The Independent Payment Advisory Board: Why It Is So Difficult to Kill the Death Panel Myth

In August of 2009, Sarah Palin claimed that the health legislation being crafted by Democrats at the time would create a “death panel,” in which government bureaucrats would decide whether disabled and elderly patients are “worthy of healthcare.”  Despite being debunked by fact-checkers and mainstream media outlets, this myth has persisted, with almost half of Americans stating recently that they believe the Affordable Care Act (ACA) creates such a panel.

The death panel myth killed neither the ACA nor Obama’s reelection bid.  But persistence of this myth could threaten the Obama administration’s efforts to implement the law, because many of its most controversial features are scheduled to be implemented over the next few years. Why is the death panel myth so hard to shake and why is its persistence relevant to the unfolding of Obamacare?

In part, the myth is hard to shake because most people have a very poor understanding of the complex law.  The ACA tries to increase access to health insurance through a bewildering combination of Medicaid expansions, private insurance subsidies, health insurance exchanges, and the infamous health insurance mandate.  It attempts to improve healthcare quality through things such as reimbursement reforms and promotion of electronic medical records.  And it encourages the formation of more efficient healthcare organizations, with inscrutable names like “accountable care organizations” and “medical homes”.

The myth is also likely to persist because the law calls for the establishment of a 15 person committee– the independent payment advisory board (or IPAB)–which is given the job of recommending cost-saving measures to the Secretary of Health and Human Services if Medicare expenses rise too quickly.  The IPAB will consist of independent healthcare experts who are forbidden, by law, from proposing changes that will affect Medicare coverage or quality.

In other words, they are a far cry from a death panel, with the ACA specifically noting that this group is not allowed to do anything that would “ration” healthcare.  The law also makes sure that the IPAB is not in a position to make policy, but instead to simply make recommendations to the Secretary of Health and Human Services, proposals that Congress is specifically empowered to override if it sees fit.

But the limits to the power of the IPAB won’t prevent the death panel myth from persisting.  Indeed, in a recently published study, my colleagues and I show why the death panel myth may even grow with time. (My colleagues, the brains of this study, were the political scientists Brendan Nyhan and Jason Reifler.)  In our study, we tested how fact-checking of the death panel myth influences people’s belief in the existence of such panels.  We discovered that debunking such myths is effective at convincing some people to give up their belief in death panels.  People who had warm feelings toward Sarah Palin, and thus believed her death panel claim, were willing to abandon that belief when faced with non-partisan fact-checking evidence that these death panels did not exist at the time of Palin’s claim.  But the fact-checking only reduced belief in death panels among Palin supporters who otherwise had very little knowledge of politics—people who couldn’t say, for example, how many U.S. Senators there are in each state.  By contrast, as shown in the picture, Palin supporters who also held basic knowledge of U.S. politics were resistant to fact-checking –debunking of the death panel myth not only failed to dissuade them from believing in death panels, but actually caused them to believe more strongly that such panels exist.

Fact-checking backfires among people who have enough basic knowledge of politics to resist evidence that contradicts their beliefs!  It is difficult for people to see the world clearly, when their vision is biased by their pre-existing attitudes.  As I have shown in earlier research, we all—liberals and conservatives, Democrats and Republicans–see the world through partisan eyes.

At the time of Palin’s original death panel claim, the IPAB hadn’t been written into legislation.  Her claim instead was focused on language being proposed in the bill that would require Medicare to pay for end-of-life counseling.  The death panel myth grabbed hold even though the vast majority of Americans are in favor of payment for end-of-life counseling.  Given the much greater controversy likely to surround the IPAB when it is formed later this year, and the psychological resistance people have to abandoning deeply held beliefs, expect a recurrence of the death panel controversy as the ACA unfolds.

The ACA has already survived a Supreme Court challenge and a reelection campaign. Only time will tell whether it survives the death panel controversy.

Peter Ubel is a physician, behavioral scientist and author of Pricing Life: Why It’s Time for Health Care Rationing and Free Market Madness and his new book Critical Decisions. He teaches business and public policy at Duke University. You can follow him on his personal blog.

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5 replies »

  1. Hey, just continue to follow Leader Pelosi’s mantra and wait until the bill plays out to see what’s in it: once this panel is in place, and we hopefully know who is on it, then we’ll see what they will do with it.

