Imagine that it is 2013, and a new President is sitting in the Oval Office. (If you prefer, imagine it is 2017, and we have a new President.) To make things interesting, let's imagine that the new President is a Republican. Imagine that he (or she) was elected on a platform of cutting taxes, rolling back the Obama administration's increased spending, and reforming the Medicaid and Medicare entitlement programs. To make things even more interesting, let's imagine that the Obama administration was able to get a substantial expansion of health insurance coverage enacted into law, but that most of the cost controls were stripped out or weakened as a result of political opposition. Health care spending has continued to rise at breakneck rates, and the Medicare trust fund is about to run out of money.
What is a new President to do?
Because the most promising approaches to gradually "bend the cost curve" - comparative effectiveness research, coverage of evidence-based preventive services, advance care planning, reductions in regional variations in the quality and cost of care, and the public option - were left out the health reform bills, the only cost-cutters left are hugely unpopular ones. Increase the age of eligibility and slash Medicare benefits? Means-test Medicare to exclude the rich? Slash payments to doctors and hospitals? Go back on your campaign promise and raise Medicare payroll taxes? Or let Medicare go broke? You either incur the wrath of the largest generation in history - the tens of millions of boomers who now depend on Medicare - or the younger tax payers who will be called upon to bail out the program.
(If you prefer, you can run a similar scenario with another Democrat President - only in this case, the most likely option is that the new President would propose a complete, U.K. style take-over of the health care system, to give the government all the regulatory levers it needs to control costs.)
These scenarios are very real if the critics of the cost controls in the current health reform bills have their way. Right now, notwithstanding the oft-repeated charge that the House and Senate bills "do nothing" to control costs, Marc Aminder writes in The Atlantic that the cost-benders in the legislation are getting praise from well-respected economists, Republican and Democratic alike.
But the same cost-benders are under unrelenting attack.
John Wennberg and Shannon Brownlee blog in Health Affairs about the efforts by some academic medical centers and hospitals to discredit and explain away Dartmouth Atlas data on regional variations in quality and cost. They fear that the research will lead to policies to reduce such variation, at their institutions' expense. Some physician membership organizations are flatly opposed to any policies that would redistribute payments among physicians based on efficiency and outcomes of care, specialty, or any other criteria, for that matter. They also don't like the idea of an independent commission to develop recommendations to control costs under a fast-track legislative review process. The end-of-life counseling in the House bill has been falsely labeled as leading to death panels. Research on the comparative effectiveness of different treatments has been called rationing of care. A public option is called socialized medicine. Even the medical home, which was developed by physician membership organizations, is labeled as this decade's version of HMO-style limits on care.
My point is that the politicians and interest groups who criticize these and other cost-benders may find that if they succeed in emptying the toolkit of the most promising approaches to gradually slow the cost curve and improve outcomes, they may leave a future President and Congress with nothing but draconian and enormously unpopular cuts in benefits and provider payments, tax increases, or the much-feared government take-over of health care. And it could be their guy and their party who will be in charge when the day of reckoning arrives.
(Oh, and by the way, Happy Thanksgiving to you and your loved ones!)
Today's question: What do you think about the above scenario? And what is your favorite Thanksgiving dish?