in purgatory,” according to Jonathan Oberlander, PhD, in a May 29 “Perspective” in The New England Journal of Medicine.

Oberlander is professor of health policy and management in the Gillings School of Global Public Health and of social medicine in the UNC School of Medicine.
The IPAB has been controversial since it was established as part of the ACA. Recommendations of the (potentially) 15-member, nonelected board are to be implemented by the U.S. health and human services secretary if Congress does not approve the recommendations or propose alternate cost-saving legislation in a timely way.
The board’s supporters say it ensures that Medicare’s growth is moderated, even if Congress ignores the problem. IPAB’s critics, who include members of health care industry groups, fear that the board’s proposals will cause Medicare payments to drop. Other critics, particularly Republicans, believe it to be a rationing of medical care.
With all the storm und drang, it appears nobody noticed on April 30 when a report projecting Medicare spending growth through 2015 was released. The report forecasts spending growth of 1.15 percent from 2011 to 2015, far below the target growth rate.
“Because Medicare spending growth has moderated,” Oberlander writes, “the IPAB will not be as important as either its supporters or its detractors have claimed. It’s much more likely to be irrelevant than to become the centerpiece of cost containment. Now the IPAB’s ability to move forward at all is in doubt.”
Three years after the enactment of the ACA, the IPAB still has no members. The President has not nominated anyone, and Republican leaders have not provided suggestions for appointees.
“The difficulties in launching the IPAB point to a more fundamental problem,” Oberlander says. “The board’s appeal lies largely in its aspiration to remove politics from Medicare — to create a policymaking process that is informed by experts and insulated from electoral pressures, interest-group demands, financial considerations, and partisan divisions. But given Congress’s extreme partisan and ideological polarization, the ongoing fight over the ACA, the legacy of mythic ‘death panels,’ and recriminations over Medicare reform, the IPAB’s rough start should not be surprising. This is not the sort of political environment in which an independent board charged with making controversial decisions about one of America’s most popular social programs is likely to thrive.”
Oberlander says the board’s difficult early journey “has underscored just how entrenched politics are in health care policy.”


Gillings School of Global Public Health contact: David Pesci, director of communications, (919) 962-2600 or