Tuesday, June 16, 2009

You don't always get what you want...

We just have to decide how that line will be drawn.   Despite the intense rhetoric this week surrounding health care reform, the central issue is still barely mentioned.  The Republicans, for example, have keenly honed in on a list of things they think Americans don't want, and of course, one of them is any hint of restraint in health care for any reason (for people who have insurance already, of course).
As President Barack Obama tried to sell the American Medical Association today on his health care overhaul, the top Senate Republicans launched a familiar line of attack.
They warned of rationed medical care, lack of patient control and government bureaucracy.
"The American people will not stand for rationed health care," Senate Minority Whip Jon Kyl said Monday. "We believe that a one size fits all approach is the wrong approach." [More of a news story that mentions "ration" several times]
I think this will be the Great Wall for defenders of our current system: curtailing any amount of health care is anathema.  Oddly voices on the right have been pointing out that's exactly what is needed, although we can't bring ourselves to use the word "ration".
 There are only three ways to pay for this expansion of health insurance coverage: increased taxes, reduced benefits, or shiny gold ingots falling out of the sky. Voters emphatically prefer the latter option, so that is the one most likely to be embraced by Congress and the administration.

One way to bring down the cost of health insurance is to limit access to certain doctors, treatments, and medicines. But the Kaiser/Harvard poll found most people are averse not only to paying more but also to anything that would "involve government limiting or dictating their choices."

Or anyone else, by the way. Most people have forgotten that in the 1980s, the private sector devised an ingenious way to reduce medical outlays. Known as managed care, it put modest restrictions on the freedom of patients to get care from specialists, limited hospital stays and gave doctors incentives to choose less costly therapies. It saved money, and it didn't appear to reduce the quality of care.

It was a perfect remedy, except for one thing: Patients and doctors hated it. Why? Because it kept them from behaving as though cost is no object.

So managed care is history. But the dilemmas it addressed are not.

One of these days, we'll have to address them, but not now. The administration would rather pretend we can get generous government-sponsored coverage for everyone without higher taxes, higher insurance premiums or rationing of health care. In short, it refuses to treat us like grownups. I wonder why. [More]

The tricky political problem for the GOP is the number of people with coverage they like is dropping. Uncontrolled expenditures are pushing premiums up, even as employers offload the burden to workers. And if you lose your job...

The status quo is rapidly deteriorating.  Something has to give on health care, according to economist Tyler Cowen - hardly a left-winger.

Scholars have been applying comparative-effectiveness research to Medicare for years, and the verdict is not altogether pretty. It turns out that some regions spend more on Medicare than others — sometimes two or three times as much, as documented by the Dartmouth Atlas Project. Yet the higher-spending regions often fail to produce superior health care results.
Robin Hanson, professor of economics at George Mason University, surveys evidence demonstrating the ineffectiveness of many medical expenditures in his 2007 paper, “Showing That You Care.”
If we are willing to take comparative-effectiveness studies seriously, we could make significant cuts in Medicare costs right now. We could cut some reimbursement rates, limit coverage for some of the more speculative treatments, like some forms of knee and back surgery, and place more limits on end-of-life-care.
Those cuts alone will not solve the fiscal problem, but if we aren’t willing to take even limited steps to conserve resources, we shouldn’t be spending any more money elsewhere. [More]

If you didn't pick up on it "comparative-effectiveness" is how you actually go about the unspeakable practice of spending health care dollars to the greatest benefit.  It will be one key aspect to any useful reform effort.

More seriously, there is something about the arguments against CER that I have never understood. The opponents of CER claim that it will inevitably be used to make decisions about care. Insurers will not want to pay for care that is not effective, and so people will be deprived of the care they need. But notice what "deprived of care" means here. No one is seriously proposing to make it illegal to purchase whatever medical care you want on your own. 

This means that even if your insurance company decides that it will not pay for some treatment that has been shown to be ineffective, you will, under any proposal being seriously considered, still be able to get that care; you just won't be able to get someone else to pay for it. If not having someone else pay for your medical care counts as being "deprived of care", then 46 million people are being deprived of care even as we speak -- and that's just the uninsured; it doesn't include people who have insurance that doesn't cover the treatments they need. And yet, strange to say, the opponents of CER generally do not see this as a problem.

Moreover, once you notice that what the opponents of CER describe as "being deprived of care" just consists in someone's deciding not to pay for some treatment, the idea that decisions about who gets what treatment are currently made by your physician is true only if you pay for your care out of your own pocket. If, like most of us, you rely on medical insurance, then someone other than your doctor is already making decisions about your care. All CER would do is allow this person to do so on the basis of actual knowledge about what works and what doesn't. [More]
Doubtless we will "ration" in a convoluted and obscure method, but the point is made that at some time even the most lavish insurance programs will have to draw some lines on the expanding array of medical treatments and drugs that provide minscule benefits while burdening countless others with the costs.  
That point approaches, I think.


Ol James said...

What if, Senators, House Members, "The Prez" and others had the same medical coverage program. Such as Medicare?? Had to abide by the restrictions and limits? Instead of their current medical program.. They might have considered Sen. Kennedy's condition as elective.
The solution to the problem may just be the conditions...

Anonymous said...

I hate to say it, but I think the starting point is to make employer paid insurance premiums taxable income. Suddenly a tax free perk is just compensation, and everyone is on a (more) level playing field. When it is your own money you spend, you'll do what it takes to limit costs. Wish we could figure it out for medicare too.

Anonymous said...

I think one thing that would help is for all ins. cos. to use the same forms,I see no reason for each ins. co. to use a diff. form.
If they could come to some agreement on malpractice awards perhaps the Drs. would not have to order so many tests to start with,then perhaps they would be happier with it.