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Remember Harry and Louise, the made-for-television couple whose advertisements helped scuttle the Clinton health care plan 16 years ago? President Barack Obama does. Every time he talks about health care reform, the president dodges the type of concerns that Harry and Louise raised about limited choices and bureaucratic hassles by insisting that Americans "must be free" to choose their own doctors and health insurance coverage.
But Obama's seeming support for free choice resembles a bait-and-switch scam. Though the president has offered few details, White House Chief of Staff Rahm Emanuel admits that the administration's first priority is "getting health care costs under control." This goal comes with a bitter truth: If 40 million currently uninsured Americans are to be brought into public or private health plans with unlimited choice of physicians, the only way to cut costs is to restrict the services those doctors provide. Inevitably, patients would see fewer choices and lower-quality care. Even in the best system, every consumer cannot expect Lexus-caliber health care. Rather, the more pertinent issue is whether everyone--or the vast majority--will be relegated to options on par with a Chevy compact. Developments on Capitol Hill suggest the latter.
According to a House of Representatives staff report describing cost-cutting measures in the economic stimulus package, treatments found to be less effective, or in some cases more expensive, "will no longer be prescribed." A Senate Finance Committee report released in April proposed reducing the number of physician specialists and the use of high-cost services such as expensive drugs and state-of-the-art medical technologies. As former Sen. Tom Daschle--the one-time nominee for the position of secretary of the Department of Health and Human Services--sums it up, the approach would eliminate treatment options that don't provide enough "bang for the buck." I think I hear the Chevy pulling into the driveway now.
These developments should come as no surprise. Much has been made of the fact that Americans spend far more for health care than do citizens of other industrialized countries. But the cost difference stems largely from the fact that American patients have much freer access to new and innovative treatment options for chronic and life-threatening illnesses.
In "model" countries like Canada and Britain, the quality of low-cost primary care is about the same as in the U.S., and even rated higher in areas such as the waiting time to see a doctor. But these same countries have far inferior quality of treatment for serious conditions like cancer and kidney failure because they limit access to medical specialists and refuse to pay for many of the pricey medicines, diagnostic tools and complicated operations that are standard medical practice in America.
For example, in 2005, so many participants of a government-run program in Canada were dying while on the waiting lists to receive treatment that the Supreme Court of Canada ruled that a provincial ban on private health insurance in Quebec violated patients' "liberty, safety and security" and was, therefore, unconstitutional. Many Canadians want their system to be more like ours, but would-be health care reformers (read: cost-cutters) want to make the American system more like that of Canada and Britain by restricting access to expensive treatment options.
In February, Congress and President Obama allocated $1.1 billion to fund a new government bureaucracy called the Federal Coordinating Council for Comparative Clinical Effectiveness Research. Its mission is to compare the effectiveness and expense of various medical treatments and to decide which ones should be covered by government health care plans like Medicare, Medicaid and the federal insurance pool proposed by President Obama and congressional Democrats.
In theory, research on clinical effectiveness can help doctors better understand the likely benefits of the medicines they prescribe and improve the quality of care they deliver, but congressional advocates support the program specifically because it would, in Daschle's words, "have teeth." House Appropriations Committee Chairman David Obey has admitted that the point of studying "comparative effectiveness" is to keep patients from getting more expensive medications and procedures.
The comparative effectiveness council is modeled on a U.K. government program called the National Institute for Health and Clinical Excellence, known by the ironic acronym NICE. That program denies British citizens access to breakthrough drugs for debilitating and life-threatening conditions like cancer, multiple sclerosis, Alzheimer's disease and macular degeneration because those medicines are not sufficiently effective--as judged by bureaucrats--for every patient who takes them. But as Karol Sikora, a professor of oncology at Imperial College School of Medicine in London, observes, "The real cost of this penny-pinching is premature death for thousands of patients."
And lest those enrolled in private health insurance plans think they're safe from this kind of rationing, Daschle has proposed that Congress revoke the tax exclusion for private plans that do not comply with government cost-effectiveness recommendations. So much for competition and consumers' freedom to choose.
Equally troubling is the long-term impact that this kind of cost-cutting would have on medical innovation. Often, the medical condition for which a new drug is initially approved turns out to be only one small part of its eventual use because more important applications are discovered only after the drug is approved and doctors begin testing it for other conditions.
This was the case for the therapeutic protein interferon alfa-2a, sold under the brand name called Roferon-A. First approved for a rare blood condition called hairy cell leukemia--for which it is now seldom used--Roferon-A was later found to be effective for a number of other far more prevalent conditions, including chronic hepatitis C and chronic myelogenous leukemia. Had the prescribing and reimbursement of the drug been blocked by bureaucratic bean counters early on, its additional uses likely would have never been discovered.
Roferon-A is just one of numerous such examples. Yet, at a recent conference on health care "Economics and Ethics," one participant even suggested that pharmaceutical development programs should not proceed beyond mid-stage clinical trials until the corporate sponsor is assured by reimbursement agencies of a positive coverage decision based on clinical endpoints. This additional obstacle to the already high-risk process of pharmaceutical R&D would be the logical, yet absurd, outcome of bureaucrats' cost-benefit determinations.
Harry and Louise may be absent this time around, but we still cannot provide more and better care to a larger number of people without busting the budget. Just as was the case 15 years ago, health care reform today means making tough choices. And in the hands of government bureaucrats, the rationing of expensive care is likely to be a cure worse than the disease.