In his column Robert Samuelson addresses the accusation not only at President Obama but at Washington politicians more generally and the American public as well:
Americans generally want three things from their health-care system. First, they think that everyone has a moral right to needed care; that suggests universal insurance. Second, they want choice; they want to select their doctors — and want doctors to determine treatment. Finally, people want costs controlled; health care shouldn’t consume all private compensation or taxes.
If you believe Obama, what’s not to like? Universal insurance. Continued choice. Lower costs.
The problem is that you can’t entirely believe Obama. If he were candid — if we were candid — we’d all acknowledge that the goals of our ideal health-care system collide. Perhaps we can have any two, but not all three.
If we want universal insurance and unlimited patient and doctor choice, costs will continually spiral upward, because there will be no reason or no one to stop them. We have a variant of that today — a cost-plus system, with widespread insurance and open-ended reimbursement. Higher costs push up premiums and taxes. That’s one reason health spending has gone from 5 percent of gross domestic product in 1960 to 16 percent in 2007. (Other reasons: new technologies, rising incomes.) But controlling spending requires limits on patients and doctors.
The reform I’d hoped for was reform that would have changed the system in such a way that we might be able to have our cake and eat it, too. Everyone would have given up something but everyone would have gained something, too.
Unfortunately, it strongly appears as though both we and our political leaders are determined to put off the piper’s bill for as long as it’s possible. It won’t be possible much longer and when the payment due date is inevitably here the tab will hit us that much harder for our desire to stave it off.
Totally agree, unfortunately most people are innumerate on the subject or in denial, or both.
For example, the administrative cost issue. I can’t tell you how many times I’ve seen people argue that the higher administrative costs for private insurance is a waste. When I point out that a profit maximizing business also minimizes costs at the profit maximizing level of output I don’t get a response. People just repeat the intial claim as if mere reptition will somehow make the claim true and all reasonable objections moot. So, to any commenter who believes the administrative cost mumbo-jumbo please explain to me why a cost minimizing entity would not minimize costs and piss away profits?
Related question: Is Obama going to cut waste, fraud and abuse, or administration costs?
To my ear in his speech last week President Obama was using the word “waste” in a novel way. I may be imagining things but I think he was bundling comparative effectiveness with eliminating waste in Medicare.
I’m highly skeptical of comparative effectiveness and I think that such bundling is a stretch but I see no other way that the savings he’s talked about could be realized.
“When I point out that a profit maximizing business also minimizes costs at the profit maximizing level of output I don’t get a response. ”
In the ideal world. What happens in reality? Look at the financial industry circa 2000-2008 and tell met that the interests of corporate employees and management align perfectly with those of the corporation. What about Enron? Worldcom? LTMC? In every bureaucracy, there is a tendency to perpetuate the bureaucracy. Hell, that is part of the job of the lower level workers.
An insurance company that was showing very high profits risks public outcry. This is health care dont you know? So, if they turn down care for some lady with cancer while announcing huge profits, they risk consumer backlash. They also risk government intervention. Politicians on both sides, probably more on the Dem side for this issue, love to play the concerned populist role. Given these problems, I suspect there is strong internal pressure at insurance companies to expand the work force (lessen the amount of work), increase bennies (internal profits if you will) and increase internal salaries rather than send out profits to shareholders.
Steve
Dave-That was my sense also. A question I keep meaning to ask, shouldnt we be glad that Obama is at least willing to address Medicare at some level? We all know it needs to have its cost structure addressed at some point. I look at cost effectiveness research as a way to non-arbitrarily make some needed Medicare cuts. If you try to take on, Oh let’s say the back pain industry, without solid data, you will have some aggrieved patient/provider making claims about rationing. With cost effectiveness research it becomes not rationing but rather refusing to subsidize ineffective care.
Steve
There’s a distinction between evidence-based medicine and comparative effectiveness. As I see it EBM is affirmative while comparative effectiveness is negative.
EBM says “this is the evidence that Treatment A works”. Comparative effectiveness says that “Treatment A is x% more effective than Treatment B”. From my point of view EBM is scientific; comparative effectiveness might be scientific but it might also be pseudo-science.
From my POV as a physician, they can both be pseudo-science. You need to read the studies, as always. Comparative effectiveness can clearly be positive, as when it shows that a given treatment provides significant benefits compared with its costs, or the costs of prior treatments. In the same manner, good EBM is often negative. It often shows that there is no change in outcome with some of what we do. EBM is largely responsible for the large decrease in pre-op testing.
Steve
Which raises the question, is off-label drug use EBM? I believe the argument for off-label is that it is scientific, just not regulatorily-approval. My sister, an NP for an oncologist, tells me that perhaps as much as a majority of their drug prescripts are off-label, and she even went to Mayo Clinic to give a lecture on a particularly successful off-label use. From a top-down view that science is that which is government approved, off-label has to be eliminated (or unfunded), but from the view that doctors are also practitioners of science, I think the conclusions are mixed.
Contrary to popular opinion, medicine remains a mixture of art and science with results mediated by the individual biochemistry of the patient. That doesn’t lend itself neatly to a top-down approach.
Off label means many things. Few drugs are actually approved for pediatric use. Drug companies do not want the liability. Many drugs are approved for a given use, but docs find they work for other diagnoses. The use of anti depressants for some pain syndromes might be a good example. Medicine remains an art at least partially because you are often trying to take statistics derived from large population models and applying it to an individual who never exactly matches the model.
Steve