Friday, August 14, 2009

"First, do no harm"

Rick Esenberg, a blogging law professor at Marquette University, has begun a series about the proposed public option segment of health care reform. Here he explains "Why Obama is losing the health care debate":
We do know that when we look at things that the health care unambiguously delivers, i.e., timely care, good survival rates and medical innovations, the US system is unrivaled - and much of the innovation that leads to these things is then adopted by other countries which do not themselves produce them.

My conclusion - and I think it is a reasonable one - is that our current system does many things well for the overwhelming majority of people. So, to borrow from what has become an accepted part of the Hippocratic oath (although some say it was not there originally) - "first, do no harm." The reason that the President is losing the health care debate (indeed, may have already irrevocably lost it) is that his ambition largely dismisses that advice.

If there were nothing to lose, then the proposed centralization of "best practices, "pay for a (uniform concept of) performance," federally standardized coverages, and a public option that may undercut private alternatives and dampen incentives for innovation even as it results in greater equality wouldn't bother people.

But there is something to lose. The awful and immoral health care system that is portrayed by our friends on the left is not the health care system as experienced by somewhere between 75 and 90% of Americans. If you don't begin your thinking by acknowledging that, you aren't going to get anywhere.

And Obama hasn't. The problem is not that "special interests" (a much abused term) are unfairly frightening people. It's that people have reason to be frightened. Like Mrs. Clinton before him, Obama is making the perfect the enemy of the good.

This isn't to say that universal coverage isn't a laudable goal (we should seek it) or that there is no room for improvement. But folks are understandably reluctant to throw the baby out with the bath water. The President has consistently failed to take that concern seriously. He knows it is a problem. This is why he began by claiming that no one would be forced out of their current coverage before he had to acknowledge that he only meant that the government wouldn't mandate such an outcome, although it might very well occur. His speculation about "red pills" and "blue pills" and pain killers instead of treatment for those who are too old or too sick plays into what everyone knows are the weaknesses of public health plans. .... [more]

And this morning The Wall Street Journal explained further:
While claims about euthanasia and "death panels" are over the top, senior fears have exposed a fundamental truth about what Mr. Obama is proposing: Namely, once health care is nationalized, or mostly nationalized, rationing care is inevitable, and those who have lived the longest will find their care the most restricted.

Far from being a scare tactic, this is a logical conclusion based on experience and common-sense. Once health care is a "free good" that government pays for, demand will soar and government costs will soar too. When the public finally reaches its taxing limit, something will have to give on the care and spending side. In a word, care will be rationed by politics.

Mr. Obama's reply is that private insurance companies already ration, by deciding which treatments are covered and which aren't. However, there's an ocean of difference between coverage decisions made under millions of voluntary private contracts and rationing via government. An Atlantic Ocean, in fact. Virtually every European government with "universal" health care restricts access in one way or another to control costs, and it isn't pretty.

The British system is most restrictive, using a black-box actuarial formula known as "quality-adjusted life years," or QALYs, that determines who can receive what care. If a treatment isn't deemed to be cost-effective for specific populations, particularly the elderly, the National Health Service simply doesn't pay for it. Even France—which has a mix of public and private medicine—has fixed reimbursement rates since the 1970s and strictly controls the use of specialists and the introduction of new medical technologies such as CT scans and MRIs.

Yes, the U.S. "rations" by ability to pay (though in the end no one is denied actual care). This is true of every good or service in a free economy and a world of finite resources but infinite wants. Yet no one would say we "ration" houses or gasoline because those goods are allocated by prices. The problem is that governments ration through brute force—either explicitly restricting the use of medicine or lowering payments below market rates. Both methods lead to waiting lines, lower quality, or less innovation—and usually all three. ....
And seniors are particularly vulnerable:
Mr. Obama has also said many times that the growth of Medicare spending must be restrained, and his budget director Peter Orszag has made it nearly his life's cause. We agree, but then why does Mr. Obama want to add to our fiscal burdens a new Medicare-like program for everyone under 65 too? Medicare already rations care, refusing, for example, to pay for virtual colonsocopies and has payment policies or directives to curtail the use of certain cancer drugs, diagnostic tools, asthma medications and many others. Seniors routinely buy supplemental insurance (Medigap) to patch Medicare's holes—and Medicare is still growing by 11% this year.

The political and fiscal pressure to further ration Medicare would increase exponentially if government is paying for most everyone's care. The better way to slow the growth of Medicare is to give seniors more control over their own health care and the incentives to spend wisely, by offering competitive insurance plans. But this would mean less control for government, not more. .... [more]

Shark and Shepherd: Why Obama is losing the health care debate, ObamaCare Will Lead to Rationed Care for Elderly -

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