Tuesday, September 22, 2009
Helping the Health of the American People: Bending The Medical Curve Away From Scarcity and Rationing
This piece was published earlier today at Foxnews' Fox Forum.
“Bending the cost curve” on health care is the hot wonk idea in Washington this year. Everybody in D.C. is talking about it: They want to flatten the upward angle, they say, of health care costs. Of course, as we all know, when they say “bending the cost curve,” they really mean rationing and imposing scarcity.
But what if the Beltway curve-benders are missing the point? The true point of health care, which is, after all healing? What if the real goal is not to bend curves down, or flatten them, but rather to bend them up?
The curves we really want to bend--and bend upward--are health curves. Cost curves are important, and nobody wants them to go up unnecessarily, but the curves that the American people really want to see bent--bent downward--are the curves of sickness and disease. Bend those “disease curves” downward, and the American people, currently deeply skeptical of the whole political crew in Powertown, would rally in support.
We’ve done disease-curve downward-bending before. We’ve bent down the curves for tuberculosis, polio, AIDS, and many other diseases. Is anybody you know suffering from scurvy? Or rickets? Or whooping cough? No? Good--mission accomplished.
The curve of those diseases has been bent downward, going from being huge killers and disablers to comparatively minor afflictions. Polio has virtually disappeared, tuberculosis is a minor problem for the public as a whole, and even AIDS deaths in the U.S. have fallen by more than two-thirds in the last fifteen years. We might pause to think more about AIDS: Just two decades ago, we were told that AIDS had the potential to be a mass plague in America, and yet now, thanks mostly to massive scientific intervention, AIDS has been reduced to a chronic disease, which kills every year just a fraction of the number currently dying from diabetes.
Every life lost is a tragedy, of course, and so there’s much more to be done. But the medical urgency of better health only underscores the moral necessity, as well as the political popularity, of bending death-and-disease curves, down to zero wherever possible.
We Americans think that life is precious. And so we are willing to spend a lot to improve, lengthen, and enhance life. In addition, in the back of our minds, we understand that good health is good economics; healthy people make for more economic output and invention than do sick people. Moreover, if we invent good medicines and treatments here, in this country, we can sell them to the rest of the world, creating jobs and generating economic benefits. In addition, if we wanted to, we could give such medical goods away, for either humanitarian or foreign-policy strategy reasons. What I have called the Serious Medicine Strategy is the ultimate example of “enlightened self-interest.”
It’s this larger view of the moral and economic value of good health that seems to elude the current crop of “experts” in Washington. They seem focused on the “cost” side of the ledger, while they mostly ignore the “benefit” side. If one only focuses on the “cost” side, then it makes sense, for example, to chop away at health care spending--to bend those cost curves downward. And if old people go untreated and die earlier? Well, as in Great Britain (sample headline: “Sentenced to death on the National Health Service”), that’s cheaper isn’t it? Isn’t rationing of health cheaper?
And if young people get sick and die from preventible diseases? Or if veterans cost an “inconvenient” amount of money in V.A. hospitals? Deaths in those categories are losses to both society and the economy--to say nothing of the families--but they could be, and are, seen as savings in the eyes of government bean-counters. Seen only a short time-horizon, the scarcity model is cheaper.
In contrast to the number-crunchings of cost-obsessed bureaucrats, if one looks at the whole of life, including all the benefits of being alive, then one further sees that the benefits of a healthy, happy, and productive people far outweigh the costs.
And by the way, someone should tell elected politicians, who are more sensitive to public opinion than the unelected bureaucrats who do the policy advising and agenda-setting: The folks out there will re-elect only the politicians who seem to be rooting for them to succeed at living long and happy lives.
But in the meantime, at least until the next midterm election, both the political and policy elites are locked into their vision of curve-bending cost containment. Testifying before Congress in June, Christina Romer, chair of the White House Council of Economic Advisers, declared, “In discussing cost containment, I want to focus on slowing the rate of costs. This is the so-called ‘curve-bending’ that can last for decades.” And not to be outdone on curve-bending, Aetna Insurance has created a whole website, entitled “bending the cost curve.com.”
