Wednesday, October 3, 2012

The real deficit is leadership, but don’t blame the candidates

The National Journal reports that jobs and the deficit are likely to dominate tonight's presidential debate, but the most important deficit is the candidates' absence of leadership on unsustainable health care spending, not the federal budget. But before you blame Governor Romney and President Obama, first look in the mirror: politicians don’t level with voters about the sacrifices required to lower health care costs because we would vote them out of office if they did.

Tonight’s 90-minute debate is on domestic issues only. The first 45 minutes will be on the economy, followed by 15-minute segments on health care, the role of government, and governing. But even though health care is supposed to get only its 15 minutes of fame, you really can't talk about the other topics without talking about health care spending. Because, if you solve the health care spending problem, you solve the deficit and you improve the economy. And controlling health care spending involves fundamental questions of how the candidates and the general public view the role of government and approaches to governing. Problem is, we the voters won’t allow either President Obama or Governor Romney to tell us the truth about health care spending, because we wouldn't like what they would have to say, even as we bemoan the lack of straight talk from politicians.

Because this is what an honest answer to the question, "What should the United States do about health care costs and access?" would sound like:

"The simple fact is that we can’t afford our health care system. It is too expensive, even as it leaves tens of millions of us without any health insurance coverage. My opponent and I disagree on how best to lower spending, but there is no disagreement that health spending has to come down—soon, by a great amount, and in ways that none of us will like.

Here is why: spending on health care is the biggest single cause of our exploding budget deficit and debt. We can't balance the budget without reducing how much we spend on Medicare and Medicaid. As our population ages, Medicare is covering more and more people, even as we have fewer younger people supporting it with their taxes. Yes, all of us pay into Medicare during our lifetimes, but get much more from it in return than we put into it.

An average-wage worker pays $60,000 into Medicare in their working years, but receives $170,000 in benefits if a man, $188,000 if a woman. The rest comes from our grown children, but there won’t be enough of them to pay for the many millions of baby-boomers—I am talking about my generation—not without massive tax increases on them. Or we can borrow the money, plunging us more into debt, debt that will also be passed on to our kids.

Our health care system provides excellent care to many of us, and we lead the world in medical advances and innovation. But millions of us do not get good access to care. Forty-six million have no health insurance coverage. And we know that people without health insurance delay getting needed care, and many of them suffer more serious illnesses or die from illnesses that could have been prevented with better access. And the rest of us end up paying for their care. One thing the two of us have in common (pointing to the other candidate) is that we both have signed laws to cover most Americans, in Massachusetts and on a national basis through ObamaCare, yet we and our country remain terribly divided on whether the national law should be implemented, improved, or repealed, and if repealed, what would replace it.

It is possible to cover everyone in the United States and still spend much less, because every other modern industrial country, the countries that we have to compete with in a global economy, have managed to cover all of their citizens at half to two-thirds of what we spend.

And we know that much of the money we spend on health care in the United States is wasted, as much as $700 billion each year, according to studies on medical care, that have little or no benefit for the patient. And we wonder why we can’t afford our health care system!

Here's the rub: solving the health care spending crisis won’t be easy. We will all have to give something, to sacrifice for the greater good. A solution will involve people who can afford paying more for their care. It will involve modest increases in Medicare taxes now rather than huge tax increases or benefit cuts later. It will mean that some drugs, physicians, and hospitals will be paid less. It may mean asking our seniors to wait a few years longer to enroll in Medicare—but if we do, we are obligated to help them get coverage in the meantime so they don’t join the ranks of the uninsured.

It will mean some of health care benefits will have to be curtailed, so we pay only for the things that are most effective in improving health. It will mean changing the way we pay doctors, so we pay them based on how well they help people stay healthy rather than how many services they provide. It will mean forgoing unnecessary tests, like an MRI for back pain, when studies tell us they offer little or no benefit. It will mean finding an alternative to lawsuits against doctors and hospitals that result in unnecessary testing and higher health care costs. It will mean requiring our doctors and hospitals to work together to improve health and lower costs and holding them accountable for the results. It will mean that each of us has to take more responsibility for keeping ourselves well.

In other words, all of us working together to make tough decisions on what we can afford to spend on health care, what we can’t, and how to get the best bang for the buck. The days when everyone can get all of the health care they want, whenever they want, are over, and the sooner we recognize this, the better.

Yet out of all of this, I am confident that through American ingenuity, we can build a better health care system, one that covers and provides good access to care for everyone but at a cost we can afford. Are you with me?"