    By then, Barry O and I bet Nancy P and Harry R are long gone and we’ll hear their laughter fading as they are running away…

  2. Between 2000 and 2010, Medicare spending essentially doubled from $250 billion to over $540 billion — while the number of people on Medicare went from 40 million to 46 million.

    In the face of such relentless growth, the timid little recommendations of an iPAB will be the proverbial spitting in the wind.

    First its proposals must go to the Secretary of HHS, who may or may not introduce legislation, to a Congress that may or may not even consider the legislation.

    Congress has done nothing, I believe, about overpayments for wheelchairs. If you cannot cut spending for a simple piece of equipment, how can you make serious cuts in spending for cancer drugs that only extend life for 3 months?

    I had forgotten that no cuts can be made to hospital reimbursement until 2020. That must have been one of the giveaways to get the ACA onto the floor of Congress. By 2020, of course, Medicare spending will be on track toward $1 trillion a year.

    The IPAB does nothing to disturb the fiscal illusions that surround Medicare in the public eye. What we need is a President who would be an unpopular truth teller, and who would say:

    “America, if you want to continue Medicare as is, paying for anything that extends life, then here is your tax increase.

    And if you vote against a tax increase, then I will reduce all Medicare payment checks to all providers by 5%, or whatever it takes to hold down spending. Maybe we will pay for no elective surgeries in December, I don’t care.”

    That would be my kind of IPAB!

  3. I think it’s ridiculous to suggest that paying doctors for end of life counseling will lead to death panels. To me, it seems like basic common sense to help patients and their families to understand end of life care options and the quality of life implications of each. To Palin and her supporters, it appears that anything short of a full court press to prolong the dying process, no matter how futile or expensive, is rationing care by a death panel. For those who wonder why healthcare is so expensive in the U.S., this attitude is an important contributor, in my opinion.

  4. From Wikipedia
    “A 2009 Kaiser Health News article predicted primary care doctors would likely see benefits from an “independent Medicare commission because the panel would be more likely to increase their fees and lower specialists’ rates”.[13] While payment cuts to hospitals and hospices are off-limits until 2020, and clinical laboratories are off limits until 2016, physician fees may be cut unless a doc fix to Medicare’s sustainable growth rate formula makes those cuts off limits.[3] Other “savings would have to be found in private Medicare Advantage plans, Medicare’s Part D prescription-drug program, or spending on skilled-nursing facilities, home-based health care, dialysis, durable medical equipment, ambulance services, and services of ambulatory surgical centers”.

    From an ER physician site (EMRA)
    4. What exactly will IPAB do? When IPAB is asked to reduce Medicare costs without reducing benefits, increasing premiums, or making reimbursement cuts to hospitals or nursing homes, it seems the only option left will be to cut physician reimbursement. Unless Congress provides for an equal amount of cuts elsewhere in the budget, or vetoes the IPAB plan with a supermajority (60 votes in the Senate), IPAB’s recommendations will become law.

    5. How does this affect our patients? Cutting reimbursement to physicians will lead to fewer physicians accepting Medicare patients, and thus decreased access to health care. This will lead to more visits to emergency departments which will exacerbate the crowding plaguing many of our EDs. According to a recent study, the number of physicians who no longer accept Medicare patients increased from 4.5% to 7.1% over just 3 years (2005-2008)[ii] and many other physicians no longer accept new Medicare patients. The bottom line: Cutting physician reimbursement hurts patients’ ability to access quality health care.”

    If you think the “death panel” idea is the only objection to IPAB, think again.

  5. Uhmmmh … this study is interesting. But where is the outrage, or at least some clear words? I am not a policy insider, but my impression is that as a result of SP outrageous claim and its effectiveness, there will be few if any politicians that will touch serious problems such as end of life care and overutilization with a 10 foot pole. Instead, we are served the usual “both parties/end of the spectrum” mumbo jumbo (“As I have shown in earlier research, we all—liberals and conservatives, Democrats and Republicans–see the world through partisan eyes.”). IMHO, the viciousness and dishonesty of large parts of the right spectrum is breathtaking (Democrats excellence in nonsensical partisanship is mostly confined to defending President Obama’s to a large extent very moderate if not right of center agenda against progressive critics).

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