For the most part, political appointees, such as Romer, and insurance companies, such as Aetna, are careful to say that they want to see no loss in the quality of treatment. And if pressed about the prospect of future medical improvements--which might lead to new cures, and a long-term reduction of costs, by making people healthier--they would undoubtedly say, yes, they are for those kinds of improvements. But such talk about medical improvements is strikingly absent from their testimonies and advertisements. And why is that? Because Romer, Aetna, and all the rest are cost reducers, not benefit increasers.
Indeed, sometimes Obamacare supporters tip their hand, showing that they worry about cost control--and little else. A case in point is Ezra Klein, writing for The Washington Post, who clearly empathizes with the Obama agenda, never hesitating to offer helpful suggestions to his team. On Sunday, conceded that the problem faced by the would-be cost-curve-benders is that their ideas are “abstract, speculative and, at times, even unpopular.” Yes, “unpopular.”
That’s for sure. People don’t like scarcity and rationing. And so there are times when Obamacare--predicated on cost-curve-bending, a.k.a. scarcity and rationing--is “unpopular.” Like now. Today, 56 percent of Americans say that they are opposed to Obamacare and to the Democratic vision of “curve-bending.”
But then Klein, the staunch Obamacare guy, added a revealing sentence in his Post piece, as he mulled over what might worry the White House healthcare policy team: “What if it finds that some brand-new and incredibly expensive treatments are wildly effective? That could raise spending.” [emphasis added] Well, yes, a “wildly effective” treatment could “raise spending.” But here’s a not-so-bold claim: People would love to learn of a great new treatment. The average American would cheer. But Klein’s choice of words reveals much about how Washington elites see the issue of medical innovation; such progress is to be dreaded, not heralded.
Obviously, some curves are meant to be bent, with or without medical breakthroughs. Sometimes less is good. If one is overweight, one should eat less. If one smokes, one should stop. But the politics of nagging and nudging people about their health-styles are tricky, full of human-nature-based boomerangs and backlashes. And as we have seen twice now, during “Clintoncare” in 1993 and now Obamacare in 2009, the politics of cost-curve reduction are toxic.
But the elites are so in love with their rationing vision that they keep pushing their same cost-curve-reduction ideas. Just last week, two blue chip outfits, The Committee for a Responsible Federal Budget (CRFB) and the Peterson-Pew Commission on Budget Reform (PPCBR), released a report calling for “a strengthened Medicare advisory panel tasked with recommending Medicare savings.” In so advocating, CRFB and PPCBR are referring to the Medicare Payment Advisory Commission (MedPAC), an independent agency created by Congress in 1997, to advise the federal government on Medicare issues.
It’s no secret that fans of the current MedPAC want to see it grow much stronger in its ability to control costs. They hope that MedPAC could become as secretively powerful over health care as the Federal Reserve Board has been secretively powerful over monetary policy. It is better, Obamacare advocates figure, to kick “tough” decisions over to an an un-elected group of obscure experts--and such a plan would be good, of course, for the ongoing employment of the expert class. Indeed, would-be Obama health czar Tom Daschle proposed a “Federal Health Board” last year in his book, Critical: What We Can Do About the Health-Care Crisis. Echoing Daschle, CFRB/PPCBR budget experts made a (very) little joke, calling their strengthening idea “MedPAC on steroids.”
There’s a certain logic in trying to sneak such curve-bending cuts under the political radar, but there’s no logic if the curve-bending stratagem is guaranteed to be “outed” as scarcity and rationing, and thus guaranteed to be voted down. And yet that sort of politically fatal exposure is a certainty in today’s media environment--a world of Glenn Beck and Rush Limbaugh and any number of Internet-based diggers and bloggers.
There is simply no chance that a “MedPAC on steroids” would be effective in its work in a small “d” democratic society. By herself, working from her Facebook page, Sarah “death panels” Palin alone could beat back a MedPAC.
The cost-curve controllers have driven head-on into the trap of what free-market economists call static analysis. What they need is dynamic analysis, which could point the way toward better health and lower costs.
More on that in Part Two.
Posted by James P. Pinkerton at 6:02 PM