Association for Public Policy Analysis & Management

Enacted as part of the 2010 Patient Protection and Affordable Care Act, the Medicare Independent Payment Advisory Board (IPAB) was hailed by some analysts as a major institutional innovation in US health policymaking and cost control. If per-person Medicare spending growth exceeded specified targets, a non-elected board of experts would be empowered to make recommendations to curb Medicare spending to Congress. IPAB embodied the aspirations of technocracy: an expert, non-elected board could rise above both partisanship and interest group pressures, formulating Medicare policy recommendations on the basis of reason rather than politics. Yet IPAB never managed to escape the politics and partisanship that its advocates had hoped the new board would counter. From its inception, Congressional Republicans criticized IPAB as an instrument of rationing and bureaucratic intrusion in medicine, alleging that it was a real life “death panel”. Major segments of the health care industry, fearful that IPAB would reduce Medicare payments, opposed it intensely and called for eliminating IPAB. And even some Democrats who supported the ACA were wary of surrendering Congressional powers to an unelected board.

This paper aims to explore what the IPAB experience tells us about the promise and limits of technocracy in US health policy. How did Congress come to pass IPAB and how do we understand its appeal to many in the health policy community? Why did IPAB not only fail to live up to the hype, but never get off the ground? And how do a political environment of polarization as well as the institutional arrangements of US government impact the opportunities for use of evidence and expertise in policymaking? IPAB’s history offers a cautionary tale about the limits of evidence-based and expert panels in policymaking.

I will review the origins of IPAB, its rationale, proposed structure, associated controversy, and non-implementation. The paper will explain why IPAB and the idea of rational policy resonated strongly in health services research and with some policymakers. The paper will also draw on political science research on delegation of legislative powers to administrative bodies and explore what examples from other areas of policymaking can tell us more broadly about the success and failure of efforts to create and sustain independent boards. I will argue that IPAB was destined to fail in part because the conditions necessary for an independent board to succeed did not exist either in Medicare or in US politics. I will also argue that IPAB was an answer to an ostensible problem—Congressional inaction on high Medicare spending—that was incorrectly diagnosed. Finally, I will explore why the vision of an apolitical health policymaking, which has long roots in American politics and was reflected in IPAB’s technocratic aspirations, is ultimately impossible to achieve.