Tuesday, September 1, 2009

Why are fiscal conservatives opposed to Medicare cuts?

Anyone looking for ideological consistency and clarity of thinking should stay away from Washington. It is no secret that liberals and conservatives alike take positions in conflict with their usual governing philosophy when it suits their political interests. Still, there are times when the bending of philosophical underpinnings is so pronounced it makes you have to stand up and take notice.

Fiscal conservatives are supposed to be all about reducing federal spending on social programs, while liberals are supposed to be passionate about defending such expenditures. Except, that is, when they don't.

Case in point: the broad opposition from so-called fiscal conservatives to just about every measure in pending health care reform bills that hold the promise of reducing federal spending.

Writing in the Washington Post, Michael Steele, the chairman of the Republican National Committee, proposes a "Medicare Patient Bill of Rights" in which he expresses opposition to Medicare savings, "First, we need to protect Medicare and not cut it in the name of 'health-insurance reform' " - and specifically expresses opposition to the $500 billion in Medicare "cuts" being considered by Congress. (Take the entire $500 billion off the table, though, as Mr. Steele suggests, and health care reform will drive an even bigger hole in the federal deficit.)

He wants to "prohibit government from getting between seniors and their doctors" and the creation of "government boards that would decide what treatments would or would not be funded" and opposes comparative effectiveness research because it could "actually lead to government boards rationing treatments based on age. For example, if there are going to be only so many heart surgeries in a given year, the Democrats figure government will get more bang for its buck if more young and middle-aged people get them."

(Even though the pending bills do not give the federal government the authority to deny coverage based on cost or age, nor does it create government boards to decide which treatments will be funded.)

Mr. Steele also opposes having the government fund discussions between physicians and patients on end-of-life care, and pledges to protect the Tri-Care for military families from cuts.

All of this may make for good politics, since the latest polling suggests that seniors are the most concerned about the impact of health reform legislation on their care. The RNC is now running an anti-reform ad targeted at seniors.

Mr. Steele's proposal has received the predictable criticism from liberal quarters but also from Robert Costa writing in the conservative National Review, who suggests that Mr. Steele's position is a "capitulation to the Medicare crowd."

It isn't only Republican politicians that have ruled out Medicare cuts; "Blue Dog" Democrats also are complaining about many of the same Medicare cuts even as they pledge to "bend the curve" on health spending. And, ironically, it is the liberals who are saying that cuts in Medicare are needed to fund the broader health reform and that the government needs tools, like comparative effectiveness research, to bring down overall health care spending.

The problem is that even though promises to protect Medicare may be good politics, they are at odds with the reality that the program is not sustainable. If the GOP regains power, it will have to deal with the governing consequences of running as the protectors of Medicare - knowing that spending on the program will have to be trimmed, no matter who is in charge.

As Simon Johnson and James Kwak write in today's Washington Post, "if you are for fiscal discipline, you should be for health-care reform. If our government cannot produce some kind of reform, that will only reinforce the perception that our political system is incapable of resolving our largest, most difficult problem -- and that is what will make investors think twice about investing in America."

Today's question: What do you think about fiscally conservative politicians who are opposed to cutting Medicare's costs? And about liberals who support such cuts to fund broader health reform expansions?


PCP said...

Of course this has degenerated into pure politics now. For the last 2 weeks I do not see anything constructive coming out.

Conservatives are not gullible enough to believe that "savings from medicare" will be applied to a budget neutral bill that will magically cover the 50 million uninsured. If you believe that you probably also believe in the tooth fairy, santa claus and many more fairy tales.

It is also clear that the Gov't is incapable of cutting health care expenses in a way that is "sensible". When they cut, far from the scalpel they like to think they wield, they use chainsaws.
They generally cut across the board, and those with the means to game the system or lobby and stop the cuts do so and those without, face the consequences. Think of our predicament over the last decade with the SGR. Why no SGR on Medicare A, or Medicare D?
Does anyone in Primary care General IM need a reminder of this reality? We have seen first hand the wanton destruction of our practices by nearsighted policies when we and our patients fully well knew the value they brought. Furthermore we have seen all sorts of other marginally useful services(and arguably a lot less worthy) get reimbursed quite handsomely, and as they are scalable, get fully exploited to the benefit of corporate elites.

