Thursday, March 12, 2009

Bloviation vs. Reality on Stimulus Health-Care Provision

This short column by Steven Pearlstein is old news for those of us who have been paying attention, but very important to the health care reform public discussions now underway. *§*

By Steven Pearlstein
Friday, February 13, 2009

To most Americans, the language on Page 52 of the report of the House Committee on Appropriations would have seemed perfectly sensible.

The report spelled out the committee's rationale for including $1.1 billion for something called "comparative effectiveness research" in the massive economic stimulus bill. For those of not steeped in the argot of health policy, that's research done by doctors and statisticians who troll through large number of patient records to determine, for any particular disease, which treatments work best.

"By knowing what works best and presenting this information more broadly to patients and healthcare professionals, those [treatments] that are most effective . . . will be utilized, while those that are found to be less effective and in some cases more expensive will no longer be prescribed."

There's nothing particularly new about comparative effectiveness research -- the National Institutes of Health, along with the Agency for Healthcare Research and Quality, have been doing it for years, with a budget last year of about $335 million. But with the strong backing of the Obama administration, House Democrats are anxious to ramp up the effort, which nearly all experts agree is a necessary first step to reforming a broken health-care system.

To some, however, the wording in last month's House report was anything but innocuous. To them, it was a warning shot across the bow, the camel's nose under the tent of a government-run health system, the dangerous first step on the slippery slope toward European-style health-care rationing.

" 'Stimulus' bill may change health care forever," blared the headline in the Washington Times over a commentary written by Amy Menefee, communications director for the Galen Institute, a nonprofit think tank that aims to bring free-market ideas to the health-care debate.

"Ruin Your Health With the Obama Stimulus Plan," warned Betsy McCaughey, former lieutenant governor of New York and adjunct senior fellow at the conservative Hudson Institute, in a commentary distributed by Bloomberg News several days later.

No sooner had the McCaughey commentary hit the tape then -- what a coincidence! -- radio bloviator Rush Limbaugh was quoting it on his syndicated show, warning that under the world envisioned by the Obama stimulus bill, old people would be denied all costly medical treatments under a new "duty to die" regime meant to save taxpayer money. The McCaughey commentary also got a prominent mention by uber-blogger Matt Drudge.

The next day, the Wall Street Journal's senior economics writer, Stephen Moore, was on Fox News warning that the stimulus bill would put the government in control of what medical treatments you and your family would be allowed to receive. That set the stage for Megyn Kelly's interview with Sen. Arlen Specter, who was virtually browbeat by the anchor until he promised that "we are not going to let the federal government monitor what doctors do."

The Journal's editorial page picked up the campaign the next day, drawing the line of causation from electronic health records -- another beneficiary of the stimulus bill -- to comparative health records to government price controls and then a government-run "health tech monopoly."

This right-wing brushfire didn't start on its own, of course. It was a work of political arson by the country's drugmakers and medical device makers, which have the most to lose if there is solid research showing that some of their most expensive and high-margin products aren't really better than the low-priced spread. The flames were also fanned by "disease groups" like Easter Seals and the American Cancer Society, which fear that any attempt to determine what works best will inevitably lead to a one-size-fits-all approach to treating people with serious chronic conditions.

It's not that these various groups have no reason for concern. If comparative effectiveness research is done badly, or if the results are used simply as an excuse to deny insurance coverage for all expensive treatments, then there would be plenty of reason to get out the pitchforks and storm Capitol Hill. And there are surely examples from Britain and other countries of people being denied access to the latest drugs and procedures, including some that are significantly more effective than other treatments.

What the critics don't have, however, is any shred of evidence that the professionals who do this research are incompetent or have any but the best intentions in trying to figure out what treatments are the most effective for patients. There is no reason to believe that once this clinical research is completed, it cannot be used in a disciplined, scientific way by physicians, economists and medical ethicists to determine whether there are drugs, tests, surgical procedures or devices that simply don't deliver enough benefit to justify their cost. And there is no reason we cannot set up reasonable procedures, overseen by independent health professionals, to protect patients who can demonstrate a special need for a treatment that is not normally cost-effective.

This isn't Britain. This is a country in which there is a deep cultural and political preference for autonomy and individual choice, particularly when it comes to health care. Ours is a country that values competition, embraces innovation, respects markets, and is suspicious of politicians and government bureaucrats. It is a country that is both willing and able to spend more than any other country on its medical care.

But ours is an economy that is sinking under the weight of a health-care system that costs twice as much as any in the world while delivering poorer health outcomes. The cost of health care has crippled entire industries, disadvantaged our companies in international competition and brought millions of families into bankruptcy. Worst of all, in denying vital medical services to the 40 million Americans without health insurance, we engage in the most immoral kind of medical rationing imaginable -- rationing by the ability to pay.

The good news is that the $1.1 billion for comparative medical research has apparently survived the House-Senate conference on the stimulus bill, despite behind-the-scenes efforts to remove it or hamstring it with provisions prohibiting any kind of cost-benefit analysis or circumscribing how the results can be used in determining insurance coverage.

This little kerfuffle, however, is a warning to the Obama administration that the coming battle over health-care reform is likely to be every bit as vicious and divisive as the one that defeated the Clinton health plan, requiring not only care in designing the plan but the need to develop easy-to-understand data and compelling anecdotes that demonstrate in a compelling way how wasteful and ineffective our current system has become.

*§* Changing wrong thinking is tedious, boring, and repetitious hard work. I know because I have done it for years in the service of civil rights. Since 1963 I can report that the job today is not nearly as tough as it was when I started, but the need for it will never vanish in my lifetime. Not often, but still, I come across a few individuals who for whatever reason have grown to adulthood having never come face to face with a load of old-fashioned ignorance. And the only way past that handicap is a patient, sympathetic but uncompromising presentation of truth. When confronted with facts even the most ignorant of people will change. I know because my own father was such a person. He didn't change easily, but if confronted with a mountain of incontrovertible evidence he did on occasion change his mind.

I add this footnote to underscore the importance of patient, repetitious, unemotional arguments to anyone out to change minds and attitudes in the American public square when the subject of health care reform arises. Embedded ignorance, denial of facts and a very human fear of change is as much a barrier to progress as a cloud of flies in a bakery.

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