June 15th, 2012
The Patient Protection and Affordable Care Act (ACA) establishes the executive-appointed 15-member Independent Payment Advisory Board (IPAB). The IPAB is an expert body charged with trimming Medicare costs and improving the quality of health care. Board members will be required to make recommendations to cut Medicare funding in years when spending growth exceeds targeted rates. The board is not allowed to recommend changes in premiums, benefits, eligibility, or taxes, or other changes that would result in “rationing” of care to Medicare beneficiaries. For Congress to block IPAB recommendations, it must veto the board’s proposal with a 60 percent majority and pass alternative cuts of the same size. The IPAB could make its first recommendations as early as 2014.
The IPAB is a key element of the ACA and a source of intense debate, particularly in Congress, about the appropriate role of experts in policymaking. On one side are those who are extremely concerned about an independent expert panel making health policy decisions, as opposed to elected members of Congress or individual clinicians. Opponents of the IPAB point to the fact that it does not function in a truly advisory capacity but instead makes policy. They also argue that it will reduce Medicare spending by eliminating or reducing access to expensive new therapies, drugs, and devices. On the other side, proponents in and out of Congress note that historically it has been extremely difficult for Congress itself to make policy decisions that reduce Medicare spending due to political pressure and lack of consensus over how to slow expenditures. In March 2012, the House passed legislation to repeal the IPAB with a vote that reflected the significant divide on Capitol Hill on this score.
In this post, we suggest that the IPAB controversy is part of a larger philosophical debate about the appropriate role of science and evidence in government decisionmaking. Because this issue has already evoked so much political controversy before its implementation, we focus on the political forces that that are likely to shape responses by elected officials and the public to IPAB recommendations.
Our observations are based on a substantial body of literature that has examined the role of experts and evidence on political decisionmakers’ views and those of the general public. These reviews suggest that the context in which a policy issue is being decided and its particular nature determine how evidence will influence public-sector decisionmaking. Many of these studies suggest that scientific-based policy decisions and politics are often inseparable.
This includes at times the critical influence of public opinion on decision-making. Prior studies have shown these views can influence the responses of elected officials. Placing the IPAB debate in this broader political analysis framework allows us to identify several factors that are likely to shape public and elected officials’ responses to IPAB recommendations in the future. We also highlight proposals for cutting Medicare spending that are more or less likely to generate significant political controversy. In the last section, we provide some general guidelines for increasing the use of evidence in policymaking in a more political environment that has surrounded recent policy decisionmaking nationally.
I. Expert panels and health care: Public perspectives on the use of science and evidence in policymaking
If the ACA goes into effect as currently written, the IPAB will make choices about how to trim Medicare costs and improve the quality of health care. Decisions made by the panel will directly affect certain segments of the population, and experts will need to maintain public trust and support.
The panel will begin its deliberations in a climate where two-thirds of Americans (67 percent) already believe that the government and private insurance plans withhold high-cost prescription drugs and treatments very or somewhat often from some people who might benefit from them in order to save money. In addition, about six in ten Americans (61 percent) say they do not trust the federal government to make the right health care decisions.
Even before the IPAB is established, polls show that a substantial proportion of Americans express little trust in expert panels in health care to make recommendations about coverage and spending. When asked how much they would trust a panel of experts from a scientific organization to make recommendations about the tests and treatments that should be covered by insurance companies, more than four in ten (41 percent) said they would trust such a panel “just a little” or “not at all.”When such a panel was described explicitly as being appointed by the federal government from an independent scientific organization, a majority (57 percent) expressed little or no trust.
When Americans were asked how much they would trust an independent panel of fulltime experts appointed by the president and confirmed by the Senate to make proposals about ways to reduce Medicare spending and keep the program sustainable in the future, nearly half (47 percent) expressed little or no trust. These are exactly the type of decisions that the IPAB is charged with making.
Added to this level of public distrust of expert panels are large differences in the views of Republicans and Democrats, likely to be reflected in Congress. In each of the three cases described above, a clear majority (57 percent to 69 percent) of Republicans expressed little or no trust in expert panels. When it comes to an independent panel to make proposals about Medicare, 59 percent of Republicans expressed this level of distrust, compared with 33 percent of Democrats.
II. Anticipating public and policymaker reactions to IPAB recommendations
In addition to partisan differences, there are several other factors that are likely to drive public, and by extension elected officials’, responses to IPAB recommendations. These include the salience, complexity, and existing polarization surrounding proposed Medicare changes, and the information preferences, experiential knowledge, and policy goals of members of Congress.
A. Salience, complexity, and polarization
The salience, complexity, and polarization around IPAB-proposed Medicare changes will influence the reaction of the public and elected officials. Some changes to Medicare would be highly visible to the public, and policymakers are likely to be held accountable for their choices by the public; other changes to the program are likely to receive little public attention or scrutiny. Although the IPAB is not authorized to make some of the most politically charged changes to Medicare—raising premiums, altering program eligibility, or other changes that result in “rationing” of care—the panel may choose to make a variety of potentially high-profile changes not covered by those limitations, such as changing physicians’ fees. The importance of public salience of the changes draws support from work on the influence of public opinion on policy outcomes. (See for example here, here, here, here, here, here, and here.) As the visibility of an issue increases, so does the level of government responsiveness to the public’s view. When issue salience is taken into consideration, public opinion always has a substantial effect on policy.