Why does no one ask these hard questions? Why is it that liberals continue to believe that, this time it will be different and the Gov't will allocate more sensibly?

Why are there so many advertisements for home health care. Why so many scanners in our midst? Why are there PT/OT national chains all over? There are countless other profit centers.
The answer is quite simply that those services are handsomely reimbursed viz a vie their cost of provision.
On the other hand, why is there such a dearth of General IMs wanting to pursue private practice medicine in the face of an aging population that would clearly want/desire their services? Why are these folks gradually being railroaded into One Doc and 3 PA practices, or NP Practices or CHCs/FQHCs etc. Are they not deserving of a competent, well qualified Internist?
This is the height of manipulation of payment policies, to the detriment of beneficiaries.
The ACP needs to get serious and argue for our rightful place in health care. We need not compromise much here, the Public is with us if we can only articulate our position well. We do not have to just take the bones the liberals throw us.

Conservatives have long proposed the direction of flexible spending accounts, appropriately structured, they provide an alternative. Perhaps medicare beneficiaries will also need to be brought into that and then the medical decision making will return to where it belongs.

Americans quite simply do not want their gov't to set limits on their care. They want some formula where they in discussion with their trusted advisers do it. Why is it that those in DC find that so hard to understand?

Arvind said...

This is exactly what happens when politicians, i.e. government gets involved in running a legalized Ponzi scheme called Medicare. All principles go out and politics takes over.

It is time everybody realized that a Ponzi scheme is just that, no matter who runs it. Madoff went to jail for it; how about politicians playing with other peoples' money?

Robert J. Sobel, M.D. said...

Bob, this is why you are in Washington. Clearly, there are multiple realities that the politicians must face that influence what concepts they put forth, and thus, what labels apply. Again, it seems like physician services are what will be cut, while the other areas we have been discussing seem to be spared.

We cannot cut costs effectively if we misdiagnose the problem. The breakdown of costs is pretty well established, though, as I keep hammering my message, I am pretty certain the pharmaceutical cut of the action is underestimated by current statistics. Every commercial we keep hearing is your tax or premium dollar blowing into thin air. The concerted marketing strategies that give me labels galore to apply to my patients are followed, just in time, by a drug just for such condition. Being overtly manipulated is not what we want and certainly not what our patients need.

It took a bipartisan Act (Hatch-Waxman) to facilitate this pharmaceutical insanity. It will take new thinking to undo this disaster. Unless we respect the drug inventions developed to date, we will have a crashlanding, as the biologic and genetic megagrowth backfires. Reform without controls on new drug costs is absurd and offensive. I don't care how big the players are. Let's fix this obvious imbalance and we can stabilize costs. Otherwise, all the wellness programs in the world won't get us anywhere.

Steve Lucas said...

From my perspective many of those against CER, the formation of a variation of NICE or other changes to determine what really works are answering the call of the drug, device and insurance lobbies.

These groups have a system that works very well for them, and see no reason to stop the gravy train. Time and time again we see drug and device products that are approved based on incomplete date, or in recent cases fraud. A review of Health Care Renewal should frighten everyone.

Insurance companies are no longer insurance companies but financial service companies. Large salaries and shareholder gain are the driver, not coverage and service.

This is why I feel we should break up the reform bill into smaller parts, so as to focus public attention on those areas that are controversial and present fact to dispel rumor. A bill this large is always going to have something, someone is not going to like, that someone can rally the troops to defeat, while all of the good is left behind.

Expanding our currently dysfunctional system will on garner a larger dysfunctional system, and this will financially bankrupt this country.

Steve Lucas

Jay Larson MD said...

An election is coming. Universal peace is declared and the foxes have a sincere interest in prolonging the lives of the poultry.
T. S. Eliot