The gross domestic product and health care spending.

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. These dynamics are unlikely to recede soon, which means that the IPAB is stuck in purgatory, neither operational nor canceled — an institution designed to be above politics that cannot escape the political binds holding it back. The longer-term picture is, as always, cloudier. Perhaps President Obama will pursue recess appointments. A new president and Congress could, in 2017 and beyond, unshackle the IPAB in response to deficit pressures and the search for Medicare savings. And if Medicare spending growth accelerates, the IPAB’s role could expand. Yet a new president could also refuse to appoint any members or enforce the spending targets, and Congress could repeal the IPAB in 2017. The IPAB’s demise would, in that scenario, deal a symbolic blow to health care reform and cost containment. But the impact on Medicare expenditures and national health spending would be negligible. For all the hype, the Congressional Budget Office currently forecasts no savings from the IPAB over the next decade. Regardless of the IPAB’s future, one thing is clear: rather than removing politics from Medicare, the board’s difficult early journey has underscored just how entrenched politics are in health care policy. Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.