Now, what would happen to a candidate who made such remarks? The pundits would declare the he lost the senior vote and blew the election. Physicians, hospitals and drug companies would immediately express fierce opposition to cuts. The trial lawyers would go bananas over reforming the med mal system. Ideologues on the right would blast the candidate for proposing government-run rationing, higher taxes and universal coverage, ideologues on the left for cutting benefits, delaying Medicare eligibility and charging patients more.

How likely would it be that the voters would reward the candidate who said something like the above? The Pew Research Center reports that seniors are "highly resistant to Medicare changes" and "A wide majority of seniors (66 percent) said people on Medicare already pay enough of the cost of their health care, compared with 24 percent who said people on Medicare need to be responsible for more costs to keep the program financially secure" and a majority in all age groups say that preserving Medicare and Social Security benefits is more important than reducing the deficit.

So don’t expect honest answers from Governor Romney and President Obama tonight. The deficit in leadership from the candidates on tackling health care costs is because that is exactly what we voters say we want from them.

Today’s questions: Do you agree that there is a deficit in leadership among both candidates in addressing health care costs? And who is to blame, them or us?


Steve Lucas said...

This post would reflect my current feelings about our political debate. While I did not watch the debate I was disappointed to read that President Obama used the AARP as a reference.

The bright spot for me is that Canada, England, and Germany have all gone through what we are now experiencing, growing social programs supported by an ever decreasing tax base. Voters realized this and voted in a government that would use some common sense and resolve these problems over time, allowing people the opportunity to adjust.

I can only hope we are ready for the change, and do not go the way of France.

Steve Lucas

ryanjo said...

Bob & I disagree about many aspects of the health care debate, but in my opinion, he is right about the lack of leadership on the national level. There are apparently no national political leaders who are willing to stand up and take any heat to solve the chronic problems. Like most stakeholders, physicians feel strongly (and I feel rightly) that we have been demonized enough by the so-called reformers, and it is awful hard to take more loss of autonomy and economic reductions while the more influential segments of the medical economy post record profits. But I think all of us could take more bitter medicine if solutions were fair, and had some chance of success. And although Bob will disagree, the mishmash of half-baked measure that make up the ACA only makes sense to our present politicos -- no one else.

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

There is no way the macroeconomic approach of managed care(the trickle down of institutionalizing quality measures, to riff on the debate) will be a worthy investment. The addition of bureaucracies is rarely cost effective, and certainly not when unnecessarily redundant. See if Europe has examples relevant to this. The sentiments of ryanjo are right on. Fairness would involve correcting the status quo in favor of cognitive medicine without the micromanaging hassles. Defending us against the extant and emergent overhead of modern U.S. private practice is long overdue from organized medicine, as it is at the level of the patient-physician that all of these coercive policies work their dastardly deeds.

If I make decisions to perform solely or substantially based upon financial gain, shame on me. If I make decisions not to do because of financial gain, that is also shameful, as well as deceptive and dismissive. If guidelines shield me, than I am again corrupted, this time by the panel. I would argue again that there is a paucity of solutions from organized medicine that defend the independence of physicians. They are out there as general philosophies, but they are sabotaged by producing medical homes and supporting meaningful use, among the many bureaucratic constructs that promise sclerosis without cost savings. They further erode the primacy of clinical deliberations.

This health care puzzle is most challenging. I wish those who represent us daily would understand the implications upon consolidation of these new bureaucracies. They should instead focus on understanding how infrastructure growth, derivative industries, and administration continue to absorb more of the health care pie. There is no reason for independent physicians not to feel assaulted in this current environment.

Costs will only be stabilized by prorating the cost of the new. It is clear that there are ballooned costs in health care. Instead of coercing behavior in the perverse ways discussed above, we should attack the prices in a more coherent, balanced, and fair way. Thus, a gradaul correction of the SGR mechanism is more fair than bundled payments and the like, especially as the latter again directly promote consolidation, while the former function democratically. As well, enticing innovation through indefinite exclusivity (carrot) will make fair and negotiable (but independent of the patient-physician relationship) price regulation of pharmaceuticals (the stick). This would be much more straightforward, stable, and receptive to innovation than the current Hatch-Waxman regime of an artificial brand-generic dichotomy. This is a proposal (regulated royalties) that would restore professional independence in prescribing (and save insulins from their Biosimilar fate). It is my business to provide good clinical care, not to be trapped in third party hassles while I try to manage hypertension, diabetes, and everything else where all my energies should be directed.