In his health care infomercial, Barack Obama repeated a comment that has become part of the accepted, underlying assumptions of the health care debate, that as much as 30% of health care spending is worthless and wasteful. If we could save that 30%, universal health care would pay for itself. Michael Kinsley, in the process of highlighting the key flaw in the discussion, repeats the meme:
Health Care Faces the 'R' Word
The Obama administration believes that health care can be made cheaper without any reduction in quality. It has evidence to back this up. According to the famous Dartmouth studies, health care costs two or three times as much per person in some places in America as it does in others, with no measurable difference in results. Atul Gawande's deservedly admired recent essay in the New Yorker makes a similar point. So in theory it's easy: Just figure out how the cheap places do it and apply this knowledge to bring down the cost in the pricier places.
But that doesn't mean rationing will be easy to avoid. Statistics on life expectancy or infant mortality are averages. The easiest way to raise your averages -- maybe even the best way, if we're being honest -- is to concentrate on the general level of care and not to squander a lot on long-odds cases. But if the long-odds case is you or a family member, you may well feel differently. [Emphasis mine-SW]
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Less care doesn't necessarily mean worse care. The administration is investing great hopes (and $1.1 billion of stimulus money) in "comparative effectiveness research." Because we don't collect and compare in any systematic way the vast piles of data we have about individual patients and their treatment, we know astonishingly little about which treatments work and which are a waste of money. [Emphasis mine-SW] The administration is touting the figure of 30 percent of all health-care costs as spending that may accomplish nothing.
I suspect that what a billion-plus dollars' worth of research will find is that perhaps 30 percent of what we spend on health care is almost entirely worthless, or just barely better than a much cheaper alternative. Or it might be better and no one knows for sure. Denying someone these treatments or tests is rationing.
Micheal Kinsley does an excellent job illuminating the meaning of rationing in health care but, as with so many commentators, misses an essential point about how Medical knowledge increases and care evolves.
When a new drug or procedure is approved for use in humans it has typically spent many years being tested in the laboratory, on animals, and finally on a select group of patients for short term trials. Only at that point, and after $1.4 billion dollars (in the case of new drugs) is the medication approved for use by an uncontrolled population of patients of varying degrees of illness, varying degrees of associated conditions, and varied genetic and constitutional endowments. It is only at that point that a true naturalistic, long term study begins. Generally, the first patients who receive such treatments are those who are long odds cases, for whom the usual treatments are likely to be ineffective. Later, as the procedure is found to be reasonably safe, the individual calculation of risks versus benefits are made by thousands, then millions, of patient-family-Doctor triads and the experiment expands. Only after millions of doses of the medication (or thousands to hundreds of thousands of iterations of the treatment) do the results begin to arrive, as the signal is teased out from the noise.
For example, not too many years ago, after something on the order of a million Cardiac Artery Bypass Graft Surgeries, did the data become clear enough to enable Cardiologists to begin to construct a rubric by which to determine which patients would best be treated by the surgery versus those who would do just as well with diet, exercise, and various combinations of medications. Today, there are many fewer CABG surgeries than there were ten years ago. Or consider Breast Cancer. Our best understanding of breast Cancer twenty years ago suggested that it could be cured if caught early by a radical mastectomy in which the woman's breast, lymph nodes, and underlying muscle tissue were sacrificed. This was a horrendous surgery that had long term implications for the woman's psychological health and only after many, many years, and millions of cases, did we learn that for a great many Breast Cancers, a more limited procedure, often without the need for any mutilation, followed by radiation and/or chemotherapy, offered the same or better survival rates. Now we understand Breast Cancer as a systemic disease with contributions from the immune system, genetics, etc.
The point is that at any given moment, our knowledge of best treatments for any individual is limited and constantly evolving. The "best practices" today may well be superseded or even contradicted by new "best practices" as our knowledge grows.
Further, Medicine is at a revolutionary moment:
We are in the earliest stages of Individualized Medicine. We can already identify specific tumor markers and genes that indicate specific treatments. One day this will be true for every tumor; today it is true for a small fraction of cancers. Before we arrive at a time where an individual's cancer treatment sis inexpensive and routine, we must first pass through a time when an individual's cancer treatment is extraordinarily time intensive, expensive, and anything but routine.
Government run health care will destroy, or at best indefinitely delay, the advent of Individualized medicine. If the guiding principle behind the cost savings of Government Health care is "to concentrate on the general level of care and not to squander a lot on long-odds cases" and "comparative effectiveness research" we will be effectively enshrining the status quo as the gold standard of affordable medical care. How could we expect an insurance plan that has an overriding interest in minimizing costs to pay for a new treatment that is unproven and much more expensive than the current "best practice"? Even if there are some patients who will benefit, it usually (as above) takes a long time, and millions of cases, before significant outcome improvements can be conclusively shown to exist. This is a prescription for stagnation in Medicine.
Barack Obama (and the Congress) are certainly hypocritical; none of them would agree to accept the kinds of plebeian health care insurance they would foist upon the rest of us. Their gold plated health insurance allows them to receive state of the art health care, However, even they will suffer when potentially like extending and life saving treatments are simply never developed because the expense of development can never recoup the investment.
Unfortunately such "opportunity costs" are hard to describe in brief commercials and op-ed pieces. Health Care as a Right is so much simpler and easier to support. Sacrificing the future for present votes and power has never been a dififcult calculation for politicians, in any event.
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