Friday, March 4, 2011

A confused and contradictory lot, continued ...

Several of the frequent commentators to this blog took issue with my characterization of Americans being a confused and contradictory lot when it comes to their views of the federal budget.

But the fact is—and yes, I am talking about fact, not opinion— that most Americans have no clue about how the federal government spends their taxes and the trade-offs involved in balancing the budget. Yesterday’s Washington Post fact-checker blog goes as far as to give the American people four "pinnochios" (the site’s worst possible rating for accuracy) "for not knowing the basic facts about how the U.S. government spends taxpayers' money." I know, some of you are going to say that the Washington Post can’t itself be trusted because it is part of the Washington establishment. I ask, though, that you first read the fact-checker post, in its entirety, because the bloggers support their assessment by citing extensive evidence from surveys and studies. Most Americans, for instance, think that the federal government spends more than one out of four dollars collected on foreign aid, but the real number is less than three percent.

The fact-checker blog does more than decry Americans state of blissful ignorance about the budget; it also offers a nice interactive webpage to help people understand where their money is really going now compared to 1981. You can click on any programmatic area of spending and get a nice graphical illustration of how much spending has increased.

And guess what? The biggest increases, by far, have been spending on Medicare (more than 400% increase) and all health care spending combined (more than 500% increase). Nothing else comes close.

The answer to the federal budget deficit, then, ultimately will come down to getting a handle on health care costs. Whacking away at discretionary programs that largely benefit the poor, as the House of Representative’s Continuing Resolution would do, will not get us there. Nor will circling the wagons to protect Medicare from cuts, as liberal Democrats are prone to do, get us there. We have to spend less on health care, period, end of story. And this can only be done if physicians take a leadership role in explaining to their patients and the public the consequences if we allow unrestrained spending on health care to continue. Physicians must also be willing to take responsibility to reduce unnecessary, inefficient, duplicative or marginal care.

ACP’s is trying to do its part. ACP has released a major new paper on why and how the United States must make decisions about conserving and allocating limited health care resources, rationally and effectively. It is also asking its members to participate in the High Value, Cost Conscious Care initiative, which will help identify the benefits, harms and cost of different tests and procedures.

If you care about the deficit—as we all should—then help ACP start a national conversation about controlling health care costs. And help us disabuse the public that deficit reduction can happen by cutting foreign aid or funding for education or assistance to the poor, while leaving Medicare and other health programs untouched and without asking anyone to pay more with higher taxes.

Today’s question: What is your reaction to the evidence presented in the Washington Post’s fact-check blog about Americans “not knowing the basic facts” about the budget and the trade-offs involved, the fact that health care spending trumps all other parts of the budget in terms of increased spending over the past thirty years, and ACP’s efforts to address the cost problem with the public and with its members?


doc777 said...

I fully agree that our citizens have no clue where their tax dollars go. That is why it upsets me immensely that the ACP and others continue to extol the virtues of the ACA to our patients without explaining the sacrifices needed now and in the future to make it happen.

Those of us opposing the ACA see it as another bloated government program that will increase costs dramatically and lead to substantial government rationing of health care. Does anyone really think that adding 1000 IRS workers (that is just in 2012) and dozens of new bureaucratic entities will help improve access to health care in this country and at the same time reduce costs? The Massachusetts health care plan is almost identical to the ACA and gives us a clear view of where we are heading. The review of the Massachusetts health care plan’s effects at is sobering.

Our state has also expanded our Medicaid program in order to approach universal coverage. However, this was funded with one-time sources of money including the tobacco settlement, raids on various segregated funds, and stimulus dollars. Taxes have also been increased dramatically. Illinois just increased their income tax by almost 70%, and theirs is still less than our state’s current income tax. We now face more than $1 billion in cuts to the Medicaid budget in order to keep our state in the black.

The ongoing implication that those of us opposing the ACA do not care about the uninsured is starting to get quite irritating. I have spent my entire career caring for primarily underserved populations. I have been a strong advocate for the uninsured and have consistently worked toward increasing access while maintaining, or even improving, quality. I have also increasingly educated myself on true market-driven solutions to reducing health care expenditures.

This is not about politics. Congressman Ryan and others on his side are truly fearful that we are within a couple years of experiencing the same problems being experienced in Greece, France, and other European countries. People think the turmoil in Wisconsin, Ohio, and Indiana is bad, but do we really want to see the total chaos that Greece and France have experienced? In addition, the dollar’s status as the world's standard currency is in jeopardy. If we don't get our costs under control now, the entire system is going to collapse. Then, we won't be able to provide anyone with health care. I’m sorry, but I just don’t see the wealthy country others see. We are on a collision course with reality. It’s time we learn to live within our means. Adding a huge new entitlement program when we cannot afford the ones we have, is not something I can support.

Steve Lucas said...

The budgets cuts taken so far represent the fulfillment of a political promise to cut the budget.

The recent CBO report gives guidance to cut the large amount of waste in the government touted for so long as the way to balance the budget. A side benefit will hopefully be to make business more competitive both here and abroad. The EU started streamlining regulations years ago.

Hopefully these actions will set the stage for an adult conversation on entitlements. Medicare, Medicaid, and Social Security all are in need of reform in order to remain solvent.

Expansion of the Medicaid roles, and required services, has left almost every state with a looming budget deficit. Simply pushing this responsibility onto the states does not solve the tax issue, but is only a shift in responsibility. Expecting doctors to run their practices at this reimbursement level places an unfair burden on them and makes them responsible for a societal issue.

This is the start of a process that I feel it will be driven by those outside the beltway.

Steve Lucas

Harrison said...

In health care we have to confront a challenging paradox. We waste a lot of money at the point of care, and so it is important for the whole system to focus on cost savings at the point of care. It is however potentially unethical to balance the budget at the point of care.

It is fine for the health care delivery system with third party payers to impose budget limits on the choices available to a doctor and a patient.

It is not ethical for a doctor to limit discussions of possible options for the purpose of saving the system money.

If the ACP can keep that conflict in focus then it can help.
We need easy access to evidence based diagnostic and treatment tools that will help at the point of care.
We also need tools that will help with the discussion of evidence with patients.
Shared decision making tools can help.
Tools to help with end of life care and planning can help.
Tools to help primary care with distinguishing between truly valuable screening tools, and tests that serve only case finding functions can also help.
If we move into a patient centered medical home model then we will need to learn how to appropriately refer care to specialists. Primary care doctors cannot simply function as gatekeepers. That will not work. A primary care physician cannot simply say no to a patient relative to a specialist referral and then not offer anything to help with the problem.

Quality and access and costs. We have problems with all of these areas and if we only focus on one then we will make the system worse.