tom daschle, the former senate democratic leader who was obama's first choice for health secretary, argued that ipab should have been expanded to cover all forms of health insurance in order to prevent doctors from shifting costs onto patients with private medical insurance. after voting for the 2010 health care reform, pete stark (d-calif.), said that the ipab "sets up for unsustainable cuts" that will endanger the health of patients, and that he would "work tirelessly to mitigate the damage" the panel would cause. lobbying groups the pharmaceutical research and manufacturers of america said that elimination of the payment board was its top priority in the 2011 congress. the american hospital association and the american medical association (ama) have spoken out against the board. the ama wanted to change the ipab requirement that members have no outside employment so working physicians could be considered. the ama also opposed any independent commission which could cut physician payment rates. dr. j. fred ralston jr., president of the american college of physicians (acp), expressed support for the idea behind the ipab, saying "making complex medicare payment and budgetary decisions is very difficult within a political process with substantial lobbying pressures," but the group wanted to see significant changes. the acp supported creating a position for a primary care physician on ipab, additional protections to ensure that cost reductions would not lead to lower quality of care, authority for congress to reject proposals made by ipab via a simple majority vote, and equal treatment of all healthcare providers. dr. elaine c. jones, government relations committee cochair of the american academy of neurology stated, "we are also very concerned about the power of the ipab to cut payments to physicians. the sole function of the ipab is to cut spending with little guarantee of maintaining quality, access, and scientifically proven care. there may be no physician representation on the board either. these elements are concerning and unacceptable." ron pollack, the founding executive director of the health care advocacy group families usa, advised democrats against being divided and conquered by supporting repeal of specific portions of the health care reform, such as ipab. two major nursing home associations, the american health care association and the american association of homes and services for the aging, along with seventy two other healthcare groups, urged congress to reject ipab. they argued that the board would have had too much control over medicare and would affect the ability of healthcare providers to lobby for changes in how they are reimbursed. the groups also argued that ipab would have only been accountable to the president. the american academy of orthopedic surgeons made ipab a focus of their advocacy work. hospital exemptions from 2015 to 2020 as well as the lack of practicing physicians on the board itself were major concerns. lobbying efforts in april 2011 focused on making these modifications if not fully eliminating the board. medical specialty groups spearheaded efforts to repeal ipab. the american society of anesthesiologists and american association of neurological surgeons co-lead a coalition of 26 medical specialties and patient organizations representing more than 350,000 physicians and their patients dedicated to repealing ipab. the coalition endorsed efforts in the 113th congress to repeal ipab. howard dean, a consultant for washington, d.c.-based lobbying firm mckenna, long and aldridge and former democratic governor of vermont, believed the ipab would fail to control costs and should be abolished. he opposed the premise of the board, writing in the wall street journal that it was "a health-care rationing body" and that "rate setting—the essential mechanism of the ipab—has a 40-year track record of failure." editorials in an editorial opposing sen. cornyn's bill to repeal ipab the washington post wrote, "the political system failed when it came to controlling health-care costs. the 15-member panel that mr. cornyn et al. deride as 'beltway bureaucrats' would be a group of experts in the field, nominated by the president, chosen in part by congressional leaders of the opposing party and subject to senate confirmation. congress isn't bound by its proposals if lawmakers can come up with what they think is a better approach. getting costs under control is going to require difficult choices – including, in the case of medicare, difficult political choices. this unwise bill is not a good sign about washington's willingness to make them." death panel controversy the term "death panel" was used in conjunction with ipab. sarah palin wrote in the wall street journal that the national commission on fiscal responsibility and reform "implicitly endorses the use of "death panel"-like rationing by way of the new independent payments advisory board." the new york times reported some obama administration officials feared the independent payment advisory board could be "target for attacks of the 'death panel' sort"; an october 2010 national right to life article wrote the ipab was "a good candidate for the title of 'death panel,'" and a december 2010 wall street journal editorial associated 'death panels' with the ipab. former omb director orszag responded: "i think it's only in washington, d.c., that a board created to help address our long-term fiscal imbalance while boosting quality in health care and that is specifically by law prohibited from rationing care could be called a death panel". congressional budget office scoring the congressional budget office (cbo) estimated that ipab would achieve medicare spending reductions of $28 billion through 2019—amounting to 0.4 percent of the projected medicare spending of ~$7 trillion for the period. in march 2011, the cbo estimated the medicare baseline level of spending would not exceed targets throughout the years of 2015 to 2021; thus, the ipab was not expected to affect any medicare spending. fiscal commission report the 2010 presidential commission, the national commission on fiscal responsibility and reform, issued a report on reducing the federal deficit and voted 11 to 7 to strengthen the ipab. it wished to bring forward the time by which health care providers would be affected by ipab decisions. the recommendations "would hit hospitals the hardest, which gained an exemption from the group's decisions for several years." lawsuit as part of legal challenges from conservative organizations and state attorneys general in about twenty states to the affordable care act, arizona's conservative goldwater institute, along with three republican congressman from arizona, filed a suit challenging the constitutionality of the ipab. the hill reported that "while the suit illustrates conservative frustration with the federal government, the courts rarely strike down advisory boards created by congress." the suit was dismissed in 2012. the ninth circuit found for the government on appeal, and the supreme court declined to hear a further appeal.