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Politics : A US National Health Care System? -- Ignore unavailable to you. Want to Upgrade?

To: Lane3 who wrote (6776)	5/13/2009 9:43:48 AM
From: Lane3	Respond to of 42652

The Structure of Comparative Effectiveness Revolutions 12 May 2009 05:54 pm Liberal blogs have been bashing conservatives over the "comparative effectiveness issue". And they're basically right. The idea that the government shouldn't test the relative effectiveness of various treatments because this might, someday, lead some moronic bureaucrat to try to ban treatments, is not a good argument. Comparative effectiveness research is one of those things that even a conservative should be willing to at least think about having the government do, because the government doesn't have a vested interest in the outcome. I do want to raise some potential issues here, however, not because I am against the idea--I am for it--but because there is a danger that the government seal of approval may become far too powerful. Governments do not have the obvious conflict of interest that plagues some pharmaceutical industry research. But they have different problems, some more prevalent in government because there is no countervailing market discipline to weed them out. * Perhaps the most obvious problem is that we won't entirely eliminate the financial motive--government workers sometimes leave their agencies, and the obvious place for them to go is to the companies they regulate. If you wall off this lucrative avenue of escape (say by dictating that they can't work in a regulated company for 1-5 years after they leave their agency), you may have trouble recruiting good people in the first place, because working for the government will become something like a prison sentence. * Science isn't always cut and dried, but government reports are supposed to produce answers. There's a danger the bureaucrats will be more definite than the science calls for. This is a risk in the private sector, too, but private sector errors of this sort are rarely as powerful as government errors of the same kind. Once the government establishes a standard of care, private companies will probably follow, even if they are wrong, because it's o Easier than doing their own analysis o A lot easier than getting sued o Possibly cheaper than the more effective treatment * Government agencies are much more vulnerable to interest group pressure than private companies. Researchers will come under tremendous pressure to say that things work when they don't--not just from big, bad Pharma companies, but from patients who do not want their insurance company to cut off access to the treatment. And see above: a government report saying snake oil might work has more impact than a dozen private company reports saying the same. * Government power can perpetuate a bad paradigm. I'm currently reading a book called Cure Unknown by a science journalist who believes she and her family are suffering from chronic Lyme disease. I don't know if Chronic Lyme Disease exists, or is a figment of the imaginations of people with some unspecified systemic or psychological problem. But some of the things she's angry about ring true to me because they sound a lot like other episodes from the history of science. The spirochete that causes Lyme is hard to detect, so treatment guidelines focus on the "bullseye rash", not because there's any particular reason to think it must follow infection by the borrelia bacterium, but because it's easy to diagnose, and . . . it's part of the diagnostic criteria. Everyone who has "real" Lyme disease has the rash, because the definition of "real" Lyme disease is having a rash. This, of course, makes it hard to test the theory that the spirochete might cause symptoms other than a rash. Weintraub makes a compelling case that these sorts of hard-and-fast diagnostic rules have, at the very least, left some indisputable cases of Lyme undiagnosed, including that of Weintraub's son. The CDC has turned this into a major problem, since of course most physicians do not pour through the journals themselves; they glance at the CDC criteria, which are quite restrictive. It's pretty clear that scientists who have a lot vested in the current model of Lyme (their careers, possible malpractice accusations), have at least for now won the debate. It's not quite so clear that they should have. And the government imprimatur has done a lot to seal the fate of the dissidents. This is all standard stuff to anyone who's read The Structure of Scientific Revolutions. But those revolutions happen because there are multiple possible centers of power. The government has the ability to potentially shut the revolutionary centers down. As I say, I am in favor of doing the research. But the dangers of this sort of government sanction are not quite so far off and imaginary as Matthew Yglesias and Hilzoy seem to think. I don't think conservatives have done a very good job of articulating those dangers (and don't get me started on the pharmaceutical industry!) But I still think they're worth keeping in mind. meganmcardle.theatlantic.com

To: Lane3 who wrote (6776)	5/21/2009 4:19:51 PM
From: TimF	Respond to of 42652

We Are On Our Way To Confusing Entitlement Expansion With Health Care Reform I generally find Washington Post business columnist Steven Pearlstein levelheaded. But his column today has me shaking my head. Effectively, he is saying forget what it costs--health care reform needs to be done. His biggest problem is that he doesn't know the difference between entitlement expansion and health care reform. But the way things are looking neither does the U.S. Congress. From Pearlstein's column: There is, for example, general agreement that it will cost $100 billion to $150 billion a year to provide the subsidies necessary to allow all Americans to afford a basic health plan. But the Congressional Budget Office, the official scorekeeper on these matters, has been reluctant to certify the major cost savings that might come from various proposals to restructure the health delivery system, or reform the health insurance market to make it more competitive, or change the way doctors and hospitals are compensated so they have the incentive to use only the most cost-effective treatments. It is, of course, the CBO's job to be skeptical, particularly after a number of past experiments in this area have yielded disappointing results. But it is also true that because nothing of this scale and complexity has been tried before, projecting the fiscal impact is next to impossible. This budgetary standoff will leave Congress with no choice but to try to finance its health-reform efforts by raising taxes or limiting payments to doctors and hospitals, possibly jeopardizing the entire project. We can certainly applaud policymakers for their reluctance to enact another expensive and popular entitlement program without finding the money to pay for it. But it is folly for them to put themselves in a political and procedural straitjacket. In all of history, no revolution was ever made by budget analysts. Health reform requires leaders with the foresight and confidence to take a leap into the unknown. Indeed, health care reform will require a bit of a revolution. Entitlement expansion only requires we pour more money on this mess we call a health care system. He isn't the only one I've heard recently say that finally getting health care reform is more important than how we will pay for it. I think it's time to remind ourselves that there is a difference between health care reform and entitlement expansion. Health care is the problem it is for America's fiscal solvency because its costs are out of control. As the President has very correctly pointed out we need to accomplish health care reform to get our costs under control, and in turn fix our economy and long-term fiscal health, and to convert the waste everyone agrees is there into the cash we need to cover everybody. The big mistake here is that Pearlstein is calling for the expansion of the health care entitlement and confusing that with health care reform. He's saying we'll just hope for the best that costs can somehow be controlled even, as he says here, "particularly after a number of past experiments in this area have yielded disappointing results." There is entitlement expansion--you just raise taxes, lop a little off the top of provider reimbursement, or pare back benefits--to come up with what you need to pay for it. That looks to me like what the Congress is getting ready to do. Health care reform--the thing we really need to do--creates new, powerful, and measurable incentives that actually begin to convert the waste to the money we need to cover everyone and control our costs. Entitlement expansion is just loading more people onto the Titanic. Health care reform is the refashioning of the system into something that is sustainable. healthpolicyandmarket.blogspot.com