Thursday, April 23, 2009

Slip slidin' away, slip slidin' away ...

Paul Simon probably wasn't thinking health care reform when he sang "slip slidin' away, slip slidin' away ... the nearer the destination, the more you go slip slidin' away" but he might as well have been. It seems like every time the U.S. gets closer to the destination of universal coverage and delivery system reform, something comes up to send us slip slidin' away.

It looked from the Senate Finance Committee roundtable on delivery system reform on Tuesday that we are getting close to agreement on bipartisan reforms to improve health care delivery. But today comes word that a fight between Republicans and Democrats over using "budget reconciliation" to enact health care reform could grind things to a halt. (Budget reconciliation would enable health care reform to be passed on a simple majority vote, a tactic that most Democrats favor but is fiercely resisted by the Republican minority.) A few hours ago, confirmation of Governor Sebelius as Secretary of the Department of Health and Human Services was held up because of more partisan squabbling.

On an optimistic note, E.J Dionne opines in the Washington Post that health care reform has become "irresistible" so we should not assume "that [every] snag, controversy or disagreement over the effort to pass comprehensive health-care reform" represents a collapse of the process.

I certainly hope Mr. Dionne is right. But eternal vigilance will be required of health reform advocates. Right now, polls show that voters are solidly behind the Obama administration's broad goals for health reform, but they will soon be getting an onslaught of opposition messages designed to make them think twice.

One of the opposition messages will be to invoke the "slippery slope." We've already seen this in the debate of government funding of comparative effectiveness research (CER). The argument being made is that although CER funding appears benign enough - providing clinicians and patients with comparative efficacy data based on head-to-head trials of different clinical treatments - it will inevitably result in the government using such information to deny access to care based on economic criteria, not quality. In other words, give the NIH money today to do clinical trials of different treatments, and tomorrow we'll be throwing grandma under the bus to save money.

Now, to be clear, I don't believe that the slippery slope argument - and its rhetorical sister, the "foot in the door" analogy - are totally without merit. An ACP member, who I highly respect, told me yesterday that she was concerned that CER would be a slippery slope to rationing based on cost. She pointed to the experience in the United Kingdom, where CER is used to deny care to people when their projected cost of care, over their estimated months of quality life, exceeds a dollar threshold. Those of us who favor CER need to take such concerns seriously and accurately describe how CER should, and should not, be used. This morning, Dr. Hal Sox, editor of the Annals of Internal Medicine and chair of a new Institute of Medicine committee on CER, gave the best argument I've heard yet on why internists should support CER to a packed gathering of internists at the opening session of ACP's annual scientific meeting.

The problem with the slippery slope analogy is that it ultimately becomes an argument for the status quo: Any new policy change can potentially lead to other changes that may not be desired or intended, so why take the risk of changing things? It assumes a degree of inevitability in public policy that in my experience isn't the case. In a democratic society with a representative government, one thing doesn't have to lead to another, if the voters don't want it to.

Finally, we know that if we don't change the health care system, the U.S. health care will slide into more uninsured persons, exploding costs, lower quality and enormous budget deficits caused by spending on Medicare and Medicaid. This is the one slippery slope that is inevitable unless we have the desire and will to change things.

Today's question: Do you buy the "slippery slope" argument that health care reform will result in the government taking control of health care decisions?


emily said...

If things can't go on as they are, it would be in everyone's best interest to think of something different.

Perhaps the CER research would be valuable towards starting a tiered approach meaning that everyone gets some basic level of proven beneficial coverage/ primary care through the govt. and then they become self pay or purchase a secondary insurance for treatments that are outside of the CER research.

It would be a challenge to think this way and determine the specifics, but then most people would have at least a basic level of coverage and those who want more could buy it. It's not rationing when a person is still allowed to buy something but has to pay more than s/he would like.

David said...

Time for political courage.

"The dogmas of the quiet past are inadequate to the stormy present. The occasion is piled high with difficulty, and we must rise with the occasion. As our case is new, so we must think anew and act anew."--Lincoln

Jay Larson MD said...

Insurance companies have already taken control of health care decisions. Decisions made by insurance companies are hap hazard with no merit (other than financial) behind them. We already are on a slippery slope and the end of the slope is devastating.

Steve Lucas said...

Throwing grandma under the bus is a strawman argument. One of the more interesting comments I have read was by a British doctor who stated he found the guidelines "liberating." The reason being that once the decision was made not to pursue low result treatment the real discussion as to what should be happening in a person's life took place.

Bob Centor often blogs about the need to have frank end of life discussion. One caveat is to always look at the person's value system, not impose the doctor's desires, or those of other family members. Palliative care is often delay until the benefits are minimal.

My personal belief is that much of the anti-CER rhetoric is generated by the drug and device companies. With only marginal results from many medications, or even dangerous guidelines, the fear is a loss of revenue, not patient care.

Today's WSJ Health blog highlights the $100B spent on cancer research, with only a 5% reduction in deaths. Certainly CER would have an impact in this area.

I have less of a problem with CER than I do the wasteful nature of our current system.

Steve Lucas