The link between issue salience and government responsiveness suggests that Congress is likely to give IPAB recommendations more scrutiny when they implicate areas of care that are very salient to the public. Policymakers will be more attentive to public opinion and IPAB recommendations may be met with stiff opposition from elected officials if they suggest policy options that are inconsistent with deeply held public or constituent preferences. The complement to this is that when a proposed change is not very visible or is somewhat far-removed from the public eye—for example, spending formulas for skilled-nursing facilities or administrative cost payment charges to private health insurers that offer Medicare Advantage plans—policymakers may be more likely to adopt the IPAB’s recommendations.
Complexity refers to the technical aspects of the decision in question. Some IPAB recommendations might call for members of Congress to espouse a broad set of principles or values, while others are narrow in scope and require considerable knowledge about how a system or process works. An earlier examination the role of health services research in public policymaking found that technical or “content-driven” decisions were more amendable to the influence of research. This suggests that IPAB recommendations that focus on more nuanced mechanisms to control Medicare costs—such as risk adjusted payments to private health plans—might be viewed by the public and elected officials as a policy decision best left to the experts.
Finally, the degree of polarization around a given issue — the extent to which views and preferences are divided among policymakers and the public — is critical to an assessment of how members of Congress are likely to respond to IPAB recommendations. Some issues, such as end-of-life care, involve deeply held religious or moral beliefs and tend to arouse strong emotional reactions in various segments of the population. (See Benson JM, Herrmann MJ., “End-of-life care”, in American Public Opinion and Health Care, Blendon RJ, Brodie M, Benson JM, Altman DE, editors, Blendon RJ, Brodie M, Benson JM, Altman DE, editors pp. 318-345)
Research suggests that when individuals consider these value-laden issues, many find it difficult to incorporate scientific evidence in their decisionmaking. Prior research indicates that emotional responses are relatively insensitive to the present of scientific data, and introducing evidence in the context of highly polarized issues is likely to reinforce—as opposed to change—pre-existing opinions. In these situations, individuals accept confirmatory evidence at face value, while subjecting contradictory evidence to critical evaluation and scrutiny. IPAB recommendations that touch on sensitive and polarizing topics will very likely be met with significant resistance from Congress and generate intense political debate.
B. Information preferences, experiential knowledge, and policy goals
The IPAB’s recommendations will be subject to congressional review and elected officials are likely to evaluate and obtain evidence differently than IPAB members. Congressional decisionmakers’ past and present experiences, information preferences, and policy goals will serve as a filter through which the recommendations are processed. Information preferences refer to how members of Congress are likely to obtain evidence and the indicators they use to assess the quality of evidence. Legislators and public officials often rely on the advice of trusted colleagues, favor sources they perceive as credible and trustworthy, and prefer face-to-face oral communications. They are also more likely to choose sources that summarize data and provide condensed treatment of complex issues due to heavy demands on their time and attention. Accessibility matters a great deal and refers to the ease with which legislators can obtain policy-relevant evidence. Evidence can be more or less accessible depending on the effort and costs that are required to locate the information. Given this context, the IPAB recommendations most likely to minimize political controversy about the appropriate means to cut Medicare spending will incorporate readily available evidence from sources that are respected by a wide range of policymakers and describe how the proposed change will work in plain language.
Legislators will often draw on their own personal experience—and the experiences relayed by vocal constituents—to assess the quality and feasibility of IPAB recommendations. Moreover, they may have policy goals that will limit the direct application of evidence—or in this instance, IPAB recommendations—to policy problems. Balancing budgets, collaborating with colleagues, or responding to constituents may take priority over incorporating or considering scientific evidence or research. Moreover, evidence-based policy recommendations may be more or less consistent with a legislator’s political party or ideology. If an IPAB recommendation suggests changes contrary to party views or beliefs, it is likely to be rejected by that elected official and he or she will distance him or herself from that policy option. The IPAB’s cost-cutting proposals for Medicare may promote consensus among elected officials—or at least avoid intense scrutiny—if they avoid changes that will impact widely used plans or services that many Medicare beneficiaries or elected officials have experience with.
III. Looking forward: Diminishing controversy and increasing the use of evidence in health policymaking?
As with the ACA itself, the fate of the IPAB is unclear. Assuming that the IPAB survives pending challenges, its recommendations are likely to be introduced into a highly polarized and partisan environment and this context will influence how proposed Medicare changes are received.Many Americans may not trust recommendations presented by an independent panel of experts. Moreover, Republicans are less likely to trust the decisions of expert panels.
Issue salience, complexity, and polarization will also shape how the IPAB’s proposals are viewed in this environment. IPAB recommendations that touch on sensitive and polarizing aspects of the program will very likely be met with resistance and generate intense political controversy. Conversely, recommendations that target complex or technical aspects of Medicare spending, such as rebates from prescription drug manufacturers under Medicare Part D or payments to private plans, may be more readily accepted by the public and elected officials.
The information preferences and experiential knowledge of Congress will serve as a lens through which members will view IPAB recommendations and elected officials may be more likely to challenge proposals that affect widely used constituent plans or services. The IPAB is rooted in a desire to see Medicare policy move past politics and the undue influence of special interests. However, its success in generating cost-cutting proposals that are actually adopted will rest in part on a solid understanding of the political context in which its recommendations are made.
In the current difficult economic times, public views about independent economic regulatory boards, such as the Federal Reserve, are mixed, with many holding unfavorable views. However, they have become an established part of U.S. economic decisionmaking. The initial decisions and priorities of the IPAB could shape its future political support or opposition and determine whether or not it becomes an established decisionmaking institution in U.S. health policy.Email This Post Print This Post