GOP Grills Obama's Medicare Chief
Thursday, when questioning Medicare head Dr. Donald Berwick, the GOP may have missed an opportunity to hit at Obamacare's real flaw: no cost controls.
On Thursday, the House Ways and Means Committee had the opportunity to question Dr. Donald Berwick, the new head of the Center for Medicare Services, on Obamacare. As expected, he was forced to discuss his views on rationing of health care services. It will be very unfortunate if that is all that the House takes away from the exchange. The fact that this issue has become such a lightning rod borders on the tragic given all the really substantive issues out there.
The great shame of our health care debate has been the utter failure to engage in a rational discussion on issues of cost control which threaten not only our health care system but the very economic well-being of the country. The financial problems of Medicare, like those of Social Security, have a major demographic component but there is also an intrinsic growth in the demand for services and the costs of ever expanding technological innovations to deal with. The essence of Obamacare has been to create a plan for coverage of the uninsured with a little -- strike that -- a trivial nod to cost control. The idea that hundreds of thousands of patients are denied access to health insurance because of pre-existing conditions was a powerful notion that has been a featured talking point in the debate. [We hear a little less about this after only 8,500 people signed up for the high risk pool unable to purchase individual insurance coverage compared to an expected 350,000.] But while lip service was paid to the reality that the trajectory of health care cost growth is a national emergency, it was all about coverage. One of the throwaway lines of the debate was that Obamacare would emphasize clinical effectiveness by restricting care to those who would actually benefit from care and to treatments that would be of proven efficacy. Proponents like Dr. Berwick hailed this approach as a key answer to cost control; opponents raised the specter of euthanasia. Both were wrong.
While it sounds attractive to have the clinical effectiveness tools that Dr. Berwick has advocated in the past put into place, a program emulating the British NICE (National Institute for Health and Clinical Excellence) won’t “bend the cost curve”. Nor will the problem of rapidly escalating healthcare costs be solved by rationing of care by central authority. Neither approach has worked in Great Britain so why should it work here? Yes, health care costs per person are less by a large percentage in the UK compared to the US but that is a function of the availability of services and the price of services, the latter driven in large part by the costs of advanced technology. The rate of rise for costs in the UK is quite similar to that of the US (see OECD data). Moreover, the British, like most European countries, have a two tier system where the more affluent have a private healthcare enterprise to access.
There is no argument against using the best data to guide recommendations of therapy. To attack Dr. Berwick for taking this position is ridiculous. It is not rationing to decide to forego futile treatments when there is complete agreement that they will not help. It is just common sense. However, despite the hype, there are unfortunately very few examples where the scientific data have led to rigorous understanding of the best approach to diagnosis or treatment. Moreover, it is often the case that more expensive technologies or treatments are better. Also, the application of large comparative studies to individual human beings with unique problems and concerns often produces unexpected and bitter responses. Just remember the mess around the frequency of mammography for those women under the age of 40 and one can see the controversies lying in wait for those who think an American NICE will solve our health care cost problem.
Those like Dr. Berwick who admire a single payer plan, a national health care plan, or whatever you want to call it, wherein someone in Washington DC makes the call about what care is allowed and what care is not allowed will never do the job of bending the cost curve. Medicare has tried this over the years and last we checked, Medicare attempts at real cost control are abysmal. Sure, go ahead and set up the mechanisms to evaluate care but don’t tell us that this will be the answer to cost control.
On the other hand, fears that our future healthcare system, whatever its nature, will be characterized by widespread restrictions on the use of effective therapies to relieve suffering and prolong meaningful life are understandable but quite unrealistic. There will always be controversies and anecdotes over particular examples where patients apparently had limited access to treatments that were truly critical, but this rarely occurs in any of the advanced countries and is unlikely to occur here no matter what system we have in place. Dr. Berwick should not be hounded about this possibility.
According to the trustees of Medicare, Medicare's long-term debt, based on a 75-year actuarial projection, is now estimated to be $32.4 trillion. Rather than grilling him about rationing, it would have been better if someone on the House Ways and Means Committee could get Dr. Berwick to explain how that number will be managed if we continue to fail to address the demographics of too few workers funding the care of too many Medicare recipients, never institute means testing for Medicare, reject employing defined benefits as outlined by Rep. Paul Ryan, fail to deal with the demand for services and the unrestrained growth in technology of uncertain benefit and if neither physicians nor patients are put at some financial risk for healthcare services.